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Adapting Podiatry Practice To COVID-19: Key Principles And Protocols
Regardless of one’s practice setting or region, revolutionary changes have taken place in health care in an attempt to prevent, contain and treat the novel coronavirus. With this in mind, this author talks with DPMs throughout the country regarding their experiences providing lower extremity care during the COVID-19 pandemic and how their day-to-day professional lives continue to change.
The emergence of the COVID-19 virus caused significant and sweeping changes to the landscape of medical practice. From immediate concerns about transmission and safety to longer-term concerns about practice viability and operations, podiatrists continue to adapt and change the very essence of their professional activities. Though the pandemic is ever evolving, let us take a closer look at the impact of COVID-19 on podiatry practice and how podiatrists continue to meet the associated challenges.
In July 2020, the Physicians Foundation collected over 3,500 responses from doctors across the country about the impact of COVID-19 on their practices.1 Close to half of those surveyed felt that the pandemic will continue until at least the summer of 2021. Nearly three-quarters of those polled expressed concern about significant health consequences in their communities due to patient reticence to seek care during this time with 88 percent specifically stating that spikes of COVID-19 may cause moderate to severe risks for their patients.1
“Patients are absolutely delaying their own care because they are afraid of coming to the hospital ‘to catch COVID,’ so when we see them, the problem is much worse,” says Rebecca Moellmer, DPM, FACFAS.
Recent research shows a more than two-to threefold risk of amputation in high-risk patients during the first wave of the pandemic.2 However, this number appears to be growing exponentially. Another recent study found a 10.8 times higher risk in patients with diabetic foot issues of undergoing any level of amputation at a level one trauma center in the first eight months of 2020 in comparison to the same time interval in 2019.3
Outside of the public health emergency, the Physicians Foundation survey inquired about what impact physicians experienced professionally due to COVID-19.1 Eight percent of respondents closed their practice as a result of the pandemic. Staff reductions became necessary for 43 percent. Almost three-quarters of doctors reported a reduction in income and 55 percent lost more than 26 percent of their revenue.1 Additionally, 41 percent of those surveyed have experienced more than a 26 percent decrease in patient volume, which the Physicians Foundation describes as possibly “difficult or impossible to sustain for more than a few months.”1 More than half of the respondents felt that the independent physician practice model will decrease in prevalence as a result of the COVID-19 pandemic and nearly the same number of physicians felt hospitals will play a more powerful role in influencing the delivery of health care.1
The Financial Ramifications Of COVID-19 On Podiatric Practice
Practice owners whom I spoke with for this article overwhelmingly related significant financial impacts to their practices, especially in the early weeks and months of the pandemic. Many made attempts to avoid furlough or layoffs in the spring of 2020. Employed physicians related pay cuts, hour reductions and even cancellation or deferment of their employment contracts, especially for those newer to practice. Some doctors willingly accepted pay reductions so staff could remain employed. At the time of this publication, most practice owners I spoke with noted full staff rosters.
Jacob Fassman, DPM, FACFAS and Eric Gessner, DPM, FACFAS, note their Colorado Springs, Colo.-based practice experienced a nearly 75 percent reduction in patient volume during April and May of 2020, which caused a significant financial hit for the first and second quarters of the year. They continue to say that financial relief from programs like the Coronavirus Aid, Relief and Ecomonic Security (CARES) Act helped them stay afloat without having to furlough or lay off staff.
“It was an extremely stressful time for us,” recalls Dr. Fassman. “Gathering all the initial data and appropriate techniques in order to keep everyone safe and conduct necessary patient care while still paying our staff and overhead costs was extremely challenging. In addition, the unknown variables of the virus, impacts to the health of our patients, friends, family, our staff and business, were intimidating for everyone. Luckily, we were able to persevere through the most challenging of times.”
While patient volume began to rebound throughout the rest of 2020 for most practices, there is evident trepidation regarding the long-term impact of coronavirus cases that skyrocketed again in the fall of 2020.4 John Guiliana, DPM, MS, the Executive Vice-President of the Podiatry Risk Group, offers suggestions on how podiatry practices can survive during these uncertain times.
“Practices that will thrive throughout this pandemic are those that learn to adapt by doing more with less,” says Dr. Guiliana. “This necessitates being more comprehensive on each visit, which will raise the practice’s per visit revenue (PVR). Improving PVR not only allows for financial gains to fill the void but frequently results in better patient outcomes as a result of the improved comprehensiveness. It is crucial that practitioners see beyond the chief complaint of the patient and address both clinical and subclinical pathologies.”
As many practices either did look or are currently looking at the efficiency and productivity of their practices, Dr. Guiliana suggests this may also be a good time to evaluate two traditionally leading costs on a profit and loss statement for podiatric practices: staff expenses (excluding the providers) and medical supply costs. He shares that staff expenses should comprise less than 30 percent of collections and that leveraging purchasing power through entities such as DocShop Pro may help practices contain costs.
One example of supply costs that is particularly relevant to the pandemic is that of PPE. Although seemingly easier to obtain than in early 2020, PPE acquisition still remains a challenge, especially for smaller, independent practices. According to a 2020 American Medical Association (AMA) survey, the majority of physicians reported an increase in PPE costs of 57 percent.5
Another recommendation for podiatrists is to make sure their practices have enough cash flow and liquidity.
“Generally speaking, one should strive to have at least six to nine months of cash on hand in the form of credit lines, etc. Doctors should speak with their banks right now about these options,” says Dr. Guiliana.
Changes In Practice Protocols: The Podiatric Experience
Every podiatrist commenting in this article related making changes to their practices in concordance with state, local and Centers for Disease Control and Prevention (CDC) recommendations. Several also related that American Podiatric Medical Association (APMA) resources provided guidance.
Sarah Benjamin, DPM, who is in private practice in Littleton, Colo., shares that she met with her staff to collaborate on and decide how to address each relevant issue one by one based on CDC recommendations.
“It was just my office manager and I working in the office for three months,” recalls Dr. Benjamin. “It was exhausting to run an office with just the two of us but we made it, and it was a relief when I could bring my medical assistant back.”
As COVID-19 cases began to rise again in the fall of 2020, though, she expresses concern that tough staffing and practice management decisions may be yet to come.
“I have started to become a little more stressed with the second spike but at this time my office is busy and full,” says Dr. Benjamin. “Fingers are crossed that we get through this second spike without having to make heartbreaking decisions again.”
Dr. Moellmer, who practices primarily in a county hospital in California, states that her COVID-19 mitigation plan originated from her institution and changed frequently when the hospital census was full. However, she relates that protocols are now fairly consistent.
Many podiatrists relate intentionally limiting or staggering patient appointments at some point during the COVID-19 pandemic in order to accommodate social distancing, enhanced cleaning protocols and manage the volume of people in the physical office/treatment space. Commenters shared anywhere between a 30 and 75 percent reduction in patient volume, first peaking in the spring of 2020, with some relating that patient schedules are now much closer to or fully back to expected numbers as this issue went to press.
Anecdotally, however, this varies greatly based on region and geographic variance in COVID-19 case volumes with some podiatrists noting continued reductions in new patients and those seeking elective surgery. The aforementioned AMA survey supports this variation, finding that 81 percent of the 3,500 physicians queried were still experiencing fewer in-person visits in July and August of 2020 with the average revenue decrease being 32 percent.5
Waiting rooms are another significant change in most podiatry practices. Podiatrists note removing chairs, spacing chairs further apart and removing magazines or refreshment/coffee stations. Depending on the specific office environment, some clinicians even eliminated the waiting room completely by having patients wait in their cars until a treatment room is available.
Assessing The Impact Of COVID-19 On Employee And Patient Policies
Dr. Fassman notes that the staff at his practice has daily temperature checks. If any of his staff experience symptoms, Dr. Fassman says they are advised to stay home, call the office manager, see their personal physician and have COVID-19 testing if appropriate. If an employee tests positive, Dr. Fassman shares that the whole staff would have subsequent testing. Other DPMs relate similar policies with slight differences in protocols for testing and quarantine based on local guidance.
Melissa Lockwood, DPM, DABPM adds that for employees deemed close contacts of someone who tested positive for COVID-19, she requires two negative tests 48 hours apart. Additionally, she relates following federal guidelines and compensating employees for any forced quarantine. At her Bloomington, Ill.-based practice, Dr. Lockwood also has two “teams” in case of exposure so the opposite team can step in if one group needs to quarantine.
In addition to previously mentioned mitigation and prevention protocols, podiatrists universally relate a pre-visit screening process for patients. This questionnaire, including information on symptoms, recent travel and known exposure, is relatively standard in content among the podiatrists I spoke with for this article. Some have staff administer this screening in person at check-in while most have staff do this questionnaire screening over the phone prior to a patient entering the office. Masks are a universal requirement although some doctors do relate occasional patient resistance to this or improper usage.
When a patient screening reveals a concerning answer or an elevated temperature, every DPM I spoke with relates rescheduling that visit. Dr. Benjamin shares that if a patient’s temperature is over 100oF, he or she has to wait outside for five minutes before a temperature recheck prior to rescheduling. Other providers note ordering COVID-19 testing when appropriate and notifying the patient’s primary care physician.
A Closer Look At The Role Of Telemedicine And Other Technological Advances During The Pandemic
The emergence of telemedicine is one clear evolution in medical practice since the pandemic began. The aforementioned Physicians Foundation survey found that 52 percent of doctors plan to increase telemedicine services in their practices.1 However, there is concern about sustainability of telemedicine from a reimbursement standpoint. Seventy-two percent of doctors in this survey said that widespread telemedicine is unlikely to continue unless payors continue to reimburse at similar rates to in-person visits.1 The AMA survey found telehealth visits increased fivefold at the height of the first spike in COVID-19 cases and as of summer 2020, these visits still occurred three times more often than they did pre-pandemic.5
Many podiatrists quickly incorporated telemedicine into their practices since the onset of COVID-19. Those who I spoke with relate that there are significant pros and cons to this service, but that most patients and caregivers have had reasonable expectations and understand the inherent limitations. Doctors relate that telemedicine visits allow for smooth follow-ups, triage of concerns and communication with caregivers or ancillary providers such as home health nurses. While he says podiatrists can fill a patient volume void with this service, Dr. Guiliana points out that many podiatry visits are procedure-oriented, which poses a challenge with the telemedicine format.
Danielle Butto, DPM, FACFAS, agrees. “For anything that needed to be touched or seen, we did this in person,” acknowledges Dr. Butto, who is in private practice in Avon, Ct.
Telemedicine is not the only technology podiatrists adopted during the COVID-19 pandemic. Some podiatrists note that they took the time to reevaluate their electronic health record (EHR) systems, billing systems or other software they use in their practice.
Dr. Lockwood relates that her practice incorporated the Weave medical software and phone system (Weave Communications) to enhance communication with patients and even accept payments over text messaging. She also says she and her staff increased the production of emails as well as videos on YouTube aimed at patients and demonstrating practice safety procedures and telemedicine capabilities. Dr. Guiliana notes that SpeakEasy, an EHR add-on voice recognition technology, is another example of a system that doctors have investigated and adopted during this time.
Recognizing New Challenges With The Preoperative Process
Many surgeons experienced a shutdown of elective cases during the early months of the pandemic. As coronavirus cases spiked again in November 2020, many podiatrists noted anecdotally that hospitals began to limit elective surgeries again and post-anesthesia care units (PACUs) became makeshift inpatient units to accommodate growing patient censuses.
When elective cases first resumed earlier in 2020, preoperative testing protocols changed to include mandatory COVID-19 testing. While each facility may have different pathways, most outpatient centers seem to require testing within 72 hours of the case with the patient self-quarantining until surgery to preserve the validity of the results.
Dr. Gessner shares that facilities in his area require COVID-19 testing five days prior if the case involves elective surgery. Additionally, he notes if the case is to utilize general endotracheal anesthesia, OR staff wear N95 masks during intubation and extubation. Dr. Gessner says postoperative protocols remain unchanged.
Although hospitals often manage the preoperative COVID-19 testing required for inpatient cases, Dr. Butto says one must consider the time frame for testing and results when adding on a patient case last-minute.
Some DPMs share, however, that they must personally actively manage the inpatient preoperative testing to ensure timely completion of the process.
“Rapid tests are not always rapid. There is concern about false negatives as well,” points out Dr. Moellmer. “Sometimes, I have to call several times to make sure the swab is obtained and dropped in the pathology box. … My hospital asks us to plan for a 24-hour turnaround.”
Aside from testing for COVID-19, surgeons relate a change in the preoperative patient selection process in light of the pandemic.
“Before any elective surgery, I need to consider the patient,” says Patrick McEneaney, DPM, FACFAS. “If this patient has a complication and needs hospitalization or transfer to a nursing or rehabilitation facility, will he or she be at risk for COVID-19-related complications? We treat some very sick patients and must consider this accordingly.”
Does Podiatry Have A Role In Administering COVID-19 Testing?
Interestingly, there are DPMs who now administer COVID-19 testing in their practices. Dr. McEneaney saw a need for rapid testing in his community in the Chicago area that he felt his practice could fill.
“In my area, there was not an easy place to get COVID-19 testing. Our practice had the infrastructure to take on a challenge like this,” says Dr. McEneaney. “I looked at the gap in patient care and I knew we had to do something. It was not an easy process. There are certifications, processes and approvals (based on state laws) that one needs to obtain before even considering testing.”
Community members might need a negative test before returning to work, school, sports or undertaking travel plans. This is where his practice could provide some peace of mind and help those otherwise unable to obtain testing, especially without symptoms, according to Dr. McEneaney.
What Does The Future Hold?
Doctors commenting for this piece agree that many changes in practice that came with COVID-19 are here to stay, including enhanced disinfecting efforts, telemedicine, more thorough preoperative screening and elevated standards for PPE. These are tumultuous times for podiatry practices, from both patient care and practice management perspectives. It is apparent that podiatrists and other health-care providers need relief personally, financially and operationally.
Prior to the COVID-19 pandemic, physicians already faced significant challenges, including administrative burden, technical demands, economic forces and professional cultural expectations.6 This has not changed and, if anything, may be increasing. Their personal mental and physical health, along with the health and well-being of their patients and their practices, continue to be at stake.
Podiatrists share a razor-sharp focus on comprehensive care as a motivator in these difficult times.
“Treat each patient comprehensively, be flexible in HOW you treat the patient (telemedicine, temporary home visits if needed, change booking strategies to space them out, etc.), and spend the time on follow up,” says Dr. Lockwood.
A rollout of at least two different COVID-19 vaccines was taking place shortly before this issue went to print. In the interim, podiatrists and other health-care providers await further data as well as guidance on the future of their practices and their patients in light of this society-changing pandemic.
Dr. Spector is a Fellow of the American College of Foot and Ankle Surgeons, and the Immediate Past President of the American Association for Women Podiatrists. She is the Senior Editor for Podiatry Today.
Dr. Guiliana discloses that he is the Executive Vice-President of Podiatry Risk Group, which owns SpeakEasy.
1. The Physicians Foundation. 2020 survey of America’s physicians. COVID-19 impact edition. Available at: http://physiciansfoundation.org/ wp-content/uploads/2020/08/20-1278-Merritt- Hawkins-2020-Physicians-Foundation-Survey.6.pdf . Published August 2020. Accessed October 27, 2020.
2. Spector JJ. Studies note increase in amputations after arrival of COVID-19 pandemic. Podiatry Today. 2020;33(10):10-11.
3. Casciato DJ, Yancovitz S, Thompson J, et al. Diabetes-related major and minor amputation risk increased during the COVID-19 pandemic. J Am Podiatr Med Assoc. 2020. Online ahead of print. doi: 10.7547/20-224
4. Roser M, Ritchie H, Ortiz-Ospina E, Hasell J. United States: Coronavirus pandemic country profile. Our World in Data. Available at: https://ourworldindata.org/ coronavirus/country/united-states?country=~USA . Accessed December 19, 2020.
5. American Medical Association. COVID-19 Physician Practice Financial Impact Survey Results. Available at: https://www.ama-assn.org/system/files/2020-10/ covid-19-physician-practice-financial-impact-survey-results.pdf. 2020. Accessed November 15, 2020.
6. Spector JJ. Physician burnout: recognizing the warning signs and keys to prevention. Podiatry Today. 2020;33(1):22-27.
