In this recent CoffeeTalk, two providers share some of their key learnings from the COVID-19 crisis. Hear from Josh Marx, Managing Director & Vice President from Medical Service Company, and Shaw Rietkerk, COO from AdaptHealth, on their experiences.
- How to leverage new technology approaches
- What processes work for setting up telehealth
- How to make changes to patient care and reimbursement
If you can benefit from ways to move your business forward during COVID-19, watch this CoffeeTalk.
Transcript of the discussion
Q: What have been your biggest surprises due to COVID-19?
Shaw Rietkerk: A few things that we recognized as surprises were, one, how quickly referral sources stopped an onsite presence. It was like one day you’re there servicing the referral and then the next day, literally, it was, “You can’t come.” Obviously, we had to adjust and use technology to still accommodate the orders and the service levels, but it really was like a next day it happened.
One of the other surprises I think that we really saw as well was referral sources not adapting to technology for their own practice: like sleep centers not moving to telehealth and not moving as quickly as I thought they would have to maintain the business. And some even today, two months later, still shut down, versus actually enabling themselves to service the patients.
One other surprise to me in the industry was how poorly some of our providers in the industry reacted to some of the changes from COVID. We had relaxation in some of the policies to help service patients, and they really used that to capitalize on getting orders and marketing to patients and providers in a poor way. Unfortunately, it reflects badly on all of us as an industry. But I know that the vast majority did the right thing and continue to do the right thing through the process.
Q: Josh, what were some big surprises for you?
Josh Marx: Before I jump in, I just want to give a shout out to all our essential workers, doctors, nurses, first responders, respiratory therapist, medical equipment technicians, hospital liaisons, everybody. Thank you, you guys are definitely the heroes.
Some things that we saw that were really interesting and challenging. First, we operate in seven different states, and so similar to AdaptHealth and Shaw’s business, there are different challenges in different markets. One of the things that was interesting for us to see was each state had different policies that they rolled out. They had different proclamations, different mandates and the health departments for each governor had a different idea on how to control this.
And, so for us, as we looked at how we could maintain business continuity at Medical Service Company, it depended on the state. And it wasn’t necessarily Medical Service Company’s best practice or a desired direction at that exact moment, but we would zig and zag with each state. A couple examples, Michigan and Pennsylvania require us to check the symptoms of all of our employees before they report to work. Indiana and Ohio require us to submit our ventilator inventory to the state on a weekly basis in the event that they need it for acute care in the hospital setting.
Those are just some examples that challenged us. We joked a lot as a business continuity committee. We met every day, and we felt like in the first six or seven weeks, every day was about a week’s worth of decisions with things moving quickly and things being managed to the state degree and then to the county degree, too.
Q: As you look at it now, how many COVID-19 patients are in your organization’s care right now? Is it starting to slow down?
Josh Marx: We’ve got a significant presence in Michigan, and primarily in the Detroit region, which is where we saw a hotbed. Watching the news and reading, you see Detroit coming up for those reasons. Throughout the last eight to nine weeks, we’ve cared for upwards of a thousand COVID-confirmed patients throughout our network, and those span from over a dozen different markets. Michigan was the largest, but we saw patients in Indiana, Ohio and New York. We’re feeling it all over the place.
As far as what that curve looks like, in April, we saw it climb and we saw it climb fast. It hit us in the mouth very, very strong. Towards the end of April and fast forward to where we are today, and it’s certainly slowed down. We’re onboarding several new confirmed COVID patients every day, but it’s not the dozens per day that we were doing in April.
Our concern is as states are opening up, which understandably so business and commerce needs to carry on, there’s going to be a direct correlation to the virus spreading more once people are out more. So, it won’t be the same surge that we felt in April because there’s social distancing and other protective measures like many people wearing face coverings and things like that, but we’re very guardedly cautious to know that this isn’t behind us. And until there’s a vaccine, we’ll continue to care for these patients on a daily basis.
Q: How many patients do you still have in your care and is there that same flattening or slowing down?
Shaw Rietkerk: Right now to date, we’ve serviced just over 2,000 COVID patients at AdaptHealth, and we continue to see a fairly high trend. We did see some flattening in certain areas. But just because we have presence in so many different locations, we’ve also now seen spikes coming in other areas as the hotbeds kind of move around the country.
Being in New York, I think we got hit pretty heavy in the very beginning. New York’s one of our biggest presence as a company, and New Jersey and Pennsylvania, all of which were really the hotbeds in the beginning. We got quite the kickstart into the process.
I think as a company though, we also took a little bit different approach, and we actually started helping the hospitals manage COVID in some of the hotbed areas. So, we’re providing them or partnering with them for beds and oxygen and vents to be able to actually help them in the process of the discharge of the patient. That’s a different approach we took in the beginning just because of some of those relationships, especially in New York and New Jersey, which is definitely what has become the epicenter of all of this growth.
We do expect that we’re going to have another rise. One thing at least from this, I think now we’re much better prepared to handle it when it comes. I would say everybody has taken what we’ve learned from this and set it up for the next wave. Because, unfortunately, I’m pretty confident that we’re going to have it. Hopefully, not as bad, but I think everybody says it’s inevitable.
Q: What treatment plans do you have for those COVID-19 discharges or other COVID patients in your care? What is that process and what equipment are you utilizing the most?
Shaw Rietkerk: We’re generally saying oxygen is the main treatment that we need to do as part of this process. We did a lot of partnerships doing POCs out of the hospital to get the patients home in a quicker fashion and give us more time to get there and set up a longer-term solution if needed.
What we’re finding is a lot of times the longer-term solution isn’t needed. The oxygen levels aren’t high. And it really is a POC for the matter of three months, two months, one month. I think that’s the problem we don’t know is what the length is going to be on those. When we look, I think we’re all going to run into some issue of saying, how do we end the cycle, get the equipment back and recycle, and go through the whole process of disinfecting it and starting over? But POCs has been a more positive way I think to help discharge faster for most cases.
We’ve been lucky in the fact that we haven’t had any shortage of equipment. We’ve been able to do all modalities of oxygen for the patients, but definitely seeing POCs as the higher area and focus.
Q: Josh, how about for your team and your organization?
Josh Marx: It’s interesting when I talk to friends who are outside of the industry, and I tell them that virtually none of the patients that we take care of require a ventilator. It’s just surprising because that’s what you hear about. And there are certainly shortages of ventilators in the HME channel and also obviously in the hospital channel. But like Shaw mentioned, about nine out of 10 of our patients are on oxygen therapy.
One thing that we observed that’s very interesting is early on in late March and early April, the oxygen that was being prescribed was pretty traditional, two and three liters continuous. And then as the surge really ramped up and the hospitals started having less and less beds available, we saw the oxygen prescription change to a higher liter flow. What that tells us is patients are being discharged faster in an effort to free up more space in the ICUs for more patients because of the surge.
Through April, we saw those higher liter flows. And now fast forward to where we are today, we’re not only seeing more traditional liter flows being prescribed, but we’re also seeing more general DME being prescribed either as well or instead of, which again tells us the hospitals have more capacity to take care of that patient. Let them work through the virus and those really challenging symptoms and wean them off of oxygen therapy in some cases. Where at this point, about eight out of 10 of our patients are on oxygen. Just an interesting thing to kind of map out as we see the peaks and valleys in different markets.
Q: As you went through this, how did you decide who received that equipment? How did you go through that process of making those decisions?
Josh Marx: The first thing I’ll do is I’ll give a shout out to our logistics team and our equipment sourcing group. We scrubbed through the Rolodex to make sure that we had all of our vendors in the loop as far as what our needs were, and we didn’t have to turn away any oxygen patients, whether they were confirmed COVID or not.
I think the challenges were twofold. Number one is just because you have the inventory in one part of your enterprise, it doesn’t mean that it’s in the right part of the business to serve the market that’s in need. That was a significant challenge, and leveraging our inventory, the technology that we have and just our committed team to get equipment from point A to B at the right time is really what was important for us.
The other challenge that we all have is, even if and when you can get the equipment, it’s at a premium in price. We’re paying 30-50% more for this equipment than we were previously, and the reimbursement’s not changing. The profit logic is probably worse because, like Shaw said, this is going to be short-term oxygen — three weeks instead of three years — and it’s the same cost to pick up and deliver the equipment regardless of how long it’s out there.
We’re experiencing other headwinds that we have to work together as an industry on to thwart and to impact positively. We know competitive bidding is around the corner on January 1st. As an industry, knowing that pricing is going up on sourcing equipment because the service to do it is more expensive because of the PPE. We really need champions in Washington and throughout the nation to get competitive bidding stopped and to find a more sustainable reimbursement model. All of the groups are doing that, and I would just encourage everybody to be a part of that.
Q: How are you leveraging new technology approaches? And as you navigate patient care and reimbursement, what are you doing differently?
Shaw Rietkerk: From just the initial patient-care perspective, PAP specifically, we quickly moved to telehealth setups. It was something that we did previously, but maybe in a 20% manner and now we’re more in the 80% range of telehealth. Probably a lot of organizations will continue with this after the fact as well because we’re seeing fairly good success with compliance post-telehealth setup as well.
We implemented Zoom technology to do the actual telehealth setup and then DocuSign, which we actually integrated into Brightree or API’d into Brightree. We were actually able to get all of our documentation as well from a billing perspective, all within that one setup process.
Q: When you say telehealth, what are you actually doing for the setup? Walk us through that process.
Josh Marx: We actually drop ship most of the equipment directly from VGM to be configured for the patient. And then once the patient gets it, we set up a Zoom session and we go through the entire education and setup process with the patient through Zoom. We do have some other technology options as well that we use, but Zoom is definitely the primary one and seems to be the most successful because it’s very user friendly. It’s been good from a patient’s perspective, from a user side.
As part of that process, we also go through the entire delivery ticket documentation process for everything we need to be able to build from the patient’s perspective as part of that process. By the time we end the setup session, we’ve actually got all signed documents back, put into Brightree and ready from a delivered and signed perspective through our telehealth setups. So no sending documentation after the fact, which is what used to happen. We’d send the papers after the fact and say, “Okay, we did your setup,” and then you’re chasing to get them back.
And it’s been great with Brightree and our development team because we’ve been able to actually take that documentation from DocuSign and load it directly into BDM now. It’s automatically in a system available for our teams to use.
We also pushed very heavily on electronic orders, heavily using Parachute and GrowScripts today. And so, we really pushed into the referral sources that were maybe a little resistant to it prior to the COVID situation, and now they see the benefits of it. I mean, we broadly expanded our electronic ordering through that process and also took some alternative approaches of allowing it to fax into our electronic ordering system, and then we communicate back out to the physician through that system to help, again, drive that communication. Because when you’re not there face to face, the next best thing is that they can look at the application and say, “Okay, here’s the order process. Here’s where it’s at.” Instead of sitting there calling back and forth.
I think like most organizations, we moved to an at-home workforce. We did it in the matter of a week. We moved about 3,000 of our workers home using a desktop as a service solution and then a telecom solution that we had been working to implement for about a year and then fast-tracked the rest of it to happen. Interestingly though, I think what other organizations are probably seeing as well, we’re actually seeing better productivity. We’re seeing a lot of better service levels from call volumes and answering and responses.
The dedication of the staff didn’t change when they went to work from home. A lot of that is there’s visibility in the tool sets that we use, but you could tell there’s still that clear commitment. It’s more than a job. The team really wanted to be able to service the patients at home and be able to handle that process after go live as well or after moving home from COVID. We’ve really tried to capitalize on technology just to maintain service levels, and actually I think what we’re going to end up seeing out of it is improvement.
Q: What are some of the learnings that will be different moving forward for your business in how you treat patients, how you treat your referral sources and how you interact with both?
Josh Marx: There’s such a speed of innovation with how different platforms are being leveraged now in a work-from-home standpoint like Shaw mentioned. The big takeaway for us is we’re going to continue to take care of patients the way that we always do. We’re going to drive outcomes for our partners. We’re going to bring value. We’re going to be a difference maker. And so I think all of that is somewhat going to remain intact.
The pieces that we will carry forward most significantly that will impact our business is how we take care of our people specifically. We talk about working from home. Most of our people, they want to work from home. Like Shaw said, in large part, they’re just as productive if not more productive, and they’re wearing their fuzzy slippers, and I’m okay with that. If our people can work from home and be productive, then they should be able to do that. That’s one of those big takeaways.
With working from home and having a remote workforce requires a lot of communication. And one of the things that we’re very proud of taking on very early on was sending out daily emails to all of our staff. As soon as we sent our team home, people are wondering, “What does this mean for our job? What are our benefits going to look like? What happens with taking care of the kids? Is your 401K changing?” Daily communication with our team was very important and is very important.
We have weekly video webinars with our management team to make sure that they’re engaged. And we even held our annual meeting virtually on Microsoft Teams, a live event a couple of weeks ago with over 200 people from seven different states present. And it was one of those things that you don’t want to stop the show just because we’re in this public health emergency. You’ve got to keep powering forward and find a different way to do things. The communication was really important for us.
And then the final thing is speed. And so we’ve really embraced the saying that, “You don’t want to let perfect be the enemy of good.” And like Shaw mentioned, you get thousands of people at home; and the same thing for us, we had hundreds of people that we got home in three days. That was done by taking a fast approach and making sure that 80% of the challenges and perceived bottlenecks were buttoned up, but there was still 20% out there that we weren’t really sure would work. Are they going to have connectivity here? How are we going to do this? And you figure it out. But for the safety and the security of our people, for our patients, for our communities, taking that calculated speed-based approach was really important and something that we’re going to make sure that we continue to utilize.