Health system medical groups are facing a series of unique COVID-19 challenges, from adjusting staffing to handle the surge to reducing or eliminating elective procedures to confronting the financial realities the pandemic leaves in its wake.
In this interview, Claude Deschamps, MD, President and CEO of the University of Vermont Health Network Medical Group, explores his organization’s efforts to prepare for the surge and beyond, including the tough issues of redeploying staff and adjusting compensation. Deschamps also provides insight into his approach to leadership in difficult times, and how his team is beginning to assess the long-term impacts of COVID-19.
In all Kaufman Hall interviews, the expert opinions expressed are those of the interviewees and should not be considered opinions of Kaufman Hall. This interview was conducted on April 7, 2020.
Q: How did you prepare your organization for a surge in COVID-19 patients?
A: Our medical group consists of approximately 900 physicians in six hospitals and several outpatients sites across two states. The medical group is a subsidiary of the network. We are expecting our surge for COVID-19 patients in late April, early May. We have worked with hospital leadership to set up a command center in every hospital. Each command center then reports into a network coordination center, which is led by an administrator (Mr. Al Gobeille) and a physician (Dr. Howard Schapiro, MD).
Every afternoon at 4 p.m., everyone reports back on daily progress. That includes the hospital presidents, CMOs, IT, regional physician leaders, pharmacy, supply chain, medical group, communication, and even community partners that are not part of our network, including local community hospitals in both states. One individual (Dr. Cheung Wong) serves as the link between the coordination center and the medical group.
Within the medical group, we have created a deployment process for the physicians we will need for the surge. We have nine high-risk service areas that we're basing our redeployment around: the emergency room, the hospitalists, nursing homes, urgent care, pediatrics, labor and delivery, palliative care, the ICU, and a University gymnasium that is serving as an extension of the hospital.
Each deployment period will be two weeks long, though staff will receive off days during their deployments to maintain well-being. Each of the high-risk areas will first be staffed by members within their own department. When the patient volume increases, workforce decreases, or when they can no longer staff the service from within their own department, the clinical lead for each service area will use the resource pool to identify staff for their team. After the second or third wave of the surge, we’re anticipating that physicians will be deployed regardless of their specialty, under the supervision of the clinical lead within those areas.
We've stopped any elective cases in the network until mid-May. We are very challenged financially, so we have stopped the variable pay plan for all physicians in the network until the end of the financial year. We're guaranteeing base salary for two months for those who are working and reassessing after that. We are asking people not to take vacation before and around the surge, and we are also intensifying our telemedicine program.
Our productivity has decreased and so have our expenses, but our current run rate is not sustainable if we continue to do this for several months. We're certainly looking forward to the other side of that surge.
Q: What has been the response among the physicians in your medical group?
A: The physicians are remarkably engaged and committed. We have had some concerns expressed about salary. In general, I think people are afraid in the face of uncertainty and the risk of becoming sick or losing their job. There have been various reactions. "Am I going to be deployed to an area where I don’t have clinical competencies?" "What happens after two months? Will I still have a job?"
Many of our providers have expressed concerns about personal protective equipment [PPE]. People were concerned that they wouldn’t be protected adequately in the face of the COVID-19 virus.
Most physicians want to help if they can, and we’ve had many volunteers for the resource pools that are part of our redeployment efforts.
Q: How are you assuaging those concerns?
A: First off, we're listening and communicating with people, and we have aggressively acquired more supplies. We have a very good chief supply chain officer, Charles Miceli, and he's been going above and beyond, including working with suppliers in Canada and China and finding ways to be flexible.
We want there to be one consistent message to our entire network in terms of usage of PPE, which is complicated by the fact that we have some facilities in New York State. New York Governor Andrew Cuomo recently signed an executive order that allows the state to redistribute hospital supplies to facilities that they decide are most in need.
I think he's being reasonable, but it's a challenge for us because some of our New York hospitals are really challenged by PPE. Their inventory is low, and their census is high. Today, we have more patients in Plattsburgh, New York, on the ventilator with COVID-19 than we have in Burlington, Vermont.
The epidemic in New York City is starting to spill up north of Glens Falls [in upstate New York], and we think it's going to get worse. We're trying to reassure people and come up with a policy that makes sense. We can't afford to have different policies for the doctors, nurses, and the other workers. We have to have the same policy for everybody. We have also provided guidance for our pregnant and high-risk healthcare workers.
Q: Are you experiencing situations in which the entire staff wants to wear masks all day long?
A: Yes, and that's being complicated by the fact that the states where we operate have changed their position a number of times. As of last week, the state of Vermont is recommending that everyone wears a mask in public spaces. So, we've changed our policy in the hospital as well to allow more flexibility.
Q: What’s your current situation in terms of ventilator capacity?
A: First off, we have purchased additional ventilators to prepare. With regards to modeling for surge capacity, the data that is available nationally has been somewhat confusing. As a result, we have taken elements of several different models to create our own model and we are reevaluating daily. There is early indication that social distancing and other measures have made a difference to flatten the curve in Vermont.
At the moment, our model is anticipating a peak in demand in the latter part of April/beginning of May. So we started this thinking we would have 100 patients under ventilators for our hospital in Burlington, and now the models are asserting that the peak of the surge seems to be flattening a little bit. The current modeling suggests we will have enough ventilators for the peak but it is always good to overprepare, and that is what we are doing.
Right now our biggest immediate threat is not ventilator capacity. It is the mass spread of COVID-19 at a nursing home that is not part of our network, but is located not far from our academic medical center. That facility currently has more than 25 patients with COVID-19. If those patients cannot be cared for on-site, they will be sent to our medical center and decrease significantly our capacity to face the surge when it comes. We are very proactive and sending personnel and supplies to help that situation. We are also concerned about the risk of the pandemic affecting detention centers/prisons in both states, and we are working with government officials to address that proactively.
Q: How did you reduce the medical group expenses?
A: First off, we stopped all ambulatory visits and elective surgical and diagnostic procedures that were not essential or elective. Essentially, we said to our staff, "If you have no work, go home and take vacation time. If you have no work and you have no vacation time, build a negative balance up to two weeks. If you are working, we'll pay you base salary for two months." And then we find ways to make sure that people are working by enhancing our telemedicine capacity.
Q: You mentioned earlier in the interview that the current run rate isn’t sustainable. How are you approaching scenario planning in terms of physician compensation, particularly for physicians who are elective proceduralists or otherwise who really aren't busy right now?
A: We intend to start looking into those issues within the next week. We have been waiting to see how state and federal funding would impact our situation. The network is also exploring borrowing money to help us reconstruct and restart.
Q: Have you begun exploring what might happen to your volumes and your physician workforce after the surge?
A: We had a meeting of our executive planning team yesterday, and we're already thinking about our reentry after the surge. Jeff Wasserman, our medical group’s executive director, already has a plan for us to ponder regarding what we will look like in three months, six months, and a year. One of my big concerns is, how are we going to take care of our people?
In terms of our physicians, we have a very dedicated, competent and loyal group of providers. Vermont is a special place. People come in from other places because of Lake Champlain, the mountains, the academic and clinical environment, and there’s real attachment to what it means to work and live in this environment. So far, even if our turnover has increased in recent years because of burnout and other factors, we know that the rest of the country is going through the same experience.
I don’t predict people leaving en masse. I'm hopeful that our volume will come back after the surge. To get there, we will have to reassure patients that it is safe to come back to clinics and hospitals. The problem is that if patients stay home when they are sick, they’ll get sicker, and then they’ll come to the emergency room with an advanced acute condition. Appendicitis becomes peritonitis, chest pain becomes a heart attack with heart failure, abdominal pain becomes a ruptured abdominal aortic aneurysm, and so on.
So that's the risk right now. My biggest concern is the people: the doctors and other providers who have faced challenges after challenges for the last three or four years. We’re going to ask them to help us recover and we will have to be smart about this.
Q: Do you predict a financial return to your previous position?
A: I’m not sure when it will happen but I think it's going to take us several months, and it will depend on how we practice medicine and how we will be reimbursed. We must not only get back to where we were before the pandemic, but we must improve our performance.
Q: Do you expect that care models will change after the surge?
A: Absolutely. In fact, it has already started to change. It has been a big “aha” moment for many providers that they can do a lot of their work via telemedicine. My concern is whether these new payment models that have been liberalized will remain in place. We absolutely need to change our approach to care.
Q: Do you have any advice or lessons learned for other healthcare leaders that are
managing physicians in a crisis like this?
A: In my office at home, I may have 40 books on leadership, which can be very useful and give you different perspectives. But, in a crisis like this, leaders have to lead their people to the right place, by being supportive, by communicating, and by simply being there with them. There's no book for that. There's no other place I would rather be than here at this time.
That’s the big lesson. It’s about leading in battle and about being with your people—understanding, adapting, admitting mistakes, trying to understand, and being human. It’s not doing it on the back of your people. You cannot try to be a hero. The only way you will be a hero is by making difficult decisions and doing the right thing.