By JEFF KISER

The first wave of the coronavirus pandemic essentially gutted a big part of the U.S. healthcare system, like family and pediatric practices, obstetrics and gynecology clinics and internal medicine. By the end of May, almost a fifth of primary care practices had shut their doors and two in five had laid off or furloughed staff.

Florida’s primary care community shared the national pain as patients put off care through traditional office visits for fear of contracting COVID-19. But one of central Florida’s largest medical groups, Orlando Family Physicians (OFP), jumped fast on what would become one of the most significant healthcare trends in 2020 – and one that’s expected to continue strong into 2021: telehealth. In expanding its capabilities, OFP not only was able to manage more patient visits, but was one of the few provider groups in the region to accept new patients at the time.

Telehealth was boosted by a lifesaver thrown out by the Centers for Medicare and Medicaid Services, allowing for virtual visits and in-person visits to be paid at the same rate. It’s been a bonus when you consider the following trends and issues that were brought into sharp focus as a result of the pandemic crisis. The industry will be challenged to manage them and rebuild as 2021 progresses: 

1. Telehealth – a potential opportunity, but be wise to the risks

It took a pandemic for technology that previously got a lot of talk but not much adoption to finally get accepted. It’s proven to be a safe way for primary and specialty care practices, hospitals and others to consult with and remotely monitor patients. But practices and their professionals must be wary of the inherent risks, as well.

Consider:

• If this hasn’t happened already, it should be a top priority for 2021: Update risk management policies and procedures to reflect added telemedicine services. These should cover documented standards of care for telemedicine evaluated against the use of the technology by each provider. The issue is overreach and ability to maintain standard of care – the professional’s ability to distinguish an ordinary skin lesion from melanoma, and to advise when an in-person evaluation is needed.

• Cyber and billing fraud are risks too. The Department of Justice has the antenna up for escalating telemedicine claims fraud, charging 86 medical professions with submitting $4.5 billion in allegedly fraudulent claims in October. Cyber liability steps up, too, requiring extra rigor in creating technologically sound platforms, well-protected Internet connections and thorough employee training in security protocols. Healthcare continues to rely on third-party electronic medical record management and cloud-based storage, so organizations remain vulnerable to security breaches. It makes a strong case for ensuring your cyber insurance is at the right limits and that your cyber risk management efforts are adequate.

2. Pandemic may speed shift from volume to value-based payment model

One reason for the straits of many healthcare practices during the pandemic was the billing model that many have yet to move away from: volume-based payment for service. Plus, there was a lack of parity in reimbursements between virtual and traditional office visits. It put the spotlight on a long-standing deficiency of the U.S. healthcare system – the fee-for-service payment model, where quality of healthcare provided still tends to matter less than number of office visits, lab tests, surgeries, etc. (i.e., fewer patient visits equaled decreased payments).

The pandemic was a harsh lesson, but it may speed up the trend over the next five years toward the CMS reimbursement form of bundled payments, or value-based care. By whatever name, the end goal is to generate better health outcomes through a shared risk approach with set prices built around “bundles” of services like comprehensive primary care, joint replacement or oncology care. When costs come in below the target, a share of the savings is returned; when they are over, a share is paid back. Protections like stop-loss insurance help against the downside risk.

3. Mounting personnel issues pressure credentialing processes

Telemedicine’s resurgence caused a general influx of requests for telemedicine services and appointments. While CMS opened the door wider to telemedicine’s availability across state lines with the coronavirus, it didn’t allow telemedicine to be practiced independently, without proper state credentials. Meeting the continuing heightened demand for telemedicine will also continue the boom in related contracted healthcare services into 2021.

There’s a downside, though. The pressures of the times have resulted in credentialing and privileging protocols being relaxed, a risk at any time. This potentially can degrade a practice’s quality and make professional liability insurance very costly for everyone. In a pandemic crisis, though, when the pressure’s on, it can be too easy to check the license but skim over a bad pattern of claims. And under the “vicarious liability” theory of law, third party employers – clinics, private practices and hospitals – can be sued for their contractors’ negligence.

The best protection is due diligence based on best practices for credentialing and privileging. Credentialing must be done before the doctor or nurse is allowed to provide care, while privileging must be timely, so the organization’s governing body approves privileges before care is provided. The approval process should also be reviewed by counsel for updates or changes. And look for potential red flags, like unusually high loss runs in lower-risk practices, job hopping and license suspensions in higher risk specialties. Professional liability coverage is under too much pressure to risk a bad hire.

The big challenge for healthcare in 2021 will be in successfully marshaling the resilience to emerge from the other side of the pandemic whole – and better positioned than ever to balance the opportunities and risks ahead.

As Chief Sales Officer for HUB Florida, Jeff is responsible for overall leadership and results of the sales organization. In 2003, he joined SellersKuykendall, which became part of HUB International Florida in 2014.

Jeff specializes in placing Property & Casualty business, establishing new carrier relationships and growing/managing a P&C book of business.  He has served as President of Independent Insurance Agents, Volusia County; and on the board of the Orlando Chamber of Commerce, Blankner School Foundation, and Florida Citrus Sports Foundation.

He graduated with a BSBA from the University of Florida and since then, earned designations as a Certified Insurance Counselor (CIC), Chartered Property and Casualty Underwriter (CPCU) and Certified Risk Manager (CRM).