How Practices are Managing COVID-19 Related Cash Flow Crunch

Published - Written by Ikenna Nwamba, MD

How Practices are Managing COVID-19 Related Cash Flow Crunch

In the below podcast transcription, Gentem and Anesthesiologist Dr. Brandon Claxton cover:

  • How practices are managing Covid-19 related cashflow crunch.
  • How Covid-19 related challenges are impacting physician salaries in private practice.
  • The key differences between a large and small private practice.

Succeeding in private practice is not easy but, with the right support, a rewarding path to greater autonomy awaits.

IN: [00:00:00] Hi everyone. I’m Dr Ikenna Nwamba, physician executive at Gentem Health, and we’re joined by Dr Brandon Claxton today. Thanks for spending some time with us. Before we jump into things, tell us a little bit about yourself. What motivated you to become a doctor and how did you go from Brandon Claxton to Dr. Brandon Claxton?

BC: [00:00:22] Yeah, so, um, I’m originally from Detroit, Michigan, um, spent, so some of my early childhood years living in the city limits and moved to Southfield.

I’m the oldest of three. Um, came from, come from pretty much a blue collar family. Um, my father worked in the plant at general motors and my mom. Um, I could say kind of was the one who, uh, initiated, initiated me into medicine. Uh, she was an ER nurse and a B. Her being me being her oldest child, I spent a lot of time as a youth watching her progression through nurturing school and learning medicine through her.

And then you fast forward to high school and college [00:01:00] summers spent, uh, working in ER research with a phenomenal African-American doctor who I could identify with. Uh, dr Emanuel rivers. Uh, based here, um, here at Henry Ford, he had a lot of research based in early goal directed therapy, and he was somebody I could really identify with.

I mean, he grew up in river Rouge, Michigan. He had a passion to help people. He went to Michigan and he’d go hoop, you know, and that was, you know, a passion of mine at the time. You know, I was always a push. With the academics, but, you know, playing basketball was one of my passions. So we kind of clicked on that front.

And then also, um, him just kind of ushering me into, um, the medical field. Um, and he ultimately was my, uh, was the catalyst for me getting into medical school, uh, which was paramount because I was a very, uh, subpar premed student academically. Um, when I did get to med school at everything. [00:02:00] Um, it was like a light bulb went off.

Um, uh, you know, ultimately ended up graduating probably in next in the top 10% of my class was eligible for AOA. So things worked on a long, long run. I went on to do my training at the Cleveland clinic in anesthesiology and then, uh, went directly into private practice after that, so. 

IN: [00:02:20] Great. So what led you to choose private practice over academia or any other paths 

BC: [00:02:26] yeah. So to be honest, it was a more of a desire to stay away from the academic setting and the faculty commitments that that entailed. Um, I can honestly say, I think maybe it has something to do with my medical school background. Coming from a small, historically black medical school and then transitioning to the Cleveland clinic, this world, we’re now a hospital and you know, it was a bit overwhelming.

And I think after the four years that I was there, it was my, my utmost desire to get as far away from [00:03:00] that sort of setting as possible. So, um, I didn’t pursue a fellowship because honestly, I was just fatigued and ready to start, you know, getting into the workforce and just, you know, moving the needle forward with my life.

So I felt like I received great training at the Cleveland clinic and that made me feel well prepared for private practice. I mean also, I didn’t want the responsibility to work for residents, um, who will be in their first and second years of training and working under my supervision and ultimately my medical license.

I felt like even though I had spent four years in residency, I was even myself still learning my craft while being in my early years of private practice. So it just didn’t seem like a great fit to go in academia. And me being a naturally a blue collar guy, being able to want to go and do my job and come back home and leave, work at home, leave, work at work, and be at home and keep those lives separate.

Private practices seem to fit that [00:04:00] mold and ultimately that was the better option for me.

IN: [00:04:05] Would you say that right now you’re perfectly happy with where you are in private practice?

BC: [00:04:11] Yes, I, I am. Um. I am pretty happy. I, uh, especially, um, the, you know, the private practice has different connotations depending on your specialty. So I’m in anesthesiology and, uh, in anesthesia, and a lot of anesthesiologists are signed or have contracts with private practice groups that have contracts with different instance settings, so a hospital or outpatient setting.

So right now, um. Since December, I’ve been employed by a private practice anesthesiology group that only is focused on out on the outpatient setting, which has made my life, um, from a lifestyle perspective has made it a lot more, uh, I would say flexible. Um, you know, I’m not [00:05:00] taking as much call. Um, um, uh, you know, uh, feel like I’m dealing with healthier patients on a day to day basis.

Um. And it’s just overall, just made, made things a little bit more brighter as far as just like on this end, be honest, compensation is even better as well. So I’m thinking in terms of everything has been a lifestyle upgrade in this outpatient setting that’s in private practice.

 And it sounds like your journey, um, was chosen fairly early, at least in your mind. Um. Is there any advice you would give a physician who might be choosing between two options? I’m sitting in private practice.

 Right? I would think the most important thing is to be true to the things that matter to you. I think a lot of times when we [00:06:00] are progressing through our residency training, um, as, and I wouldn’t say this is necessarily a bad practice.

But we tend to latch on to the desires of the faculty that we look up to and more so than our own desires. And I feel like there has to be a balance there. Um, you know, a lot of times when you attend an academically based, um, training program, you tend to feel this immense pressure that shouldn’t be worn.

It isn’t necessarily warranted to pursue. And an environment like that. After your training concludes, you feel pressured to pursue further specialization in principal sewer fellowship. When you otherwise wouldn’t do that. You know, I think it’s important to, you know, write down or identify what, what matters to you, what commitments do you actually could, you know, [00:07:00] could you see yourself.

In the position as a faculty, do you enjoy teaching residents? Do you enjoy research? And, um, if, if that is the case, there may be the academic setting is for you good. If it’s not, then I think private practice is a healthy alternative. And I think in terms of choosing the private practice you would like to pursue, you know, find someone in the practice that can give you some insight into that code, the practice of that culture.

Um, even though it was not an academic setting per se, it’s still medicine and it’s a team-oriented endeavor. So you want to have that collegial working environment that allows you to run ideas by your fellow physicians about different clinical scenarios should they present themselves. Also, kind of find out about the outlook of the practice.

What’s the physician turnover like? Are people happy? Are the partners looking to sale? And if soda, who, because the culture of the practice, as you may know it in that moment, may change drastically under new leadership. Find out about the partnership track. How many track, how [00:08:00] many people make partner?

Just ask lots of questions. It’s always nice when you have a former colleague, ideally from your residency program or Calla. We’re a program that can speak candidly, candidly to you about the ins and outs of the practice. Maybe they’ve been there for about two years, a year and a half or so, and can give you a healthy insight into what’s going on.

And also you’ll know if they’re. If that person is thriving in the practice and you guys trained somewhere, you assume that you guys have similar skill sets give you had the same residency training experience and that would speak to whether, Oh, I would do well if I joined his practice because I trained the same places this person is, and they’re doing well.

They, they’re, you know, they obviously were trained well enough to, you know. Be able to contribute right away and felt, um, pretty independent and strong clinically to, to be able to do well. So those kinds of things or somehow advice I would give someone who was interested in private practice. [00:09:00] Great points.

What, uh, well, as it relates to our training in medicine, we are focused solely on the clinical side. So when we step into a private practice environment that’s a little bit business oriented, that can be a little bit unsettling. Right. Have you had any experiences or can you testify to any,  events in your private practice lifestyle that maybe, um, you felt that businesses,  is it a skill set you wanted to develop?

Right. Yeah. So I can totally speak to that. Um, you know, when I’ve finished residency in the summer of 2017 join a pretty large Michigan based anesthesia group, uh, and. I want to say maybe a year and a half later, this group, our group was looking to sell and um, [00:10:00] you know, just not necessarily knowing a lot of aspects as far as, especially not being part of the leadership in a group at the time, you know, um, I’m nowhere near in position to become partner.

I haven’t been with the group long enough. And then here they are on the cusp of a lot to sell to a big corporation and I’m on the outside looking in and just not necessarily. Understanding all of the dynamics and the practice management and the business decisions that are being made. You know, you definitely can’t feel more like just a cog in a bigger wheel at the time.

And, um, even fast forward to now, I feel like I’m part of a great group now. Much smaller, um, well-established outpatient setting. You got the guys I worked with, I feel like have a great business sense. This group was started by two. Two anesthesia docs, I want to say in the early two thousands. And, um, you know, the businesses, floors continuing to do well.

Um, but me, [00:11:00] I’m the youngest guy in the group and a lot of these, you know, these guys have had some, uh, significant amount of experience with just the business side and practice management. You know, it’s a lot. It’s a lot that I don’t understand. Um, and as much as I feel like great about and confident about these guys, know what they’re doing, you know, um, business in great is in great hands.

I do also feel a little weary at times about not knowing enough about the business side of private practice as it pertains to acquiring contracts and submitting requests for proposals to different set outpatient settings where. We could potentially pick up another contract and you know, reimbursements.

It’s a lot of administrative business decisions that are, I don’t necessarily know the language, just how medicine you know, requires you to be able to speak a certain language so that you and I can sort of quote unquote talk shop about a patient. [00:12:00] It’s the same thing that I feel as we come out of residency.

We’re not well versed on these kinds of things. It kind of becomes something that you intuitively pick up or you have a vested interest in learning later, or do you don’t learn at all. And you just kind of are at the whim of those who are well versed in that, in that aspect of, uh, practicing medicine. So, you know, um, yeah.

So that, that, that’s just kind of, that’s just to answer your question. 

IN: [00:12:34] That’s a really helpful, I think that business is, as I mentioned before, not something that we cover in our core clinicals. So when you step into a new world that’s not academic and you, um, are met with new terminology, it can be, um, it can be, uh, just kind of like an adjustment, right?

[00:13:00] So. So definitely, um, in light of covert 19, um, this coven 19 pandemic and what that has done, uh, to the business side of healthcare, um, what has been your experience, um, in private practice. 

BC: [00:13:18] Right? Yeah. So, um, particularly a necessity. Now, working outpatient surgery is presented a lot of challenges, um, for my specialty, uh, for, uh, uh, I would say a reasonable amount of time approximately, you know, maybe two months or so, even up until today, we’ve had big changes, but, uh, elective surgeries were essentially brought to a standstill and, uh, it was deemed, um, you could only do surgery if it was considered essential.

Okay. Uh, so patients that will have a bad outcome, should you not intervene. Um, and a lot of discretion was taken away from the physicians and trying to interment in terms of deciding whether a certain patient should [00:14:00] have surgery or not given the risks that they could, you know, acquire Colgate 19, uh, you know, a lot of these, a lot of procedures were put on hold and that affected a lot of revenue.

You know, um, certain, some of the, you know, other healthcare personnel that work in the outpatient surgery centers, their, you know, their, their work hours were affected. I had a temporary salary reduction just because, you know, we were taking small business loans to stay a fellow, um, because it was just so much revenue lost over this time period.

Um, and, uh, you know, even, you know, you had a lot of surgeons. During this time, they haven’t been able to evaluate patients that they would do surgery. And you know, some, some, you know, some preop workup that involved evaluations by surgeons are either done through telehealth or they’re not feasible at all.

Not all surgeons. And so you feel comfortable operating on a patient operating on a patient without physically seeing them, the patient or [00:15:00] off office also, I can, I, I foresee. I’m coming down the pipeline. A large shift in patient volumes to the outpatient setting. Um, Colby 19 has kind of cast this dark cloud over the hospital environment, steer patients away from seeking care within the confines of the hospitals, simply just fearful that they can contract the virus from there.

So even in the last few weeks, as electrosurgery has kind of brought being brought to this stance, Hill stand still was starting to pick back up as of late in the outpatient surgery centers. And we’re seeing patients that may have previously been scheduled to have surgery in a hospital. They may be, we’re going to have a knee replacement or hip replacement, not are they going to do it in the hospital?

And now they’re like, no, I’m going to go to the outpatient surgery center. It just seems safer. Um, you know, we were also at one point preserving our PPE. We were. There was rumblings of possibly using a surgery center as a, uh, I want to say overflow, you know, given if the hospitals were [00:16:00] overrun with coronavirus patients, you know, they, and they need to be managed.

Anesthesia machines might be converted into ventilators. I mean, these were, this was at the height, the peak, April, you know, Mar, uh, mid marks, late, late March, early April when things were extremely bleak. Um, we don’t allow visitors to come back to. Back with patients that are rooms, they have to come back by themselves.

Um, so these patients usually get instructions after surgery, usually nice to have a loved one there at bedside who hasn’t just had anesthesia space to get discharge instructions. Um, so it’s been a number of, I can go on and on disinfection. Oh, you know, we tackling, we’re having a tackle on his backlog of cases and trying to decide which surgical cases are more urgent to others.

I mean, it’s just been a myriad of issues that we’ve had to confront and continue to have to confront, you know, protecting our, [00:17:00] um, you know, our anesthesia staff when we’re intubating and things like that where we can, are most at risk. Yeah, way of contracting the virus, trying to decrease the risk that a patient will call for blood during placement, but, and no tracheal tube or any other kind of airway device.

So just so many different things that you know, come or come across our table that we’ve had to deal with. But I think we’re managing today. Governor would basically say even non-essential procedures can be done so. Cosmetic surgery was a less, I want to say specialty that had been on hold and now they’re going to be allowed to operate now going forward.

So I think we’re going to be pretty busy through the third or fourth quarter of the year for sure. Definitely. 

IN: [00:17:50] It sounds like there were a lot of changes that affected operations, affected your workflows.  and I’m just curious, were there. [00:18:00] Um, were they conversations around the business side and how that business side was impacted in terms of dollars and cents? Or were you shielded from that more so, and you just kinda, um, you trusted those who had bit more seniority and experience?

BC: [00:18:17] Um, so I, uh, you know, it wasn’t necessarily privy to the conversation that led up to the decision to apply for. I want to say like a small biz, I forget, maybe it was a business grant or there was a lot of, there was, there were, um, I think a lot of money or grant money allocated under the cares act to, um, ambulatory surgery centers to help keep them afloat.

And the partners on a group had, you know, they, they alerted us at the time, Hey, will you apply for this grant money? But in the meantime, you know, we gotta decrease your biweekly pay. For the, for the foreseeable future, but the thought is [00:19:00] we’re going to shore up everybody in a third and fourth quarter quarter because we think we’ll be pretty busy.

And, um, you know, basically we appreciate you guys toughing it out. And that was pretty much the extent of the information we were privy, privy to as far as that was concerned. Um, you know, granted there was probably, yeah, there were likely some more detailed conversations going on. Um. You know, amongst the partners of the group, you know, uh, but that was, that was about the most that I, I was told, uh, perfectly fine, you know.

IN: [00:19:37] It was a whirlwind for a lot of practices. Absolutely. Um, so, um, it’s actually, um, reassuring to see how. Resilient. Those private practices worked during that tough time, especially seeing that you guys are ramping back up and how you guys were able to kind of tighten down the hatches, [00:20:00] um, and retain the sort of morale within the group.

Uh, despite that, down that downturn. Um, if there was anything you could change to improve private practice in light of. Everything that’s transpired over the last year, what would it be?

BC: [00:20:18] Or one of the, one of the snags, I feel like, uh, so speaking back to that conversation about what was told about salary reduction and how we’ll try to, um, sure up everybody’s income and the third and fourth quarter, it was predicated based on.

Uh, once we get back going, you know, it takes some time, uh, after two, after you submit paperwork and documentation to get reimbursement, that it will take some time to get that reimbursed some money. I think the discussion was it takes, it’s going to take about three to four weeks. So the thought is [00:21:00] once we get back to work, they were just telling us, Hey, don’t expect.

That’s your salary is going to go back to exactly what it was right away. We have to wait on the reimbursement, and I feel like, uh, that a lot of the administrative burden of navigating a private practice, um, needs to improve. Um, you know, uh, re I, I, I was, we’re doing a lot of reading that reimbursement rates can be lower for private practice, um, compared to larger groups.

And, uh. Private practice groups can be kind of pushed out from narrow, pretty narrow physician networks. Um, and um, you know, a lot of private practice groups are being swallowed up by larger corporations. And ultimately what happens is it dilutes the patient care when you have, um, a hundred and something.

I mean, the group that I left that I initially joined was a hundred and something anesthesiologists. And why [00:22:00] the quality of care was not consistent from physician to physician. And, uh, I think you ultimately get away from having a certain standard of care that appeals to, um, the hospital. And I feel like, I feel like if, if the private practice sector was given a better, I don’t want to say, not give, given a better.

Um, hand dealt a better hand of cards from the get go in terms of being able to compete, compete with larger corporations in terms of being able to navigate all the administrative bureaucracy, the red tape and everything that comes along with just practice management. I think they wouldn’t necessarily have to succumb to the pressures of joining a larger corporations who promised to basically take care of all of that for you.

Uh, they would be able to just kind of stand on their own. Two feet. And so [00:23:00] that is an area where I feel like if that there was some improvement there, then you can have a more of a focus on delivering high quality, efficient patient care. 

IN: [00:23:13] Well said. Well said. Um, and. There’s nothing more that I can add to that. Uh, it’s something I totally agree with. 

BC: [00:23:23] Right? I figured it’s got a right segue. Right? So, so what, you know, what you are really pushing, you know, in terms of just trying to improve that aspect for private practice. You know, and it totally, when I, when I, when the, um, one of the partners mentioned that to me, I immediately thought of you, I’m like, this is what.

They’re trying to get rid of, you know, trying to help. This is where you guys are trying to step in and provide some relief and provide a better, more efficient, um, Avenue for a [00:24:00] physicians to get reimbursed, you know? 

IN: [00:24:02] Yeah. Really support. Right. Right. Um, and partner and, um, you know, kind of, um. Take that burden off the shoulders of the physician so that they can have a peace of mind.

Um. And recognize that they’re going to earn what they deserve, um, without the, uh, the headache that can arise when you’re, you’re navigating that at the administrative trenches because that’s, that’s, that’s it’s own body of work in of itself outside of the clinical. Um, responsibilities that you might have.

So definitely, um, thank you for validating that and sort of bringing it into the context of the story. So that’s, um, listeners can appreciate the relevance. 

Um, if, uh, you know, if that. [00:25:00] If that covers everything that you know, those are all our questions for today. I want to give you an opportunity to share anything else that you might have on your mind.

Anything you want to get off your chest. Um, you know, this is your floor to, to your stage, to really share that message. 

BC: [00:25:18] Oh my, uh, my message right now, which is probably what everybody’s dealing with, is just a lot of uncertainty. In terms of like, how to just go about your day to day, um, and how to process all this information and everything.

And it’s data that’s out there. And I, I, um, I really feel like, uh, we as a people, um, should be given more of a, uh, I don’t wanna say a assurances. And just competence that, you know, we can make the best choices for ourselves. Um, [00:26:00] that and that, that isn’t, uh, it isn’t necessarily a strike towards, you know, not social distancing or, um, that what we hear in media outlets isn’t true or accurate.

Um, it definitely means respecting all of those things that are out there to protect us, but also not living in fear. Um, you know, and, and, and I want people to think that things will improve. Um, we’ll continue to keep living our loved ones and still continue to be here. Um, you know, and we’ll be safe about, about things as, as the country starts to reopen.

You know, I have a lot of friends and relatives and, you know, just different, different people around me that. You know, everybody has their concerns, you know, and everybody’s thinking about not only themselves, but someone else. And, um, you know, I, I just, I, I, my thing is, you know, fear, just living in a state of fear is just, [00:27:00] is not an option.

Um, you know, we have to just kind of continue to live and, and do the best we can. And, and, um. You know, turn them, turn a news channel off every now and then and you know, and trust your instincts and take responsibility for your lives. Don’t leave it into the hands of, you know, in hearing it from a physician, don’t leave it in the hands of physicians and politicians.

IN: [00:27:29] Search and seek out the truth and find truth on your own accord and live within those. Absolutely. Parameters. So, yeah, I totally agree with that. Um, well, you know, thank you for your message. Thank you for your time. Really appreciate you coming on to the podcast and, and dropping some gems, you know, for the audience is great, man.

BC: [00:27:53] Thanks for having me. I haven’t ever done anything like this, but I think it was a very thoughtful [00:28:00] conversation and giving me something to reflect on as well, you know, so, no, I appreciate the opportunity.

IN: [00:28:07] All right, for sure. We’re signing off. Thanks again, Dr. Claxton. Have a good night. 

Gentem Heath is a physician-led company that transforms the medical reimbursement experience for independent practices. They're led by Physician Executive and Physician Innovation Network member Dr. Ikenna Nwamba