Private Practice During COVID - 19 Save
An Interview with Dr. Herb Baraf and Dr. Dan Ricciardi on the state of private practice rheumatology, technology, Telehealth, Return to normal, the future and more....
Transcription
Hi everyone, I'm Jack Cush with RheumNow. I'm here with my friends, guys in practice, Dan Ricchiardi in Brooklyn, Herb Baraffin, Marilyn. Gentlemen, how are you?
Good, thank you.
Great, Very good.
Alright. So let's start off by telling us what your biggest challenge has been in the last six weeks. Herb, why don't you go first?
Well, the biggest challenge of doing telehealth after the adjustment is basically to connect because sometimes you're spending twenty five minutes on the phone trying to get them to get the video working, and you're going from platform to platform. We use doxy.me, sometimes FaceTime, Doximity, sometimes WhatsApp. That's the sometimes just the telephone and a lot of hair pulling. I had a full head of hair before this began.
You know, what you just described in about fifteen seconds really is the script of what we've been doing for the last thirty minutes trying to connect with each other in our own technology. So if we're having troubles, they're having troubles. Not to mention yesterday. Yesterday, we won't talk about our problems.
You guys say we
did this
whole thing. We did a recording
yesterday, and at the end they said, gentlemen, guess what? It didn't record. We're we're gonna come back and try it again. Take two. That was just a that was a dry run, a rehearsal.
You know? Danny, what what's your biggest challenge?
My biggest challenge is unlike most, I would say half my patients do not have access to what we have access to. And it's a big problem. These are all the people 75, you know, middle, you know, working middle class people with the heart and soul of this country. And they got a flip phone maybe, but that's about it. And, and those who have children with them will help them, but it's, you know, it's a challenge.
You know, actually, I've seen some 93 year olds just go on like that as compare and typically on a snow day here in the Northeast, I'm in Washington. When there's ice on the ground, it's the 90 year olds that come in. It's the 37 year olds stay home. Sometimes you get that same dichotomy with connecting you on telehealth.
Tell me you haven't had this happen to you. You call and say, missus Schwartz, is it okay to do a telephone visit or televideo visit? She says, sure. I'm driving. You're on the freeway, how am I gonna do a joint exam?
I mean, it's already crazy enough as it is. But I'm interested in what Danny said, and I wanna hear a little bit more about Danny, what your plan is. People who can't come in, people who don't have the technology. What's the, what, do you just have to come and see them live? What are you doing?
Well, no, we try to, we try the telephone, we try some FaceTime, some of them do have you know, iPhones. But if not, you know, if they really I think I know them well enough that I could talk to them on the phone, just plain talking on the phone, and to treat them. And if they really need to come in, then we have to make arrangements for them to come in on a half hour basis so there's no overlap. But the biggest issue that we have in New York City is that a lot these people do not drive. They take public transportation or something called accessoride.
And that's where you just sit in a bus with a whole bunch of sick people. So you don't want them doing that. And it takes six hours to get from their home to the office and back. But they only charge you the price of a subway.
And are scared. So they're afraid to go out. And, you know, this is a big boon. I think Medicare got it right. One of the few times in my forty plus year career that Medicare actually did the right thing by lowering the barriers, making it easier.
Recently they just equated telephone calls with audiovisual calls in terms of reimbursement to make it easy for patients to get access, realizing that access has been a big problem and people don't want to leave their homes.
Herb, you've been on a lot of ACR committees. Danny, you too. But especially around government affairs and whatnot. What are the things you surprised about in transition that they've done right? Reimbursement allowing for telephone video be same as a 43 telephone visit for thirty minutes is the same as a 99214, you know, in person visit.
But what else have they gotten right in this in the last few weeks?
Well, they they they dropped all the HIPAA restrictions that that hog tie us in trying in terms of trying to deal with patients and communicate. You know, we're off-site. We gotta talk to our office. Well, our offices are a bunch of people. And we're we got onto a Microsoft Teams platform to communicate with one another because you gotta coordinate labs and X-ray and the telehealth visit itself.
And HIPAA is so constraining that it really gets in the way of patient care. So by saying that and also saying they're not gonna audit these calls takes a big burden off of our shoulders because you can just document what you need to and not whether your patient is still wearing a bicycle helmet in their nineties, you know, which
And what you put down on the EMR is a lot less constrictive than what you normally would have to do. You know, there are, I mean, there's restrictions to all of this in terms of you don't know what the vital signs are. Don't, you know, and basically, you know, you've been in practice forty years, I'm thirty six years, you know, you could tell just by looking at a patient, how they're doing. So, you know, especially with lupus patients, rheumatoid, know, rheumatoid you could deal with a lot on the phone because if you're doing the right thing, they're stable and, you know, their chronic conditions. It's getting them their medicines and following up with that is, you know, I find more problematic than actually seeing them.
How many patients have you seen face to face in the last two weeks? Dan?
20. That's it. But I've restricted it. I've restricted it.
I'm not going.
20? No, no, I'm sorry, Jack. I did 20 charts. So and I left about another eleven, twelve, so about 32.
Face to face? Yeah.
Yeah. Face to face.
I haven't gone in at all. I haven't gone in since the March 24.
Mhmm.
We have one person in each of our offices. One office, we have two people.
You have
an Aultan? I'll send in the joint injections and patients who need films, but I haven't seen and I can look at their films remotely.
Herb, you're an old altercover. You you have to worry about going in. You understand?
Yeah. Yeah. Yeah. Know, I'm on I'm on the other side of what? The other side of 67?
Yeah. Well, that's we're we're both senior citizens collecting Medicare. But no, it's and the only reason why I go in, you have a group. I'm the dinosaur. I'm the last of the solo practice.
I think there's two left in Brooklyn, me and one other person. So I have to go in. But the beauty of it is I have the folks who work in my office. One girl comes in just to do all the authorizations for the, you know, for the biologics. One woman comes in just to take, just to listen to them.
So every day we have somebody there except Friday. We try to play Shabbos on Friday. So we're doing the same thing.
We've been doing one day a week where someone's in the office in our clinic, but in the future we're going to have it. We have a we have a bunch of clinics and whatnot. It's going to be where every day there's going to be someone in the office to cover an urgent visit or a joint injection or some kind of face to face service. So I don't think that we need to be back at work yet, especially while the numbers are going up. Only in New York are they coming down.
It's still not a good thing in New York, but the rest of the country, the numbers are going up. I think it's a little premature to try to go back to work. Survey today said that patients don't want to come in. Two thirds of people are wary of getting out and trying to resume activities. So there's going to come a time that could be soon, but we just don't know when that's going be.
I want to go to go ahead, Dave.
Do think going to happen? Yes, they don't want to come back because they got nice. You're talking to them on the phone. You're talking to them like this. What happens when they for straight Medicare patients, when they start getting that 20% bill?
Am I going to be charged it's a little different. About that. So on a full visit, it's going to cost them 20%, 25 Doctor, you talked to me on the phone. I didn't see you. You didn't touch me.
You think I have to pay you? Think about that one. We haven't seen that wave come yet. But I'm telling you, it's coming very soon. Herb, what do
think is going happen with that?
Well, know, the trick in practice is to collect what's owed You know, as a solo practitioner, you know that. I'd say most of the junior members of my group are not quite as aware as the older members of the group when we were a small group and dependent on cash flow, much more dependent on cash flow. You've got to collect, and patients will say that. He never touched me, and, I don't know why I owe him anything. It was a telephone call.
You know? Leave me alone. So so the the economic model works under this stressful situation, but it it may not. I I think it's gonna be slow for for patients to start coming back in even when the numbers are way down. You know, New York City, for example.
People have been traumatized, but they're not gonna wanna leave their homes unless they absolutely have to. But we have learned that it's the voice and maybe the eyeballing in this two way video thing that the patients respond to and we feel, you know, if you're following somebody who's on Fosamax, what what do you really need to do except make sure they're tolerating it, they're taking it, and and they're doing what they're supposed to do. There's nothing to examine in truth.
Mhmm.
And there's a lot of the visits that we do that way. We're just looking for safety for the meds that we give.
You're still doing Flossomax. Come on. You should be.
Let me ask you about assessing patients. Danny correctly said, we know our patients. We know, you know, who you can the subtle hints on one patient that you have to pay attention to and others that you know that they have too many hints to pay attention to and then new patients that you're going to see. And the question is, you know, how is the joint exam working? Know, I was really worried about this.
I put a video up on how to do a video joint exam. And I got to tell you, my experience over the month has been, you know, for the most part, it's pretty effective. I can see that they pretty much have nothing or not enough to get too worried about. The ones that I'm worried about have such obvious, you know, swollen PIPs and MCPs that I know I'm gonna start therapy with methotrexate or whatever. But, you know, I think that the assessment part hasn't been all that difficult.
That's been a surprise to me. What's your experience? Good to know, Hope.
Well, you know, it's funny. I was on a conference call with United Rheumatology Monday, and this question came up about disease activity measures. And Joseph Smolin and Daniel Alataha were on the line because they had done this sort of self examination study. Because apparently, it really doesn't matter whether the patient self examines for swelling and tenderness or the doctor examines. Differences are really not all that great, and it doesn't matter whether the patient is trained or not trained.
I'm more of a gestalt person, so I'm not really driven by those numbers. And, you know, it always surprises me in doing clinical trials. Guess where the patient put themselves on the visual analog scale, and I was usually pretty close to where they were in terms of how severe they were affected by their arthritis. Really based prior to examining them based on what they were telling me, how they were answering my questions.
Dan, wait a second. I just want to say a few things about the research on this point. I've heard what Smolin and Dan have said, but the research on patient self exams has been a lot of it. And actually, I looked at this, I've done this in my own practice with a measure I use called the GAS, which relies on tender joint counts, not swollen joint counts. And I've compared it to the PGAS, the patient GAS, which has the patient do their joint exam.
Patient joint exams and physician joint exams only agree to a pretty good amount, like a correlation coefficient of seven, only for tender joints, not There's for swollen total discordance there. And then the last point about patient globals and physician globals, there are a lot of patients where they really do coincide. The more severe the patient and the more comorbidities the patient, the more they don't coincide and there's a problem there. But it is what we got. Good, Dan.
No, what I'm saying, I invented the Brooklyn hack and I always
Brooklyn hack, what is that?
How you feeling today, Mo? Show me your hands. Show me the money. Get up this morning. Let me I thought I invented that.
What's that? I thought I invented.
I was in Brooklyn before you.
But I have to tell you, so, you know, before we had DASH, before we were doing it. So, and I think from our perspective, we've trained, you could look at somebody and tell them and see if they're hurting or not. And just, in five, ten questions, you could really get your own score, get your own HAC score without touching every joint. Roy Flashman is the funny one. Oh, I do this.
Do this. Roy. Come on, Roy. Who are you talking to? You know?
He's the original Brooklyn guy. So He's he's funny.
He's Brooke he's he's Bronx. Oh, he's the Brooklyn?
He's Brooklyn.
Is he Brooklyn? Yeah.
He went to downstate. He went to Columbia downstate. You win his class?
No. No. He was ahead of me.
Yeah. Okay.
Well, he was there before me. Don't know about it. He had
a Alright. So let me ask you this. In the future, you know, when all this is over, we'll get to when all this is over later. When this is all over, will you use this video and telephone interface more than what you used to use in the past, especially if you can get paid for it? What do you think, Dan?
Oh, absolutely. Why would you? You could actually close your office one day, do it from your home, okay? Hang out with your grandchildren, okay? And, you know, have a margarita at 05:00 and you're good.
You know, you don't have to travel. You don't have to deal with, you know, 9,000 different things in the office. So it has a value. I don't think it has a long term value. I mean, you know, making it your solo practice.
But yeah, it actually, for folks our age who are on the downside, it's a wonderful thing. We could stay active and not really, you know, work as hard in a sense.
Yeah. But if you're in your thirties or forties and you're on the upswing, I don't think these telephone visits are anywhere near as efficient as face to face visits.
Well, doesn't build symbiosis with the patient. You know, you have to understand something. You know, you've got to understand there's a certain touch that you develop with people a long time, just like by going like this to the patient and knowing you care for them, some empathy. And I don't know how much empathy you could get on these things.
I mean, we can do this, we've been successful at it. And Danny makes a case for doing it in the future. Herb, do you think this works from an economic model and the way practices are run?
No. No, I don't. Well, you know, we're a practice that's large, and we're sort of a one stop shop. So we have laboratory and x-ray and ultrasound and bone density testing. And, frankly, being not being in the office is a tremendous from an economic vantage point and from a thoroughness vantage point, you lose a lot.
You lose a lot. You lose revenue, but you really lose sight of what's going on with your patient. This is not a good long term plan. It I think it will be ancillary to the basic care that we give, and, hopefully, the payers will allow it under certain circumstances or a certain amount of it. But I really think being able to examine a patient if they need an injection, do it there and then, or if they need an x-ray, get it.
It's a much better way to manage these patients than to take care of them.
I totally agree. I think this is good if somebody can't make it to the office, a chronic rheumatoid that has to work, if there's something, got a problem. But you can't make it a habit because what happens is everybody gets used to the easy way. I mean, we've been doing this a long time. And that's going be a problem.
A study just came out this week about American hospitals are going to lose $50,000,000,000 a month.
Months, yeah.
A total of 200,000,000,000 between March, April, May, June, up to July 1. That's the projection and they think it's pretty spot on. That's just in hospitals. We're going to be feeling that as well, and it's going to be interesting as we The go
flip side, UnitedHealthcare just announced they're going to pay 1,500,000,000. When they're gonna pay it, they're gonna forgive that much in terms of premiums. So and, you know, their stock's doing great because they know that there's a lot of medical care that's not happening, not just the hip replacements and the knee replacements, but the sore throats and shoulder You
ever see people from the emergency room visits? Do you
realize You're laid down.
Do you realize what it costs somebody to go to the, an insurance company to go to emergency room for abdominal pain, they charge $12,000 I mean, Elise, she went there, she had an abdominal, dollars 12,000 for a CT of the abdomen and they pay. So the bill to go to the emergency room is $20 just for belly pain. So my heart bleeds for the insurance companies. I'm really they're crying with five loaves of breads on their arms.
That's also true about $20,000 the emergency room. That's a lot of money that the hospital's getting that they're losing. So, you know, there's a fair amount of fat in our system for sure, and that gets exaggerated in a situation like this.
So that in the system, I hope you're not making a comment about the No. Think
I'm back. And
f b three here.
We'll
talk to we'll talk about f b one, two, and three offline when Gipo's around. But we're doing a little bit, not just less face to face visits, we're doing other things differently. Tell me one thing that you're doing differently in your practice. Are you doing less labs, less DEXs, less infusions? Are you switching infusion?
What's the one thing that you're doing in your practice that is a sort of trim the fat sort of thing other than seeing less patients face to face?
I'm simple. I'm just doing less lab and less radiology. Gave up a few years ago, I gave up all the fancy stuff, the x rays, the bone densities, and everything else. And you remember, Jack, I sold the building. I went small.
So yeah, that's the only thing that I see. And the biggest issue is you're actually prescribing less medication to folks. And the medication side is usually you give them this, you'll give them that. You know, when we're being a little bit, I would say, I don't want say selfish, but being a little frugal in what we give. And I think there's fear because we don't know what's going to happen if we give something.
Know, I think we have some, you know, trepidations. We haven't seen the patient. So am I going to give her this or give her that? So,
you know. There's a tendency to temporize, to put off until you actually can get your hands on the patient. I think that's part of what you're describing. I'll tell you what we did, a few things. We shut down musculoskeletal ultrasound March.
It's going to gradually reopen at end of this month. We stopped doing bone density testing. We felt that was something that could be put off, and patients probably were not gonna come in for it. We we wanted to social distance for infusions, and so because there's little foot traffic in the offices, we moved Prolia to the physician side. So the physician who's in the office will do the Prolia injections, the Avinity injections, new colic as we do some, you know, allergy injections for the allergists, and kept the infusions up in the Infusion Suite but separated the chairs so that patients were at least six or eight feet apart.
So, these were these were strategic, and logistical moves. I'm not sure that they're necessarily streamlining moves, it does allow for social distancing. I think the real problem would be when you when the demand begins to grow for face to face patient visits, some of those changes that we made will need to be unwound, and, having one patient in the office, in a six doctor office at a time won't fly. Strategically, how do you increase foot traffic in the office when we're all so skittish about another wave of this coming back? That's the challenge.
What's your take on nurse practitioners picking up some of the slack on this via, telemedicine. I think they're to move. They're going to come out of the back like a horse race. And they're going to come up into the fourth or fifth position and start taking over some of our business with this?
Personally, I think that would be a great idea. I'm a big advocate for them. You know, I'm working with a bunch of groups on this and they have remained very active and maybe the need for them could go up. On the other hand, you know, if people start trimming their practices for less face to face visits, they're going to trim their staff. They're going to say, I don't need more docs.
I don't need to hire that NP or PA like I was thinking of. So I think it depends. I think the more you're big like I am at the university, I think you're gonna hire or a big practice like Herb's, I think maybe less new hires or that. But I think for people that are in by themselves, they might see this as an opportunity, just like learning about televideo to bring on a nurse practitioner and develop that as another service line. Makes sense.
On the back office functions, we found that we can manage collections, pre authorization, our call center, and our triage people all off-site with laptops. And, you know, we have we we were expanding our footprint in terms of our the amount of real estate we were renting, and now we're sort of coming around to the notion that we can do it cheaper. You know, one thought is to put it in the cheapest piece of real estate. You can put it in at the lowest rate, but there's no cheaper piece of real estate than somebody's home sitting at the kitchen table.
It's called insourcing, not outsourcing. Yeah.
There's another problem there's another problem is that as you wanna bring people back with with your staff, because most most ancillary staff in in medical offices are female, and they're managing their kids at home and helping them with schooling, and they can't get their childcare back in place. Maybe their parents are separate, and so the mother-in-law can't look after the grandkids. And we're finding now, as we wanna open up, that some of our some of our staff can't come back because they don't have that in place.
That's a big problem.
That's a big issue at our center, too. Two more questions. One, I want to know when are you going to return to at least three full days in the clinic per week? I'm not right now. I mean, I need to watch the numbers and believe for myself when it's safe, but then I have to make my patients believe it's safe.
I'm projecting early June for myself, but when are you guys thinking of going back to the office and seeing patients both full time, part time, or more than what you're doing now?
I mean, from my perspective, you know, again, I own the property. I'm surprised, Herb, you guys didn't buy old property. That's how I made my money. I bought property. But So you're all good.
See, you guys all left. But it it took No.
We did. We we did buy one office. But it you know, when you pay rent to yourself and you have a bunch of partners who are not you, they're not the recipients of the rent, they're the they pay the rent.
No. No. I know. I two I have two parts.
Not fair.
Anyway yeah. Well so but when you when you
You're you're both a a bunch of Trump wannabes. You're real estate magnets. You're supposed to be doctors.
Well, listen, I bought a building. I didn't know how to get air rights. How did I know I was going to make all that money? Do you buy a building? You don't know how to have air rights.
My wife found out. She said
she got air rights.
Thank God. We sold it to a private school a few years ago. But anyway, so I think, you know, you have to look at it. I'm going to stay one day a week until September and we'll see how it works out. I think in New York, I was in Brooklyn two days ago, was like nuclear dust had settled on Downtown Brooklyn.
And it was really scary. You went down Montague Street, which is the height of Brooklyn Heights, three or four people walking the street. So you got to play it by ear. Nobody has a crystal ball. It's what the governor says we could do.
Donald gave it all over to Andrew in my neighborhood. So and then I got, you know, I got the best mayor in the world. So you know?
We're we're not. We're I I I'm I'm not gonna go in until probably June. I'll go in one day a week, and then as as demand increases and as I get more comfortable and the numbers look better, I'll increase that. I'd like to be back full time. It's a very awkward time in a group when you're my age, and a few of us in our practice are we've been around for a long time, and we're starting to think about retirement.
How do you ease yourself out at a time like this, which eases everybody out? Right? It's very hard to figure out what to do with your life as a professional and your career as you get to this stage when there's all this uncertainty.
So let's end with a story of humanity or what you're seeing. You know, this is a different way of dealing with patients and whatnot. And I've been struck by something that Artie brought to my attention, Artie Cavanaugh. And that is that in this era of sort of strange communication and whatnot, the surprising thing is how humane the patient and our patients are nice, they love us and they treat us well. And they buy us ties and wine bottles, and then they really don't have to do that, but they're just so appreciative.
But even now it's more palpable, more and I had a patient who I had an interrupted interview and I came back, said I'm so sorry. I have a patient. I have a friend of mine who's in the hospital in New York with the COVID infection. And anyway, at the end of the visit, she said, Are you okay? Are you going to be okay?
Are you taking care of yourself? But then she also reached back at me several days later, How's your friend doing? How are you doing? You know what mean? They're really very concerned about us and I find that really amazing.
Do you have any similar stories from what you've done in the last few weeks?
Well, I think the biggest issue, you know, my practice, Jack, I've always gotten all these presents and Christmas was always, you know, they're always bringing me lunch, Parmesan sandwiches, etcetera. But I think what you said is the most important thing. They're worried about you. And my girls are telling me, I can't say that today. The women who work for me today, when they call me, oh, they want to know how you're doing, how you feeling, doc.
So I say, give me their number. I'll call them. So I call them just to say hello. Because they're concerned about me. So you give them that little extra care, and they love it.
So really, there is an interesting
There's a certain intimacy about these telehealth visits. And there is a lot of, you know, how are you doing? And, Noah, how are you doing? How's your wife? How's, you know, how's the family?
How is this affecting you? Where are you getting your groceries from? When's the last time you asked a patient how they get their groceries? So there's a lot of interchange of information that's more, let's say, social and less medical. And, you know, I think the three of us have been around long enough to have these very strong relationships with patients, caring in the full sense.
You know, my biggest complaint about health care in the last few decades is that care has become a euphemism for indifference. And you feel the care. You feel and the care goes both ways because we you know, patients and doctors
Feel the love again, Herb. It's the love you feel again, which we've lost in the past ten years. Like us again. We're not these gone ups that they all think we are, that we're portrayed as. You know?
So I really do believe.
Until you start charging for the co pay of the telephone.
It
is real. It's palpable. It's very people really care about you as a person, and you can show how you care about them. And it
really does to see that Doctor. Baraf's an old Brooklyn Dodger fan by that cap he's got on his desk. And Doctor. Ricciardi's taking care of me from his house in the Hamptons. I mean, it's a different level of intimacy.
Now you're much more of a real person, part of their family. And we've always been very family oriented in the way we take care of our patients. That's what makes rheumatology so wonderful.
You know, we are lucky in another sense. If this occurred twenty years ago, there's no there's no FaceTime. There's no Zoom. No nothing. You know, I think about Passover for the Jewish members of the group, and everyone did this by Zoom.
You know, there'd be six families all together on a on a on a laptop on the dining room table eating two by two. There is a lot of there is a lot of intimacy in this way of communicating. And we are all completely tuned in to what's happening in the world, not just here, but in Italy and in China and, you know, you name it. And so the world is a very small, intimate place, and this is a great way to connect.
Do you know that in 1969, if you guys remember, the Honok Kong flu hit America. A hundred thousand people died. I don't know if everybody's aware of that. A hundred thousand people and we had Woodstock with only two twenty million people as opposed to three forty million people today. And we didn't and it's interesting you say that, Herb, because in 1969, we just let people die.
Know, we just let it ride. You look this up, and it's so true, Jack. I know you're gonna, I'm not a Donald Trump. It's not fake news here. Okay.
It's the real thing. But it was the Hong Kong flu. One hundred thousand people died in The United States. And you know, nobody knows about it. So it's an interesting, like you said, because we, what did we know?
We had a rotary telephone back then.
And also the Mets won the world series.
And the Jets, okay. And the Knicks. Don't forget that was the
only
time in the history of New York City where you had three winners that year.
No, I just heard a trivia that, you know, with Schuler passing away this week, Schuler was the Baltimore coach that we view back in the Jets beat in that Super Bowl.
Jack and I both know Joe Namath. Joe's been here a couple of times. He's got bad knees. He's got bad arthritis. And he plays golf our friend.
He played this mini golf every day down in Jupiter.
I want to close with this. These are hard times. The uncertainty is very unnerving to a lot of people, and that's what we're dealing with. But we're leaders. I want to remind you and all of you listening that you got to stay in touch with your people.
We talked about that how you're communicating with your people, your employees, your clerks, your records people. They look to us for guidance and for leadership and let them know that they're going to be okay if they do x, y, and z. So we got to be leaders in that situation, especially amongst our staff. That's really, really important. Right.
Absolutely. Every day in every way.
All right.
Just remind me, forgot to call a patient. I got to go call them.
Right. Well, you hurry up and call them. We'll close it. Take care of yourselves, gentlemen.
All right. Thank you, Thank you, Jack. Thank you, Herb. Stay well. Enjoy.
Stay safe.
Good, thank you.
Great, Very good.
Alright. So let's start off by telling us what your biggest challenge has been in the last six weeks. Herb, why don't you go first?
Well, the biggest challenge of doing telehealth after the adjustment is basically to connect because sometimes you're spending twenty five minutes on the phone trying to get them to get the video working, and you're going from platform to platform. We use doxy.me, sometimes FaceTime, Doximity, sometimes WhatsApp. That's the sometimes just the telephone and a lot of hair pulling. I had a full head of hair before this began.
You know, what you just described in about fifteen seconds really is the script of what we've been doing for the last thirty minutes trying to connect with each other in our own technology. So if we're having troubles, they're having troubles. Not to mention yesterday. Yesterday, we won't talk about our problems.
You guys say we
did this
whole thing. We did a recording
yesterday, and at the end they said, gentlemen, guess what? It didn't record. We're we're gonna come back and try it again. Take two. That was just a that was a dry run, a rehearsal.
You know? Danny, what what's your biggest challenge?
My biggest challenge is unlike most, I would say half my patients do not have access to what we have access to. And it's a big problem. These are all the people 75, you know, middle, you know, working middle class people with the heart and soul of this country. And they got a flip phone maybe, but that's about it. And, and those who have children with them will help them, but it's, you know, it's a challenge.
You know, actually, I've seen some 93 year olds just go on like that as compare and typically on a snow day here in the Northeast, I'm in Washington. When there's ice on the ground, it's the 90 year olds that come in. It's the 37 year olds stay home. Sometimes you get that same dichotomy with connecting you on telehealth.
Tell me you haven't had this happen to you. You call and say, missus Schwartz, is it okay to do a telephone visit or televideo visit? She says, sure. I'm driving. You're on the freeway, how am I gonna do a joint exam?
I mean, it's already crazy enough as it is. But I'm interested in what Danny said, and I wanna hear a little bit more about Danny, what your plan is. People who can't come in, people who don't have the technology. What's the, what, do you just have to come and see them live? What are you doing?
Well, no, we try to, we try the telephone, we try some FaceTime, some of them do have you know, iPhones. But if not, you know, if they really I think I know them well enough that I could talk to them on the phone, just plain talking on the phone, and to treat them. And if they really need to come in, then we have to make arrangements for them to come in on a half hour basis so there's no overlap. But the biggest issue that we have in New York City is that a lot these people do not drive. They take public transportation or something called accessoride.
And that's where you just sit in a bus with a whole bunch of sick people. So you don't want them doing that. And it takes six hours to get from their home to the office and back. But they only charge you the price of a subway.
And are scared. So they're afraid to go out. And, you know, this is a big boon. I think Medicare got it right. One of the few times in my forty plus year career that Medicare actually did the right thing by lowering the barriers, making it easier.
Recently they just equated telephone calls with audiovisual calls in terms of reimbursement to make it easy for patients to get access, realizing that access has been a big problem and people don't want to leave their homes.
Herb, you've been on a lot of ACR committees. Danny, you too. But especially around government affairs and whatnot. What are the things you surprised about in transition that they've done right? Reimbursement allowing for telephone video be same as a 43 telephone visit for thirty minutes is the same as a 99214, you know, in person visit.
But what else have they gotten right in this in the last few weeks?
Well, they they they dropped all the HIPAA restrictions that that hog tie us in trying in terms of trying to deal with patients and communicate. You know, we're off-site. We gotta talk to our office. Well, our offices are a bunch of people. And we're we got onto a Microsoft Teams platform to communicate with one another because you gotta coordinate labs and X-ray and the telehealth visit itself.
And HIPAA is so constraining that it really gets in the way of patient care. So by saying that and also saying they're not gonna audit these calls takes a big burden off of our shoulders because you can just document what you need to and not whether your patient is still wearing a bicycle helmet in their nineties, you know, which
And what you put down on the EMR is a lot less constrictive than what you normally would have to do. You know, there are, I mean, there's restrictions to all of this in terms of you don't know what the vital signs are. Don't, you know, and basically, you know, you've been in practice forty years, I'm thirty six years, you know, you could tell just by looking at a patient, how they're doing. So, you know, especially with lupus patients, rheumatoid, know, rheumatoid you could deal with a lot on the phone because if you're doing the right thing, they're stable and, you know, their chronic conditions. It's getting them their medicines and following up with that is, you know, I find more problematic than actually seeing them.
How many patients have you seen face to face in the last two weeks? Dan?
20. That's it. But I've restricted it. I've restricted it.
I'm not going.
20? No, no, I'm sorry, Jack. I did 20 charts. So and I left about another eleven, twelve, so about 32.
Face to face? Yeah.
Yeah. Face to face.
I haven't gone in at all. I haven't gone in since the March 24.
Mhmm.
We have one person in each of our offices. One office, we have two people.
You have
an Aultan? I'll send in the joint injections and patients who need films, but I haven't seen and I can look at their films remotely.
Herb, you're an old altercover. You you have to worry about going in. You understand?
Yeah. Yeah. Yeah. Know, I'm on I'm on the other side of what? The other side of 67?
Yeah. Well, that's we're we're both senior citizens collecting Medicare. But no, it's and the only reason why I go in, you have a group. I'm the dinosaur. I'm the last of the solo practice.
I think there's two left in Brooklyn, me and one other person. So I have to go in. But the beauty of it is I have the folks who work in my office. One girl comes in just to do all the authorizations for the, you know, for the biologics. One woman comes in just to take, just to listen to them.
So every day we have somebody there except Friday. We try to play Shabbos on Friday. So we're doing the same thing.
We've been doing one day a week where someone's in the office in our clinic, but in the future we're going to have it. We have a we have a bunch of clinics and whatnot. It's going to be where every day there's going to be someone in the office to cover an urgent visit or a joint injection or some kind of face to face service. So I don't think that we need to be back at work yet, especially while the numbers are going up. Only in New York are they coming down.
It's still not a good thing in New York, but the rest of the country, the numbers are going up. I think it's a little premature to try to go back to work. Survey today said that patients don't want to come in. Two thirds of people are wary of getting out and trying to resume activities. So there's going to come a time that could be soon, but we just don't know when that's going be.
I want to go to go ahead, Dave.
Do think going to happen? Yes, they don't want to come back because they got nice. You're talking to them on the phone. You're talking to them like this. What happens when they for straight Medicare patients, when they start getting that 20% bill?
Am I going to be charged it's a little different. About that. So on a full visit, it's going to cost them 20%, 25 Doctor, you talked to me on the phone. I didn't see you. You didn't touch me.
You think I have to pay you? Think about that one. We haven't seen that wave come yet. But I'm telling you, it's coming very soon. Herb, what do
think is going happen with that?
Well, know, the trick in practice is to collect what's owed You know, as a solo practitioner, you know that. I'd say most of the junior members of my group are not quite as aware as the older members of the group when we were a small group and dependent on cash flow, much more dependent on cash flow. You've got to collect, and patients will say that. He never touched me, and, I don't know why I owe him anything. It was a telephone call.
You know? Leave me alone. So so the the economic model works under this stressful situation, but it it may not. I I think it's gonna be slow for for patients to start coming back in even when the numbers are way down. You know, New York City, for example.
People have been traumatized, but they're not gonna wanna leave their homes unless they absolutely have to. But we have learned that it's the voice and maybe the eyeballing in this two way video thing that the patients respond to and we feel, you know, if you're following somebody who's on Fosamax, what what do you really need to do except make sure they're tolerating it, they're taking it, and and they're doing what they're supposed to do. There's nothing to examine in truth.
Mhmm.
And there's a lot of the visits that we do that way. We're just looking for safety for the meds that we give.
You're still doing Flossomax. Come on. You should be.
Let me ask you about assessing patients. Danny correctly said, we know our patients. We know, you know, who you can the subtle hints on one patient that you have to pay attention to and others that you know that they have too many hints to pay attention to and then new patients that you're going to see. And the question is, you know, how is the joint exam working? Know, I was really worried about this.
I put a video up on how to do a video joint exam. And I got to tell you, my experience over the month has been, you know, for the most part, it's pretty effective. I can see that they pretty much have nothing or not enough to get too worried about. The ones that I'm worried about have such obvious, you know, swollen PIPs and MCPs that I know I'm gonna start therapy with methotrexate or whatever. But, you know, I think that the assessment part hasn't been all that difficult.
That's been a surprise to me. What's your experience? Good to know, Hope.
Well, you know, it's funny. I was on a conference call with United Rheumatology Monday, and this question came up about disease activity measures. And Joseph Smolin and Daniel Alataha were on the line because they had done this sort of self examination study. Because apparently, it really doesn't matter whether the patient self examines for swelling and tenderness or the doctor examines. Differences are really not all that great, and it doesn't matter whether the patient is trained or not trained.
I'm more of a gestalt person, so I'm not really driven by those numbers. And, you know, it always surprises me in doing clinical trials. Guess where the patient put themselves on the visual analog scale, and I was usually pretty close to where they were in terms of how severe they were affected by their arthritis. Really based prior to examining them based on what they were telling me, how they were answering my questions.
Dan, wait a second. I just want to say a few things about the research on this point. I've heard what Smolin and Dan have said, but the research on patient self exams has been a lot of it. And actually, I looked at this, I've done this in my own practice with a measure I use called the GAS, which relies on tender joint counts, not swollen joint counts. And I've compared it to the PGAS, the patient GAS, which has the patient do their joint exam.
Patient joint exams and physician joint exams only agree to a pretty good amount, like a correlation coefficient of seven, only for tender joints, not There's for swollen total discordance there. And then the last point about patient globals and physician globals, there are a lot of patients where they really do coincide. The more severe the patient and the more comorbidities the patient, the more they don't coincide and there's a problem there. But it is what we got. Good, Dan.
No, what I'm saying, I invented the Brooklyn hack and I always
Brooklyn hack, what is that?
How you feeling today, Mo? Show me your hands. Show me the money. Get up this morning. Let me I thought I invented that.
What's that? I thought I invented.
I was in Brooklyn before you.
But I have to tell you, so, you know, before we had DASH, before we were doing it. So, and I think from our perspective, we've trained, you could look at somebody and tell them and see if they're hurting or not. And just, in five, ten questions, you could really get your own score, get your own HAC score without touching every joint. Roy Flashman is the funny one. Oh, I do this.
Do this. Roy. Come on, Roy. Who are you talking to? You know?
He's the original Brooklyn guy. So He's he's funny.
He's Brooke he's he's Bronx. Oh, he's the Brooklyn?
He's Brooklyn.
Is he Brooklyn? Yeah.
He went to downstate. He went to Columbia downstate. You win his class?
No. No. He was ahead of me.
Yeah. Okay.
Well, he was there before me. Don't know about it. He had
a Alright. So let me ask you this. In the future, you know, when all this is over, we'll get to when all this is over later. When this is all over, will you use this video and telephone interface more than what you used to use in the past, especially if you can get paid for it? What do you think, Dan?
Oh, absolutely. Why would you? You could actually close your office one day, do it from your home, okay? Hang out with your grandchildren, okay? And, you know, have a margarita at 05:00 and you're good.
You know, you don't have to travel. You don't have to deal with, you know, 9,000 different things in the office. So it has a value. I don't think it has a long term value. I mean, you know, making it your solo practice.
But yeah, it actually, for folks our age who are on the downside, it's a wonderful thing. We could stay active and not really, you know, work as hard in a sense.
Yeah. But if you're in your thirties or forties and you're on the upswing, I don't think these telephone visits are anywhere near as efficient as face to face visits.
Well, doesn't build symbiosis with the patient. You know, you have to understand something. You know, you've got to understand there's a certain touch that you develop with people a long time, just like by going like this to the patient and knowing you care for them, some empathy. And I don't know how much empathy you could get on these things.
I mean, we can do this, we've been successful at it. And Danny makes a case for doing it in the future. Herb, do you think this works from an economic model and the way practices are run?
No. No, I don't. Well, you know, we're a practice that's large, and we're sort of a one stop shop. So we have laboratory and x-ray and ultrasound and bone density testing. And, frankly, being not being in the office is a tremendous from an economic vantage point and from a thoroughness vantage point, you lose a lot.
You lose a lot. You lose revenue, but you really lose sight of what's going on with your patient. This is not a good long term plan. It I think it will be ancillary to the basic care that we give, and, hopefully, the payers will allow it under certain circumstances or a certain amount of it. But I really think being able to examine a patient if they need an injection, do it there and then, or if they need an x-ray, get it.
It's a much better way to manage these patients than to take care of them.
I totally agree. I think this is good if somebody can't make it to the office, a chronic rheumatoid that has to work, if there's something, got a problem. But you can't make it a habit because what happens is everybody gets used to the easy way. I mean, we've been doing this a long time. And that's going be a problem.
A study just came out this week about American hospitals are going to lose $50,000,000,000 a month.
Months, yeah.
A total of 200,000,000,000 between March, April, May, June, up to July 1. That's the projection and they think it's pretty spot on. That's just in hospitals. We're going to be feeling that as well, and it's going to be interesting as we The go
flip side, UnitedHealthcare just announced they're going to pay 1,500,000,000. When they're gonna pay it, they're gonna forgive that much in terms of premiums. So and, you know, their stock's doing great because they know that there's a lot of medical care that's not happening, not just the hip replacements and the knee replacements, but the sore throats and shoulder You
ever see people from the emergency room visits? Do you
realize You're laid down.
Do you realize what it costs somebody to go to the, an insurance company to go to emergency room for abdominal pain, they charge $12,000 I mean, Elise, she went there, she had an abdominal, dollars 12,000 for a CT of the abdomen and they pay. So the bill to go to the emergency room is $20 just for belly pain. So my heart bleeds for the insurance companies. I'm really they're crying with five loaves of breads on their arms.
That's also true about $20,000 the emergency room. That's a lot of money that the hospital's getting that they're losing. So, you know, there's a fair amount of fat in our system for sure, and that gets exaggerated in a situation like this.
So that in the system, I hope you're not making a comment about the No. Think
I'm back. And
f b three here.
We'll
talk to we'll talk about f b one, two, and three offline when Gipo's around. But we're doing a little bit, not just less face to face visits, we're doing other things differently. Tell me one thing that you're doing differently in your practice. Are you doing less labs, less DEXs, less infusions? Are you switching infusion?
What's the one thing that you're doing in your practice that is a sort of trim the fat sort of thing other than seeing less patients face to face?
I'm simple. I'm just doing less lab and less radiology. Gave up a few years ago, I gave up all the fancy stuff, the x rays, the bone densities, and everything else. And you remember, Jack, I sold the building. I went small.
So yeah, that's the only thing that I see. And the biggest issue is you're actually prescribing less medication to folks. And the medication side is usually you give them this, you'll give them that. You know, when we're being a little bit, I would say, I don't want say selfish, but being a little frugal in what we give. And I think there's fear because we don't know what's going to happen if we give something.
Know, I think we have some, you know, trepidations. We haven't seen the patient. So am I going to give her this or give her that? So,
you know. There's a tendency to temporize, to put off until you actually can get your hands on the patient. I think that's part of what you're describing. I'll tell you what we did, a few things. We shut down musculoskeletal ultrasound March.
It's going to gradually reopen at end of this month. We stopped doing bone density testing. We felt that was something that could be put off, and patients probably were not gonna come in for it. We we wanted to social distance for infusions, and so because there's little foot traffic in the offices, we moved Prolia to the physician side. So the physician who's in the office will do the Prolia injections, the Avinity injections, new colic as we do some, you know, allergy injections for the allergists, and kept the infusions up in the Infusion Suite but separated the chairs so that patients were at least six or eight feet apart.
So, these were these were strategic, and logistical moves. I'm not sure that they're necessarily streamlining moves, it does allow for social distancing. I think the real problem would be when you when the demand begins to grow for face to face patient visits, some of those changes that we made will need to be unwound, and, having one patient in the office, in a six doctor office at a time won't fly. Strategically, how do you increase foot traffic in the office when we're all so skittish about another wave of this coming back? That's the challenge.
What's your take on nurse practitioners picking up some of the slack on this via, telemedicine. I think they're to move. They're going to come out of the back like a horse race. And they're going to come up into the fourth or fifth position and start taking over some of our business with this?
Personally, I think that would be a great idea. I'm a big advocate for them. You know, I'm working with a bunch of groups on this and they have remained very active and maybe the need for them could go up. On the other hand, you know, if people start trimming their practices for less face to face visits, they're going to trim their staff. They're going to say, I don't need more docs.
I don't need to hire that NP or PA like I was thinking of. So I think it depends. I think the more you're big like I am at the university, I think you're gonna hire or a big practice like Herb's, I think maybe less new hires or that. But I think for people that are in by themselves, they might see this as an opportunity, just like learning about televideo to bring on a nurse practitioner and develop that as another service line. Makes sense.
On the back office functions, we found that we can manage collections, pre authorization, our call center, and our triage people all off-site with laptops. And, you know, we have we we were expanding our footprint in terms of our the amount of real estate we were renting, and now we're sort of coming around to the notion that we can do it cheaper. You know, one thought is to put it in the cheapest piece of real estate. You can put it in at the lowest rate, but there's no cheaper piece of real estate than somebody's home sitting at the kitchen table.
It's called insourcing, not outsourcing. Yeah.
There's another problem there's another problem is that as you wanna bring people back with with your staff, because most most ancillary staff in in medical offices are female, and they're managing their kids at home and helping them with schooling, and they can't get their childcare back in place. Maybe their parents are separate, and so the mother-in-law can't look after the grandkids. And we're finding now, as we wanna open up, that some of our some of our staff can't come back because they don't have that in place.
That's a big problem.
That's a big issue at our center, too. Two more questions. One, I want to know when are you going to return to at least three full days in the clinic per week? I'm not right now. I mean, I need to watch the numbers and believe for myself when it's safe, but then I have to make my patients believe it's safe.
I'm projecting early June for myself, but when are you guys thinking of going back to the office and seeing patients both full time, part time, or more than what you're doing now?
I mean, from my perspective, you know, again, I own the property. I'm surprised, Herb, you guys didn't buy old property. That's how I made my money. I bought property. But So you're all good.
See, you guys all left. But it it took No.
We did. We we did buy one office. But it you know, when you pay rent to yourself and you have a bunch of partners who are not you, they're not the recipients of the rent, they're the they pay the rent.
No. No. I know. I two I have two parts.
Not fair.
Anyway yeah. Well so but when you when you
You're you're both a a bunch of Trump wannabes. You're real estate magnets. You're supposed to be doctors.
Well, listen, I bought a building. I didn't know how to get air rights. How did I know I was going to make all that money? Do you buy a building? You don't know how to have air rights.
My wife found out. She said
she got air rights.
Thank God. We sold it to a private school a few years ago. But anyway, so I think, you know, you have to look at it. I'm going to stay one day a week until September and we'll see how it works out. I think in New York, I was in Brooklyn two days ago, was like nuclear dust had settled on Downtown Brooklyn.
And it was really scary. You went down Montague Street, which is the height of Brooklyn Heights, three or four people walking the street. So you got to play it by ear. Nobody has a crystal ball. It's what the governor says we could do.
Donald gave it all over to Andrew in my neighborhood. So and then I got, you know, I got the best mayor in the world. So you know?
We're we're not. We're I I I'm I'm not gonna go in until probably June. I'll go in one day a week, and then as as demand increases and as I get more comfortable and the numbers look better, I'll increase that. I'd like to be back full time. It's a very awkward time in a group when you're my age, and a few of us in our practice are we've been around for a long time, and we're starting to think about retirement.
How do you ease yourself out at a time like this, which eases everybody out? Right? It's very hard to figure out what to do with your life as a professional and your career as you get to this stage when there's all this uncertainty.
So let's end with a story of humanity or what you're seeing. You know, this is a different way of dealing with patients and whatnot. And I've been struck by something that Artie brought to my attention, Artie Cavanaugh. And that is that in this era of sort of strange communication and whatnot, the surprising thing is how humane the patient and our patients are nice, they love us and they treat us well. And they buy us ties and wine bottles, and then they really don't have to do that, but they're just so appreciative.
But even now it's more palpable, more and I had a patient who I had an interrupted interview and I came back, said I'm so sorry. I have a patient. I have a friend of mine who's in the hospital in New York with the COVID infection. And anyway, at the end of the visit, she said, Are you okay? Are you going to be okay?
Are you taking care of yourself? But then she also reached back at me several days later, How's your friend doing? How are you doing? You know what mean? They're really very concerned about us and I find that really amazing.
Do you have any similar stories from what you've done in the last few weeks?
Well, I think the biggest issue, you know, my practice, Jack, I've always gotten all these presents and Christmas was always, you know, they're always bringing me lunch, Parmesan sandwiches, etcetera. But I think what you said is the most important thing. They're worried about you. And my girls are telling me, I can't say that today. The women who work for me today, when they call me, oh, they want to know how you're doing, how you feeling, doc.
So I say, give me their number. I'll call them. So I call them just to say hello. Because they're concerned about me. So you give them that little extra care, and they love it.
So really, there is an interesting
There's a certain intimacy about these telehealth visits. And there is a lot of, you know, how are you doing? And, Noah, how are you doing? How's your wife? How's, you know, how's the family?
How is this affecting you? Where are you getting your groceries from? When's the last time you asked a patient how they get their groceries? So there's a lot of interchange of information that's more, let's say, social and less medical. And, you know, I think the three of us have been around long enough to have these very strong relationships with patients, caring in the full sense.
You know, my biggest complaint about health care in the last few decades is that care has become a euphemism for indifference. And you feel the care. You feel and the care goes both ways because we you know, patients and doctors
Feel the love again, Herb. It's the love you feel again, which we've lost in the past ten years. Like us again. We're not these gone ups that they all think we are, that we're portrayed as. You know?
So I really do believe.
Until you start charging for the co pay of the telephone.
It
is real. It's palpable. It's very people really care about you as a person, and you can show how you care about them. And it
really does to see that Doctor. Baraf's an old Brooklyn Dodger fan by that cap he's got on his desk. And Doctor. Ricciardi's taking care of me from his house in the Hamptons. I mean, it's a different level of intimacy.
Now you're much more of a real person, part of their family. And we've always been very family oriented in the way we take care of our patients. That's what makes rheumatology so wonderful.
You know, we are lucky in another sense. If this occurred twenty years ago, there's no there's no FaceTime. There's no Zoom. No nothing. You know, I think about Passover for the Jewish members of the group, and everyone did this by Zoom.
You know, there'd be six families all together on a on a on a laptop on the dining room table eating two by two. There is a lot of there is a lot of intimacy in this way of communicating. And we are all completely tuned in to what's happening in the world, not just here, but in Italy and in China and, you know, you name it. And so the world is a very small, intimate place, and this is a great way to connect.
Do you know that in 1969, if you guys remember, the Honok Kong flu hit America. A hundred thousand people died. I don't know if everybody's aware of that. A hundred thousand people and we had Woodstock with only two twenty million people as opposed to three forty million people today. And we didn't and it's interesting you say that, Herb, because in 1969, we just let people die.
Know, we just let it ride. You look this up, and it's so true, Jack. I know you're gonna, I'm not a Donald Trump. It's not fake news here. Okay.
It's the real thing. But it was the Hong Kong flu. One hundred thousand people died in The United States. And you know, nobody knows about it. So it's an interesting, like you said, because we, what did we know?
We had a rotary telephone back then.
And also the Mets won the world series.
And the Jets, okay. And the Knicks. Don't forget that was the
only
time in the history of New York City where you had three winners that year.
No, I just heard a trivia that, you know, with Schuler passing away this week, Schuler was the Baltimore coach that we view back in the Jets beat in that Super Bowl.
Jack and I both know Joe Namath. Joe's been here a couple of times. He's got bad knees. He's got bad arthritis. And he plays golf our friend.
He played this mini golf every day down in Jupiter.
I want to close with this. These are hard times. The uncertainty is very unnerving to a lot of people, and that's what we're dealing with. But we're leaders. I want to remind you and all of you listening that you got to stay in touch with your people.
We talked about that how you're communicating with your people, your employees, your clerks, your records people. They look to us for guidance and for leadership and let them know that they're going to be okay if they do x, y, and z. So we got to be leaders in that situation, especially amongst our staff. That's really, really important. Right.
Absolutely. Every day in every way.
All right.
Just remind me, forgot to call a patient. I got to go call them.
Right. Well, you hurry up and call them. We'll close it. Take care of yourselves, gentlemen.
All right. Thank you, Thank you, Jack. Thank you, Herb. Stay well. Enjoy.
Stay safe.
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