How to adapt your practice amid the coronavirus crisis

April 20, 2020

The coronavirus has created a challenging environment for all dermatology practices. Todd Petersen, CEO of VitalSkin Dermatology, discusses how to make the most of a bad situation by using telemedicine, making plans to reopen and performing a strategic review of your practice. 

Todd is the Chief Executive Officer of VitalSkin Dermatology, a world-class dermatology and aesthetics practice management firm., Mr. Petersen has over two decades of C-suite experience, including CEO, COO, CFO, and CHRO roles. He is a growth expert with a passion for new entrepreneurial challenges, revenue growth, improving operations, and building teams and partnerships.

The coronavirus has created a challenging environment for all dermatology practices. After all, most are suffering through significant patient visit declines, or have shut down altogether. The adage by Sir Winston Churchill, "Never waste a good crisis," applies to our current situation. But to come out of this crisis stronger, we’ll discuss how to make the most of a bad situation by adding telemedicine, getting prepared to reopen, and performing a strategic review of your practice. Let's create a checklist you can use to explore all aspects of your dermatology practice.

Add Telemedicine to Your Practice

Embrace telemedicine.  Many practices have already made a hard pivot toward telemedicine. Indeed, some have converted as much as 30% of their schedule to telemedicine visits. During this period of social distancing, telemedicine allows a physician to provide care for their patients and still keep the "lights on" in their practice. Since adding telemedicine will help you serve patients now, and to keep revenue flowing to the practice, we suggest this being your first priority.

In mid-March, the Department of Health and Human Services Office of Civil Rights and the Centers for Medicare and Medicaid services relaxed privacy and payment regulations to encourage telemedicine visits, now reimbursing them at the same level as office visits. Taking a longer-term view, many believe the COVID-19 pandemic will permanently transform the health care delivery system, and telemedicine will become a permanent mode of treatment. Telemedicine can also help you connect with your patients in a way that might make your practice more inviting, allowing them to feel more comfortable with you and your practice in the future-both of which are good for business.

Get Prepared to Reopen Your Practice

Focus on supply chain management. To reopen your practice, you’ll need to procure new supplies of personal protective equipment (PPE) to safeguard you, your staff and your patients. Supply procurement may be the most significant limiting factor that keeps practices from reopening. As you look to secure needed supplies, you may find your old sources are no longer sufficient, and you need to spend time finding new suppliers. You may also find the costs for PPE have dramatically increased. Larger practices have teams dedicated to supply chain management, and are currently solving this constraint. For smaller practices, we suggest getting to work on this issue early by contacting your current supplier, connecting with competing suppliers, and networking with other physicians on the topic. Checking with other physicians may help you to find new sources for PPE, as some practices have found new sources of PPE in China. 

Replenish working capital.  Your practice will need an adequate amount of working capital to restart or ramp your practice back up. If your practice is like a lot of others, you lost money during this extended slow-down, and the financial loss has depleted your working capital. Working capital is the difference between current assets and current liabilities. Current assets include assets like cash, accounts receivable, inventory and supplies. Current liabilities include accounts payable, payroll payable, short-term loans and the portion of long-term bank loan payments that need to be paid over the next year. If you are like many practice owners, you moved quickly to furlough some or all of your team members to conserve your working capital. However, this by itself will not preserve the critical assets.

As your accounts receivable are paid down from Medicare, payors and patients, you probably have been able to keep up with most of your overhead payments in the past. However, depending on your practice location, you are now 30 to 60 days into the slow-down caused by the pandemic. This means future cash flow from your accounts receivable will be minimal until your accounts receivable balances are built back up, and a normal cash cycle is reestablished. Therefore, your primary source of cash is coming to an end for a period of time. However, as your practice begins to ramp back up, it has to have the working capital from other sources to meet your short-term obligations like rent or mortgage payments, payroll, standard accounts payable, etc. 

Fortunately, there are multiple sources to obtain additional working capital. First, start with the new Coronavirus Aid, Relief, and Economic Security (CARES) Act, which provides five different sources of additional working capital for your practice. These sources are as follows:

  • Paycheck Protection Program Loans (PPP): Eligibility for this loan from the Small Business Administration is based on meeting two criteria. First, your practice must have 500 or fewer employees, and second, you must demonstrate harm from the coronavirus. The loans are based on two and a half times your average monthly salary up to $10 million. When calculating your average monthly payroll, each employee is capped at $100,000 of annualized earnings. Seventy-five percent of the loan proceeds must be used toward payroll, benefits, and payroll taxes and 25% of the loan proceeds can be used toward non-payroll expenses like mortgage interest, rent and utilities. All of the loan may be forgiven if you keep all of your employees on payroll or rehire them by June 30, 2020. If you reduce headcount during this time and do not rehire employees back by June 30, the loan forgiveness will be reduced in proportion to the reduction in headcount. As of April 10, it's estimated that 70% of eligible small businesses had already applied for this loan. If you have not applied for this loan already, we strongly recommend you go to an SBA-certified lender and make an application.

  • Emergency Economic Injury Disaster Loans (EIDL): Part of the EIDL application allows a practice to apply for an immediate emergency loan of up to $10,000 that does not need to be repaid-making it effectively a grant. The amount of the emergency loan/grant is based on the number of employees at the practice times $1,000. Like the PPP loan, eligibility for this loan from the Small Business Administration is based on meeting two criteria. First, your practice must have 500 or fewer employees, and second, you must demonstrate harm from the coronavirus. If you qualify, you can apply for a loan up to $2 million. These proceeds from this loan are designed to provide working capital for payroll, operating expenses, and debt obligations. The loans carry a low interest rate, with loans under $25,000 requiring no collateral, loans over $25,000 requiring a general security interest, and loans over $200,000 requiring a personal guarantee.  

  • Provider Relief Fund: Eligible providers started receiving grant checks on April 10 from CMS this week. The Provider Relief Fund was designed to deliver funds quickly to Medicare providers who accepted and treated Medicare FFS patients. Assume your practice received $500,000 in Medicare FFS payments in 2019. Your payment would have been calculated by taking your $500,000 amount divided by the $484 billion in Medicare payments in 2019, then multiplied times the $30 billion Provider Relief Fund. In this case, your practice's prorated share would be about $31,000. No application is required for these funds, and these funds do not need to be repaid.

  • Medicare Advance Payments: The Center for Medicare and Medicaid has expanded its Accelerated and Advance Payment Program. This program allows CMS to accelerate payments to any practice that submits a request to their Medicare Administrative Contractor and meets the program requirements. Most practices will be able to request up to 100% of their Medicare payments for the previous three month period. Repayment of the advance will begin 120 days after the advance was made. Practices will continue to receive their normal Medicare payment during the 120 days. When the 120 day period ends, the recoupment process will begin. Each Medicare claim submitted after the 120 day period will be offset until the repayment of the advance payment is fulfilled. Any practice that wants to avail themselves of this program must complete a request form. 

  • Payroll Tax: The CARES Act allows employers to defer payment of the employer's share of payroll taxes. The deferred period is from March 27, 2020, to December 31, 2020. Half of the deferred payment must be paid by December 31, 2021 and the other half must be paid by December 31, 2022. 

Second, practices can reduce or eliminate draws or payments for their partners for a reasonable period of time. Usually, these payments are a practice's most significant use of working capital, and by eliminating or reducing these payments, the practice can substantially reduce the loss of working capital.

Third, lease payments are often the next biggest expense for a practice behind owner and staff compensation and benefits. If you lease your practice location, we suggest negotiating new terms with your landlords. In this environment, landlords appreciate quality tenants with historically successful businesses. Finding new, quality tenants is difficult and risky. Approach your landlord and propose a three month rent abatement while your practice is closed in exchange to a lease extension. This can be a win-win arrangement for both of you.

Fourth, practices can make a capital call from its owners/partners. An injection of new capital from the owners'/partners' personal savings can be an immediate source of new working capital.

Fifth, successful practices can approach a commercial lender for a line of credit secured by the assets of the practice or a personal guarantee of its owners/partners.   

Evaluate the quality of your team.  This is a perfect time to evaluate the quality of your team members. We recommend you use a tool like "nine-box matrix" to help you to evaluate each one of your staff members. The bottom axis of the matrix ranks each employee's performance in three boxes; high performer, average performer, poor performer. The vertical axis of the matrix ranks each employee's potential in three boxes; high potential, average potential, and low potential. Employees in the upper right quadrant are your most valuable employees; they are high performers with high potential. The employees in the bottom left quadrant are your least valuable employees; they are low performers with low potential. When considering who to furlough or who to bring back when the business starts to pick up, this evaluation will help you prioritize your decision. 

Focus on your organization's culture. While there is no one right way to build organizational culture, the best organizational cultures are nurtured every day. This shutdown can be an opportunity to step back, and with your team determine what cultural changes you should make. In order to remain connected with team members during this period, consider setting up a private Facebook group, group text message, or similar communication medium. Perhaps you could consider hosting a regular, virtual happy hour with your staff to stay connected and have fun during these stressful times. Facilitating such communication will allow you to develop culture further and engage more. When it’s time to ramp up again, your people will appreciate the connection you kept with them, and be more likely to return and rally around you. 

Complete your annual CME. If you still need to complete your CME requirements for the year, we suggest you use this downtime to find virtual CME courses to satisfy your annual requirements, and continue to build your skills. When it comes time to ramp your practice back up, you won’t have to take the time to complete your CME. Instead, you can be laser-focused on rebuilding your practice. 

Conduct a Strategic Review of Your Practice

Revisit your mission statement, vision statement, and values. Any strategic review of your practice starts with a review of your practice's mission statement, vision statement, and values. Your mission statement should help you identify your core customer, define your business, and articulate your practice's purpose. Your vision should help define your long-term objective to help with internal decision-making. Your values should help you determine how you achieve your mission and vision. Together, a well-considered mission, vision and values statement help you select and retain like-minded team members and improve their commitment.

By way of example, VitalSkin Dermatology's mission statement is: "VitalSkin Dermatology is a world-class dermatology and aesthetics practice management organization built from the ground up to align with the clinical, financial, and lifestyle priorities of its partner physicians." The mission statement identifies our core customer, our partner physicians. It also defines our business as “ A dermatology and aesthetic practice management organization.” And it represents our purpose: “To align with the clinical, financial, and lifestyle priorities of our partner physicians.” VitalSkin Dermatology's vision statement is to support 150 partner physicians by December 31, 2030. This provides us with a simple, long-term focus to guide our internal decision making. Our values statement is: As a company and as individuals, we serve our partner physicians every day by having fun, being a team, being resilient, being accountable, being courageous and being entrepreneurial.

Revisit your strategic plan.  A strategic plan should be developed every three years and revisited and tweaked every quarter. McKinsey Consulting defines strategy as a set of integrated, hard-to-reverse decisions made ahead of time in the face of uncertainty to create and capture economic surplus. Before embarking on a strategic planning process, spend time framing your problem statement. When VitalSkin Dermatology embarked on our strategic planning process we were wrestling with the following problem statement: "The challenge at hand is to define a market penetration strategy in the dermatology and aesthetic practice management space that differentiates us from large physician-owned and private equity-owned group practices, and provides a compelling value proposition to our partner physicians."

After you develop your problem statement, start to identify all your strategic choices. To organize your big decisions, start by asking the following questions:

  • In which geographies should we compete?

  • Which services should we offer?

  • Which customers should we serve?

  • How should we compete?

  • How do we time or roll out our choices?

In Jim Collins' book, "Good to Great," he suggests that a great strategic plan answers the following three questions:

  • What can you be best in the world at?

  • What can you be passionate about?

  • What drives your economic engine?

If the answer to these three questions converge, then you have a compelling and winning strategy. He referred to a company's answer to these three questions as a company's Hedgehog. At VitalSkin Dermatology, we believe we can be best in the world at aligning with our partner physicians, we are passionate about serving our partner physicians, and the number of partner physicians we serve drives our economic engine. The answer to these three questions all converges and focuses on our partner physicians. 

Marketing Strategy.  A great marketing strategy requires you to define the market segments you are going to serve. Market segmentation requires you to divide the broader patient group into subgroups or archetypes based on shared characteristics. The best market segmentation considers the behaviors and attitudes of patients. Unfortunately, this level of insight requires sophisticated research methodologies that many practices cannot afford to conduct. As such, many practices segment their patient populations into more generic patient segments like age, gender, payor (Medicare, FFS, Medicaid, etc.), geography, etc. No practice can adequately serve every market segment, because each segment has competing needs and desires. Therefore, you must pick and understand the market segments you are going to serve.

Once you choose those market segments, you can develop a comprehensive marketing plan. Now, with your market segments defined and selected, consider revisiting how you are currently marketing your business, and where marketing other aspects of your business-or marketing via different channels-may create more value. If you haven't embraced social media, now could be a great time to refresh your profiles and plan content for the coming months. With patients most likely quarantined too, you can imagine they are getting lots of screen time, making it the prime time to step up your social game.

One word of caution: in these difficult times, it can be easy for businesses to forget just how their communities are hurting. If you sell too much, you'll likely alienate your audience-including patients who have previously been supportive of your practice. Instead, focusing on positive things your practice is doing or can do for the community is a more effective tactic.

Update your digital footprint. Your website, Google Business, and Yelp listings are great places to start, but you will likely also want to review your social media pages. Ensure that if COVID-19 impacts your services and hours, you make those updates. It's also essential patients know how to contact you if they have an emergency. Consider sending an email to your patient base or including a separate statement on your website with instructions for emergency contact. Making contact seamless as possible for your patients while closed will help you remain engaged with your patients.

Focus on building community. Use this time to focus on building community connections around your practice. With record unemployment, people notice businesses that are there for them instead of merely there for their money. Look at ways you and your team can help in your local community, and you may be surprised at the rewards your business receives in the future. Patients come to you for many reasons (such as the services you offer or your price points in comparison to other service providers). However, there are likely to be more patients who want to support businesses that are part of their local community. Not only is being there for your local community the right thing to do, but it's good business practice, too. There's no better time to rededicate your practice to being a community partner than in times of crisis like now.

Let's not waste a good crisis. Let this list be a starting point for you to reflect on what you can do today and tomorrow to ensure that you are in the best shape possible. And don't be afraid to ask for help - we‘re all in this together!

Over the next several weeks, Todd will continue to share valuable insights as to what dermatology practices can do to make the most of this unprecedented time. He invites you to register for VitalSkin’s newsletter and to visit VitalSkinDerm.com regularly for ongoing information directly relevant to dermatology practices during this unprecedented time.