COVID-19: Private Practitioners Report on Office Closures and Telepractice

As schools and businesses shut down the week of March 16 in response to social distancing and shelter-in-place directives related to COVID-19, private practitioners put the brakes on in-person treatment. To keep their services going in this uncertain time, many have embraced telepractice—a new medium for some.

State and individual payer regulations vary on telepractice coverage; check state and payer websites regularly for updated information. ASHA is continually updating webpages on telepractice and COVID-19 (also listed below in the resources section), and has also released new guidance on providing private-pay services to Medicare Part B beneficiaries.

Whether in solo practice or owner of large, interdisciplinary clinics, audiologists and speech-language pathologists are adapting their practice model to continue to serve clients–as best they can—and to keep their businesses afloat. Here’s what some of them are saying.

Susan Arnold, MS, CCC-SLP, Professional Speech Association, Coral Springs, Florida; president, American Academy of Private Practice in Speech Pathology and Audiology

Susan Arnold spent the week of March 16 cancelling a three-day conference, trying to convert her practice to telepractice, and answering questions from AAPPSPA members.

Arnold takes pride in the way private practitioners from throughout the country have stepped up to help one another. “One person will call an insurance company, sit on the phone for hours, get an answer, and send the information out on our listserve,” she says. “Everyone is sharing information, supporting each other, and joining together.”

After canceling the AAPPSPA annual conference, originally scheduled for April in Orlando, Arnold is scrambling to find ways to help members earn the CEUs they had been counting on, perhaps by moving the sessions online. She’s also trying to set up videoconferences with pertinent information—one of the scheduled conference speakers, a financial planner, is doing a free videoconference to answer questions, and she is working to secure an attorney to do the same.

Like her colleagues throughout the country, Arnold is trying to move her practice—which includes physical and occupational therapy, as well as speech-language services—to telepractice. “There’s a steep learning curve,” she says. “We’ve never done it before.” She anticipates that of the practice’s “couple of hundred” weekly speech-language clients, only her private-pay clients, and teen and adult clients, will be willing to try the new format.

“This situation is really uncharted,” she says. “No one really knows what to do.”

Erika Shakespeare, AuD, CCC-A, Audiology and Hearing Aid Associates, La Grande, Oregon

Shakespeare shared her experiences via email:

How has COVID 19 impacted my small rural private practice? How has it impacted me, as a business owner, provider, human being? It is always difficult to know where to begin when discussing a topic that has been, and still is, so very disruptive. Disruption—that is a word that has been thrown around a lot in audiology in the last couple of years. Right now, I long for the days when my biggest concern was how to address threats to my patients’ hearing health from internet sales, chain, or big box stores, and access to services for the veterans. The last several weeks have been this fluid attack to my sense of confidence and safety. I expected a top-down approach of direction and guidance on how to behave as a business owner—that did not happen. I have a responsibility to my community, my staff, my family, and myself to act. Controlling the spread of this pandemic virus requires a bottom-up approach; we do not have leaders that will show us the way. It is up to us. It is up to me to make decisions that will protect and influence those around me.

About a month ago I started planning and talking strategy with my staff and my family. It is hard to believe that only three short weeks ago I canceled my flight to Kansas City for the National EHDI conference out of concern for the safety of my community and the risk I could pose to the vulnerable population that I served. Just two weeks ago, I sent out my first memo to my patients and staff about our plans to respond to the spread. Today, our waiting room is closed, we are limiting our services to curbside “visits” and remote hearing aid programming to make sure our patients still have access to their hearing so they can stay connected to their families and news sources.

We have established protocols and processes that are updated and changed daily, based on local district health and national recommendations. New phrases like “social distancing,” “self-imposed quarantine,” and “sheltering in place” are part of our daily lexicon. This is a whole new world, and I no longer feel brave. But I will continue to stay adaptive and fluid to keep things afloat for those who depend on me for their own survival.

Courtney Wright, owner, KidPRO, Nashville, Tennessee

Perhaps, thinks Courtney Wright, the data she collects on the efficacy of telepractice treatment will be the silver lining in the coronavirus cloud.

Wright switched her practice—which provides combined speech-language and applied behavioral analysis treatment—to telepractice-only on March 18, after spending two days exploring platforms, researching insurance, and notifying families.

And although most of her families are willing to give telepractice a try, some local insurers are not covering it.

“Families don’t necessarily know what it means or what it will be like,” Wright says. “But they’re hopeful and positive we’ll figure it out together.”

But she also acknowledges that some clients may not be appropriate for telepractice—if, for example, the child needs an environment with no distractions, or a child is just learning a skill and isn’t yet ready to generalize it to home. She’s also exploring the option of using telepractice for direct parent training.

Some major insurance carriers in Wright’s area are covering telepractice, while others are not. “We’re calling those insurance companies every day,” she says, “and having parents send them emails that say, ‘Everyone else is on board with telepractice coverage, why aren’t you?’”

Wright wants to use this time to prove the efficacy of telepractice so that insurers have no reason to deny coverage. “My goal is to pull data that demonstrates this is real, this works—let’s keep doing this,” she says, “and share it with insurance companies. Because when the pandemic is over, telepractice would still be a great option for certain situations: The car breaks down, a sibling is sick so the parent can’t bring the child to an appointment, or a child is ready to ‘graduate’ from treatment and wants to practice skills in the home environment. And we could expand our range of services geographically, especially to underserved areas.”

Hallie Bulkin, MA, CCC-SLP, Little Sprout Therapy, Bethesda, Maryland

In Montgomery County, Maryland, home of Little Sprout Therapy, schools are closed for at least five weeks. Bulkin’s practice has 23 contract SLPs, mostly part-time, who provide services to about 130 clients each month in clients’ homes, schools, or daycare centers.

“The hit to the practice is significant,” says Bulkin, who is trying to convert all clinicians and clients to telepractice. But not all clinicians and clients are on board.

At least 50% of her families have refused telepractice—they think their insurance company won’t reimburse, that their child won’t cooperate, or that school will resume soon.

Bulkin, who believes the schools will be closed for much longer, will contact those families at the end of two weeks. She plans to collect telepractice success stories from her clinicians and share them with clients in hope that the stories—and parents’ recognition that their child is regressing—will convince parents to try remote services.

Some of her clinicians are also wary of telepractice. And it’s not just the older SLPs who are not comfortable, Bulkin says. Younger clinicians are concerned about clients’ behaviors and ability to pay attention. One of her SLPs who is experienced in providing telepractice to a toddler has been sharing tips.

“I’m thankful,” Bulkin says, “because my therapists are contractors, not employees, and I don’t have a facility. I’m feeling it a little bit less than others. We’ll get through this. We’ll weather the storm.”

Robyn Merkel-Walsh, MA, CCC-SLP, Ridgefield, New Jersey

In her solo practice, Robyn Merkel-Walsh specializes in oral motor treatment for feeding disorders, myofunctional disorders, tongue- and lip-tie, and myofunctional disorders. She sees about 25 clients per week.

“Now, I have zero patients per week,” Merkel-Walsh says. “My practice is very hands-on, and I’ve never done telepractice”—but she is trying to figure out a way to make it work.

She is taking online courses to get up to speed on telepractice, and hopes her clients can adjust. “In my practice, parents are always in the room and always being trained,” she says. “I demonstrate, and the parent is the assistant and engaging in therapeutic activity. I would be stealing people’s money if I just did therapy and then sent them home.”

Merkel-Walsh gives parents a personalized schedule book with notated illustrations of the exercises the client needs to practice at home—making the transition to telepractice easier. She doesn’t know if her patients will accept—or adapt to—online treatment, which she views as a maintenance program to avoid regression until normal practice resumes.

For clients who are concerned about reimbursement for telepractice or unwilling to participate in online treatment, she is offering free 15-minute video check-ins. “I don’t want to abandon my patients because they can’t pay me,” she says. “I have patients who are two weeks post-surgery and relying on me to monitor them.”

Merkel-Walsh, who rents office space, expects her income to drop to less than half. Her catastrophic business insurance does not cover the coronavirus pandemic.

“At first we thought this was short-lived , but now I don’t hear any private practitioners saying, ‘We’re going to be OK, we’re going to get through this,’” she says. “More and more, therapists are saying, ‘Will our patients be there when we get back? Will they get used to having no therapy? Will they lose their jobs and not be able to come back?’ No one thinks they’re going to get back to a full schedule. I’m going to have to restructure my future work—perhaps branch out into other areas, perhaps keep telepractice as a part of my practice. [The pandemic] is going to forever change the way we look at our practices.”

Amy Wetherill, MA, CCC-SLP, co-owner, The Pediatric Development Center, Rockville, Maryland

Wetherill and her partner, occupational therapist Tracy Wilson, have 49 employees and two locations, with 1,200 pre-pandemic clients. She wrote via email:

My staff has been amazing. We closed our office late Monday March 16) afternoon and have been working around-the-clock to learn telepractice. Therapists volunteered to be team leaders … learn one day—teach their team the next. Billing and front office have been calling insurance companies to verify telepractice benefits for all BlueCross BlueShield clients. Medicaid now pays in Maryland! Today (March 19) everyone is communicating with their families and test-driving it. Kids are saying, “Let’s do that again! When are you coming back?”

As of right now, 83 session are booked for next week—we need at least 560 hours each week to make payroll and pay expenses. Our goal is to at least break even, so nobody has to be laid off, even temporarily. We are prepared to dip into our line of credit or put money back in the business, but we are praying we do not need to. We are not expecting to make money ourselves during this time, but I just want to be able to keep my staff whole and continue to serve my community well.

The “we can do this” attitude abounds at PDC. I have been moved to tears more than once this week.

Marnie Millington, MS, CCC-SLP, co-owner, Children’s Speech and Feeding Therapy, Needham, Massachusetts

Marnie Millington and Arden Hill have never advocated so strenuously.

They began March 14 by posting an online petition calling for local insurance companies to cover telepractice services for their practice. Within 24 hours, they had more than 1,000 signatures, and are rapidly closing in on double that.

And when the Massachusetts governor subsequently directed insurance companies to reimburse telepractice for medical providers and behavioral health providers—without specifically including SLPs—Millington began to contact his office, as well as those of her U.S. senators and state representatives, to clarify if speech-language services were covered in the directive. She sent them the petition, along with information indicating other states routinely cover telepractice and noting the financial crisis SLPs are facing.

No government official—nor the local news reporter she contacted—was interested.

“What we do is so important,” Millington says. “Language is like the Massachusetts Turnpike. All of the trucks drive on it—the math truck, the reading truck, the social truck. Language is such a fundamental part of the human experience.”

But while state legislators haven’t been responsive, some insurers have been: The state’s Blue Cross Blue Shield program—which covers about 60% of her clients—agreed to cover telepractice services at the same rate as face-to-face. “That may just keep us afloat,” Millington says.

But then Harvard Pilgrim, another large local insurer, agreed several days later to cover the service—at 80% of the normal rate. Millington lodged a complaint about the lack of parity with the deputy insurance commissioner, at which point the insurer agreed to 100%.

Millington and Hill are trying to work out payment details for uninsured clients. “This is devastating to our families,” Millington says.

Millington shut the doors of her brick-and-mortar practice March 20, after a week of about 50% attendance at her clinic, whose seven SLPs usually see about 200 clients each week, many with multiple sessions.

“From an ethical and medical perspective, the only thing to do is switch to all telepractice,” she says.

“As a concept, the majority of families are excited about telepractice,” she says. “Kids are rapt by our presence in their kitchens and dining rooms, and parents are excited about being e-helpers. The capacity for generalization is greater—now you’re in their house! If we can reopen the clinic, telepractice will be a great augmentation to face-to-face service delivery.”

Millington didn’t particularly enjoy making the endless phone calls and receiving negative responses, “but I’m fighting for the families we serve and for the professional lives of seven employees, my partner, and me.”

Sue Ellen Krause, PhD, CCC-SLP, Krause Speech and Language Services, Chicago

With the shelter-in-place requirement in Illinois, Sue Ellen Krause has turned her solo practice into telepractice-only.

Krause, who specializes in child language, phonology, and fluency, said that her school-age students do very well on telepractice, because they are comfortable with her and with working on a screen. Most of her clients have echoed what a high school boy—in his first telepractice session—told her: “I’m glad to be able to have this treatment session. I’d rather see you in person, but this is OK.” Others are wholly embracing the new method, and she has seen a very small drop-off in her practice.

As a sole proprietor, Krause does everything—from scheduling to evaluations and treatment to billing—on her own. Insurance is not an issue, thanks to the Illinois governor’s mandate that insurers cover telepractice. But bringing in new clients is an issue, because she can’t complete evaluations remotely. Krause says she has a new family that was ready to come on board, “But now we need to wait until this veil is lifted, and it’s safe for someone to come to my office,” she says.

“I hope this situation won’t last very long,” she says. “I think telepractice works, but in some cases it’s not as desirable as face-to-face. But right now, I’m healthy and all of my client families are, too—and our goal is to keep it that way.”

Resources

Temporary Closure

ASHA Ethics: Client abandonment issues may arise when clinicians can’t provide services that match their established treatment plans. If you are not able to provide ongoing services try to provide as much notice about your closure as possible; give clients options, including home exercises/suggestions for activities and/or referrals to others; and document the reason for the interruption in services, including what additional options or information you provided and/or state or county regulations that may be in place (such as shelter-in-place orders).

Essential Workers

ASHA: Service Delivery Considerations in Healthcare During Coronavirus/COVID-19

Carol Polovoy is managing editor of The ASHA Leader. [email protected]

Jillian Kornak is writer/editor for The ASHA Leader. [email protected]