COVID rules of the road

By Emily Margosian, Assistant Editor, February 1, 2022

As the COVID-19 pandemic passes the two-year mark, lawmakers have begun proposing new regulations to promote public health and safety, giving shape to the next iteration of ‘the new normal.’ 

“At the end of the day, in terms of regulations, I think it’s going to be based on how things go. We’re all getting used to the idea that we may not be done with COVID any time soon because of new mutations of the virus,” said Harry Dao Jr., MD, FAAD, associate professor and chair in the department of dermatology at Loma Linda University Health, and member of the Academy’s Practice Operations Committee. 

This month, DermWorld offers a roadmap of new COVID-era practice regulations that pertain to dermatology and takes a renewed look at how physicians have adapted their practice in a post-COVID world.

Employee vaccination rules 

According to New York Times data, nearly 60% of Americans are fully vaccinated, with 70% having received at least one dose. These numbers are likely to continue to climb with the approval of COVID-19 vaccination in children five years or older, and expanding vaccine requirements for businesses and health care workers. 

In early November 2021, OSHA and CMS both released emergency rules that expanded vaccination requirements. However, both rules were halted in late 2021. “The CMS rule applies to staff at any facility that accepts payment from Medicare or Medicaid. While the term ‘facility’ refers to a specific category of health care entities that does not include individual physician offices, it would likely affect dermatologists and their staff who work for hospitals and ambulatory surgery centers,” explained Faiza Wasif, MPH, Academy associate director of practice management. Under the CMS rule, facilities are required to establish and implement a policy in which eligible staff must receive one of the three approved vaccines and complete their vaccination series (for those who choose Pfizer or Moderna). 

“The OSHA rule mandated that any business with more than 100 employees must require those employees to either be fully vaccinated for COVID-19 or tested weekly.”

According to Wasif, “The OSHA rule mandated that any business with more than 100 employees must require those employees to either be fully vaccinated for COVID-19 or tested weekly — a rule that would have affected some larger dermatology group practices. The OSHA rule would have also required employers to provide paid time off for employees to get vaccinated. Employers with more than 100 employees would need to ensure that all their unvaccinated workers wear a face mask in the workplace.”

On Nov. 12, 2021, the OSHA emergency rule for businesses was stayed by the U.S. Court of Appeals for the Fifth Circuit, delaying implementation during court review. The Biden administration appealed the stay of the OSHA rule by the Fifth Circuit, but in January, the U.S. Supreme Court blocked the OSHA rule. Medical practices must still comply with pre-existing OSHA COVID-19 workplace safety requirements as applicable to their practice type. Learn more.

The Supreme Court did, however, allow the CMS rule to go forward. Additionally, some states may have mandates regarding vaccination or testing. Dermatologists should review their state’s rules at the National Academy for State Health Policy website (use the health workers tab).

Some practices have proceeded with their own staff vaccination policies. “We did move forward this year with mandatory vaccination for staff in our clinics. If they choose not to be vaccinated, then they submit to weekly in-office testing, which we pay for,” said Amy Ross, MD, FAAD, CEO of PHDermatology, and member of the Academy’s Council on Practice Management. “We gave people plenty of notice, and it did encourage a lot of people to get vaccinated. We have a couple of people with reasons to avoid vaccination, but the bulk of our employees are, and everyone is required to wear masks in the clinic.” 

However, not all practices have had a smooth rollout of their employee vaccine policies. “The California Department of Public Health mandated that all employees at facilities with CDPH oversight either provide proof of COVID vaccination or get COVID testing weekly or biweekly if working on the outpatient or inpatient basis, respectively,” said Dr. Dao. “From a logistical standpoint, that was really challenging for the institution. How do we get enough COVID testing kits? How do we deal with employees who aren’t in compliance? It also affected how a lot of employees viewed the workplace. There were some who viewed it as grounds for early retirement or to leave the state. Fortunately, for the most part, things really calmed down when the deadlines came up and folks realized they had to pick one or the other, and most people fell in line with the new rules.” 

Access additional Academy guidance on vaccination, including information on who is eligible and how to discuss vaccination with patients.

Physician attitudes about COVID 're-entry'

In November 2021, DermWorld conducted an informal poll of an AAD workgroup regarding their thoughts on workplace re-entry. See below for results.

Telehealth

The adoption of telehealth services skyrocketed during COVID-19, allowing for continued access to care without putting patients and physicians at risk during the height of the pandemic. As a result, CMS broadened access to Medicare telemedicine services by suspending geographic and originating site restrictions, state-specific licensure requirements, and penalties for non-compliance with HIPAA rules. In response to these waivers, many states and private insurers followed suit. 

However, nearly two years since the initial declaration of the public health emergency (PHE), what is the status of telehealth compliance requirements? In October 2021, the Department of Health and Human Services (HHS) again renewed the PHE for COVID-19, extending all telehealth waivers and other flexibilities for another 90 days. The Biden administration has indicated that it intends to provide the health care community with 60 days’ notice prior to allowing the PHE to lapse. 

While the use of non-HIPAA compliant video chat platforms for telehealth services were not penalized by HHS during the PHE, “the Academy encourages members to utilize HIPAA-compliant platforms when possible,” advised Swapna Pachauri, MPH, the Academy’s manager of health technology and informatics. For more detailed information on third-party video applications permitted in the provision of telehealth services during the PHE, visit the HHS website.

Regarding the waiver of telehealth licensure requirements during COVID, “While many states waived license rules, many malpractice carriers did not. Dermatologists should first check with their carrier to make sure it is allowed, keeping in mind that some states have also stopped the waiver,” said Rachna Chaudhari, MPH, the Academy’s director of practice management. Dermatologists can determine the status of telehealth licensure waiver in their state by consulting information tracked by the Federation of State Medical Boards (FSMB).

Changes to practice management

Since the spring of 2020, dermatology practices have been forced to quickly adapt to meet the safety needs of their patients — and in some cases, the new workplace expectations of their staff. 

Patient and staff safety measures

“We’re in Florida, which reopened earlier than other states and has a different perspective on COVID than a lot of other places in the country,” said Dr. Ross. “However, when we reopened, we had plexiglass, masks, and all the other typical safety precautions that I think everyone has observed. I’ve been asked to roll back the patient mandate for masks — which I won’t do. All our patients are still required to wear masks at all times.” 

In addition to requiring that patients wear masks during visits, Dr. Ross says she has no plans to discontinue wearing her own mask when seeing patients in the future. “I think it’s something I will continue to do. We’re a pretty big group now; we have 30 doctors. I was having dinner with one of our doctors recently, and he said that he would never be comfortable seeing a patient without a mask on again. It’s just kind of a habit and feels like the new norm.” 

Dr. Dao agreed, “I think a lot of folks in our group, including myself, will probably be wearing masks for quite a while now. Before COVID, I was not used to wearing masks. With that said, I have had so many sick patients in my lifetime coughing and sneezing in my face while I’m doing skin checks. I just think it’s safer for us, our families, and our other patients, especially those who are immunosuppressed.” 

Remote work for staff 

As with many other workplaces, medical practices have begun considering the long-term viability of allowing staff to work remotely from home. “While we did allow staff to work from home for the six-week period while we were closed at the start of COVID, we asked everyone to come back once we reopened, and I will tell you, we lost employees,” said Dr. Ross. “This year, we lost our credentialing person and one of our coders because they found jobs that allowed them to work remotely. It’s just not a policy we’ve ever had, but now we are intending to implement a hybrid work model in 2022.” 

According to Dr. Dao, his institution also broadened its work-from-home horizons in this past year. “We actually used to be pretty strict about it because we couldn’t guarantee the work would get done well, but we’ve relaxed that idea quite a bit,” he said. “Folks who aren’t clinical — our biller, coder, and admin folks who didn’t necessarily need to be physically in the office — had the opportunity to work remotely. While some are being transitioned back, a lot of people are still working from home. Even one of our providers does 100% telehealth two days a week, because it worked out well with her childcare schedule. So, we’ve been able to be more flexible with our clinical and non-clinical folks.” 

Telemedicine and e-communication 

Although many dermatology practices have seen a reduction in demand for telehealth over the past year, it has nevertheless remained a permanent fixture for many practices that may not have offered the option prior to COVID. “Most patients still prefer to be seen in-person, but we do have a telehealth platform that a lot of our younger patients use. It’s great for acne follow-ups and rosacea,” said Dr. Ross. 

According to Dr. Dao, while virtual visits accounted for roughly 90% of appointments at the start of the pandemic, they’ve dwindled to about 15%. “The rest are in-person, but we’re giving patients a choice now. They don’t have to be locked into one or the other. That’s helped decrease foot traffic to some degree, as we’ve opened up more in-person slots for patients who need to come in.”

Concurrent to the rapid adoption of telehealth, however, was a rise in electronic communication between patient and physician — a change that has remained consistent and popular, according to Dr Ross. “We have seen a dramatic shift in the way we communicate with patients. Online scheduling is now a big portion of our scheduling system whereas people always used to call in. Even our older patients are much more comfortable. The use of online bill pay has increased significantly for us as well. I think with the pandemic, people just got much more comfortable paying for things online — they were using Instacart, getting things delivered because they didn’t want to leave the house — and just got in the habit. We had a patient portal prior to COVID, and usage has doubled. For us, the biggest change hasn’t necessarily been telehealth, but an increase in electronic communication with patients.” 

Sick leave policy

While COVID has had a dramatic impact on remote work policies across multiple industries, it likewise has reshaped many people’s attitudes toward coming to work sick — including those in medicine. According to Dr. Ross, her practice didn’t have a strict policy about coming to work sick prior to COVID. “I think there was the assumption that if you were sick, you wouldn’t come to work, although many doctors, myself included, were like, ‘I’ve never taken a day off!’ We didn’t enforce it before, but now, 100%, absolutely,” she said. “Our office managers know that if anyone has symptoms — cough, fever, runny rose — they are sent home. I think sick leave policy is something that we are enforcing now and definitely were not prior.”

Additional DermWorld Resources