‘We prepare and display our best skill sets, when we have faceless enemies’
India as a country, had battled various contagious virus spreads. From Swine Flu, to Dengue to Nipaa Virus, we had overcome many major crisis, without being paralyzed on our day to day routine, or business. And most of the past contagions were mostly regional and geographic attacks, the country was never crippled or paralyzed with these incidents.
Unlike past, this Pandemic, due to COVID CORONA is one of its kind, which has gripped the entire world, and poising threat of annihilation of large population across the globe.
In literal meaning, CORONA is light or a glow around sun. But in our profession of giving light, it has spread darkness and insecurity to large number of eye care practices in the country.
Ophthalmology is blessed as a White Collar medical specialty with no mortality, and no morbidity. As a day care and an ambulatory service segment, it was an investors fertile sweet spot. ROIs are comparatively the best amongst other specialties, and the need was large in the country. Since past 3 decades, we saw a euphoric growth in eye care segment with many emerging single practices, group practices, and corporate practices which thrived and flourished in the country.
Although under the bracket of health care practices, as being an elective surgeries practice, the lock down imposed by the government, has locked down our practices also. As the lockdown date came without a warning, some states were allowing emergency surgeries, and pharmacy business in ophthalmology too. But because of the restriction in mass movement and social distancing conditions, none of the practices which kept open for emergency cases also could not see much inflow. Most of the cases reported overcoming all local barriers to reach the hospitals, were also postoperative reviews.
I will share what we were doing since the outbreak of this virus in our hospitals, in the heart of Telangana, which was reported 3rd critical state with this contagion. People did have panic, and social media was more virulent with viral messages, than the original virus. But hospitals did not report any drastic fall in daily OPD. Very few surgeries got postponed, and we gave them indefinite dates in April.
From the initial days of contagion, all our hospitals implemented thermal screening, self-declaration forms, and provided hand sanitization to every human being entering to our hospitals. Those who have reported 99+ temperature in thermal guns, were sent back politely. Entire floors, doorknobs, lifts, stairs were sterilized every day with diluted Aldasan with additional staff in housekeeping. All staff and doctors were provided N95 masks and all slit lamps were given protective acrylic sheet barrier.
We suspended all our outreach, and outdoor marketing activities and delegated all our marketing personnel across our network hospitals, to provide the screening services. Our entire marketing activities were focusing on reassurance communication to all our patients about the safety protocols we have implemented in our hospitals, and our call centers were active for help and clarification for all incoming calls. We also had called our refractive surgery patients and gave deferred dates of surgeries, to avoid lesser crowd inside the system.
All were fine and patients were still walking in till the day the lockdown was announced and we were directed by the state to operate for only emergency cases, pharmacy and opticals.
We received a barrage of calls to our contact center, from patients, who wanted to check their eyes for various emergency, and post op conditions.
Many of our surgeons/hospitals, had operated lot of cases even on 21st which was the eve of the Janta Curfew, need to be seen, for post op reviews, and further advises. 3rd day, and 7th day post operative reviews, especially in Vitreo Retina and critical eye surgeries, are very crucial. For few days, we opened our hospitals with minimal staffing and expedited all immediate post op reviews and then eventually closed down due to less reporting.
In a lockdown period, the best way to keep our business and operations alive would be to display our ethics of medical practice; that is responsibility to care the patients who have been operated by us and clueless on any post op issues. We have to continue seeing patients who are in need of emergency care, post op reviews etc, as a part of our medical ethics. We should communicate our service timings to all post op patients over phone. Not many may not be able to pass through movement restrictions in the town, for whom, we can send out mails/images of doctors advise to be shown to the authorities. This service will go a long way in building trust and belief on our hospitals, and they will be our loyal patients forever.
Having said that we also need to take care of our doctors and staff safety, who will be servicing these patients. As being restricted operations for limited walk ins, we should operate the hospitals for lesser hours, preferably during the ease time, given by the local cities, for people to go out for purchase of essentials, etc. A small team is only needed to take care of lesser patients, one doctor, (preferably operating surgeon), one optometrists, one pharmacist, and one Front office staff. Since most of the OT staff are well trained in sterility procedures, we can depute one OT staff to assist the doctor in seeing the patients, medications etc. We should invite volunteers amongst our doctors, optometrists, and pharmacist, who can offer their part time services, and operate under strict sterile protocols. Staff members who are volunteering for this service, can be offered additional insurance coverage and also allowances. Later during the good times, they can be honored with some awards.
This will keep our practice alive, and also display our responsibility to our patients.
Another window to reach patients is to offer Video call consultations to offer primary eye care advises, and care. Apps like Whatsapp and GoogleDuo offers excellent and clear video calls. We can choose one surgeon from each specialty and advertise their number, and specialty with their numbers, on which patients can call on video call app. Their appointment timings can be advertised as certain hours during the day, so that these doctors can prepare themselves. Doctors can listen to the patient complaints, see their eyes on close up and offer safe advises as per their diagnosis. As being much limited diagnosis than on a slit lamp, doctor should be careful before he gives any advises of medication.
If the hospital website has a payment gateway, the patient can book the appointments online and can get a call from call center on confirmation of call timing. Though this is not going to give any revenue impetus, it is basically to keep a potential pipeline of surgeries from the day we commence operations.
For all practices, more fearful than the virus would be the uncertainty in resuming business and reviving. Most critical worry is how to manage costs on a ‘no income period’
Let us assume that there will be no income generated in the month of April, and probably 30% of regular income during the month of May, and 75% of regular income in the month of June. Typically, ophthalmology practices are 30 to 50 percent credit business and cash flows will go for a toss on this kind of indefinite business vacuum. We should smartly plan our cash flows to sustain the cash balances, to ensure no bankruptcy, while we start again.
Our Fixed costs during no operations period are, salaries, building rentals, and utility payments.
30% of most of eye care group practices or corporate practices cost is on salaries of doctors and staff. Health care practices are for the people, with people. Staff and doctors are very important for us during crisis and post crisis like these. Right now, all your employees will be having a lot insecurity amongst themselves on their job, and cash reserves. It is important that we instill confidence in them, that we are not going to lay off any employees unless the crisis prolongs year long and we face shutdown of our business. Promoters should realize, that we need these resources with us, and standby them, during these critical hours.
But with no income, this 30% cost will not be practically possible throughout the shutdown period. It is also important that employees do not stare at a no pay month after 1 or 2 months, due to unpredictable prolonging of the pandemic and business slowdown. This is where a diligent planning needs to be made to extend the cash reserves at least for 3 months from April to keep the resources alive.
To prioritize, HR Cost need to be evaluated against our next 3 months cash flow, our cash reserves and forecasted income from our credit business. Accordingly, a slab wise salary deduction (retention) should be made, which will be paid after our business revives. 20% to 30% of salaries of most of the salaried class goes towards EMI’s against home loans, vehicle loans etc. As there is a moratorium announced by the government for next 3 months, deductions can start from 20% which can be reduced or increased as per the grade, and pay structure.
Our HR team should personally counsel all the staff to take a slab wise, salary deductions, during crisis period, which will be in reserves and paid back as soon as business normalizes. All incentives, special allowances can be deferred and paid after we get into comfort of regular business.
Next major cost is on building rentals. Promoters should personally request and document a request of moratorium or deferring of rental payments till June. This is very critical, and force majure clause in many lease agreements will help insulate us from legal implications.
All other post dated cheques to equipment companies, and other vendors and payments to creditors can be deferred till we regain our business, through properly documented request letters. All AMC payments, CMC payments to medical equipment vendors can be deferred. These all savings will help us maintain a cash reserve towards paying salaries of employees, on above slab wise retaining pattern, and also keep enough working capital to sustain the first two months of business slow down, post pandemic control.
Almost all insurance companies have resorted to working from home. Our recovery department should be aggressively pursuing for credit payments more than ever before and drive in maximum payments during this period.
As being blessed as an elective surgery, the patients who need vision care surgeries like Cataract or Glaucoma, will wait for the dangerous time to pass, which will largely depend on the public messaging, and government ease of restrictions on the community. Post this crisis, there would be lot of concerns on possibility of infections from hospitals during the surgeries. This is where our Communication department should 12/7 work on individually communicating and reassuring the general public and prospective patients about the safety protocols we always been following in our OR.
At this critical crisis the entire nation is staring at, much-ignored health care sector has come to foremost attention now from all bodies of government. The Ministry of health care is being looked upon by the population on preventive and corrective measures and policies. Doctors and paramedics have risen up to the occasion braving the risks associated with themselves and rendering humanitarian service in detection tests and ICU care. We all look upon the government to focus on reviving the health care segment, and prepare all medical fraternity for any such future crisis nation may have to battle collectively. Much is expected from the government to subsidize the input costs of surgical consumables, and medical equipment costs, and also support indigenous manufacturing houses of medical equipments, peripherals, and consumables. Also the appalling payment systems of CGHS and State government health care schemes. Many hospitals are facing financial crisis, due to large receivables from health care schemes of government. Post this crisis, the government should take concrete steps to release outstanding payments to healthcare players, in order to revive the cash crisis to revamp the operations and come back to normalcy.
To summarize, these are action plans during this crisis period:
1) Continue limited mode operations of hospitals to service critical patients during lock down and retain data of these patients to call back after resuming normalcy
2) Operate hospitals to see only critical cases, like trauma, retinal cases, and follow up glaucoma patients, and continued post op care
3) Explore options of patient care through whats app video calls, google duo, skype etc to provide critical care diagnosis, and advice, post-op advises etc
4) Retain staff and doctors displaying continued financial support by part salaries, advances etc, within the cash flow ambit
5) Support government preventive control measures, by volunteering your extra space for isolation wards etc
6) Request landlords, creditors and equipment companies for deferred payments
7) Implement diligent measures on regular spends, incentives etc to preserve cash balances
MR Sudheer is COO of Hyderabad Based Eye Hospital Chain – Maxivision Eye Care Hospitals