How a Typical Employer in Physician Practices, Outpatient Clinics, Behavioral Health and Allied Health Operates
The employer of this class sells the in-person encounter. Its revenue arrives when a patient sits in a waiting room, is roomed, is examined, undergoes a procedure, gives a specimen or completes a course of therapy, and every one of those events happens at a fixed premises, with a licensed clinician, with supplies bought in a regulated market, on a schedule fixed weeks ahead, for a patient who traveled there from a home, a school or a workplace. Each of those elements is a thing an order can reach, and between March 2020 and September 2021 each was reached. This section states the functions in operational terms, the revenue lines, the inputs and counterparties, the workforce, the seasonality and geography, and the counterparty map that the layers section then fills with instruments.1
The functions
CL, clinical intake and the waiting room
Patients arrive at a fixed time or walk in, check in at a desk, sit in a shared waiting room, are called, roomed by a medical assistant who takes vital signs, and are examined by a physician, advanced practice provider or therapist. The waiting room's occupancy, the screening of every person at the door, the masking of staff and patients, the isolation of symptomatic patients, the exclusion of companions and the spacing of chairs are each a condition on this function, and each was imposed by order in 2020 and 2021.2
PR, procedures and elective visits
This function comprises office-based surgery, injections, endoscopy, dermatologic and cosmetic procedures, courses of physical and occupational therapy, chiropractic adjustments, routine and preventive visits, annual examinations, well-child visits and immunization visits, and the hospital and ambulatory-surgery-center cases that practice physicians schedule and perform. This is the revenue function the elective-procedure orders of March and April 2020 suspended in terms, the conditional-resumption orders governed from April through 2021, and the regional hospital triggers of 2020 and 2021 reached through the counterparty.3
DX, diagnostics and laboratory
This function comprises in-office laboratory testing, imaging, electrocardiography, pulmonary function testing and sleep studies; the reference laboratories and imaging centers to which specimens and patients are sent; and the supply of test kits and reagents. The laboratory-prioritization and reporting orders of Michigan, Ohio, Pennsylvania, Florida, Delaware and New Jersey reached this function directly, and the postponement orders that named "testing" (Arkansas) and "diagnostic and treatment centers" (New York) reached it in terms.4
TM, telehealth under waivers
This function comprises video and audio-only visits billed under the Medicare blanket waivers and the State parity orders, remote monitoring and e-visits. This function did not exist at scale before March 2020 because the law forbade it: Medicare did not pay for a visit to a beneficiary's home, most States did not permit audio-only encounters or out-of-State practice, and the privacy rules did not tolerate consumer video platforms. The federal and State instruments that removed those bars were permissions; the State orders that postponed and conditioned in-person care were the compulsion. Telehealth is the compelled mode, not the continuation of comparable operations.5
FD, front desk and scheduling
This function comprises check-in, insurance verification, appointment management, recall and cancellation, patient flow through the waiting room and the examination rooms. When an order postponed every elective procedure, this function cancelled and rescheduled every affected appointment; when an order required screening at the door, appointment-only service, capacity limits or vaccination verification of every entrant, this function performed it.6
OF, billing and administration
This function comprises revenue-cycle work, credentialing, compliance, human resources and information technology. State telework directives moved this staff home in 2020 and, in New York, Michigan and Pennsylvania, by order in the winter of 2020-21; the reporting orders of the State health departments made every practice running point-of-care tests a reporting entity; and the written-plan requirements of the conditional-resumption orders and the OSHA standard sat on this desk.7
SC, PPE and supplies
This function comprises N95 and surgical masks, gowns, gloves, face shields, sanitizer, test kits, vaccines and drugs. From March 2020 through June 2021 this function bought in a market under federal allocation and export detention, under a federal designation that made accumulation of these goods above reasonable demand a crime, and under State conservation clauses that conditioned every procedure on the practice's PPE self-sufficiency; in July 2021 the FDA revoked the emergency authorizations under which a large share of the respirators in that market had been imported and decontaminated.8
HR, hiring, credentialing and training
This function comprises recruiting, licensure, credentialing, training, continuing education and conferences. The licensing boards and the governors suspended, waived and re-made the credentialing regime in eighteen months of successive emergency orders, and the venue orders cancelled the conferences at which continuing education is earned and staff are recruited.9
WF, workforce availability
The industry's workforce is predominantly female, includes a large share of parents of school-age children, commutes by transit in the largest metropolitan areas and, because it is exposed to patients, was the object of the quarantine, isolation, testing and, from mid-2021, vaccination orders that named health care workers in terms. School and child-care closures, quarantine and isolation orders, the federal conveyance face-covering regime, an airborne-transmission control on every transit commute, the State workplace standards' exclusion duties, the OSHA standard's medical-removal rule and the vaccination-or-testing mandates each fixed who could come to work on a given day.10
CB, patients, referral sources, employers and payers
The patient base was confined by the stay-at-home orders, the travel quarantines, the directives isolating persons over sixty-five, and the face-covering and other exposure-control orders on every indoor public space; the referral sources, hospitals and ambulatory surgery centers, were under elective-procedure, capacity-reservation and visitor orders; the employers that buy pre-employment physicals, drug screens and occupational medicine were closed or sent home by order; and the payers operated under waiver, prior-authorization and parity orders that changed what was billable and how.11
MK, marketing and outreach
This function comprises community events, health fairs, school and sports physicals, sponsorships and referral development, each dependent on gatherings and schools that the gathering caps and school closures suspended.12
The revenue lines
The revenue lines are professional fees for evaluation and management visits, which in the Commonwealth Fund and Phreesia sample were about 47 percent primary care and the remainder spread across more than twenty-five specialties; procedures and surgery; ancillary diagnostics; telehealth; occupational medicine and employer services; distributions from ambulatory-surgery-center ownership; and hospital call and directorship stipends. Every line depends on a physical encounter or on a counterparty whose physical operations were themselves ordered.13
The inputs and counterparties are hospitals and ambulatory surgery centers, which operated under elective-procedure, capacity-reservation, visitor and reporting orders in every quarter and under staff-testing and staff-vaccination orders in 2021; reference laboratories and imaging centers; pharmacies; distributors of protective equipment under the FEMA allocation rule and the State conservation orders; Medicare, Medicaid and commercial payers under the waiver and parity orders; schools, athletic associations and employers as buyers of physicals; referral networks; and landlords in medical office buildings under the moratoria. Each is a class of counterparty whose orders limited this industry's commerce, and each appears in the layers section with exhibit identifiers.
The workforce
The workforce comprises physicians, advanced practice providers, nurses, medical assistants, technologists, therapists, and front-desk and billing staff. The clinical staff are licensed by a State board and credentialed by hospitals and payers; the non-clinical staff are, under the California, Illinois and Washington mandates of 2021, "workers" and "Health Care Workers" in terms, so that the vaccination status of a biller or a receptionist became a condition of the practice's operation.14
Seasonality and geography
The calendar
Preventive visits and school and sports physicals concentrate in summer and early fall; procedure volume is highest in the fourth quarter, when deductibles have been met. The suspension of March through May 2020 fell on the spring procedure season and the second-quarter preventive cycle; the winter re-tightening fell on the fourth-quarter procedure peak; and the third-quarter 2021 mandates fell on the back-to-school physical season.
The map
The industry is everywhere: 212,620 establishments in offices of physicians alone, in every county, with the largest concentrations in the metropolitan areas whose local health officers issued the orders catalogued in the layers section, and with a large share of practices in the twenty States whose orders named "health care practitioners' offices," "outpatient clinics," "physicians' offices," "clinic-based settings," "Clinics & Doctor Offices" or "physician offices" in terms.15
The counterparty map
For each counterparty class the orders that reached it are stated by category, with the part of the layers section in which the instruments appear.
| Counterparty class | Orders that reached it | Where the instruments appear |
|---|
| Patients | Stay-at-home orders; curfews; travel quarantines; isolation of persons over sixty-five; face-covering and other exposure-control orders on every indoor public space; vaccination-proof entry conditions in four cities | The fifty States and the District of Columbia; the largest metropolitan areas; the ecosystem |
| Hospitals and ambulatory surgery centers (referral and procedure venues) | Elective-procedure prohibitions; capacity-reservation and regional-trigger orders; visitor and entrant screening orders; daily reporting orders; staff testing and staff vaccination orders | The fifty States and the District of Columbia; the sector regulators; the counterparties |
| Reference laboratories and imaging | Laboratory prioritization and reporting orders; antigen-reporting orders | The sector regulators |
| Distributors of protective equipment | Defense Production Act orders; scarce-materials designation; FEMA export detention; State conservation and inventory clauses | The federal layer; the ecosystem |
| Payers (Medicare, Medicaid, commercial) | Section 1135 waivers; CMS interim final rules; State telehealth parity and cost-sharing orders; prior-authorization suspensions | The federal layer; the sector regulators |
| Licensing boards and health departments | Emergency rules of minimum standards; renewal, reactivation and out-of-State practice waivers; vaccine-provider orders | The sector regulators |
| Schools and child care (the workforce's children) | Statewide closures of spring 2020; remote and hybrid orders of 2020-21; school and child-care mask and quarantine orders of 2021 | The counterparties; the ecosystem |
| Transit and travel (the commute and the patient's journey) | Transit service reductions; State and federal conveyance face-covering orders (airborne-transmission controls on every transit commute); entry proclamations; land-border notices | The federal layer; the largest metropolitan areas; the ecosystem |
| Employers (occupational medicine buyers) | Closure and telework orders; workplace standards | The fifty States and the District of Columbia; the ecosystem |
| Landlords and lenders | Eviction and foreclosure moratoria; court closures | The counterparties |