As academic institutions and healthcare organizations are supported by in-house human resources professionals and legal teams as they navigate through the Covid-19 pandemic, those of us in community-based practices are left searching for answers on our own. How do we as private practice owners best manage the business aspects of our clinical practices in these unprecedented times? What are our rights, responsibilities, and need-to-knows as owners and employers?
While professional organizations such as the Canadian Medical Association offers us as its members valuable updates and lists of resources related to Covid-19(1), clear direction on managing practical challenges for those of us owning private practices seems relatively lacking. It is true that we are small business owners, and as such management decisions are unique to each business. Having said that, in addition to our shared commitment to maintaining patient care as best as possible during these difficult times, private practice owners face day to day dilemmas in the business of practice management. Where there are significant reductions in clinic flow, can all staff members be retained? Where there are clinic closures, for how long? With respect to employee wages, what are the options? How do we support our teams of dedicated administrative and technical support staff both personally and financially? What about ongoing overhead expenses?
As part of the overall health care community, community-based physicians are facing unique challenges and dilemmas during this pandemic, and would benefit from support from our advocacy bodies through access to professional advice on practice-related matters. While extremely unfortunate, the circumstances highlight the need for professional organizations to survey member resource libraries, and consider developing a module on the basics of business and human resources management for private practice owners. This would not replace formal business training for professional development, but provide essential tools to complement learning modules available for other aspects of medical practice.
In the meantime, having reviewed legislation and attended various webinars in my own attempt of making sense of it all during this unprecedented time, what follows is Covid-19 from my perspective as a surgeon and private practice owner, removed from my perspectives in academic and clinical leadership roles.
Please note that the information contained in this post is general in nature and not intended to be legal, accounting or any other professional advice.
Part I: A Brief Recap on Covid-19 and Current Context
In order to support social distancing and minimize Covid-19 spread, clinics are currently operating for essential, urgent and emergency patient assessments only. Virtual care and phone technologies are being utilized where possible. Elective surgeries are being postponed to conserve hospital beds, equipment and supplies while protecting healthcare workers in preparation for a potential surge of patients with Covid-19.
Part II: Covid-19 and Canadian Medical Protective Association (CMPA)
With the nature of clinical practice in the context of Covd-19, the CMPA website has an extremely useful resource, "COVID-19 Hub: Advice, Support, and Medical-Legal Information."(7) Among the many questions and answers provided, the following are taken directly from the site and are among those I found particularly helpful:
Part III: Covid-19 and Community-Based Practice – Managing Our Employees
About a month ago, how we do everything changed. As slowdowns continue, virtual care and phone assessments increase, and closures extend for unknown periods of time, a growing concern in private practice is how best to manage our practices and more specifically, our employees. As employers and small business owners, what are our rights, responsibilities and options when it comes to our valuable administrative and technical support teams?
While collective bargaining agreements come into play in unionized workplaces such as large health care organizations and academic institutions, provincially legislated standards of employment must be upheld in both unionized and non-unionized environments. Private practices are generally non-unionized environments and together with unionized workplaces, are accountable to the Employment Standards Act, 2000 in Ontario(8). Employment standards for other provinces can be found on the Government of Canada website(9).
The Employment Standards Act, 2000 (ESA)(8) imposes minimum rights and responsibilities for employers and employees in most Ontario workplaces. Among the range of provisions laid out in the act, those that I have found most helpful for our present context include: amendment to include unpaid job-protected infectious disease emergency leave; payment of wages; termination of employment and temporary layoffs.
Amendment to ESA for Infectious Disease Emergency Leave: (directly from site)(8)
Options to Reduce Payroll Obligations:
While professional advisors should be consulted for advice on our own practices, a brief description of potential options to reduce payroll obligations is as follows:
A. Termination: (directly from site)(10) "Under the Employment Standards Act, 2000 a person's employment is terminated if the employer:
dismisses or stops employing an employee, including where an employee is no longer employed due to the bankruptcy or insolvency of the employer;
"constructively" dismisses an employee and the employee resigns, in response, within a reasonable time;
lays an employee off for a period that is longer than a "temporary layoff".
In most cases, when an employer ends the employment of an employee who has been continuously employed for three months, the employer must provide the employee with either written notice of termination, termination pay or a combination..."
"Constructive dismissal" refers to a substantial change in the terms of employment made by an employer without the employee's consent, or the employer demonstrates intention to no longer be bound by the terms of the employee contract if one exists.
B. Temporary layoff: (directly from site)(9) "An employee is on temporary layoff when an employer cuts back or stops the employee's work without ending their employment (e.g., laying someone off at times when there is not enough work to do)."
In the absence of an employment contract that expressly permits temporary layoff, employers must obtain written consent for layoff from employees to avoid constructive dismissal claims. As mentioned earlier, constructive dismissal is defined as a substantial change to the terms of an employee’s employment made by the employer without the employee’s consent.
A 50% reduction in weekly wages or hours renders an employee as being on layoff. In Ontario, a temporary layoff cannot exceed 13 weeks in any period of 20 consecutive weeks, or up to 35 weeks in any period of 52 weeks if the employer provides benefits, or in the absence of benefits, if the employee agrees to an extension in writing. Should the maximum period of layoff be exceeded, the temporary layoff is converted to termination which triggers entitlements associated with termination.
Each employee on layoff must be issued a Record of Employment (ROE)(11) completed by the employer, within five calendar days following the "interruption of earnings". Interruption of earnings is when an employee has had or is expected to have seven consecutive calendar days with no work and no insurable earnings from the employer, or when an employee’s salary falls below 60% of regular weekly earnings for reasons including coronavirus-related shortage of work (ROE reason for separation code A), quarantine or illness (code D), or refusal to come to work for reasons other than quarantine or illness (code E = quit or code N = leave of absence).
ROE forms may be completed by the employer online after registering through the ROE Web Government of Canada website(12), or by the employer's accountant after the employer provides written authorization to the accountant to prepare and submit ROE forms on their behalf. Details about the employee’s work history including insurable earnings and insurable hours are included for purposes of assessment by Service Canada for Employment Insurance benefits.
C. Reduction in work hours or work-sharing: (directly from site)(13) "Work-Sharing (WS) is a program that helps employers and employees avoid layoffs when there is a temporary decrease in business activity beyond the control of the employer. The program provides EI benefits to eligible employees who agree to reduce their normal working hours and share the available work while their employer recovers. Work-Sharing is an agreement between employers, employees and the Government of Canada."
D. Canada Emergency Response Benefit (CERB): (directly from site)(14) "If you have stopped working because of COVID-19, the Canada Emergency Response Benefit (CERB) may provide you with temporary income support. The CERB provides $500 a week for up to 16 weeks. The benefit will be available to workers:
Residing in Canada, who are at least 15 years old;
Who have stopped working because of COVID-19 and have not voluntarily quit their job or are eligible for EI regular or sickness benefits;
Who had income of at least $5,000 in 2019 or in the 12 months prior to the date of their application; and
Who are or expect to be without employment or self-employment income for at least 14 consecutive days in the initial four-week period. For subsequent benefit periods, they expect to have no employment or self-employment income."
E. The Canada Emergency Wage Subsidy (CERB): (directly from site)(15) "To help businesses keep and return workers to their payroll through the challenges posed by the COVID-19 pandemic, the Prime Minister, Justin Trudeau, proposed the new Canada Emergency Wage Subsidy... Eligible employers would include individuals, taxable corporations, and partnerships consisting of eligible employers as well as non‑profit organizations and registered charities... This subsidy would be available to eligible employers that see a drop of at least 30 per cent of their revenue...
The subsidy amount for a given employee on eligible remuneration paid between March 15 and June 6, 2020 would be the greater of:
75 per cent of the amount of remuneration paid, up to a maximum benefit of $847 per week; and
the amount of remuneration paid, up to a maximum benefit of $847 per week or 75 per cent of the employee’s pre-crisis weekly remuneration, whichever is less..."
F. Canada's Covid-19 Economic Response Plan(16) posted on the Government of Canada website includes information on programs available to individuals, businesses and industries, to help provide financial support through Covid-19 .
Options to Continue Utilizing Staff:
Not often do we have time to critically assess our practices and how we may improve efficiencies and general upkeep. In addition to duties of canceling and rebooking patients as a result of Covid-19, here are some ideas on how staff may continue to be engaged and benefit our practices overall as well:
Reorganize and declutter the administration area
Go through supplies and inventory to discard those that have expired
Review patient charts and archive those who are no longer active patients
Consider changes in workflow that may be beneficial from their perspective
Offer coaching or online training to enhance skills relevant to their work
With many questions yet to be answered and what's to come still uncertain, my hope is that sharing what I've learned so far in making sense of it all, will help colleagues in private practice do the same as we navigate the uncharted world of Covid-19.
Information is changing rapidly. Please share any insights on how you are working through these issues in your own practice so we can all learn together.
Take care everyone, and stay well.
12 https://www.canada.ca/en/employment-social-development/programs/ei/ei-list/ei-roe/register-roe.html
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