Our research team breaks down this week’s top healthcare news.
In an age of unprecedented change, staying current has never been more important. Our team at Chartis is curating news most relevant to the healthcare industry and tracking the topics that are trending on seven key issues: high reliability care, digital and advanced technology, financial sustainability, health disparities, the health ecosystem of the future, partnerships, and the provider enterprise. Each week, we break down what’s happening and why it matters.
Physician practices and hospitals continue to face substantial financial losses as a result of the COVID-19 pandemic. As we have previously noted, providers saw revenue fall from patients avoiding care, with 25 percent of practices seeing at least a 50 percent decline in revenue. At the same time, expenses have increased due to soaring personal protective equipment (PPE) and staffing costs, particularly for small physician groups that could not negotiate large volume discounts. In the case of many pediatrician groups, they also faced the expense of vaccines purchased upfront, with no backend revenue as patients avoided even regular immunizations. Many physician groups did not withstand the last 10 months of COVID and were forced to close. A survey by The Physicians Foundation found in September that nationally 8 percent of physician offices have closed this year. Those practices and hospitals that have managed to remain open have relied heavily on relief funding. Prior to accounting for CARES Act and other funding support, the median hospital operating margin fell 6 points compared to the same 10-month period in 2019.
While month over month financials were improving for many hospitals and practices through October, the pandemic has been reaching new daily peaks for much of November, and with the addition of flu season, patients could again become wary of seeking care. This new peak also comes just as many of the provisions from the earlier relief bills are set to expire in December including suspension of Medicare sequestration cuts, suspension of Medicaid disproportionate-share hospital payment cuts, and additional funding for community health centers. Medicare Physician Fee Schedule cuts are also scheduled to go into effect January 1, with no update as to when additional relief may be passed. Because initial relief has been so vital to keeping many practices and hospitals open this spring and fall, we can expect to see even more practices making the difficult decision to close their doors in the new year without further financial relief. Closing additional physician offices and hospitals makes the existing access crisis even worse. Prior to the pandemic, one quarter of Americans lived in “health professional shortage areas,” a percentage that has only grown during the pandemic. To protect providers and access to care, especially for those in rural areas, Congress must pass additional relief.
Numerous barriers perpetuate the racial disparities in U.S. COVID-19 cases and their outcomes, and also lead to those living in underserved communities receiving an inequitable share of health resources. Two specific examples of these inequities come in the form of lack of affordable testing and nutrition.
In theory, testing is to be available for free to all who need to be tested. But in practice, it can be significantly more difficult to access a test, especially in areas without enough testing facilities. Lines for free testing facilities in many locations across the country can be hours long, with not enough daily tests to get through everyone in line, not to mention the locations of many of these facilities have no easy access for those without a car. Many hourly workers cannot take time from work to wait in hours long lines with the hopes of maybe receiving a test. In some cases, there is a way to get to the front of the line or otherwise access testing, but it comes at a cost — often upwards of $100, which many who need a test cannot afford.
Access to healthy food is another barrier for many in underserved communities. Multiple pre-existing conditions that have been shown to lead to worse COVID outcomes are linked to poor diet, including diabetes and heart disease. Yet grocery store chains are still loath to put stores in these markets. Enter health systems. ProMedica and Virginia Commonwealth have partnered to open grocery stores in underserved markets; they are just two examples of health systems seeking to improve the social determinants of health of their patient populations.
To truly impact health equity, health services need to be provided in the communities where people live. This means providing services not only in community health centers but also access to testing facilities, nutrition, and other healthy resources. Health and wellness resources can and should be accessible within the institutions and neighborhoods people are already frequenting. Testing should not be a privilege available only to those who can afford to pay out of pocket and own a car to easily reach a drive-through testing site.
Access to nutritious food also should be available for all. Nutritious food sources in one’s own neighborhood have numerous positive impacts. In addition to improved health, grocery stores provide food at a reasonable cost and a convenient access point, potentially saving the community time and money while reducing stress. A local also can give an economic boost to a community and serve as a center point for other commercial activity, including local BIPOC owned businesses. Opening a new community grocery store can keep income in the community and create local jobs. The outcomes on health are clear: In one study, there was a 15 percent reduction in medical spend per person in an identified population of patients at risk for food insecurity once they had access to a grocery store. Access to care, including COVID testing, and elimination of food deserts are two small but vital steps on the path to health equity.
Our country is experiencing the third and worst surge yet of COVID-19, and it isn’t localized like those in the spring and summer. Across the United States, we are experiencing unprecedented numbers of COVID infections: On December 3 two new records were set, with 210,000 reported cases of COVID-19 and over 100,000 people hospitalized, per The COVID Tracking Project as reported in The Wall Street Journal on December 4.
Our healthcare system is being overtaxed and is reaching a breaking point. In order for it to function, three critical components are needed: space and beds, staff, and supplies. We are currently facing constraints with each and turning to creative and often desperate — though likely not sufficient — ways to alleviate the limitations and stressors we face:
Space and beds: Even the most prepared hospitals are warning that beds will likely run short. The University of Nebraska Medical Center (UNMC) in Omaha is the nation’s only federal quarantine facility and contains the largest biocontainment unit in the country — Ebola patients were sent to UMNC in 2014, and many COVID-infected passengers from the Diamond Princess Cruise Ship were airlifted to UMNC in February of this year. Protocols for a pandemic-type situation have been developed, and staff have been drilled for years. And yet, as one of UMNC’s critical care physicians stated in a recent piece in The Atlantic, “We can prepare over and over for a wave of patients,” says Cawcutt, “but we can’t prepare for a tsunami.” Another critical care physician added, “the assumption we will always have a hospital bed … is a false one.” As of November 13, The Atlantic reported that the entire state of Iowa was “out of staffed beds.” To increase bed capacity, many hospitals are converting inpatient units into intensive care units and/or reducing the number of non-COVID patients admitted to make room. Some states, municipalities, and health systems are creating field hospital sites to treat COVID or non-COVID patients — such as a former Citizens Bank call center in Providence, R.I., which opened this week, and two Northwell Health sites on Long Island, N.Y., which are prepared to open if necessary.
Staff: This is the element most in danger at this point and arguably the most critical. As Dr. Lisa Piercy, 14th Commissioner of the Tennessee Department of Health, underscored to Kaiser Health News, “Hospital capacity is almost exclusively about staffing … Physical space, physical beds, not the issue.” We can no longer source clinicians from other states to help in “hot spots” because the entire country is experiencing a surge. We can’t train new health professionals fast enough, and we can’t manufacture them. We have a finite number of health professionals and some have not stopped fighting COVID-19 since the onset of the pandemic. Many are experiencing burnout and symptoms of post-traumatic stress disorder (PTSD), finding themselves at a breaking point. Though insufficient, a variety of solutions are being put into place to help, such as allowing asymptomatic COVID-positive health professionals to return to work in Oklahoma, or imploring retired or non-working health professionals to rejoin the workforce, as is being done by hospital leaders in rural areas as well as state leaders, such as New York Governor Andrew Cuomo. However, there is no adequate “back-up plan,” should these professionals exit the workforce.
Supplies: Personal protective equipment (PPE), such as N-95 masks, and other supplies, such as testing reagents, were in short supply in the spring and summer surges. Historic whittling down of suppliers for efficiency’s sake combined with the government’s lacking response led many hospitals and states to compete with one another to obtain supplies — hardly a coordinated response to the pandemic. Individuals from Mount Sinai Health System in New York even flew to China directly to obtain supplies in March. We are now better prepared, but not adequately prepared. For example, in October, a supply chain leader at Beaumont Health in Michigan stated that they had “spent the last few months building up our inventory (of PPE) days on hand. We are anticipating less than the 1,200 (hospital patients) we had in the [April] peak." Current data and most forecasts indicate that the current surge will far surpass what we had in previous peaks, leaving hospitals to scramble once again.
We have all endured our share of hardships and major life changes during this pandemic. Our healthcare system has arguably experienced the most extreme challenges, is now severely overtaxed, and cannot take much more. Asked how much slack remains in Iowa’s health system, one Iowa nurse simply responded, “There is none.” A physician at the University of Iowa stated, “[The surge] keeps rising and rising, and we’re all running on fear. The healthcare system in Iowa is going to collapse, no question.”
A widespread failure in our healthcare system, driven by one or multiple critical elements to keep it afloat, will lead to deaths. COVID patients will not receive care and will die. Non-COVID patients with acute healthcare needs will not have access to care and may also perish. Non-emergency cases will be postponed as they were in the spring, with some patients deteriorating significantly while they wait.
We are running out of options to combat the virus and its impact, and the general public seems to lack understanding of the reality we face. One health system, UW Health (Wisconsin) went as far as to post a full-page advertisement in the Wisconsin State Journal, reading:
Widespread mask use would be a great help at preventing the spread, as has been shown in multiple scientific studies. Developing a comprehensive support system for healthcare professionals, as is proposed by Stanford’s Chief Wellness Officer Tait Shanafelt and colleagues in a new paper recently published in NEJM Catalyst, may reduce burnout and employee stress but will take time. Better protecting healthcare workers with more adequate PPE and mandated testing would prop up the workforce but will require funding and legislation. Emerging vaccines appear promising but will not be available to the general public for months. If the surge passes a certain point, we may lose our ability to control our dire predicament.
The Oklahoman: Oklahoma's Healthcare Workers Say COVID Surge Has Made Hospital Atmospheres “Bleak”
The Oklahoman: Asymptomatic Health Care Workers with COVID-19 Allowed to Continue Working in Oklahoma
The Los Angeles Times: California Urges Weekly COVID-19 Testing for Hospital Workers
Applying behavioral health insights, this paper presents a strategy for healthcare leaders to communicate and operate in ways that address patients’ and employees’ pandemic-inspired anxieties and fears, alleviate tension, and foster stability.
Health system leaders who act quickly have an opportunity to be proactive in this next phase of the crisis and build back the balance sheet. Resizing the enterprise to new volumes, restructuring costs, realigning operations and establishing the right infrastructure to support and monitor change will be required to return margin.
With a growing acknowledgement of the longevity of COVID-19, the workforce will need ongoing support as they try to cope with the anticipated peaks and valleys of the curve, which will continue until there is an effective treatment or vaccine.