The stress, disruption, isolation, and lives lost during the pandemic have exacerbated longstanding challenges in access to mental healthcare. In the graphic above, we highlight how COVID has impacted the state of mental health across generations.
Younger Americans are faring much worse. This week, the nation’s leading pediatric professional societies declared a national mental health emergency for children and adolescents, and nearly half of “Generation Z” reports that their mental health has worsened during COVID.
Mental health-related emergency department (ED) visits increased in 2020 across all age groups, with the steepest rise among adolescents. Because of a national shortage of inpatient psychiatric beds, patients with mental health needs are increasingly being “boarded” in the ED—even asnearly two-thirds of EDs lack psychiatric services to adequately manage patients in crisis.
Case in point: research on behavioral health access in Massachusetts shows one in every four ED beds is now occupied by a patient awaiting psychiatric evaluation. ED boarding of patients in mental health crisis not only delays necessary care, but leads to throughput backups in hospitals, and increases caregiver stress and burnout.
Access to inpatient treatment is most challenged for children and adolescents, as well as “med-psych” patients, who also have significant physical health needs that must be managed. New solutions have emerged during the pandemic: burgeoning telemedicine platforms don’t just increase access to outpatient therapy, they also enable psychiatrists to evaluate emergency patients virtually.
In the long term, a three-part approach is needed—new virtual solutions, expanded inpatient capacity, and greater community resources to address the social needs that often accompany a behavioral health diagnosis.
Cost-sharing is the practice of making individuals responsible for part of their health insurance costs beyond the monthly premiums they pay for health insurance – think things like deductibles and copayments. The practice is meant to inspire more thoughtful choices among consumers when it comes to healthcare decisions. However, the choices it inspires can often be more harmful than good.
The delta variant of the coronavirus continues to pile on staffing challenges for hospitals as they spend more resources on recruiting and retaining employees, jack up benefit options and offer steep sign-on bonuses, according to a Tuesday report from Moody’s Investors Service.
Those expenses will strain hospital profitability at a time when lucrative non-emergency procedures are on hold in some areas to handle incoming COVID-19 inpatients. Moody’s expects the weight on hospital budgets to continue through next year.
Although demand for temporary nursing staff dipped last week, it is still well beyond pre-pandemic levels, according to data gathered by Jefferies analysts. Crisis jobs — those that are rapid response or bill more than $100 an hour — represent more than three quarters of staffing firm Aya Healthcare’s openings, the third highest percentage Jefferies has recorded.
The highly contagious delta variant is wreaking havoc on the U.S. healthcare system as mostly unvaccinated people are filling ICUs more than a year and half into the pandemic. Clinicians who have throughout that time been stressed working long and difficult hours are reporting intense burnout as some mull leaving the profession altogether.
Meanwhile, vaccine mandates have gone into effect for many hospitals. Although they report that the vast majority of employees are complying, even the small losses of those who refuse can take a hit to staffing resources. This need has driven increases to the salaries nurses can command, as well as to benefit packages, sign-on bonuses and the offer of services like child care, Moody’s said.
The report also noted that the current shortage — unlike previous ones — also includes nonclinical staff such as dietary and environmental services workers.
While Moody’s focuses on nonprofit operators, expense challenges will be an important metric to watch during the upcoming earnings season. Although all major for-profit hospital operators beat Wall Street expectations on earnings and revenue in Q2 and most posted profit increases, expenses were a rising line item.
Hospital labor expenses rise
For-profit health systems’ labor costs year over yearhttps://datawrapper.dwcdn.net/G7DCw/2/
As the Biden administration works to encourage more vaccinations through a combination of carrots and sticks, it remains unclear when delta may peak and what future variants could bring. Even after hospitals are on more stable ground in terms of capacity, further challenges will remain as patients return for care they deferred earlier.
And there are more long-term concerns as well. “Even after the pandemic, competition for labor is likely to continue as the population ages — a key social risk — and demand for services increases,” according to the Moody’s report.
Jefferies analysts agreed, saying the demand for temp nurses will go down but remain elevated. “Additionally, the fundamental demand drivers for nurses that existed even before COVID (i.e., nurse population demographics) have been boosted by the lingering effects of the pandemic on the profession and are likely to boost demand for temp staffing post-2022,” they wrote in the Wednesday note.
n addition to treating an influx of Covid-19 patients, many hospitals are struggling with what one administrator calls a “triple whammy” of financial burdens—stemming from plummeting revenue, higher labor costs, and reduced relief funds, Christopher Rowland reports for the Washington Post.
Hospitals in less-vaccinated areas face spiking labor costs
In areas with low vaccination rates, particularly in southern and rural communities, hospitals have been overwhelmed with Covid-19 patients, exacerbating labor shortages as workers burn out or leave for more lucrative positions, Rowland reports.
“The workforce issue is just dire,” Stacey Hughes, EVP of government relations and policy for the American Hospital Association (AHA), said. “The delta variant has wreaked significant havoc on hospitals and health systems.”
In Louisiana, Mary Ellen Pratt, CEO of St. James Parish Hospital, said many nurses quit due to the grueling conditions as Covid-19 cases spiked. “I didn’t have any extra money to incentivize my staff to pick up additional shifts,” she said. “This is coming out of bottom-line money I don’t have.”
Separately, Lisa Smithgall, SVP and chief nursing executive at Ballad Health, said the health system—which has 21 hospitals in eastern Tennessee and southwestern Virginia—has faced similar problems retaining staff amid Covid-19 surges.
“We knew we were at risk in our region because of where we live and because of our vaccination rate being so poor,” Smithgall said. “At one point, we were seeing four or five nurse resignations per week. They couldn’t do it again; they emotionally didn’t have it. They were so upset with our community.”
To fill in these growing gaps in their workforce, many hospitals have had to turn to costly contract workers, Rowland reports—a significant financial burden that further strains hospitals’ resources.
For example, Ballad Health went from hiring fewer than 75 contract nurses before the pandemic to 150 in August 2020 and 450 in August 2021. Moreover, according to Smithgall, contract nurses previously made double or triple what permanent staff nurses made, but now Ballad sometimes has to pay up to seven times as much for contract nurses as hospitals compete for workers to fill shifts.
Many hospitals, including those in areas with high vaccination rates, have delayed elective surgeries, a crucial source of revenue, amid nationwide surges in Covid-19 cases, Rowland reports—further compounding financial struggles for many organizations.
On Aug. 26, Ballad Health postponed a long list of elective surgeries—including hernia repair, cardiac and interventional radiology procedures, joint replacements, and nonessential spine surgery—to preserve space in its hospitals and conserve workers. Ballad is now allowing elective surgeries again, but only for a limited number of procedures that do not require overnight stays.
Similarly, St. Charles Health System in Oregon postponed elective surgeries in August “while we responded to a surge that was significantly greater and much more sudden than the surge in 2020,” Matt Swafford, the health system’s VP and CFO, said.
According to Swafford, the health system lost $5 million a week through August and September, around $1 million of which was repayment of emergency advances on Medicare reimbursements from last year.
“I don’t think anybody saw this level of surge coming in 2021 after what we saw in 2020,” he said. “We’re just not equipped to be able to simultaneously respond to the urgent needs of the community [for more typical surgeries and care] at the same time that a third of our beds are occupied by highly infective Covid patients.”
Many hospitals likely to end the year at a deficit
Further compounding the issue, according to Moody’s Investors Service, is that the provider relief funds that previously made up 43% of operating cash flow at nonprofit and government-run hospitals in the United States are now dwindling down.
In addition, the latest portion of provider relief funds to be distributed must be based on expenses incurred by hospitals before March 31, 2021, which don’t account for months of the delta surge, Rowland reports.
Premier, a group purchasing and technology company serving more than 4,000 hospitals and health systems, analyzed payroll data of 650 hospitals and found that U.S. hospitals have spent a total of $24 billion a year during the pandemic to cover excess labor costs, primarily for overtime and contract nurses. This was an increase of 63% from October 2019 to July 2021, Rowland reports, with hospitals in the Upper Midwest and across the South seeing the largest increases.
“It’s going to leave them huge deficits that they are going to have to work out of for years to come,” Michael Alkire, Premier’s CEO, said.
Health spending in the United States is highest in the world, driven in part by administrative complexity. To date, studies examining the administrative costs of American health care have primarily focused on clinicians and organizations—rarely on patients.
A new study in Health Services Research finds administrative complexity in the U.S. health care system has consequences for access to care that are on par with those of financial barriers like copays and deductibles. In other words, we pay for health care in two ways: in money and in the hassle of dealing with a complex, confusing, and error-riddled system. Both are barriers to access. The study was led by Michael Anne Kyle, and coauthor, Austin Frakt.
Nearly three-quarters (73%) of people surveyed reported doing at least one health care-related administrative task in the past 12 months. Such administrative tasks include: appointment scheduling; obtaining information from an insurer or provider; obtaining prior authorizations; resolving insurance or provider billing issues; and resolving premium problems.
Administrative tasks often impose barriers to care: Nearly one-quarter (24.4%) of survey respondents reported delaying or foregoing needed care due to administrative tasks.
This estimate of administrative barriers to access to care is similar to those of financial barriers to access: a 2019 Kaiser Family Foundation survey, found that 26% of insured adults 18-64 said that they or a family member had postponed or put off needed care in the past 12 months due to cost.
Administrative burden has consequential implications for equity. The study finds administrative burden falls disproportionately on people with high medical needs (disability) and that existing racial and socioeconomic inequities are associated with greater administrative burden.
To measure the size and consequences of patients’ administrative roles, we used data from the nationally representative March 2019 Health Reform Monitoring Survey of insured, nonelderly adults (18-64) to assess the annual prevalence of five common types of administrative tasks patients perform: (1) appointment scheduling; (2) obtaining information from an insurer or provider; (3) obtaining prior authorizations; (4) resolving insurance or provider billing issues; (5) and resolving insurance premium problems. The study examined the association of these tasks with two important measures of their burden: delayed and forgone care.
High administrative complexity is a central feature of the U.S. health care system. Largely overlooked, patients frequently do administrative work that can create burdens resulting in delayed or foregone care. The prevalence of delayed or foregone care due to administrative tasks is comparable to similar estimates of cost-related barriers to care. Administrative complexity is endemic to all post-industrial health systems, but there may be opportunity to design administrative tools with greater care to avoid exacerbating or reinforcing inequities.
When COVID volumes waned in the spring and early summer, most health systems “de-escalated” dedicated COVID testing and triage facilities. But with the Delta variant surging across the country, consumers are now once again looking for services like drive-through testing, which is perceived as more convenient and safer.
One physician leader told us patients in the ED are asking why the hospital got rid of the “COVID tent”, which provided a separate pathway for patients with respiratory and other COVID symptoms—and a highly visible signal that the rest of the department was as COVID-free as possible.
Another system is now fielding questions from the media about whether they’ll bring back their dedicated COVID hospital: “We spent a lot of time last year convincing the community that the dedicated hospital was key to safely managing care during the pandemic. Now we’ve got almost as many COVID admissions spread across our hospitals.”
Over the past year, providers have learned how to safely manage COVID care and prevent spread in healthcare settings—but consumers may perceive the lack of dedicated facilities as a decline in safety.
Unlike last year, hospitals are full of non-COVID patients, as those who delayed care reemerge. And with the current surge likely to continue into flu season, emergency rooms will only get more crowded, necessitating a new round of communication describing how hospitals are keeping patients safe, and reassuring patients that healthcare settings remain one of the safest places to visit in the community.
The US now has more job openings than any time in history—and the mismatch in workforce supply and demand in the broader economy is even more acute in the healthcare sector. While the industry saw significant job losses in April 2020, employment in many healthcare subsectors quickly rebounded to slightly below pre-pandemic levels, according to data from the Bureau of Labor Statistics.
While ambulatory and hospital employment has mostly recovered, employment in nursing and residential care facilities has continued to decline.
Healthcare’s sluggish return to pre-pandemic employment levels is not for lack of demand. The number of job listings has grown nearly 30 percent since the second quarter of 2020, to nearly 4.5M openings, while new hires have flatlined, resulting in over half of healthcare job listings remaining unfilled as of Q2 2021.
In a recent McKinsey & Company survey of over 100 large US hospitals, health system executives ranked workforce shortages among nurses and clinical staff as their greatest barrier to increasing capacity.
Amid the current COVID surge, many systems are offering sizeable bonuses to attract new employees. These strategies will be critical across the next year, as systems look to reduce spending on costly travel nurses, manage COVID surges while continuing to offer elective care, and forestall further burnout.
But longer term, rethinking job functions, integrating new technology and finding ways to educate and upskill critical clinical talent will be key to winning the war for talent.
Scripps Health is temporarily postponing some medical procedures because of significant staffing shortages and a jump in COVID-19 cases, the San Diego, Calif.-based system said Aug. 20, according to CBS News 8.
Medical staff is deciding which procedures to delay based on clinical factors and emergency status, with time-sensitive care still being delivered, Scripps leaders said.
The health system said it is also considering temporarily consolidating some ambulatory care sites due to workforce shortages.
At present, Scripps said it is looking to fill 1,309 open positions. In August 2019, the system had just 832 openings. About 430 of the openings are for nursing positions, up from 220 open positions in 2019, according to the report.
At the same time, the health system is seeing its COVID-19 patient volume grow. Scripps has 173 patients admitted at its five hospitals, up from 13 patients on June 13.
“The COVID pandemic has taken a serious toll on healthcare workers across the nation, and many have decided to leave the field entirely for reasons such as fatigue and burnout,” said Scripps’ President and CEO Chris Van Gorder, according to CBS News 8. “We’re doing all we can to fill open positions and shifts, but options are currently limited across the board in healthcare, so we’re doing what’s necessary to ensure we have staff available for our most urgent cases.”
After a calmer start to the summer, the Delta variant is eroding consumer confidence as COVID-19 surges across many parts of the US once again. Using the latest data from Morning Consult’s Consumer Confidence Index, the graphic above shows the fluctuations in consumer confidence levels across the last year.
The most recent COVID surge has caused a five-point drop in confidence in the past month and, with cases still rising, we expect this trend to continue into the fall. Notably, with renewed masking guidance and increasing reports of breakthrough infections, confidence has dropped more among fully vaccinated individuals than among the unvaccinated.
Consumers’ comfort levels aren’t only dropping when it comes to daily activities, like grocery shopping or dining at a restaurant, but also with respect to healthcare. A recent survey from Jarrard Phillips Cate & Hancock finds that while consumers feel safer visiting healthcare settings in August 2021 than they did back in January, more than a third of consumers report the current COVID situation is making them less likely to seek non-emergency care, and 44 percent say they are more likely to pursue virtual care alternatives.
Health systems must be able to seamlessly “dial up” or “dial down” their virtual care capabilities in order to meet fluctuating consumer demand and avoid another wave of missed or deferred care.
In the past year, cost was a bigger factor driving Americans to skip recommended healthcare than fear of contracting COVID-19, according to a report released June 1 by Patientco, a revenue cycle management company focusing on patient payment technology.
Patientco surveyed 3,116 patients and 46 healthcare providers, finding 34 percent of female patients and 30 percent of male patients have avoided care in the past year citing concerns about out-of-pocket costs.
Below are three more notable findings from the report:
Healthcare affordability is not an issue that affects only Americans with low incomes, as 85 percent of patients with household incomes greater than $175,000 are less likely to defer care when flexible payment options are offered.
Across all ages, income levels and education levels, most patients said they struggled to understand their medical bills and what they owed. Nearly two-thirds of patients said they did not understand their explanation of benefits, did not know what they should do with the information in their explanation of benefits, or waited too long to obtain their explanation of benefits.
Forty-five percent of patients said they would need financial assistance for medical bills that exceed $500, and 66 percent of patients said the same for medical bills that exceed $1,000.