ED patient acuity largely unchanged by COVID (at least so far)

https://mailchi.mp/6a3812741768/the-weekly-gist-september-9-2022?e=d1e747d2d8

Many health systems are wondering if consumers are now leveraging new access points, including telemedicine, for low-acuity urgent care instead of going to the emergency department (ED), something which many experts are forecasting. For the graphic above, we partnered with healthcare software and analytics firm Strata Decision Technology to try to answer this question.

Using their national StrataSphere dataset for short-term acute care hospitals, we found that ED patient acuity levels in July 2022 were virtually identical to those in July 2019, though 2022 volumes were down by four percent. Admission and observation decisions across the two groups were also largely the same. We’ll be keeping our eye on the data to see if the story changes, as individuals who have delayed care over the last two and a half years now return, presenting to the ED with more advanced disease.

While current ED patients may not be more acute than before, the ongoing shortage of clinical labor may explain why some hospitals tell us that their EDs feel busier than ever. Measured by total worked hours of ED employees per adjusted patient day, the amount of labor dedicated to each patient requiring an overnight ED stay is down around forty percent from 2019 across hospital EDs of all staffing levels. With fewer labor hours to go around, each team member on the floor now has more to do.

Emergency visits are down, so why does the ED feel so busy?

https://mailchi.mp/efa24453feeb/the-weekly-gist-july-22-2022?e=d1e747d2d8

We’ve been noticing a disconnect recently in our conversations with health system executives. When we share national data that shows that emergency department visits are still down substantially from pre-COVID levels, the reaction is often one of surprise.

As one CEO recently put it to us, “We’re seeing exactly the opposite. Our ED feels busier than ever.” It appears that, upon further examination, what’s going on is a shift in the mix of patients who are visiting the ED. The lower-acuity, urgent-care level cases do seem to have shifted away from traditional hospital settings toward virtual visits and urgent care centers. That’s good news from an overall cost of care perspective, but it means that hospital EDs are increasingly filled with sicker, more acute patients.

One sure sign the mix has shifted: many systems are now telling us that the percentage of ED visitors who end up getting admitted is rising. But staffing-driven capacity constraints mean that it’s taking longer to find an inpatient bed for those patients, or to discharge them from the ED to other settings (or back home)—so the average length of stay in the ED is going up.

On top of that, many EDs are now seeing an increase in psych patients, who stay longer and require greater staff attention. All of that, along with staff who are completely exhausted and demoralized after the pandemic, has combined to make many EDs feel swamped these days—despite what the national data are showing. 

New Jersey hospital evacuates ED after A/C breaks

Hackensack Meridian Riverview Medical Center in Red Bank, N.J., part of Edison, N.J.-based Hackensack Meridian Health, evacuated patients July 20 after two air-conditioning units went offline, which affected the emergency department and intensive care unit.

The hospital confirmed the issue in a statement shared with Becker’s and said team members immediately acted to ensure affected patients were safely moved into unaffected areas of the facility. Some patients were also transferred to neighboring Hackensack Meridian Health facilities.

“Fortunately, our teams were able to restore air conditioning capabilities to our emergency department and ICU,” Riverview Medical said.

Although some areas of the facility remained offline July 20, the hospital estimated that service will be fully restored by the afternoon of July 21.

The air-conditioning issue at Riverview Medical comes as states across the country are facing extreme heat. As of July 20, heat warnings and advisories were issued affecting 28 states, according to the National Weather Service

Expanded national mental health crisis hotline launches July 16

https://mailchi.mp/30feb0b31ba0/the-weekly-gist-july-15-2022?e=d1e747d2d8

Individuals in crisis can dial 988 to speak with mental health professionals, receive immediate medical assistance, or be directed to treatment. Established by a 2020 law, the hotline is an expanded version of the previous National Suicide Prevention Lifeline, intended to provide Americans with a single mental health emergency access point, akin to 911.

The Gist: While 988 has the potential to help more Americans, as well as reduce some burden on overstressed first responders and hospital emergency rooms, media outlets are reporting concerns from national, state, and local partners that they lack adequate staffing and funding to handle the expected level of demand. 

The nation is long overdue for creating accessible, coordinated mental health crisis care, and this is a step in the right direction. But with one in six calls to the current hotline system now going unanswered, the rollout needs to be coupled with funding for local infrastructure needs.

Biden Administration says that all hospitals must provide abortion care in emergencies

https://mailchi.mp/30feb0b31ba0/the-weekly-gist-july-15-2022?e=d1e747d2d8

This week, federal health officials sent hospitals clarification that the federal Emergency Medical Treatment and Labor Act (EMTALA) protects the provision of abortion care during medical emergencies, regardless of state laws. The guidance also offers EMTALA as a possible legal defense for providers against state enforcement of antiabortion laws. Texas Attorney General Ken Paxton has already sued the Department of Health and Human Services (HHS) to set aside the guidance, claiming the agency is exceeding its authority.   

The Gist: This latest federal action follows President Biden’s recent executive order directing federal agencies to protect access to reproductive care, and HHS’s warning that pharmacists refusing to dispense medications used to induce abortions could be violating federal civil rights laws. The Federal Trade Commission and Justice Department have also announced that they will enforce data privacy rules and pursue legal action against states that look to restrict patients from traveling to obtain abortion care. 

These quick federal actions, while limited, are an attempt provide clarity for providers trying to deliver lifesaving care in a timely manner, without running afoul of state laws. Some Democrats, however, argue that they don’t go far enough, and are pushing for the President to declare a public health emergency on abortion, though it’s not clear that would provide much patient benefit.

Meanwhile, reports from Texas and other states with restrictive abortion laws reveal physicians are already delaying care for ectopic pregnancies and other life-threatening conditions, setting up all-but-certain legal action when patients experience adverse outcomes.

Inpatient volumes poised to grow 2% over next 10 years

https://www.beckershospitalreview.com/patient-experience/inpatient-volumes-poised-to-grow-2-over-next-10-years.html

Adult inpatient volumes will recover to pre-pandemic numbers but grow only 2 percent over the next decade, a new report from Sg2 forecasts.

At the same time, adult inpatient days are expected to increase 8 percent and tertiary inpatient days are poised to increase 17 percent, fueled by an increase in chronic conditions

“While case mix varies by hospital, it is likely this combination of increased inpatient volume, patient complexity and length of stay may require healthcare organizations to rethink service line prioritization, service distribution and investment in care at-home initiatives,” Maddie McDowell, MD, senior principal and medical director of quality and strategy for Sg2, said in a June 7 news release for the report. 

Five other key takeaways from Sg2’s forecasts: 

1. Outpatient volumes are projected to return to pre-pandemic levels in 2022 and then grow 16 percent through 2032, three percentage points above estimated population growth.

2. Surgical volumes are projected to grow 25 percent at ambulatory surgery centers and 18 percent at hospital outpatient departments and physician offices over the next decade. 

3. The pandemic-driven decline in emergency department visits is expected to plateau with a decline in demand projected at -2 percent over the next 10 years.

4. Over the next five years, home care is expected to gain traction, with home evaluation and management visits seeing 19 percent growth, home hospice at 13 percent growth and home physical and occupational therapy at 10 percent growth.

5. Telehealth is expected to resume its climb and by 2032 account for 27 percent of all evaluation and management visits.

Eyeing a rebound in emergency department volumes

https://mailchi.mp/31b9e4f5100d/the-weekly-gist-june-03-2022?e=d1e747d2d8

This week we heard from three healthcare executives that they’ve seen a recent uptick in emergency department (ED) volumes. As we’ve discussed before, ED visits plummeted at the beginning of the pandemic, and were the slowest class of care volume to rebound. Over the past year, many systems reported that ED volume had remained persistently stuck at 10 to 15 percent lower than pre-COVID levels, leading us to question whether there had been a secular shift in patient demand, with consumers choosing alternative options like telemedicine or urgent care as a first stop for minor acute care needs. 
 
An uptick in ED volume would be welcome news to many hospital executives, as the emergency department is the source of half or more of inpatient admissions for many hospitals. But according to what we’re hearing, the recent rise in emergency department patient volume has not resulted in an expected bump in inpatient volume.

“We’ve dug into it, and it seems like the jump in ED visits is a function of COVID,” one leader shared. “There’s just so much COVID out there now…even though the disease is milder, there are still a lot of patients coming to the ED. But unlike last year, most aren’t sick enough to be admitted.”

And ED visits for other causes have not rebounded in the same way: “We’re hoping patients aren’t still staying away because they’re afraid of catching the virus.” We’ll be watching closely across the summer to see how volumes trend as the pandemic waxes and wanes across the country—we’d still bet that many consumers have changed their thinking on where and how they will seek care when the need arises.   

Surprise billing ban leads to cuts at PE-backed staffing firms

https://mailchi.mp/31b9e4f5100d/the-weekly-gist-june-03-2022?e=d1e747d2d8

 When Congress passed the “No Surprises Act” in 2021, credit rating agencies like Moody’s warned that the bill would hurt physician staffing firms, especially those that provide emergency department (ED) services, which result in a surprise bill in roughly one in five visits. A piece from investigative outlet The Lever highlights how one private equity-backed physician staffing firm, Nashville-based American Physician Partners, is responding to the resultant cash flow challenges by cutting ED physician pay, after already reducing staffing levels. As the article describes, this is possible in an otherwise tight labor market because, unlike many other specialties, there’s an oversupply of ED physicians, due to the rapid growth in emergency medicine residency programs over the last decade.  

The Gist: With two-thirds of hospitals outsourcing at least some ED physician labor, the potential insolvency of large physician staffing firms could bring a crisis in access and coverage. 

In addition to revenue cuts tied to the surprise billing ban, rising interest rates also mean that PE firms may soon find it more difficult to fund their aggressive growth strategies. 

Health systems should proactively evaluate their partnerships with PE-backed physician staffing groups, with an eye toward anticipating potential staffing problems and service quality shortfalls.

Houston ER physicians say they were urged to avoid COVID tests, work sick

A group of emergency room physicians filed a lawsuit in March alleging representatives for their employer, American Physician Partners, discouraged them from testing for COVID-19 and pressured them to work while ill, according to the Houston Chronicle

Brentwood, Tenn.-based American Physician Partners staffs and manages ER physicians at more than 15 Houston Methodist facilities, including hospitals and emergency care centers. The lawsuit, which does not involve Houston Methodist employees, centers on a dispute between eight physicians and APP

The physicians allege APP is underpaying them and engaging in “unethical practices,” such as urging physicians with COVID-19 to work, as a way to boost revenue. 

APP’s protocol, “discourages testing and disregards physician, staff, and patient safety when a doctor does test positive for COVID-19,” the lawsuit alleges. The physicians claim APP is putting “profit over patient.” 

APP denied its involvement in the alleged financial damages in a response to the physicians’ complaint filed April 25. The company told the Houston Chronicle that it has been in discussions with the physicians since they raised concerns four months ago. 

“We advised them at that time that their concerns do not reflect the facts known to APP and otherwise appear to be based on misinformation,” APP said in a statement to the Chronicle. “Thus we are disappointed these physicians — who represent a very small minority of the physicians APP partners with in the Houston area — have decided to move forward with this litigation. We remain open to continuing our dialogue with these physicians outside of the litigation, which, again, APP believes is without merit.” 

Houston Methodist, which isn’t involved in or named in the lawsuit, said it cannot comment on the specific allegations, according to the Chronicle. “We are unaware of any ER doctor who came to work after testing positive for COVID-19,” a hospital spokesperson told Becker’s. 

Read the full Houston Chronicle article here.  

The growing burden of mental health on emergency departments

https://mailchi.mp/9d9ee6d7ceae/the-weekly-gist-october-22-2021?e=d1e747d2d8

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 as nearly 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.