2020 State of Healthcare Performance Improvement Report: The Impact of COVID-19

For the past three years, Kaufman Hall has surveyed hospitals and health systems on their performance improvement and cost transformation efforts. This year, these efforts met an historic challenge with the COVID-19 pandemic.

The pandemic’s impacts have been severe. Entire service lines were shut down as state governments required or strongly encouraged suspension of elective and non-emergency procedures, in part to conserve critical resources—including personal protective equipment—in the early days of the pandemic. Supply chains were disrupted, with organizations that had come to rely on “just in time” inventory practices scrambling to secure the resources needed to ensure the safety of patients and frontline clinical staff. The healthcare workforce came under incredible pressure, confronting a crisis that threatened to overwhelm the health system’s capacity to treat patients.

In a year unlike any other, our annual survey moved away from the questions of earlier years. We have focused on the impacts of COVID-19 on hospital and health system performance. Then, through interviews with survey respondents on the front line of the battle with COVID-19, we have sought to understand how health system leaders are seeking to find a path forward amid uncertainty that will likely stretch through 2021, if not beyond.

Key findings from this year’s report include the following:

  • Financial viabilityApproximately three fourths of survey respondents are either extremely (22%) or moderately (52%) concerned about the financial viability of their organization in the absence of an effective vaccine or treatment.
  • Operating margins. One third of our respondents saw year-over-year operating margin declines in excess of 100% from Q2 2019 to Q2 2020.
  • Volumes. Volumes in most service areas are recovering slowly. In only one area—oncology—have a majority of our respondents seen volumes return to more than 90% of pre-pandemic levels.
  • Expenses. A majority of survey respondents have seen their greatest percentage expense increase in the costs of supplying personal protective equipment. Nursing staff labor is in second place, cited by 34% of respondents as their most significant area of expense increase.
  • Healthcare workforce. Three fourths of survey respondents have increased monitoring and resources to address staff burnout and mental health concerns.
  • Telehealth. More than half of our respondents have seen the number of telehealth visits at their organization increase by more than 100% since the pandemic began. Payment disparities between telehealth and in-person visits are seen as the greatest obstacle to more widespread adoption of telehealth.
  • Competition. Approximately one third of survey respondents believe the pandemic has affected competitive dynamics in their market by making consumers more likely to seek care at retail-based clinics.

Einstein warns of cuts, ‘death spiral’ without Jefferson merger

https://www.beckershospitalreview.com/hospital-transactions-and-valuation/einstein-warns-of-cuts-death-spiral-without-jefferson-merger.html?utm_medium=email

How to emerge from a 'death spiral' in stocks - MarketWatch

In a court filing, Einstein Healthcare Network warned that a move by the Federal Trade Commission to block its merger with Jefferson Health could lead to a “death spiral” at its Philadelphia flagship safety-net hospital, according to the Philadelphia Business Journal.

In court documents opposing an FTC analysis of the merger, Einstein said that its financial condition has deteriorated since 2017, resulting in operating losses averaging about $30 million per year.

Einstein said it will incur even greater losses, largely because of the challenging payer mix and large underinsured or uninsured population of its flagship Philadelphia medical center. 

Without a merger, “Einstein [would have to] dramatically cut its services at Einstein Medical Center Philadelphia, leading to job losses and even further reductions in maintenance and needed investment, precipitating a ‘death spiral’ that would jeopardize access to health care for many of Philadelphia’s underserved residents,” Einstein wrote in the documents, according to the Philadelphia Business Journal. 

The FTC announced in February its intent to sue to block the proposed merger, arguing that combining the two systems would reduce competition in Philadelphia and Montgomery counties.

“Jefferson and Einstein have a history of competing against each other to improve quality and service,” the FTC said in February. “The proposed merger would eliminate the robust competition between Jefferson and Einstein for inclusion in health insurance companies’ hospital networks to the detriment of patients.”

Einstein and Jefferson Health countered that a combined system still would face competition from other hospitals and operate in a challenging market dominated by one healthcare insurer, according to the report. 

The Uncertain Future of the Medicare Trust Fund

https://www.commonwealthfund.org/blog/2020/uncertain-future-medicare-trust-fund

Medicare trust fund

The COVID-19 pandemic has increased pressures on an already-stressed public health care financing system. This is especially evident when it comes to the financial health of Medicare’s Hospital Insurance (HI) Trust Fund, which finances health care services related to hospital, skilled nursing facility, and hospice stays for Medicare beneficiaries.

In April, using pre-COVID-19 data, the Trustees of Social Security and Medicare projected that the HI Trust Fund would become insolvent in 2026 — meaning that Medicare Part A claims submitted by providers would not be fully reimbursed. The Congressional Budget Office (CBO) made a similar projection when it issued its March 2020 baseline projections. In a September 2020 report, the CBO projected that the date of insolvency had moved up to 2024.

The pandemic has disrupted economic activity in the United States in several ways: a large and rapid rise in unemployment substantially reduced payments to the Trust Fund from payroll taxes, and hospitals experienced unprecedented financial stress from lost revenues because of a dramatic drop in admissions and procedures, along with new costs arising from the pandemic. One way that Congress provided relief to address these economic shocks was to make advance payments. Between $65 billion and $92 billion in advance payments were made to Medicare Part A providers that draw upon the HI Trust Fund. This increased claims on the Trust Fund in 2020 and lowers them for 2021 — assuming they are paid back in 2021. Together these economic dynamics create a situation that requires quick action to prevent insolvency; the margin for error is small.

The duration of the pandemic and the timing and size of an economic recovery remain highly uncertain. While unemployment has declined notably, from 14.7 percent in April to 8.4 percent in August, new spikes in COVID-19 cases across the country continue to dampen economic activity. The recent jobs report also suggested a slowing of employment recovery. Further, there is great uncertainty about the timing, availability, and effectiveness of a potential vaccine. As a result, we are quite unsure when payroll tax revenues will recover or to what degree hospital finances will recover.

The Federal Reserve Bank of St. Louis recently underscored the uncertainty when it issued the following assessment:

“The COVID-19 pandemic — like all pandemics — will come to an end. Of course, nobody knows when that will be. No one also knows whether there will be subsequent waves of the virus that trigger a nationwide resumption of strict social distancing protocols or whether a proven vaccine allows a swift return to pre-COVID norms. Thus, the trajectory of the recovery is the key unknown at this point.”

Together these forces create policy tensions. It is important to continue to support hospitals and nursing homes whose revenues have not yet recovered, and those that continue to incur unusual costs because they are still carrying heavy financial burdens stemming from COVID-19. At the same time state and federal health care financing programs are under extreme financial stress.

Recent legislation negotiated between Congress and the Trump administration would permit hospitals to request an extension for repaying advance payment loans and also reduce the interest rate. Together, these provisions recognize the continued financial stress and provide relief but also introduce new uncertainty. That is, by lengthening the repayment period and reducing the costs of carrying the loans it becomes less certain when they will be paid back in full and returned to the Trust Fund, making the solvency date of the Trust Fund less certain (as specified further in Centers for Medicare and Medicaid Services guidance). In addition, this assumes that the full amounts of the loan will be paid back.

The timing of the COVID-19 pandemic has been especially unfortunate in terms of maintaining the Medicare HI Trust Fund’s solvency. The Trustees issued a warning that action was needed when insolvency was estimated to occur in 2026; it has now been pushed up to 2024. One way to address the uncertainty would be to make a fund transfer from general revenues to the Trust Fund in the amount of the outstanding loans, thereby removing any additional uncertainty around timing of repayment. This could help mitigate risks in a world with highly uncertain economic and epidemiological forecasts but would risk further increasing federal spending during an economic downturn.

New Jersey hospitals are a microcosm of potential COVID-19 financial impact

https://www.healthcarefinancenews.com/news/new-jersey-hospitals-microcosm-potential-covid-19-financial-impact

What CFOs think about the economic impact of COVID-19

The last time margins sank so deeply into the red was after the Balanced Budget Act of 1997, though today’s margins are faring worse.

COVID-19 continues to have deep and lingering financial impacts on hospitals in New Jersey. A midyear analysis of financial data shows nearly 60% of the state’s hospitals in the red and an average statewide operating margin of negative 4%.

The effects have been profound, and serve as a potential microcosm of the continuing impact of the coronavirus on hospital operating margins nationwide.

The decline in the state is the result of a dual blow of declining revenues and rising expenses, according to the report from the Center for Health Analytics, Research and Transformation at the New Jersey Hospital Association. Officials said the state’s hospitals haven’t experienced this level of fiscal distress in more than 20 years.

In fact, the last time margins sunk so deeply into the red was in the late 1990s. At that time, the Balanced Budget Act of 1997 resulted in significant payment cuts to the state’s hospitals, with margins falling to -1.7% and -2.3% in 1998 and 1999, respectively. And those numbers are not as distressing as the ones being experienced during the public health crisis.

WHAT’S THE IMPACT?

The report, “At Mid-Year, COVID-19’s Financial Wounds Continue for N.J. Hospitals,” shows the impact of continued loss of revenue from the suspension of elective procedures at COVID-19’s peak in the spring, and the slow rebound of patients returning to the hospital.

CHART’s data, comparing June 30, 2019, with June 30, 2020, shows that total patient revenues declined 6.6%. Emergency department cases plummeted 23%, while hospital admissions fell by 8% and outpatient visits dropped by 22%.

An additional aggravating factor is a 12% increase in total operating expenses, because COVID-19 required hospitals to redirect resources to increase staffing; boost supplies of personal protective equipment, pharmaceuticals and ventilators; and modify operations and facilities to expand capacity.

CHART’s analysis takes a closer look at the disruption of elective procedures in New Jersey hospitals and its lingering impact. Governor Phil Murphy’s Executive Order 109, in effect March 27 through May 26, required hospitals to suspend elective procedures during the state’s COVID-19 surge. CHART used claims data for some of the highest-volume elective procedures performed in New Jersey hospitals – bariatric surgery, pacemaker insertion, spinal fusion, knee replacement and hernia repair – to gauge the impact.

In April and May 2019, the state’s hospitals performed these procedures 4,336 times. That number plummeted to just 400 statewide in April and May 2020. The state’s executive order suspending procedures during this time allowed exemptions for cases in which a delay would result in “undue risk to the current or future health of the patient.” 

The year-over-year decline persisted even when the suspension was lifted. In June and July of 2019, 4,194 procedures from the list of high-volume procedures were performed, compared with 3,191 in June and July of 2020.

But the greatest decline in volume by percentage was seen in hospital emergency departments, where cases nosedived 23.4% between June 30, 2019, and June 30, 2020. That has healthcare leaders concerned.

NJHA officials said a hospital turnaround is critical for the statewide recovery from the coronavirus.

“The state’s hospitals pump $25 billion annually into the New Jersey economy and employ 154,000 people,” said NJHA’s Roger Sarao, vice president of economic and financial information and lead author of the CHART report. “They are an essential part of the road to recovery from this public health and economic crisis.”

THE LARGER TREND

The effects of the pandemic on the nation’s hospitals will be long-lasting, especially among nonprofits. A recent Fitch Ratings analysis showed that the full effects have yet to be felt.

The agency predicted that capital spending will be greatly reduced in the initial years post-pandemic, though some of it will ultimately accelerate due to anticipated merger and acquisition activity.

Fitch expects hospitals to take on added expenses to perform the same level of service, and predicts revenue declines from a shift in payer mix.

Lee Health to freeze pay for 13,500 employees

https://www.beckershospitalreview.com/compensation-issues/lee-health-to-freeze-pay-for-13-500-employees.html?utm_medium=email

Tuesday's Headlines: Junior Bankers Watch Out—Pay Freeze May Be Imminent |  eFinancialCareers

Fort Myers, Fla.-based Lee Health is freezing salaries for its 13,500 employees next year to help offset financial losses tied to the COVID-19 pandemic, according to the Fort Myers News-Press

The pay freeze in 2021 will mark the first time in nine years that the publicly operated health system has not given employee raises. Salaries and benefits make up about half of the system’s nearly $2 billion in spending each year, according to the report.

Lee Health is facing a budget deficit for the first time in two decades due to financial strain linked to the pandemic. The salary freeze is one of several steps the system is taking to offset losses and avoid layoffs. 

The system has halted most capital projects, and its top executives took pay cuts earlier this year. Lee Health will also reduce the match for employee retirement plans from 5 percent to 4 percent next year, and health plan premiums and copays will also increase, according to the report.

Read the full Fort Myers News-Press article here

 

 

 

 

Another 870,000 Americans filed new unemployment claims last week

https://finance.yahoo.com/news/jobless-claims-coronavirus-unemployment-week-ended-september-19-2020-184747657.html

Another 870,000 Americans filed for first-time unemployment benefits last week, unexpectedly rising slightly from the prior week to reaffirm a slowdown in the U.S. economic recovery.

The U.S. Department of Labor (DOL) released its weekly jobless claims report at 8:30 a.m. ET Thursday. Here were the main metrics from the report, compared to Bloomberg estimates:

  • Initial jobless claims, week ended Sept. 19: 870,000 vs. 840,000 expected, and 866,000 during the prior week
  • Continuing claims, week ended Sept. 12: 12.580 million vs. 12.275 million expected, and 12.747 million during the prior week

At 870,000, Thursday’s figure represented the fourth consecutive week that new jobless claims came in below the psychologically important 1 million level, but was still high on a historical basis. Nevertheless, the labor market has made strides in recovering from the pandemic-era spike high of nearly 7 million weekly new claims seen in late March.

“While jobless claims under a million for four straight weeks could be considered a positive, we’re staring down a pretty stagnant labor market,” Mike Loewengart, managing director of investment strategy for E-Trade Financial Corporation, said in an email Thursday. “This has been a slow roll to recovery and with no signs of additional stimulus from Washington, jobless Americans will likely continue to exist in limbo. Further, a shaky labor market translates into a skittish consumer, and in the face of a pandemic that seemingly won’t go away without a vaccine, the outlook for the economy certainly comes into question.”

On an unadjusted basis, initial jobless claims rose by a greater margin, or about 28,500, from the previous week to about 824,500. The seasonally adjusted level of new claims rose by 4,000 week on week.

By state, unadjusted claims in California – where joblessness due to the pandemic has compounded with labor market stress due to wildfires – were again the highest in the country at more than 230,000, for an increase of about 4,400 week-over-week. Georgia, New York, New Jersey and Massachusetts also reported significant increases in new claims relative to the rest of the country. Most states reported at least increases in new claims last week.

Continuing claims have also trended lower after a peak of nearly 25 million in May, and fell for a second straight week in this week’s report. But these claims, which capture the total number of individuals still receiving unemployment insurance, have not broken below the 12 million mark since before the pandemic took hold of the labor market in mid-March.

Consistently high numbers of individuals have been filing for, and receiving, jobless benefits from regular state programs, and those newly created during the pandemic. The number of individuals claiming benefits in all programs for the week ended September 5 – the latest reported week – fell for the first time following three straight weeks of increases to 26.04 million, from the nearly 29.8 million reported during the prior week.

Of that total, more than 11.5 million comprised individuals receiving Pandemic Unemployment Assistance, which is aimed at self-employed and gig workers who don’t qualify for regular unemployment compensation but have still been impacted by the pandemic.

One of the major downside risks to further improvement in the labor market has been concern that Congress may not soon pass another round of fiscal stimulus aimed at keeping individuals on payrolls during the pandemic. Economists have already said that the end of the last round of augmented federal unemployment benefits in late July has weighed on improvements in joblessness.

“The current picture suggests that growth has slowed sharply in the past three months, and that the labor market is stalling again in the face of rising infections and the sudden ending of federal government support to unemployed people,” Ian Shepherdson, chief economist for Pantheon Macroeconomics, said in a note Wednesday.

The need for more fiscal stimulus to encourage the economy’s ongoing recovery has become a key talking point of policymakers including Federal Reserve Chair Jerome Powell and his colleagues at the central bank. In congressional testimony Tuesday and Wednesday, the Fed leader said further fiscal stimulus is “unequaled” by any other form of support that could be unleashed, with the central bank’s lending facilities having gone largely untouched by Main Street.

“The concept of the [congressionally authorized] Paycheck Protection Program was helpful because for many of those kinds of businesses – those businesses that don’t have cash reserves – the ability to get a forgivable loan if they stay open, if they keep people employed, was sound, and did give them the prospect of staying in business,” Joseph Minarik, The Conference Board chief policy economist and former Office of Management and Budget chief economist, told Yahoo Finance. “The notion that you have businesses that have been weak over the last few months and now have simply had to shut their doors, that’s a real problem, and it is not necessity going to be solved with a loan.”

 

 

 

 

Jefferson Health CFO walks back stance that Einstein is at risk without merger

https://www.beckershospitalreview.com/finance/jefferson-health-cfo-walks-back-stance-that-einstein-is-at-risk-without-merger.html?utm_medium=email

Jefferson Health Announces Partnership with Prepared Health to Coordinate  Care Transitions from Hospital to Home - Dina

Jefferson Health walked back its stance that Einstein Health Network’s flagship hospital is at risk of financial failure without a merger during the first day of arguments at a trial, according to Law360.

The Federal Trade Commission’s legal challenge to block the proposed merger of Einstein Healthcare Network and Jefferson Health started in court Sept. 14. The FTC argues that combining the two Philadelphia-based systems would reduce competition in the Philadelphia region and Montgomery County.

In response to the legal challenge, Jefferson Health and Einstein argued that the merger is a matter of survival for Einstein’s flagship hospital

The health systems argued that Einstein, which has only had annual operating profits twice since 2012, is on a path to financial failure without the deal and needs $500 million to invest in key capital projects and deferred maintenance. Further, the organizations said that without the infusion, Einstein will continue to weaken “as it is forced to cut services or close facilities.”

However, at day one of the trial, Jefferson Health CFO Peter DeAngelis conceded during arguments that Jefferson had no evidence that Einstein is in danger of insolvency, despite painting the finances as bleak, according to Law360. 

The hearing on the preliminary injunction is expected to last the entire week, but a decision won’t happen by the end of the week. An additional round of filings must be submitted by the FTC and the two health systems by Sept. 28. The judge overseeing the case hopes to issue a decision before Jan. 1, according to The Philadelphia Inquirer. 

 

 

 

 

Executive Order On Housing Doesn’t Guarantee An Eviction Moratorium

https://www.forbes.com/sites/advisor/2020/08/10/trumps-executive-order-on-housing-doesnt-guarantee-an-eviction-moratorium/?tid=newsletter-dailydozen&utm_source=newsletter&utm_medium=email&utm_campaign=dailydozen&cdlcid=5d2c97df953109375e4d8b68#3a33cbc3359a

After negotiations for another stimulus package hit a dead end in Washington last week, President Donald Trump signed executive orders to extend relief in the meantime. One order, according to the president, would extend the federal eviction moratorium. 

The original moratorium, included in the CARES Act, prohibited landlords or housing authorities from filing eviction actions, charging nonpayment fees or penalties or giving notice to vacate. It expired on July 24 and only applied to federally subsidized or federally backed housing.

But housing advocates are pushing back, saying Trump’s executive order to extend an eviction moratorium actually does nothing at all—and keeps struggling Americans at risk of losing their housing. 

 

Details on the Order

Trump’s order doesn’t actually extend the federal eviction moratorium. Instead, it calls on the Department of Health and Human Services and the Centers for Disease Control and Prevention to “consider” whether an additional eviction ban is needed.

“The Secretary of Health and Human Services and the Director of CDC shall consider whether any measures temporarily halting residential evictions of any tenants for failure to pay rent are reasonably necessary to prevent the further spread of COVID-19 from one State or possession into any other State or possession,” reads the order.

Additionally, the executive order does not provide any new money to help struggling renters during the pandemic. Instead, it says the secretary of Treasury and the secretary of Housing and Urban Development—Steven Mnuchin and Ben Carson, respectively—can identify “any and all available federal funds” to provide temporary rental assistance to renters and homeowners who are facing financial hardships caused by COVID-19.

During a White House press briefing on Monday, Kayleigh McEnany said the president did “did what he can within his executive capacity…to prevent resident evictions.”At the time of publishing, officials mentioned in Trump’s executive order have not released guidelines on extending the federal eviction moratorium.

 

Housing Advocates React to Trump’s Eviction Order

Housing advocates have not reacted positively to Trump’s executive order, suggesting officials extend an eviction moratorium.

“The executive order that he signed this weekend is really nothing more than an empty shell that creates chaos and confusion, and it offers nothing more than false hope to renters who are at risk of eviction because that executive order does literally nothing to prevent or stop evictions,” Diane Yentel, president and CEO of the National Low Income Housing Coalition, said on Sunday during an MSNBC interview.

The House of Representatives included a more thorough plan to prevent evictions in its HEROES Act proposal. The proposal included $175 billion in rent and mortgage assistance and would replace the original federal eviction moratorium with a 12-month moratorium from all rental housing, not just federally subsidized ones. There also would be funds available to provide homeowners with assistance to cover mortgage and utility payments, property taxes or other resources to help keep Americans housed.

Sen. Richard Shelby (R-AL) introduced the Coronavirus Response Additional Supplemental Appropriations Act as part of the GOP’s HEALS Act proposal. Shelby’s bill included significantly less money for housing assistance than the HEROES Act—$3.2 billion—and would be used for tenant-based rental assistance. Shelby’s proposal did not include any language about extending the CARES Act eviction moratorium. 

A recent report by a group of housing advocates finds there could be as much as 40 million renters at risk of eviction in the coming months. The U.S. unemployment rate currently sits at 10.2%. 

Individuals who are struggling to pay rent might have assistance options available. Some cities and states have implemented their own eviction moratoriums—you can learn more about them by visiting the Eviction Lab at Princeton University. There are also legal aid options, like Just Shelter, that will help tenants who are facing eviction for low-cost or free.

 

 

 

 

Cartoon – Unemployment Insurance vs. Raising the Minimum Wage

If you make less than $600 week, you’re underpaid. Period.

No photo description available.

Pandemic relief funds pivotal in keeping hospitals afloat during Q2

https://www.fiercehealthcare.com/hospitals/hospital-earnings-highlight-pivotal-role-federal-relief-funds-staying-afloat-during?mkt_tok=eyJpIjoiTURoaU9HTTRZMkV3TlRReSIsInQiOiJwcCtIb3VSd1ppXC9XT21XZCtoVUd4ekVqSytvK1wvNXgyQk9tMVwvYXcyNkFHXC9BRko2c1NQRHdXK1Z5UXVGbVpsTG5TYml5Z1FlTVJuZERqSEtEcFhrd0hpV1Y2Y0sxZFNBMXJDRkVnU1hmbHpQT0pXckwzRVZ4SUVWMGZsQlpzVkcifQ%3D%3D&mrkid=959610

Hospital system earnings for the second quarter of the year painted a stark picture of how federal relief funding helped offset massive losses in patient volume sparked by the COVID-19 pandemic.

But a full financial recovery may not happen until next year, some analysts warn.

Major hospital systems such as HCA Health and Universal Health Services posted profits in the second quarter despite plummeting volumes sparked by the cancellation of elective procedures and patients avoiding care due to fears of exposure to the virus. A key boost, however, came from a $175 billion fund passed by Congress and loans under the Medicare Accelerated and Advance Payments Program.

“These companies survived the June quarter and exited the quarter with substantial amounts of liquidity,” said Jonathan Kanarek, vice president and senior credit officer for Moody’s Investors Services. “We think [liquidity] is probably the most critical factor for them as far as weathering the storm.”

Congress has approved $175 billion to help prop up providers, of which the Department of Health and Human Services has distributed more than $100 billion.

The Centers for Medicare & Medicaid Services also gave out $100 billion in advance Medicare payments before suspending the program in late April. But the payments are loans that hospitals have to start repaying as soon as this month, as opposed to the congressional funding that does not have to get paid back.

Hospital system earnings illustrated how pivotal the relief funds were to combat massive holes in patient volumes.

Tenet Healthcare, which operates 65 hospitals across the country, reported Monday that it earned in the second quarter adjusted earnings before interest, taxes, depreciation and amortization (EBITDA) of $732 million. But of that $732 million, more than 70% of it was aid from the relief fund.

Tenet wasn’t the only for-profit system where relief funding was a large part of their adjusted EBITDA.

Community Health Systems, which operates 95 facilities, reported an adjusted EBITDA of $454 million in the second quarter. But most of that figure was due to the $448 million that it got from the relief funds.

The provider funding made up a smaller portion of HCA Healthcare’s earnings. The system of 184 hospitals reported that the funding made up 31% of its adjusted EBITDA.

Hospital system volumes greatly declined in April as facilities were forced to cancel elective procedures and patients were scared of going to the hospital.

For example, Tenet’s hospital admissions in April were 33% of what it had in the same month in 2019. But volumes started to recover as shelter-in-place orders expired and some states got a better handle on the pandemic.

Tenet saw admissions grow in June to 90% of what they were in June 2019.

But it remains unclear what hospital finances will look like for the rest of the year. Major systems like Tenet and HCA have scrapped their 2020 financial outlook because of the pandemic.

“We don’t think the shape of this recovery or trajectory will be linear in nature,” Kanarek said. “We think there will be a lot of starts and stops.”

Those starts and stops will depend on the extent of the spread of the virus in an area.

Some states such as Florida, Texas and Arizona have seen massive spikes in the virus in recent weeks, which has put renewed strain on systems. Texas’ governor canceled elective procedures in eight counties back in June, some of which included major cities such as Houston and Dallas.

“I am a little skeptical that we are going to be back to normal before we ultimately have a vaccine,” Kanarek said.

It is also murky on whether hospitals will continue to get more financial help from Congress.

The House passed the HEROES Act more than a month ago that gives providers another $100 billion, but it has stalled in the Senate.

Congress and the White House have been in extensive talks for more than a week on a new relief package. Senate Majority Leader Mitch McConnell released a package last week that had $25 billion in relief funding and lawsuit liability protections for providers.

But even without the additional funding, for-profit hospitals have made some moves to prepare for more shutdowns such as accessing capital markets to add additional lawyers of bank liquidity, Kanarek said.

“We can only hope 2021 will look like a more normal year for hospitals, perhaps more like 2019, but there is still a lot of uncertainty out there,” he said.