Some hospital systems located in states that are seeing huge spikes of COVID-19 are continuing to perform elective procedures and developing strategies to avoid a total shutdown.
The experiences of hospitals in states such as Florida and Arizona could inform how systems will handle new surges of COVID-19 cases, especially if a second surge of the virus arrives in the fall. Hospitals have been reticent to shut down surgical procedures, which are pivotal to their bottom line and also impact patient care.
“We are not turning it all the way off,” said Marjorie Bessel, M.D., chief clinical officer for Banner Health, referring to elective procedures. “Our surgeries are needed and medically necessary and people need to have those surgeries done.”
The 28-hospital system has a large footprint in Arizona, which is experiencing a major spike in cases. Bessel said 45% of Arizona COVID-19 patients are in a Banner Health facility.
Like many states, Arizona’s governor required hospitals to shutter elective procedures to ensure there is enough capacity and personal protective equipment (PPE) for COVID-19 patients. The governor lifted the shutdown May 1, and Banner has slowly ramped up delayed or canceled elective procedures.
“We attempted to reduce the backlog of people who had been waiting or wait-listed,” Bessel told Fierce Healthcare. “We didn’t quite get back to full normal operations, but we got close.”
That progress has been hindered now as COVID-19 cases soar in the state.
But instead of doing a full shutdown, Banner is implementing a tiered and step-wise approach to surgeries.
“One of the things that we are going to try is to do surgeries for patients that don’t need an inpatient stay,” Bessel said. “We are gonna try that and see how that works for us.”
The system is also tightly monitoring the patients that need an intensive care unit stay after their surgery. Banner can transfer patients to other facilities to ensure it has enough capacity.
“We look at our [patient] census almost hourly throughout the day and the night and make these adjustments to best meet the needs of those in the community,” she said.
Tampa General Hospital in Florida resumed elective procedures back in early May and is still performing surgeries as COVID-19 cases rise. The hospital told Fierce Healthcare that it treats COVID-19 patients in a “negative-pressure unit that is separate from other areas of the hospital.”
The hospital has 81 of these rooms and 100 hospitals and has a surge plan to adjust capacity when necessary.
Another important factor for hospitals is to communicate with patients about what is going on. Tampa General, for instance, issued a release on when it is appropriate to go to the emergency room and outlined the procedures for screening patients of COVID-19 to assuage fears.
Hospitals’ own internal processes have also gotten better amid the COVID-19 pandemic.
“In the operating area, COVID-19 has made us more efficient,” said Michael Zinner, M.D., CEO of the Miami Cancer Institute, which is part of 11-hospital system Baptist Health South Florida. “It has taught us how to move things out of the general operating room into ambulatory and more efficient in the turnovers. It has taught us how to adapt.”
Some states could decide to shut down elective procedures again, which is a move Texas has decided to make in four counties in the state.
Getting and keeping enough PPE
One of the key reasons that states ordered hospitals to shut down surgeries was to preserve enough PPE for COVID-19 care.
But hospital systems say they are in a better place now in terms of PPE than they were at the onset of the pandemic, when a buying spree caused hospitals to fight among each other to get supplies.
“We are a heck of a lot better than we were two months ago,” Zinner said.
“Besides the current spike, we were preparing for what we think will be a surge in the fall,” Zinner added.
Another important development for hospitals now is there are guidelines for how to reprocess PPE.
“We have found ways to reprocess some PPE safely so you can reuse it without losing efficacy and take it through a decontamination procedure,” said Michael Calderwood, M.D., an epidemiologist at Dartmouth-Hitchcock Medical Center in New Hampshire.
He pointed to using ultraviolet light and hydrogen peroxide as among methods facilities can use to reprocess their supplies.
The type of PPE that is used in surgeries is also sometimes different than the equipment used to treat COVID-19 patients, Bessel said.
“They use a procedural mask for most of the cases, while the masks in shortage has been the N-95 respirators,” she said.
In the six months since the World Health Organization (WHO) detected a cluster of atypical pneumonia cases at a hospital in Wuhan, China, the coronavirus pandemic has touched every corner of the globe, carving a trail of death and despair as humankind races to catch up.
At least 10.4 million confirmed cases have been diagnosed worldwide, and the true toll is likely multiples of that figure. In the United States, health officials believe more than 20 million people have likely been infected.
A staggering 500,000 people around the globe have died in just six months. More people have succumbed to the virus in the U.S. — 126,000 — than the number of American troops who died in World War I.
But even after months of painful lockdowns worldwide, the virus is no closer to containment in many countries. Public health officials say the pandemic is getting worse, fueled by new victims in both nations that have robust medical systems and poorer developing countries.
“We all want this to be over. We all want to get on with our lives. But the hard reality is this is not even close to being over,” WHO Director-General Tedros Adhanom Ghebreyesus said Monday. “Globally, the pandemic is actually speeding up.”
In the U.S., the fierce urgency of March and April has given way to the complacency of summer, as bars and restaurants teem with young people who appear largely convinced the virus poses no threat to them. New outbreaks, especially among younger Americans, have forced 16 states to pause or roll back their reopening plans.
“This is a really challenging point in time. It’s challenging because people are tired of the restrictions on their activity, people are tired of not being able to socialize, not being able to go to work,” said Richard Besser, a former acting director of the Centers for Disease Control and Prevention (CDC) who now heads the Robert Wood Johnson Foundation.
“You have people who have reached that point of pandemic fatigue where they just don’t want to hear it anymore, they just want to go back to their life,” he added.
The number of new U.S. cases has risen sharply in recent weeks, led disproportionately by states in the South, the Midwest and the Sun Belt. More than a quarter-million people tested positive for the coronavirus last week, and more than 40,000 tested positive on three consecutive days over the weekend.
“We are now having 40-plus thousand new cases a day. I would not be surprised if we go up to 100,000 a day if this does not turn around. And so I am very concerned,” Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases, told a Senate panel on Tuesday.
Public health experts now worry that a rising tide of death is about to crest across the United States. Officials in Alabama, Arizona, California, Mississippi and Texas are reporting a surging number of COVID-19 hospitalizations, leading to fears that health systems could soon be overrun.
“If you’re over the hospital capacity, people will start dying faster,” said Eric Feigl-Ding, an epidemiologist and health economist at the Harvard T.H. Chan School of Public Health and a senior fellow at the Federation of American Scientists.
Already, Arizona has reported more coronavirus deaths per million residents in the last week, at 4.77, than any nation on Earth except Chile and Peru.
The response to the coronavirus pandemic has varied widely, and in some parts of the world, both wealthy and developing nations have brought it under control. In the U.S., some states hit hard early on have wrangled transmission under control.
But even in states that have achieved some measure of success, the spikes in cases stand in stark contrast to countries that have bent the epidemiological curves to manageable levels.
Mass screenings in South Korea crushed the spread, and quick action to identify and isolate contacts in more recent hot spots have meant new outbreaks are quickly contained. South Korea, with a population of 51 million, has reported just 316 new cases in the past week, fewer than the number of new cases reported in Rhode Island, a state with slightly more than 1 million residents.
Germany raced to protect its elderly population and rapidly expanded its hospital capacity. It deployed the world’s most successful diagnostics test, developed at a Berlin hospital, on a massive scale. With a population of 83 million, the country has reported 78 coronavirus deaths in the past week; Mississippi, population 3 million, reported 96 coronavirus-related deaths during the same period.
Vietnam imposed mandatory quarantines on contacts, including international travelers, in government-run centers to stop the spread. Among its 95 million residents, Vietnam has confirmed 355 total cases since the outbreak began. Alabama, population 4.9 million, reported 358 cases on Sunday alone.
Those countries have begun loosening restrictions on their populations and their economies, with few signs of major flare-ups.
The United States has begun to open up too but without bending the curve downward, and the results have been disastrous. The number of daily confirmed cases has more than doubled in nine states over the past two weeks and has increased by more than half in 17 more.
“I have really grave concerns that viral transmission is going to get out of control,” Besser said.
In interviews, public health experts and epidemiologists confess to feelings of depression and disgust over the state of the nation’s response. Some remain exasperated that there is still no coordinated national response from the White House or federal agencies.
President Trump has rarely mentioned the virus in recent weeks, aside from using racial epithets and suggesting his administration would slow testing to reduce the number of confirmed cases. He later said he was joking.
“There should be some sort of federal leadership,” Feigl-Ding said. “Every state’s on its own, for the most part.”
Left to their own devices, some states are trending in the right direction. Connecticut, Maryland, New Hampshire, New York, North Dakota, Rhode Island, South Dakota and the District of Columbia have seen their case counts decline for two consecutive weeks or more. New York reported 4,591 new cases in the last week — a startlingly high figure but only a fraction of the 65,000 cases infecting the state during its worst week, in early April.
States with their numbers on the decline have benefited from fast action and strict measures. They’re also viewed as role models for states that are now experiencing surges.
“States who are now on the rapid upslope need to act quickly, take the advice and example of states that have already been through this,” said Abraar Karan, an internist at Brigham and Women’s Hospital and Harvard Medical School. “We know what needs to be done to win this in the short run, and we are working on what needs to happen for the longer term.”
If there is a silver lining, it is that the number of tests American states are conducting on a daily basis has grown to about 600,000, on its way toward the millions the nation likely needs to fully control the spread.
But that silver lining frames a darkening cloud: As the virus spreads, even the higher testing capacity has been strained, and state and local governments are hitting their limits and running low on supplies.
The greater number of tests does not account for the speed of the spread, as Trump has suggested. The share of tests that come back positive has averaged almost 7 percent over the last week, according to The Hill’s analysis of national figures; in the first week of June, just 4.6 percent of tests were coming back positive.
If greater testing were responsible for more cases, the percentage coming back positive should decrease rather than increase. The higher positive rates are an indication the virus is spreading more rapidly.
As with so much else in American life, the coronavirus has become a political battleground. The new front is over face masks, which studies show dramatically reduce transmission. States that have mandated wearing masks in public saw the number of new cases decline by a quarter between the first and third weeks of June; states that do not require masks in any setting saw the number of cases rise by 84 percent over that same span.
“From a public health perspective, it’s demoralizing, it’s tragic … because our public health leaders know what to do to get this under control, but we’re in a situation where the CDC is not out front in a leadership role. We’re not hearing from them every day. They’re not explaining and capturing people’s hearts and minds,” said Besser, the former CDC chief. “If we have a vaccine, that will be terrific if it’s safe and effective. But until that point, these are the only tools we have, these tools of public health, and they’re very crude tools.”
With the spike in coronavirus cases in Southern and Western states, commercial laboratories say they do not have the capacity to keep up with growing demand for their testing services and predict longer turnaround times for results over the coming weeks.
The American Clinical Laboratory Association, which represents LabCorp, Quest Diagnostics and other labs, said Saturday its members have seen a steady increase in the volume of COVID-19 test orders recently, specifically calling out the fact that critical testing materials are in short supply.
Quest on Thursday issued its own warning thatdespite the rapid expansion of its testing capacity, demand has been growing faster. In particular, the lab giant noted that orders for molecular diagnostic services have increased by about 50% over the past three weeks.
U.S. commercial labs had made “significant strides” during the coronavirus pandemic by expanding testing capacity from about 100,000 tests per day in early April to more than 300,000 currently, according to ACLA.
But newly emerging hotspots like Arizona, California and Texas are putting a strain on labs and an already limited supply of testing materials, the group said.
While labs nationwide are trying to increase capacity by purchasing more testing machines and attempting to secure additional test materials from suppliers, ACLA President Julie Khani cautioned, “the reality of this ongoing global pandemic is that testing supplies are limited” and “every country across the globe is in need of essential testing supplies, like pipettes and reagents, and that demand is likely to increase in the coming months.”
Khani said ACLA has been in talks with the Trump administration and supply chain partners about the challenges labs face as they try to increase their level of respective COVID-19 testing abilities to meet the anticipated increase in U.S. demand for tests over the coming weeks.
In the absence of a solution, Khani warned that significant demand “will likely exceed” labs’ testing capacities and “could extend turnaround times for test results.”
For its part, Quest’s statement on Thursday described the U.S. coronavirus outbreak as an “evolving” situation that is putting a “strain” on the company’s COVID-19 testing resources.
“Today, we have the capacity to perform approximately 110,000 of these tests a day (770,000 a week). Despite the rapid expansion of our testing capacity, demand for testing has been growing faster,” according to Quest.
Currently, Quest’s average turnaround time for test results are one day for hospital patients, pre-operative patients in acute care settings, and symptomatic healthcare workers, and two to three days for all other patient populations. However, the company warned that “given increased demand, we expect average turnaround times near term to extend in excess of 3 days.”
Nonetheless, Quest said it is taking actions to try to increase COVID-19 testing scale, with the goal of being able to perform 150,000 tests per day. Toward that end, the company is installing additional testing platforms in its network of U.S. labs and said it is collaborating with independent labs who currently have underused capacity.
Quest’s rival LabCorp was not immediately available for comment on its testing capacity amid reports of demand increasing across the country.
Healthcare executives in the Milwaukee area say they plan to continue offering elective care even if COVID-19 hospitalizations spike, according to the Milwaukee Business Journal.
Many public health experts expect a second wave of COVID-19 infections to hit by the end of the year. But the healthcare executives said that hospitals won’t need to implement strict elective care cancellation procedures as they did in March and April because more is known about the virus.
“We know COVID now,” Jeff Bahr, MD, chief Aurora Medical Group officer for Advocate Aurora Health, told the Business Journal.“I accept that there might be another peak. The name of the game right now is to be able to continue to serve patients and continue despite another bump or spike.”
Dr. Bahr added that Advocate Aurora Health executives plan to continue “with minimal interruption” to elective surgical procedures.
Spokespeople for ProHealth Care, Froedtert Health, the Medical College of Wisconsin and Children’s Wisconsin also told the Business Journal that their organizations plan to continue some or all elective surgeries even if there is a second surge in COVID-19 cases.
Medical College of Wisconsin President and CEO John Raymond Sr., MD, told the Business Journal that “Even with a second wave or surge of COVID-19 cases, I do not believe that we will need to return to the stringent restrictions that were imposed on elective procedures and routine clinical care in March and April of this year.”
ProHealth Care and Children’s Hospital of Wisconsin officials said that they plan to offer elective care amid a spike, but the amount of that care will depend on several factors, including whether there’s enough protective gear for staff.
Health systems across the U.S. canceled elective procedures in mid-March in an effort to prepare for a spike in COVID-19 cases. As a result of the cancellations of the more lucrative services, health systems saw steep revenue drops. Throughout the last month, hospitals have started to resume elective services.
Patient volumes at hospitals, doctors’ and dentists’ offices recovered slightly in May but lagged well behind pre-pandemic levels, according to a new analysis from Moody’s Investors Service.
In all, the ratings agency estimated total surgeries at rated for-profit hospitals declined by 55% to 70% in April compared with the same period in 2019. States required hospitals to cancel or delay elective procedures, which are vital to hospitals’ bottom lines.
“Patients that had been under the care of physicians before the pandemic will return first in order to address known health needs,” officials from the ratings agency said in a statement. “Physicians and surgeons will be motivated to extend office or surgical hours in order to accommodate these patients.”
Those declines narrowed to 20% to 40% in May when compared to 2019.
Emergency room and urgent care volumes were still down 35% to 50% in May.
“This could reflect the prevalence of working-from-home arrangements and people generally staying home, which is leading to a decrease in automobile and other accidents outside the home,” the analysis said. “Weak ER volumes also suggest that many people remain apprehensive to enter a hospital, particularly for lower acuity care.”
The good news: The analysis estimated it is unlikely there will be a return to the nationwide decline of volume experienced in late March and April because healthcare facilities are more prepared for COVID-19.
For instance, hospitals have enough personal protective equipment for staff and have expanded testing, the analysis said.
For-profit hospitals also have “unusually strong liquidity to help them weather the effects of the revenue loss associated with canceled or postponed procedures,” Moody’s added. “That is largely due to the CARES Act and other government financial relief programs that have caused hospital cash balances to swell.”
However, the bill for one of those sources of relief is coming due soon.
Hospitals and other providers will have to start repaying Medicare for advance payments starting this summer. The Centers for Medicare & Medicaid Services doled out more than $100 billion in advance payments to providers before suspending the program in late April.
Hospital group Federation of American Hospitals asked Congress to change the repayment terms for such advance payments, including giving providers at least a year to start repaying the loans.
Another risk for providers is the change in payer mix as people lose jobs and commercial coverage, shifting them onto Medicaid or the Affordable Care Act’s (ACA’s) insurance exchanges.
“This will lead to rising bad debt expense and a higher percentage of revenue generated from Medicaid or [ACA] insurance exchange products, which typically pay considerably lower rates than commercial insurance,” Moody’s said.
From El Centro Regional Medical Center, the largest hospital in California’s Imperial County, it takes just 30 minutes to drive to Mexicali, the capital of the Mexican state of Baja California. The international boundary that separates Mexicali from Imperial County is a bridge between nations. Every day, thousands of people cross that border for work or school. An estimated 275,000 US citizens and green card holders live in Baja California. El Centro Regional Medical Center has 60 employees who reside in Mexicali and commute across the border, CEO Adolphe Edward told Julie Small of KQED.
Now these inextricably linked places have become two of the most concerning COVID-19 hot spots in the US and Mexico. While Imperial County is one of California’s most sparsely populated counties, it has the state’s highest per capita infection rate — 836 per 100,000, according to the California Department of Public Health. This rate is more than four times greater than Los Angeles County’s, which is second-highest on that list. Imperial County has 4,800 confirmed positive cases and 64 deaths, and its southern neighbor Mexicali has 4,245 infections and 717 deaths.
The COVID-19 crisis on the border is straining the local health care system. El Centro Regional Medical Center has 161 beds, including 20 in its intensive care unit (ICU). About half of all its inpatients have COVID-19, Gustavo Solis reported in the Los Angeles Times, and the facility no longer has any available ventilators.
When Mexicali’s hospitals reached capacity in late May, administrators alerted El Centro that they would be diverting American patients to the medical center. “They said, ‘Hey, our hospitals are full, you’re about to get the surge,’” Judy Cruz, director of El Centro’s emergency department, recounted to Rebecca Plevin in the Palm Springs Desert Sun.
By the first week of June, El Centro was so overburdened that “a patient was being transferred from the hospital in El Centro every two to three hours, compared to 17 in an entire month before the COVID-19 pandemic,” Miriam Jordan reported in the New York Times.
Border Hospitals Filled to Capacity
Since April, hospitals in neighboring San Diego and Riverside Counties have been accepting patient transfers to alleviate the caseload at the lone hospital in El Centro, but the health emergency has escalated and now those counties need relief. “We froze all transfers from Imperial County [on June 9] just to make sure that we have enough room if we do have more cases here in San Diego County,” Chris Van Gorder, CEO of Scripps Health, told Paul Sisson in the San Diego Union-Tribune. El Centro patients are now being airlifted as far as San Francisco and Sacramento.
Nonessential travel between the US and Mexico has been restricted since March 21, with the measure recently extended until July 21. However, jobs in Southern California, such as in agricultural fields and packing houses, require regular movement between the two countries. “I’m always afraid that people are imagining this rush on the border,” Andrea Bowers, a spokesperson for the Imperial County Public Health Department, told Small. “It’s just folks living their everyday life.”
These jobs, some of which are considered essential because of their role in the food supply chain, may have contributed to the COVID-19 crisis on the border. Agricultural workers often lack access to adequate personal protective equipment and are unable to practice physical distancing. They also are exposed to air pollution, pesticides, heat, and more — long-term exposures that can cause the underlying health conditions that raise the risk of death for COVID-19 patients.
Comite Civico del Valle, a nonprofit focused on environmental health and civic engagement in Imperial Valley, set up 40 air pollution monitors throughout the county and found that levels of tiny, dangerous particulates violated federal limits, Solis reported.
“I can tell you there’s hypertension, there’s poor air pollution, there’s cancers, there’s asthma, there’s diabetes, there’s countless things people here are exposed to,” David Olmedo, an environmental health activist with Comite Civico del Valle, told Solis.
Fear of New Surges
With summer socializing in full swing, health experts worry that COVID-19 spikes will follow. Imperial County saw surges after Mother’s Day and Memorial Day, probably because of lapsed physical distancing and mask use at social events.
Latinos in California are adhering to recommended public health behaviors to slow the spread of the virus. CHCF’s recent COVID-19 tracking poll with Ipsos asked Californians about their compliance with recommended behaviors. Eighty-four percent of Californians, including 87% of Latinos, say they routinely wear a mask in public spaces all or most of the time. Seventy-two percent of Californians, including 73% of Latinos, say they avoid unnecessary trips out of the home most or all of the time, and 90% of Californians, including 91% of Latinos, say they stay at least six feet away from others in public spaces all or most of the time.
A Push to Reopen Anyway
Most counties in California have met the state’s readiness criteria for entering the “Expanded Stage 2” phase of reopening. Imperial County has not. In the past two weeks, more than 20% of all COVID-19 tests in the county came back positive, the Sacramento Bee reported. The state requires counties to have a seven-day testing positivity rate of no more than 8% to enter Expanded Stage 2.
Still, the Imperial County Board of Supervisors is pushing Governor Gavin Newsom for local control over its reopening timetable. The county has a high poverty rate — 24% compared with the statewide average of 13% — and “bills are stacking up,” Luis Pancarte, chairman of the board, said on a recent press call.
He worries that because neighboring areas like Riverside and San Diego have opened some businesses with physical distancing measures in place, Imperial County residents will travel to patronize restaurants and stores. This movement could increase transmission of the new coronavirus, just as reopening Imperial County too soon could as well.
More than 1,350 residents have signed a petition asking Newsom to ignore the Board of Supervisor’s request, Solis reported. The residents called on the supervisors to focus instead on getting the infection rate down and expanding economic relief for workers and businesses.
Cruz, who has been working around the clock to handle the county’s COVID-19 crisis, agrees with the petitioners. The surges after Mother’s Day and Memorial Day made her “really concerned about unlocking and letting people go back to normal,” she told Plevin. “It’s going to be just like those little gatherings that happened [on holidays], but on a bigger scale.”
Healthcare is Hard: A Podcast for Insiders; June 11, 2020
Over the course of nearly 20 years as Chief Research Officer at The Advisory Board Company, Chas Roades became a trusted advisor for CEOs, leadership teams and boards of directors at health systems across the country. When The Advisory Board was acquired by Optum in 2017, Chas left the company with Chief Medical Officer, Lisa Bielamowicz. Together they founded Gist Healthcare, where they play a similar role, but take an even deeper and more focused look at the issues health systems are facing.
As Chas explains, Gist Healthcare has members from Allentown, Pennsylvania to Beverly Hills, California and everywhere in between. Most of the organizations Gist works with are regional health systems in the $2 to $5 billion range, where Chas and his colleagues become adjunct members of the executive team and board. In this role, Chas is typically hopscotching the country for in-person meetings and strategy sessions, but Covid-19 has brought many changes.
“Almost overnight, Chas went from in-depth sessions about long-term five-year strategy, to discussions about how health systems will make it through the next six weeks and after that, adapt to the new normal. He spoke to Keith Figlioli about many of the issues impacting these discussions including:
Corporate Governance. The decisions health systems will be forced to make over the next two to five years are staggeringly big, according to Chas. As a result, Gist is spending a lot of time thinking about governance right now and how to help health systems supercharge governance processes to lay a foundation for the making these difficult choices.
Health Systems Acting Like Systems. As health systems struggle to maintain revenue and margins, they’ll be forced to streamline operations in a way that finally takes advantage of system value. As providers consolidated in recent years, they successfully met the goal of gaining size and negotiating leverage, but paid much less attention to the harder part – controlling cost and creating value. That’s about to change. It will be a lasting impact of Covid-19, and an opportunity for innovators.
The Telehealth Land Grab. Providers have quickly ramped-up telehealth services as a necessity to survive during lockdowns. But as telehealth plays a larger role in the new standard of care, payers will not sit idly by and are preparing to double-down on their own virtual care capabilities. They’re looking to take over the virtual space and own the digital front door in an effort to gain coveted customer loyalty. Chas talks about how it would be foolish for providers to expect that payers will continue reimburse at high rates or at parity for physical visits.
The Battleground Over Physicians. This is the other area to watch as payers and providers clash over the hearts and minds of consumers. The years-long trend of physician practices being acquired and rolled-up into larger organizations will significantly accelerate due to Covid-19. The financial pain the pandemic has caused will force some practices out of business and many others looking for an exit. And as health systems deal with their own financial hardships, payers with deep pockets are the more likely suitor.”
A Moody’s Investors Service report on Thursday suggests that the U.S. healthcare industry is on the rebound from COVID-19, but recovery will likely to slow and uneven. Moreover, the report expressed concerns that regional flareups of coronavirus could majorly set back the return to normal volumes.
Investment firm Jefferies affirmed those worries in hospital traffic data shared Friday, noting “a sharp reversal” in hotspot state Arizona. Analysts tracked “record lows” in Arizona’s hospital traffic last week, down from what was thought to be the trough in April and sagging below May recovery amid a significant uptick in COVID-19 cases and protests.
“Whether states can continue their recovery even as cases increase, as we’ve seen in [Texas] and others, or if the recent reversals in [Arizona, Illinois,] etc. become more widespread is a trend to watch in coming weeks,” Jefferies analysts wrote.
Large sections of the healthcare sector all but shut down during the spring as the coronavirus led to nationwide shelter-in-place orders. However, as states and municipalities slowly reopen, so are the doors for hospitals, ambulatory surgical centers, clinics and other integral components of healthcare delivery.
As a result, Moody’s reported “considerable sequential improvement” during May. For example, while for-profit hospitals saw surgery volumes drop as much as 70% in April compared to the same period in 2019, May volumes were down about 20% to 40% compared to last year’s. Hospital-operated ambulatory surgical centers saw an 80% to 90% drop in April volumes, but only a 30% to 40% drop in May.
However, Moody’s noted that the “path to normalized volumes are not linear.” It also pointed out that emergency room care volumes, which dropped as much as 60% in April, have yet to really rebound, as they still appeared depressed as much as 50% in May.
“This could reflect the prevalence of working-from-home arrangements and people generally staying home, which is leading to a decrease in automobile and other accidents outside the home. Weak ER volumes also suggest that many people remain apprehensive to enter a hospital, particularly for lower acuity care,” the Moody’s report said.
The firm also noted that “the shape of recovery will vary by state, region and service line, reinforcing the importance of diversification for credit quality among healthcare service providers.”
However, Moody’s believes that the darkest days of March and April are behind much of the healthcare sector. It noted that most providers have stockpiled appropriate personal protective equipment and have reconfigured their offices, waiting rooms and other infrastructure to protect the health of both patients and employees.
Traffic data from 3,300 U.S. hospitals, tracked by Jefferies via mobile device pings, indicates that compared to January 2019 levels, national traffic lows of 43.7% in mid-April improved to 63.3% by early June.
But state-by-state analysis reveals some parts of the country are trending backwards. Arizona fell to a new low of 28.5% last week after hitting 51.5% on May 20. The analysts also reported Illinois hit its own new low on June 7.
While Moody’s did express some concern about regional outbreaks, it concluded that the precautions already taken “make it less likely that the U.S. would once again shut down all non-elective care across the nation if there is a second wave of coronavirus infections.”
Moody’s did express some concerns about hospital finances, but noted that for-profit hospitals “have unusually strong liquidity” due to payouts from the CARES Act and other government-sponsored financial relief programs.
Medical device firms should be prepared for a long and uneven recovery, according to Moody’s. The dental and orthopaedic sectors “will see a greater than average impact from consumers’ inability to pay for procedures or their unwillingness to engage with the healthcare system.” Moody’s forecast “a gradual, uneven pace of recovery,” with pre-tax earnings to decline as much as 30% in 2020 compared to 2019, while revenues will shrink around 10%. It expects that earnings will rebound in 2021 to 2019 levels.
Companies that operate in discretionary sectors will be hit harder as they rely on patients able to meet large deductibles or co-payments or to pay for related procedures entirely on their own. Moody’s noted that a large number of these procedures are performed in acute care hospitals with the assistance of robotics, but hospitals may be more conservative in their robotics investments given new budget constraints.
The coronavirus pandemic has shown the healthcare industry that it needs to decide whether it’s playing basketball or soccer, journalist and author Malcolm Gladwell said.
Gladwell, the opening keynote speaker at America’s Health Insurance Plans’ annual Institute & Expo, said the two sports exemplify the differences in thinking when one tackles problems using a “strong link” approach versus a “weak link” approach.
In basketball, he said, the team is as strong as its strongest, most high-profile players. In soccer, by contrast, the team is only as strong as its weakest players.
For healthcare organizations, that means making investments in the “weakest links”—such as harried clinicians who may need more training and low-income communities that cannot afford or access coverage—rather than the stronger links, like building out teaching hospitals and physician specializations.
“In healthcare, this is a chance for us to turn the ship around and say we can benefit far more from making health insurance more plentiful and more affordable,” Gladwell said.
Gladwell emphasized that healthcare is far from the only industry to largely follow a “strong link” approach to improvement. In higher education, for example, much of the investment and funding goes to Ivy League institutions and other wealthy, top-performing universities.
Meanwhile, the education system could see significant benefits if it invested in the “weak links” like community colleges and bringing down tuition, Gladwell said.
It’s a similar story in national security—and that “strong link” thinking led to two of the largest security breaches in American history, Gladwell said. Both Edward Snowden and Chelsea Manning were relatively low-ranking people within the security apparatus, but they were able to access critical files and release them.
“I would argue that ‘strong link’ paradigm has dominated every part of American society,” Gladwell said. “We have really put our chips down on the ‘strong link’ paradigm.”
How could a “weak link” approach have impacted the response to the COVID-19 pandemic? Gladwell argues that, for instance, widespread testing is hampered by a lack of supplies like nasal swabs. Investment in the supply chain could have mitigated that challenge, he said.
The virus also disproportionately impacts people with certain conditions, notably diabetes. A broader focus on preventing and treating obesity could have had a large impact on how the pandemic played out, he said.
“With this particular pandemic, I think we’re having a wake-up call,” Gladwell said.
ProPublica deputy managing editor Charles Ornstein wanted to know why experts were wrong when they said U.S. hospitals would be overwhelmed by COVID-19 patients. Here’s what he learned, including what hospitals can do before the next wave.
The prediction from New York Gov. Andrew Cuomo was grim.
In late March, as the number of COVID-19 cases was growing exponentially in the state, Cuomo said New York hospitals might need twice as many beds as they normally have. Otherwise there could be no space to treat patients seriously ill with the new coronavirus.
“We have 53,000 hospital beds available,” Cuomo, a Democrat, said at a briefing on March 22. “Right now, the curve suggests we could need 110,000 hospital beds, and that is an obvious problem and that’s what we’re dealing with.”
The governor required all hospitals to submit plans to increase their capacity by at least 50%, with a goal of doubling their bed count. Hospitals converted operating rooms into intensive care units, and at least one replaced the seats in a large auditorium with beds. The state worked with the federal government to open field hospitals around New York City, including a large one at the Jacob K. Javits Convention Center.
But when New York hit its peak in early April, fewer than 19,000 people were hospitalized with COVID-19. Some hospitals ran out of beds and were forced to transfer patients elsewhere. Other hospitals had to care for patients in rooms that had never been used for that purpose before. Supplies, medications and staff ran low. And, as The Wall Street Journal reported on Thursday, many New York hospitals were ill prepared and made a number of serious missteps.
All told, more than 30,000 New York state residents have died of COVID-19. It’s a toll worse than any scourge in recent memory and way worse than the flu, but, overall, the health care system didn’t run out of beds.
“All of those models were based on assumptions, then we were smacked in the face with reality,” said Robyn Gershon, a clinical professor of epidemiology at the NYU School of Global Public Health, who was not involved in the models New York used. “We were working without situational awareness, which is a tenet in disaster preparedness and response. We simply did not have that.”
Cuomo’s office did not return emails seeking comment, but at a press briefing on April 10, the governor defended the models and those who created them. “In fairness to the experts, nobody has been here before. Nobody. So everyone is trying to figure it out the best they can,” he said. “Second, the big variable was, what policies do you put in place? And the bigger variable was, does anybody listen to the policies you put in place?”
So, why were the projections so wrong? And how can political leaders and hospitals learn from the experience in the event there is a second wave of the coronavirus this year? Doctors, hospital officials and public health experts shared their perspectives.
The Models Overstated How Many People Would Need Hospital Care
The models used to calculate the number of people who would need hospitalization were based on assumptions that didn’t prove out.
Early data from the U.S. Centers for Disease Control and Prevention suggested that for every person who died of COVID-19, more than 11 would be hospitalized. But that ratio was far too high and decreased markedly over time, said Dr. Christopher J.L. Murray, director of the Institute for Health Metrics and Evaluation at the University of Washington. IHME’s earliest models on hospitalizations were based on that CDC data and predicted that many states would quickly run out of hospital beds.
A subsequent model, released in early April, assumed about seven hospitalizations per death, reducing the predicted surge. Currently, Murray said, the ratio is about four hospital admissions per death.
“Initially what was happening and probably what we saw in the CDC data is doctors were admitting anybody they thought had COVID,” Murray said. “With time they started admitting only very sick people who needed oxygen or more aggressive care like mechanical ventilation.”
A model created by the Harvard Global Health Institute made a different assumption that also turned out to be too high. Data from Wuhan, China, suggested that about 20% of those known to be infected with COVID-19 were hospitalized. Harvard’s model, which ProPublica used to build a data visualization, assumed a hospitalization rate in the United States of 19% for those under 65 who were infected and 28.5% for those older than 65.
But in the U.S., that percentage proved much too high. Official hospitalization rates vary dramatically among states, from as low as 6% to more than 20%, according to data gathered from states by The COVID Tracking Project. (States with higher rates may not have an accurate tally of those infected because testing was so limited in the early weeks of the pandemic.) As testing increases and doctors learn how to treat coronavirus patients out of the hospital, the average hospitalization rate continues to drop.
New York state’s testing showed that by mid-April, approximately 20% of the adult population in New York City had antibodies to COVID-19. Given the number hospitalized in the city and adjusting for the time needed for the body to produce antibodies, this means that the city’s hospitalization rate was closer to 2%, said Dr. Nathaniel Hupert, an associate professor at Weill Cornell Medicine and co-director of the Cornell Institute for Disease and Disaster Preparedness.
Dr. Ashish Jha, director of the Harvard Global Health Institute, and his team also assumed that between 20% and 60% of the population would be infected with COVID-19 over six to 18 months. That was before stay-at-home orders took effect nationwide, which slowed the virus’s spread. Outside of New York City, a far lower percentage of the population has been infected. Granted, we’re not even six months into the pandemic.
A number of factors go into disease models, including the attack rate (the percentage of the entire population that eventually becomes infected), the symptomatic rate (how many people are going to show symptoms), the hospitalization rate for different age groups, the fraction of those hospitalized that will need intensive care and how much care they will need, as well as how the disease travels through the population over time (what is known as “the shape of the epidemic curve”), Hupert said.
Before mid-March, Hupert’s best estimate of the impact of COVID-19 in New York state was that it would lead to a peak hospital occupancy of between 13,800 to 61,000 patients in both regular medical wards and intensive care. He shared his work with state officials.
David Muhlestein, chief strategy and chief research officer at Leavitt Partners, a health care consulting firm, said one takeaway from COVID-19 is that models can’t try to predict too far into the future. His firm has created its own projection tool for hospital capacity that looks ahead three weeks, which Muhlestein said is most realistic given the available data.
“If we were held to our very initial projection of what was going to happen, everybody would be very wrong in every direction,” he said.
Hospitals Proved Surprisingly Adept at Adding Beds
When calculating whether hospitals would run out of beds, experts used as their baseline the number of beds in use in each hospital, region and state. That makes sense in normal times because hospitals have to meet stringent rules before they are able to add regular beds or intensive care units.
But in the early weeks of the pandemic, state health departments waived many rules and hospitals responded by increasing their capacity, sometimes dramatically. “Just because you only have six ICU beds doesn’t mean they will only have six ICU beds next week,” Muhlestein said. “They can really ramp that up. That’s one of the things we’re learning.”
Take Northwell Health, a chain of 17 acute-care hospitals in New York. Typically, the system has 4,000 beds, not including maternity beds, neonatal intensive care unit beds and psychiatric beds. The system grew to 6,000 beds within two weeks. At its peak, on April 7, the hospitals had about 5,500 patients, of which 3,425 had COVID-19.
The system erected tents, placed patients in lobbies and conference rooms, and its largest hospital, North Shore University Hospital, removed the chairs from its 300-seat auditorium and replaced them with a unit capable of treating about 50 patients. “We were pulling out all the stops at that point,” Senior Vice President Terence Lynam said. “It was unclear if the trend was going to go the other way. We did not end up needing them all.”
Northwell went from treating 49 COVID-19 inpatients on March 16 to 3,425 on April 7. “I don’t think anybody had a clear handle on what the ceiling was going to be,” Lynam said. As of Wednesday, the system was still caring for 367 COVID-19 patients in its hospitals.
As hospitals found ways to expand, government leaders worked with the Army Corps of Engineers to build dozens of field hospitals across the country, such as the one at the Javits Center. According to an analysis of federal spending by NPR, those efforts cost at least $660 million. “But nearly four months into the pandemic, most of these facilities haven’t treated a single patient,” NPR reported. As they began to come online, stay-at-home orders started producing results, with fewer positive cases and fewer hospitalizations.
Demand for Non-COVID-19 Care Plummeted More Than Expected
Hospitals across the country canceled elective surgeries, from hip replacements to kidney transplants. That greatly reduced the number of non-COVID-19 patients they had to treat. “We generated a lot more capacity by getting rid of elective procedures than any of us thought was possible,” Harvard’s Jha said.
Northwell canceled elective surgeries on March 16, and over the span of the next week and a half, its hospitals discharged several thousand patients in anticipation of the coming surge. “In retrospect, it was a wise move,” Lynam said. “It just ballooned after that. If we had not discharged those patients in time, there would have been a severe bottleneck.”
What’s more, experts say, it’s clear that some patients with true emergencies also stayed home. A recent report from the CDC said that emergency room visits dropped by 42% in the early weeks of the pandemic. In 2019, some 2.1 million people visited ERs each week from late March to late April. This year, that dropped to 1.2 million per week. That was especially true for children, women and people who live in the Northeast.
In New York City, emergency room visits for asthma practically ceased entirely at the peak, Cornell’s Hupert said. “You wouldn’t imagine that asthma would just disappear,” he said. “Why did it go away? … Nobody has seen anything like that.”
Undoubtedly some people experienced heart attacks and strokes and didn’t go to the hospital because they were fearful of getting COVID-19. “I didn’t expect that,” Jha said. A draft research paper available on a preprint server, before it is reviewed and published in an academic journal, found that heart disease deaths in Massachusetts were unchanged in the early weeks of the pandemic compared to the same period in 2019. What that may mean is that those people died at home.
The Coronavirus Attacked Every Region at a Different Pace
Some initial models forecast that COVID-19 would hit different regions in similar ways. That has not been the case. New York was hit hard early; California was not, at least initially.
Dr. Mark Rupp, medical director of the Department of Infection Control and Epidemiology at the University of Nebraska Medical Center in Omaha, said his region hasn’t seen a tidal wave like New York. “What we’ve seen is a rising tide, a steady increase in the number of cases.” Initially that was associated with outbreaks at specific locations like meatpacking and food processing plants and to some degree long-term care facilities.
But since then, “it has just plateaued,” he said. “That has me concerned. This is a time when I feel like we should be working as hard as we can to push these numbers as low as possible.”
Rupp’s hospital has been caring for 50 to 60 COVID-19 patients on any given day. The hospital has started to perform surgeries and procedures that had been on hold because “elective cases stay elective for only so long.”
The hospital’s general medical/surgical beds are 70% to 80% filled, and its ICU beds are 80% to 90% full. “We don’t have a big cushion.”
Even in New York City, the virus hit boroughs differently. Queens and the Bronx were hard hit; Manhattan, Brooklyn and Staten Island less so. “Maybe we can’t even model a city as big as New York,” Hupert said. “Each neighborhood seemed to have a different type of outbreak.”
That needs further study but could be attributable to both social and demographic conditions and the type of jobs residents of the neighborhoods had, among other factors.
What We Can Learn From Coronavirus “Round One”
While hospitals were able to add beds more quickly than experts realized they could, some other resources were harder to come by. Masks, gowns and other personal protective equipment were tough to get. So were ventilators. Anesthesia agents and dialysis medications were in short supply. And every additional bed meant the need for more doctors, nurses and respiratory therapists.
In early February, before any cases were discovered in New York, Northwell purchased $5 million in PPE, ventilators and lab supplies just in case, Lynam said. “It turned out to be a wise move,” he said. “What’s clear is that you can never have enough.”
Northwell has spent $42 million on PPE alone. “We were going through 10,000 N95 masks a day, just a crazy amount,” he said. “One of the lessons learned is you have to stockpile the PPE. There’s got to be a better procurement process in place.”
If there’s one thing the system could have done differently, Lynam said, it’s bringing in more temporary nurses earlier. Northwell brought in 500 nurses from staffing agencies. “They came in a week later than they should have.”
Dr. Robert Wachter, chair of the department of medicine at the University of California, San Francisco, agreed. “I’ve helped run services in hospitals for 25 years,” he said. “I’ve probably given two minutes of thought to the notions of supply chains and PPE. You realize that is absolutely central to your preparedness. That’s a lesson.”
Experts and hospital leaders agree that everyone can do better if another wave hits. Here’s what that entails:
Having testing readily available, as it now is, to more quickly spot a resurgence of the virus.
Stocking up now on PPE and other supplies. “We definitely have to stockpile PPE by the fall,” Gershon of NYU said. “We have to. … [Hospitals and health departments] have to really get those contracts nailed down now. They should have been doing this, of course, all the time, but no one expected this kind of event.”
Being able to quickly move personnel and equipment from one hot spot to the next.
Planning for how to care for those with other medical ailments but who are scared of contracting COVID-19. “We have to have some sort of a mechanism by which we can offer people assurance that if they come in, they won’t get sick,” Jha said. “We can’t repeat in the fall what we just did in the spring. It’s terrible for hospitals. It’s terrible for patients.”
Providing mental health resources for front-line caregivers who have been deeply affected by their work. The intensity of the work, combined with watching patients suffer and die alone, was immensely taxing.
Coming up with ways to allow visitors in the hospital. Wachter said the visitor bans in place at many hospitals, though well intentioned, may have backfired. “When all hell was breaking loose and we were just doing the best we could in the face of a tsunami, it was reasonable to just keep everybody out,” he said. “We didn’t fully understand how important that was for patients, how much it might be contributing to some people not coming in for care when they really should have.”
Lynam of Northwell said he’s worried about what lies ahead. “You look back on the 1918 Spanish flu and the majority of victims from that died in the second wave. … We don’t know what’s coming on the second wave. There may be some folks who say you’re paranoid, but you’ve got to be prepared for the worst.”