As the pandemic rages on, hospitals across the country are experiencing significant labor shortages for critical clinical roles. In the graphic above, we highlight the shortage of nursing talent, perhaps the most sought-after role for which health systems are struggling to hire.
Even before the current COVID surge, many nurses reported feeling dissatisfied or feeling burned out. In a May 2021 survey, more thanone in five nurses said they were considering leaving their current jobs, citing insufficient staffing, workload, and the emotional toll of the work. Many health systems are offering lucrative incentives, such as five-figure signing bonuses, to fill immediate critical care needs, and to address the growing backlog of patients returning for delayed care.
As more nurses quit or retire from their permanent positions, health systems are being forced to fill workforce gaps by luring temporary talent at much higher costs (now cresting $8K a week to fund a single travel nurse in some parts of the country). Travel nurse demand reached an all-time high in August, up almost 40 percent from the previous peak in December 2020. As they struggle to fill essential openings, hospital leaders must also focus on keeping the current nursing staff engaged—a challenge that only gets harder as staff nurses compare their salaries to those paid to the temporary colleagues working alongside them.
The Centers for Disease Control and Prevention (CDC) announced results from a study Friday that found unvaccinated individuals were 11 times more likely to die from COVID-19 than fully vaccinated people.
The research, spanning more than 600,000 people in 13 jurisdictions, also determined that unvaccinated populations were over 10 times more likely to be hospitalized — figures that underscore COVID-19 vaccines protect recipients from deaths and hospitalizations.
The study also showed that unvaccinated people were 4 1/2 times more likely to contract COVID-19 than the fully vaccinated.
The studies come just one day after President Biden announced a new rule that would require private companies with 100 employees or more to mandate vaccinations or frequent coronavirus testing.
The Biden administration as a whole has pushed for the use of vaccines as the best way to combat the pandemic.
CDC Director Rochelle Walensky on Friday made the case for vaccines yet again, citing the study along with two others and stating that COVID-19 shots still work to protect recipients from the worst of the disease amid the rampant spread of the delta variant.
“As we have shown study after study, vaccination works,” Walensky said during the briefing. “CDC will continue to do all we can do to increase vaccination rates across the country by working with local communities and trusted messengers and providing vaccine confidence consults to make sure that people have the information they need to make an informed decision.”
“The bottom line is this: We have the scientific tools we need to turn the corner on this pandemic,” Walensky said. “Vaccination works and will protect us from the severe complications of COVID-19. It will protect our children and allow them to stay in school for safe in-person learning.”
The agency and Biden administration are promoting the data behind the vaccine effectiveness in their bolstered push to get the unvaccinated shots.
The U.S. has made progress with vaccinations, reaching 75 percent of adults who have had at least one dose earlier this week.
But the portion of unvaccinated people continues to affect the U.S.’s trajectory in the pandemic, with the unvaccinated making up almost all of the growing hospitalizations and deaths.
The other two studies in the CDC’s Morbidity and Mortality Weekly Report (MMWR) released Friday focused on the vaccine’s effectiveness against hospitalization.
One involving five Veterans Affairs Medical Centers found the mRNA vaccines’ overall effectiveness against hospitalization reached 86.8 percent.
Another similarly calculated that effectiveness at 86 percent among patients in emergency departments, urgent cares and hospitals across nine states.
However, the studies also provided some evidence that the effectiveness of the vaccines are starting to wane among the older population, prompting the researchers to call for further investigation.
For the patients in emergency departments, urgent cares and hospitals across nine states, the effectiveness among those aged 75 and older was 76 percent, while among those aged 18 to 74, effectiveness reached 89 percent.
But researchers urged caution, with the report saying “this moderate decline should be interpreted with caution and might be related to changes in SARS-CoV-2, waning of vaccine-induced immunity with increased time since vaccination, or a combination of factors.”
The study involving Veterans Affairs facilities determined that the mRNA vaccine effectiveness among those aged 65 and older was 79.8 percent, compared to 95.1 percent among those aged 18 to 64.
More than 82 percent of those aged 65 and older are considered fully vaccinated, according to CDC data.
Surgeon General Vivek Murthy said Friday the administration is aiming to get “as close to 100 percent as possible” through expanded outreach.
“We know that every senior matters in terms of getting them vaccinated as a potential life saved,” he said, adding that booster vaccinations “will likely be helpful” for the older population.
The Biden administration had announced it planned to start administering additional shots to recipients on Sept. 20 beginning eight months after their second shot.
But the plan led to criticism from some experts who said the administration was getting ahead of the review process at the Food and Drug Administration (FDA), although officials say the strategy depends on FDA approval.
Howard Stern was reflecting this week on the coronavirus deaths of four conservative talk-radio hosts who had espoused anti-vaccine and anti-mask sentiments when he took aim at those who have refused to get vaccinated.
“I want my freedom to live,” he said Tuesday on his SiriusXM program. “I want to get out of the house. I want to go next door and play chess. I want to go take some pictures.”
The shock jock, who advocated for the coronavirus vaccine to be mandatory, then turned his attention to the hesitancy that has played a significant role in the U.S. spread of the virus, leading to what Rochelle Walensky, director of the Centers for Disease Control and Prevention, has called a “pandemic of the unvaccinated.”He pointed to unvaccinated people who are “clogging” up overwhelmed hospitals, calling them “imbeciles” and “nut jobs” and suggesting that doctors and nurses not treat those who have not taken a coronavirus vaccine.
“I’m really of mind to say, ‘Look, if you didn’t get vaccinated [and] you got covid, you don’t get into a hospital,’ ” he said. “You had the cure and you wouldn’t take it.”
Stern’s comments come after several other celebrities expressed to their large social media audiences their frustration with the ongoing lag in vaccinations when hospitals are being pushed to their limits by the highly transmissible delta variant.
More than 185,000 coronavirus infections were reported Wednesday across the United States, according to data compiled by The Washington Post. Nearly 102,000 people are hospitalized with covid-19; more than 26,000 are in intensive care units. A slight decline in hospitalizations over the past week has inspired cautious optimism among public health leaders.
While there is not a nationwide vaccine mandate, President Biden is expected to sign an executive order Thursday requiring that all federal employees be vaccinated, without an alternative for regular coronavirus testing to opt out of the mandate, The Post reported. The order affecting the estimated 2.1 million federal workers comes as Biden plans to outline a “robust plan to stop the spread of the delta variant and boost covid-19 vaccinations,” the White House said.
Health officials, doctors and nurses nationwide have urged those still hesitant to get vaccinated — and some have gone a step further. Jason Valentine, a physician in Mobile, Ala., informed patients last month that he would not treat anyone who was unvaccinated, saying there were “no conspiracy theories, no excuses” preventing anyone from being vaccinated. Linda Marraccini, a doctor in South Miami, said this month that she would not treat unvaccinated patients in person, noting that her office would “no longer subject our patients and staff to unnecessary risk.”
The summer surge also has led celebrities to use their platform to either call on unvaccinated people to get vaccinated or to denounce them for not doing so. Actor and activist Sean Penn said the vaccine should be mandatory and has called on Hollywood to implement vaccination guidelines on film sets. Actors Benicio Del Toro and Zoe Saldana were part of a vaccine video campaign this year to help debunk misinformation about coronavirus vaccination. When actress Melissa Joan Hart revealed her breakthrough coronavirus case last month, she said she was angry that the nation “got lazy” about getting vaccinated and that masking was not required at her children’s school.
Late-night talk host Jimmy Kimmel suggested Tuesday that hospitals shouldn’t treat unvaccinated patients who prefer to take ivermectin — a medicine long used to kill parasites in animals and humans that has soared in popularity despite being an unproven covid-19 treatment and the subject of warnings by health officials against its use for the coronavirus. After noting that Anthony S. Fauci, the chief medical adviser to Biden, warned that some hospitals might be forced to make “tough choices” on who gets an ICU bed, the late-night host quipped that the situation was not difficult.
“That choice doesn’t seem so tough to me,” Kimmel said. “Vaccinated person having a heart attack? Yes, come right in; we’ll take care of you. Unvaccinated guy who gobbled horse goo? Rest in peace, wheezy.”
Stern has featured front-line workers on his show and has advocated for people to get vaccinated against the coronavirus. In December, the host interviewed Cody Turner, a physician at the Cleveland Clinic, about how the front-line doctor struggled with his mental health while treating infected patients when a vaccine was not widely available.
“We are drowning and we are in hell, and people don’t understand, not only what’s happening to people, you know, but patients across this country,” Turner said.
Stern was a fierce critic of President Donald Trump’s response to the pandemic, saying last year that his former friend was “treasonous” for telling supporters to attend large rallies, despite the risk of infection, in the run-up to the presidential election.
On his eponymous program this week, Stern referred to four conservative talk-radio hosts who bashed the vaccine and eventually died of the virus: Marc Bernier, 65; Phil Valentine, 61; Jimmy DeYoung, 81; and Dick Farrel, 65. In the weeks and months leading up to their deaths last month, all four men had publicly shared their opposition to mainstream public health efforts when coronavirus infections were spiking.
“Four of them were like ranting on the air — they will not get vaccinated,” Stern said Tuesday. “They were on fire … they were all dying and then their dying words were, ‘I wish I had been more into the vaccine. I wish I had taken it.’ ”
After he played a clip of Bernier saying he would not get vaccinated, Stern suggested that the coronavirus vaccine be considered as normal as a measles or mumps vaccine.
“When are we going to stop putting up with the idiots in this country and just say it’s mandatory to get vaccinated?” he asked.
As the healthcare industry gears up to fall under the requirements of the No Surprises Act that bans balance billing, hospitals and insurers said they need more time and information to abide by the requirements.
Payers are asking for a safe harbor until 2023 calling the Jan. 1 start day is too soon for plans to determine payment amounts to out-of-network providers and as it seeks clarification on the resolution process.
Safety net hospitals represented by America’s Essential Hospitals want implementation to be delayed until six months after the public health emergency for COVID-19 ends, saying staff and resources are spread too thin dealing with the pandemic and especially the spread of the delta variant.
HHS released the first interim final rule to implement the No Surprises Act in June — one of multiple expected to be released this year — including those from the Departments of Treasury and Labor.
A major and much-debated aspect of the law is how qualifying payment amounts — the amount paid to providers who are not in network but are providing care at an in-network facility — are calculated.
Later rules are expected to provide more detail on the key issue of how the independent dispute resolution process will be conducted.
Payers and providers both argued in their comments that without more information on that process, it is hard to prepare.
The ERISA Industry Committee, which lobbies for large employers, said that as the resolution process is developed, deviation from QPAs “should be limited to extenuating circumstances.” That’s in direct contrast to the American Hospital Association, which requested the department not overly weigh the QPA as a factor in consideration.
When Congress debated a ban on surprise billing, whether a dispute resolution process would be used or whether rates for out-of-network providers would be based on a set rate was perhaps the most hotly contested aspect. In the end, providers got the win with the arbitration clause.
In comments on the rule, both AHA and payer lobby AHIP called for a multi-stakeholder group to advise on issues such as what provisions fall under state and federal jurisdiction and other operational challenges.
The hospital lobby requested clarification on a number of aspects of the rule, such as how good faith estimates of costs should be calculated on consent forms patients may sign to waive balance billing protections and when a provider can bill a patient if their claim is denied by the plan.
In multiple instances, the group asked the department to confirm that the initial payment should not be the QPA unless both the plan and provider agree to that circumstance.
The country’s largest hospital lobby is also concerned that the act won’t do enough to ensure network adequacy from insurers and will not institute enough oversight on plans’ compliance.
AHA said it is “deeply concerned that the existing oversight mechanisms are insufficient to monitor plan and issuer behavior and a more robust structure is needed to enforce the QPA requirements.”
The Federation of American Hospitals expressed similar concerns, particular regarding “abusive plan practices” like inappropriate claims denials and downcoding. The group urged the departments “to expand their oversight of plans and issuers to prevent and address unlawful and abusive plan practices.”
AEH, meanwhile, asked for assurances that administrative burdens like the notice and consent documentation would be fairly split with insurers.
Under the rule, the QPA is to be decided by a plan’s median in-network contracted rate for a geographic area. It must have a minimum of three contracted rates to use this method. If that is not available, the payer can use an independent claims database.
FAH, in particular, asked that the rule strengthen conflict of interest regulations for these databases and have their eligibility determined by the departments instead of the insurers themselves.
AHIP’s most immediate concern is the timeline for implementation. It asked for the good faith safe harbor request to develop QPA methodologies, create the infrastructure to transmit notice and consent forms with providers and for it to receive the forthcoming information on the arbitration process.
“Health plans and issuers have responsibility for developing work streams; updating information technology; creating forms, notices, and other communications; training employees; and other operational measures necessary to effectuate obligations” in the rule, the group wrote.
States with 1332 reinsurance waivers will have more pass-through funding to implement the waivers.
The Centers for Medicare and Medicaid Services and the Biden Administration have earmarked $452 million in federal funding through the American Rescue Plan for efforts to lower costs and improve health insurance access in 13 states.
Due to the changes made to the ARP, states with 1332 reinsurance waivers will have more pass-through funding to implement the waivers, and may also have their own state funding available to pursue further strategies to promote insurance affordability.
This funding, said CMS, might otherwise have been spent on 2021 reinsurance costs.
The “pass-through funding” is determined on an annual basis by the Department of Health and Human Services and the Department of the Treasury. They’re available to states with approved section 1332 waivers that have also lowered premiums to implement their waiver plans.
WHAT’S THE IMPACT?
State-based reinsurance programs created through section 1332 waivers are designed to improve health insurance affordability and market stability by reimbursing issuers for a portion of healthcare provider claims that would otherwise be paid by some consumers and by the federal government through higher premiums.
As a result, said CMS, these programs hold the potential to lower premiums for consumers with individual health insurance coverage, and may increase access to coverage and provide more health plan options for people in those reinsurance states, without increasing net federal costs.
The additional funds announced by CMS range from $2.5 million to $139 million per state – varying based on factors such as the size of the state’s reinsurance program. The funds are the result of expanded subsidies provided under the ARP, which will result in new people enrolled, and will cover a portion of the states’ costs for these reinsurance programs.
States with approved section 1332 state-based reinsurance waivers have experienced reduced premiums in the individual market, CMS said. Overall, from plan years 2018 to 2021, states that have implemented section 1332 state-based reinsurance waivers for the individual market have seen statewide average premium reductions ranging from 3.75% to 41.17%, compared to premiums absent the waiver, according to the agency’s internal data.
For example, in 2021, statewide average premium reductions due to the waiver were 4.92% in Pennsylvania, 18.47% in Colorado, and 34% in Maryland, compared to a scenario with no waiver in place.
Beyond reduced premiums, it’s expected that section 1332 state-based reinsurance waivers may help states maintain and increase issuer participation, and may increase the number of qualified health plans available in each county in such states from year to year. For example, states like Colorado, Wisconsin, Alaska and Maryland have seen additional issuers enter or re-enter the individual marketplace since their state reinsurance programs have been implemented.
The agency’s current thinking is that stronger issuer participation in the individual market may increase competition and translate to consumers having more opportunities to obtain affordable health insurance coverage. Nationally, on average, there are more QHP offerings in 2021 than in 2020, and in states with section 1332 state-based reinsurance waivers, the average number of QHPs weighted by enrollment increased by 30.6% from 2020 to 2021.
The states, and their pass-through funding amounts, include Alaska ($43,827,328), Colorado ($49,892,498), Delaware ($10,821,203), Maine ($8,562,238), Maryland ($139,159,548), Minnesota ($64,969,985), Montana ($7,129,995), New Hampshire ($8,820,847), North Dakota ($5,798,044), Oregon ($18,948,114), Pennsylvania ($28,558,672), Rhode Island ($2,590,540) and Wisconsin ($63,408,562). New Jersey’s pass-through funding amount will be announced at a later time.
THE LARGER TREND
In April 2021, the departments announced a total of $1.29 billion in pass-through funding for the 2021 plan year and posted a FAQ that noted that the departments would inform states of additional pass-through to account for the ARP.
ON THE RECORD
“This investment is a testament to our administration-wide commitment to making healthcare more accessible and affordable,” said HHS Secretary Xavier Becerra. “This funding from the American Rescue Plan will reduce monthly healthcare costs for consumers, increase coverage, and provide more options. We will continue to work with states to strengthen the healthcare system as we respond to the COVID-19 pandemic.”
“Reducing a family or individual’s average monthly health coverage costs frees up that money for other needs,” said CMS Administrator Chiquita Brooks-LaSure. “The Biden-Harris Administration continues to work with states to reduce costs and deliver more affordable health coverage options. This is another example of how the American Rescue Plan is helping more people meet their healthcare needs.”
More than 73% of those ages 12 to 18 have received one shot, while 92.4% of those older than 65 have received at least one dose.
The U.S. hit a new milestone this week as 75% of adults over the age of 18 have received at least one dose of a COVID-19 vaccine as of Tuesday, according to data from the Centers for Disease Control and Prevention.
Among the over-18 set, almost 194 million Americans have received a first dose, while close to 165 million people are fully vaccinated, good for 64.3% of that population.
The percentages increase the older the population subset. Slightly more than 73% of those ages 12 to 18 have received one shot (with 62.3% fully inoculated), while 92.4% of those older than 65 have received at least one dose. Among that age group, 82.1% are fully vaccinated.
The data also highlighted which states are faring better in terms of total doses administered per 100,000 people. Vermont leads the nation, with other New England states – Maine, Massachusetts, Rhode Island and Connecticut in particular – following closely behind.
The South and Midwest show the lowest rates of vaccination.
The Pfizer-BioNTech vaccine, which was the first to receive full approval from the Food and Drug Administration, leads the pack in terms of total doses administered with more than 214 million shots delivered as of September 7. Moderna comes in second with 147 million-plus doses administered, followed by Johnson and Johnson, which has seen more than 14.5 million total doses administered.
The vaccine hierarchy holds true when examining the number of people fully vaccinated, with Pfizer at almost 96 million, Moderna at about 66 million and J&J at roughly 14 million.
WHAT’S THE IMPACT?
The numbers should come as some encouragement to the nation’s hospitals and health systems, which have been beleaguered by an influx of coronavirus patients, driven in large part by the highly transmissible Delta variant.
These new surges are once more resulting in operational pressure for nonprofit hospitals in the U.S., which will likely affect margins in the near term, according to an August analysis from Fitch Ratings.
Operations and resources in these new coronavirus hotspots are being stretched more than at any prior time during the pandemic, according to the ratings agency, with hospitalization rates exceeding prior peaks and ICU beds at full capacity in some states.
And while some areas are worse than others, there are no regions that are unaffected: Hospitalizations are trending upward in all states.
What this means for hospitals, and nonprofits in particular, is that additional staffing and supplies will be needed to handle the new influx of COVID-19 patients. The greater number of patients is resulting in a self-induced postponement of nonemergent surgical cases, resulting in lower hospital revenues.
Additionally, hospitals and skilled nursing facilities are competing for a limited supply of nurses, including more expensive contract nursing staff.
The vaccine has been approved for the prevention of COVID-19 for those 16 years old and older. The vaccine also continues to be available under emergency use authorization, including for those 12 to 15, and for the administration of a third dose in certain immunocompromised patients.
Just last week, Moderna submitted data to the FDA for evaluation of a booster shot for its mRNA vaccine.
The yet-to-be peer-reviewed data comes from a study of 344 individuals who received a third dose of the Moderna vaccine six months after their second shot. Moderna found that their antibodies had “waned significantly” before getting the booster shot, but the additional jab increased antibodies to an even higher level than the previous round.
Heightened protection was observed across age groups, but particularly in adults over the age of 65, according to Moderna. It also offered protection against “all variants of concern,” including the Delta variant.
Moderna’s vaccine received emergency use authorization last December and showed to be 94.1% effective in preventing symptomatic COVID-19 in its clinical trial.
HENRY KOTULA 