The pandemic’s impacts on U.S. hospitals

[0:00:23]

RICK WEISS: Hello, everyone. Welcome to SciLine’s media briefing on the pandemic’s impact on U.S. hospitals. I’m SciLine’s director, Rick Weiss. For those not familiar with us, SciLine is a philanthropically funded, editorially independent free service for journalists and scientists, based at the nonprofit American Association for the Advancement of Science. Our mission is straightforward. It’s to help reporters like you get more scientifically validated evidence into your news stories. And that means not just stories about science, but any story that can be strengthened with some science, which, in our view, is almost any story you can think of. Among other things, we offer a free matching service that helps connect you to scientists who are both deeply knowledgeable in their field and are vetted by us to be excellent communicators. We do this on deadline or as needed. Just go to sciline.org, click on I Need An Expert and while you’re there, check out our other helpful reporting resources.

I should note that we are particularly focused on helping local reporters. And today’s topic, though it’s one of national scale and deserves ongoing national coverage, lends itself particularly, I think, to local reporting. In many small- and medium-sized communities, hospitals are not only the medical lifelines, but major employers, major revenue generators. They are, in many respects, actually critical to the vitality of their communities. So if you are not already paying attention to your local hospital or hospitals as you do your local reporting, this is a great opportunity today to get up to speed on some story ideas.

A couple of quick logistical details before we start—we have three panelists who will make short presentations of about seven minutes each before we open things up for Q&A. To enter a question during or after these presentations, simply hover over the bottom of the Zoom window, select Q&A and enter your name, news outlet and your question. If you want to pose that question to a specific panelist, be sure to note that. A full video of this briefing should be available on our website by tomorrow and a time-stamped transcript within a couple of days. If you would like a raw copy of the recording more immediately for use in news today or this evening, please submit a request with your name and email in the Q&A box, and we’ll send you a link to the video by the end of today. You can also use the Q&A box to alert SciLine staff to any technical difficulties.

OK. To get started, I’m not going to take time to give full introductions to our speakers. Their bios are on the SciLine website. I’ll just say we’re going to hear first from Dr. John Hick, an emergency medicine physician at Hennepin Healthcare in Minnesota, and he’s going to speak about hospital preparedness—how hospitals have been struggling to adapt to pandemic-related challenges, such as bed capacity, equipment needs, staffing—now and for future outbreaks. Second, we’re going to hear from Dr. Jessi Gold, an assistant professor in the department of psychiatry at Washington University in St. Louis School of Medicine, who will focus on the impacts of the pandemic on the mental health of health care workers—impacts that relentlessly continue to pile up on these workers today. And third, we’ll hear from Dr. Will Schpero, a health economist and assistant professor at Weill Medical College of Cornell University in New York, who will describe how the pandemic has affected hospitals’ finances and how those strains have varied among different types and locations of hospitals and how technologies—for example, those that enable telehealth—may be part of the solution there.

OK. With those introductory remarks, let’s get started. And it’s over to you, Dr. Hick.

[0:04:10]

JOHN HICK: Great. Thank you so much. Really appreciate it, Rick, and appreciate the opportunity to be here, as well as grateful for your time today. So I’ll just talk a little bit about some of the impacts and some of the trends we’re seeing in, you know, hospitals’ response to COVID-19. Just to kind of set the stage a little bit, on the left-hand side, you can see the key elements of what we call surge capacity or basically developing additional capacity to respond to disasters. That’s the space, the staff, the supplies, and then it’s the standard of care that we try not to move the needle on too much during disasters. But as we move from conventional, where we’re doing all the usual things with the usual people, to contingency, which we’ve been in an awful lot during COVID-19, where we’re providing equivalent care but doing adapted, you know, staffing, adapted spaces, et cetera, to meet those needs—and then crisis, where, unfortunately, we’re presenting significant risk to either the providers or the patients because we’ve reached the limits of being able to adapt those strategies safely. And in that case, we’re trying to just proportionately do the best we can for everyone, you know, given the situation.

And just a note that, you know, we’ve been in crisis conditions across a variety of resources from the start of the COVID-19 pandemic, starting with the, you know, absence of appropriate respirators and protective equipment for health care workers very early on. Fortunately, that’s been rectified, but we continue to see very significant gaps in the ability to provide care as we would like to. And I think it’s important to note that COVID-19 really differs substantially from conventional disaster planning. So a lot of our preparedness is focused on incidents where we don’t have any notice. They’re relatively short. You know, our recent, you know, tornadoes, the tragedy that occurred in Kentucky and our Midwestern states here—a good example of that. The resources are highly dynamic. Usually, you start out with not enough, and you wind up with way too many within a period of hours to days. There is a cavalry coming. We’ve got lots and lots of state and federal assets. Situational awareness, initially, is poor, and decision-making is pretty ad hoc. And a lot of the behavioral health impact on providers is more of the visuals of the destruction and the injuries, whereas with COVID-19, it’s been almost, you know, 2 1/2 years now—very long duration. The resource situations change, but they change more slowly. We can’t get any help.

And that’s, honestly, the bottom line of the biggest problems here, is that we just don’t have the staffing and the personnel resources in particular. And that’s really led to an awful lot of burnout that you’ll hear about more later. But just the continuing emotional grind, in addition to the physical fatigue of caring for these patients and adapting to the challenges of working in PPE and being the only connection sometimes between patient and family has been terribly difficult. So anytime you ask a private entity like health care to take on a massive public responsibility like responding to all the health care needs of a pandemic, you’re going to have problems. There’s extraordinarily limited funding for preparedness activities. And most hospitals are not terribly well-integrated with their emergency management. Our supply chain is broken on a day-to-day basis—recent shortages, for example, of potassium, which is a common element found everywhere, but good luck getting it sterilely right now for intravenous use.

And that’s been kind of par for the course, is that our generic, you know, intravenous medications have been in and out of shortage, you know, for years now, not just during the pandemic. In fact, I think we’ve been lucky that that hasn’t been a bigger problem. Certain catheters like those that we use to exchange blood through what’s called ECMO, or extracorporeal membrane oxygenation, have been in shortage occasionally. Sometimes, though, it’s just that we’ve got everybody on all the machines that we have, and we don’t have the ability, either staff-wise or otherwise, to provide that service. We’ve certainly seen how COVID-19 has ripped open a lot of inequities within our communities, both within our BIPOC populations but also between urban and rural. Right now, one of our biggest struggles nationally is getting patients coming into small, rural hospitals into the urban tertiary care centers where they can get the full spectrum of care that they need. And it’s resulting in some very significant discrepancies in care.

Our workforce shortages are extreme. And I think it’s been extraordinarily hard on the workforce to go from being heroes to, you know, being questioned, to being distrusted, you know, to really feeling like they’re, you know, under not only the gun, but also sometimes being assaulted by patients. And so a record number of health care, you know, providers assaulted last year and nursing staff bearing a particular brunt of that from, you know, family or patient hostility, the gravity of the situation, sometimes refusing to believe that COVID-19 is real—now all of these lending themselves to a very, very difficult work environment. Also balancing out how we do nonemergency procedures at the hospitals, what we used to call elective procedures—figuring out, you know, when it’s appropriate to do a back surgery or a knee surgery or a heart surgery in relation to all the resources that are needed to care for the COVID-19 patients.

And it’s not just about the COVID-19 volumes. I just want to emphasize that penetrating trauma injuries are setting records in most major metro areas across the country, including a pending record in the city of Minneapolis, but many major metro areas have broken their homicide records this year. We see continuing mental health crises forcing many, many persons into the emergency departments. And over 100,000 people died between May of 2020 and April of 2021 from drug overdoses in the country—another record and, again, a continued pressure on the emergency department and emergency services.

So I think this gives you a little bit of a perspective on that. On the left-hand vertical column, you’ll see the total number of patients—and across the bottom, on the calendar there. The yellow line is the COVID patients in ICU. And the red line is ICU patients total. So you can see that last November in Minnesota, we had our peak of COVID ICU patients. We’re getting close to that again, although we haven’t hit it. But you can see that we’ve been well over those ICU volumes for some time now. It’s been just putting tremendous stress on the system. And this has been the case in many, many states across the nation.

So what are we doing? We’re trying to hire staff. In fact, in my institution right now, we have some federally deployed Department of Defense staff. And we’re like many other hospitals in a similar boat that have reached out for federal assistance. We’re looking for contract staff or trying to hire. But one of our major health systems reported that they lost 13.5% of their nurses in the last year. And a lot of nurses, health care assistants and others are leaving the field or changing practices. And hospitals are not alone. Long-term care facilities struggle mightily with adequate staffing to the point where many patients who could be in long-term care facilities are stuck in hospitals waiting for those beds to open up. In one major U.S. metropolitan area, there’s over 400 patients who are identified that could be transferred to long-term care, but there’s simply not beds available.

We’re really trying to visit more with patients about their end-of-life wishes and what specifically they want in case, you know, their health turns for the worse and then the worse again. Tracheostomy, a prolonged mechanical ventilation, ECMO—all of these things need to be considered. And we’re really trying to change the threshold for admission because we simply don’t have the option. It’s either wait in the emergency department for a bed, or we can discharge you without patient workup for your cardiac or neurologic or other problem, which we’re doing more and more. And we’ve expedited a lot of those services and really been able to connect people in a way that we couldn’t previously with those. But still, these are not typical times or typical practices. One of the best things about COVID-19 has been the use of transfer centers, or medical operations coordination cells, as we call them, that help to make sure that we use all available beds to the best of our ability. And sometimes, that involves actually moving patients from tertiary centers to smaller community hospitals, although many times it’s difficult to get the patients to accept those type of transfers. And sometimes, we actually have to triage and decide, you know, who is going to get a certain bed or who is going to get certain resources. And we try to do that in a structured, thoughtful way, involving, you know, multiple providers when needed, and trying not to leave that on the bedside provider to make a decision, because that can be very difficult for the provider and also, sometimes, result in decisions that are not as fair as we would like.

I just want to note, these are emergency department patients—and the number of patients is on the vertical axis on the left—that are waiting in emergency departments in Minnesota for more than four hours. So you’ll see there’s been a very steady increase in that trend line across the fall here in the recent weeks. And obviously, this morning’s number, we had over 246 patients waiting more than four hours in emergency departments across the state of Minnesota for inpatient beds that are simply not available.

So how are we doing? Well, we’re fighting against a couple issues here. Politics in many states has been problematic in getting the hospitals the relief and some of the tools that they need to adapt to the circumstances. And also, maintaining profitability, as you’ll hear about later, can be extraordinarily difficult for many hospitals that are fighting to maintain their bottom lines through the pandemic and really need to be doing some of the elective procedures in order to keep afloat. However, the more crowded we get, the more deaths that occur. Providers get busy. Cognitive tasking gets overwhelmed. And at some point, small mistakes add up. And so it’s been estimated by Sameer, et al. and the analysts of Internal Medicine that 1 in 4 pandemic deaths may be contributed to—by overloaded hospital conditions.

From a urban, rural standpoint, as I mentioned before, we’re having significant issues. And just by way of example, 481 requests in Minnesota for transfers could not be met in November alone looking for intensive care unit beds. And 235 of those were from rural hospitals that are not affiliated with a health system—again, pointing out that some equity issues between rural and urban that need to be addressed. Our inpatient and long-term care environments are saturated, as I mentioned, and intensive care particularly burdened by this. We’re worried about the holiday season coming up. We’ve already seen bumps in transmission from Thanksgiving. And we know that we’re going to have to continue to catch up on procedures.

Omicron may throw another wrench into the works here. At the same time, I think we need to be a little bit careful to maintain some guarded optimism that the end of the pandemic is signaled by a virus that mutates where it is very contagious but not very virulent, doesn’t cause very severe disease. So omicron, in a way, may be the last chapter in the pandemic. And we are still waiting to find out. I think we’ll have good bellwethers from the U.K. and other European countries as to how things are going before we get hit really hard here. But the peaks are going to come fast. And so we’ll make do with the best information that we have available.

I think we’ll see, as time goes on and we get better data on excess deaths, that we’ve had a really significant underestimation of the COVID-related mortality in this country. And that’s unfortunate. Some of that is preventable, some of it is not. But we need to focus on what’s preventable and figure out how we improve equity and access of care going forward. So moving forward, as I mentioned, omicron is something that we’re watching extraordinarily carefully. At the same time, we’re still struggling to continue to respond to the needs of the delta outbreak in many states. Omicron may not be able to compete with delta in some of those areas that have very high prevalence. We’re struggling to maintain our workforce and their resiliency. And we’ll need to continue to play catch-up on a lot of deferred care and a lot of deferred procedures. So expect the hospitals to continue to be very overloaded throughout the first quarter, at least, of next year.

In the future, we’ve got to continue to emphasize access and equity. We need to continue to communicate well and build trust. And you all are a key part of that. We really would have been lost without key media partners throughout the pandemic who have been able to provide excellent information on the efficacy of vaccination and keeping people out of the hospitals, as well as other information. And then, making sure we’re trying to leverage technology not only for communication but for patient care—and I’ll just point out, this was an ad, a full-page ad, in our newspaper, The Star Tribune, that was taken out yesterday by the CEOs of all of our major health care system. It’s just reinforcing we’re at the end of our rope. And, please, help us by getting vaccinated, social distancing and wearing your masks. It’s all you can do because we’re doing all that we can do. Thank you.

[0:16:58]

RICK WEISS: Thanks, Dr. Hick. That was a daunting but thorough overview of the situation in hospitals. And we’ll go next to Dr. Jessi Gold.

[0:17:08]

JESSI GOLD: All right. Let me get my slides up, everybody. Thank you for having me. Just by way of background, I am a psychiatrist. And I see health care workers and their families in my clinic and then also am part of the COVID-19 response in our hospital to the mental health of health care workers. I wanted to start by just kind of centering the conversation on what actually counts as health care because it’s very confusing when we use this term. When we think about it and use it according to the Census Bureau, what they mean is basically anything that has to do with health and in any setting. It’s 22 million workers in the U.S., which is 14% of the workforce. And interestingly, I suppose, it’s also female-dominated. So 3 out of every 4 full-time year-round health care workers are female. Anytime you see a QR code, that’ll take you to the website, by the way, and—or the article. If you don’t see one, there’s a bibliography at the end of my slides.

Other than this—I just put this here to quickly touch on it, which is you can tell when it breaks down in the Census Bureau, like, how many different types of health care workers there are. We often just hear from doctors and nurses, but there are so many other kinds. And I think this graph does a good job just showing you what that looks like and how many people do those jobs. I also wanted to center the conversation on the fact that health care workers are not people who had good mental health before COVID. It’s not like COVID came, and all of the sudden, we’re having problems. We had long-standing problems. I use depression and burnout as examples, but there are other mental health conditions I could use, too. When we think about depression, the numbers for people who are in training in medical school are often the highest in medical school and residency. Those are over 27% or almost 29% when you compare to depression—major depression, as we define it, in the general population of around 7%.

Burnout is another term that’s often thrown around and used, I think, sometimes as a euphemism, and we really mean depression. But when we mean burnout, it’s workplace-associated, and it has to do with emotional exhaustion, depersonalization—which in healthcare workers looks like a lack of empathy or sort of, like, treating patients like objects—and a reduced sense of personal accomplishment. So those are the three symptoms of burnout when it’s burnout. And so depression has other symptoms with it—right?—like loss of sleep, increased sleep, change in appetite, which you wouldn’t see with burnout. In physicians, it’s about 50% when you look at burnout, and that’s before COVID.

So then you throw in COVID. And we talked about some of the difficulties, but you have a lot more chance of—risk of getting ill yourself, risk of your families getting ill. You have shortages of all sorts, which is really challenging when you’re trying to do your job. And then on top of that, you have a different, you know, disease process that we don’t know how to help and we don’t understand and are learning over time. And that’s really hard because we like to know the answers in medicine. If you look at the numbers from COVID and what we do know about how the mental health has been affected, we don’t have as many studies as I wish we could show you. But I think, in some capacity, that has to do with the fact that the people doing the studies are the people who are still struggling and fighting COVID.

But the best data is out of New York in April 2020. So take that with a grain of salt. But when you look at that, you know, it’s a big survey of physicians, other advanced practice practitioners—like nurse practitioners and physician associates—and then nurses. And in that population, 57% had acute stress, which is a measure of PTSD. It’s just too close to the trauma to call it PTSD. Forty-eight percent had depression, and 33% had anxiety. Again, I put the numbers for comparison of kind of what the U.S. in general looked like pre-pandemic. Again, that’s not what medicine looked like pre-pandemic, but you can see how high those numbers are.

Seventy-five percent of people reported at least moderate insomnia, which, to me, means most people aren’t sleeping. I’d say that’s the most common complaint in my clinic, and it’s a risk factor for anxiety and a risk factor for depression. And then 65% of people reported feeling lonely and isolated. And social support is a preventer of burnout. And it also helps with PTSD. And so knowing that health care workers go to work every day and are around people but still feel lonely is important to consider. I also added this study which just kind of confirms a lot of the numbers with a bigger N. But the thing I most wanted to highlight from it is that in this study, people who had past-year burnout were at the highest risk of developing COVID-related depression, PTSD and anxiety, meaning your baseline compounds what is going on in the future, right? So what you had before is a risk for the future.

And other things to keep in mind in this population are that some groups are at higher risk of mental health conditions. We know this from some studies. We can extrapolate from what we know from other things. So health care workers who had COVID, health care workers with a (inaudible) history of psychiatric conditions, young adults and women—those are groups that, throughout the pandemic, when you look at mental health breakdowns, have had more struggles. There are also significant barriers to care. So mental health in health care workers is limited by significant stigma towards mental health treatment-seeking. So that has to do, in some part, with fear of what colleagues will say, fear of what our, you know, supervisors are going to say and what that means to patients for us to ask for help in that way.

And we also have trouble recognizing when we have symptoms even though we train in this because we have a normalized bad. So we have a culture that doesn’t sleep, feels sad. And we look next to each other, and we all feel like that’s just what being in medicine is. It makes it harder to know when you actually need help. Additionally, trauma itself has no timeline. So it’s not like COVID’s going to stop, and all of a sudden, we’re magically better. I think we’ll see a higher increase in mental health outcomes for the whole population then but particularly in health care workers. And the studies we have for comparisons from other pandemics would suggest at least two years out, we would be seeing things.

Why do we care about this? I mean, in part, it is because people will leave the field due to all of this mental health stress and strain. We already know that 450,000 people in health care have left since February 2020. It will increase this problem in nursing shortage. And we know from surveys that burnout is a reason people consider leaving their jobs in nursing and leave their jobs in nursing according to a study pre-COVID. Additionally, we know from a study in Utah that the workforce there, including physicians in this study, 21% were considering leaving and 30% considering reducing hours. And that was worse if you were female or had a clinical role. And I think that’s really important to think about, too. Those are big numbers.

Additionally, other potential outcomes are that health care families can be affected. So it’s not just the person who’s affected, right? They come home to a family. And there are not a lot of studies of this, but it affects the children in what we see in this Crisis Text Line study sort of looking at how many people are texting the hotline saying they’re frontline worker kids and what that looks like in terms of their mental health over time.

Additionally, this really affects patients. We know this because burnout affects patients. And we have studies to show that more burnt-out doctors have higher medical errors, lower patient satisfaction. People hang out in the hospital longer and have longer recovery times. But then if you kind of expand to the whole system, it also is really expensive because people will sit in their jobs with reduced productivity until they burn out, right? And then they quit because I just said that. And so that leads to increased physician turnover or other, you know, specialties and then means patients can’t get care when they need it ’cause they don’t have someone to see. And it costs a lot of money to the health care system. So all of this affects patients and the systems substantially.

I thought really briefly—and I don’t have time to go into it, really, a long time—but I—about the journalistic angles that are missing in this conversation. I also asked on Twitter for some ideas. But really, I want to just emphasize that health care worker is a lot broader than just nursing and physicians. We need to be looking at the other groups that are affected, the groups that don’t have as big a voice as—the disproportionately affected health care workers of color, people who don’t work in hospital settings because they’re also affected in other ways, in the ways that health care workers are doing their normal jobs like, say, working in a tornado and then also dealing with COVID and how that impacts their mental health. I also think it’s important to think about the bigger picture and how this affects the workforce and families and patients.

I put some of these tweets just in the slideshow, when you guys go to look at it, of examples of what people suggested would be helpful for people to cover that they didn’t think had been covered. But I can go into that more in detail in the future. But thank you so much for giving me time to talk to you about this topic.

[0:26:10]

RICK WEISS: Thank you, Dr. Gold. That’s a rather depressing look at the state of affairs among health care workers, the people who so many of us are turning to day to day to help us with our own problems clearly struggling themselves. And I really appreciate all the research that you point to there. I want to mention to folks that all these slides will be available on our website very soon at the end of this briefing. And now over to Dr. Will Schpero.

[0:26:44]

WILL SCHPERO: Well, hello, everyone. And thanks so much for the opportunity to be part of, I think, this important and timely panel. I’m going to speak for a few minutes about what we do and, I think, importantly, don’t know about how the COVID-19 pandemic has impacted hospital finances in the U.S. And I’ll begin with a bit of background on the hospital finances before the pandemic. I’ll then talk about the pandemic’s impact and the federal policy response. And then I’ll conclude with a few thoughts on implications both for policy and reporting on this element of the crisis.

So by way of background, I think the key takeaway here is that financial performance varies considerably across hospitals pre-pandemic. And so just looking at one measure, operating margin—you can think of them as comparable to sort of net profits—ranged from about -22% to +22% in 2018. Another measure, days cash on hand—this is how many days a hospital can continue to pay its operating expenses—ranged at the bottom of the distribution from zero—so hospitals effectively running on fumes to over a year, 430 days.

And then I think another measure that we can look at is very important for the pandemic as many hospitals, health systems and other provider organizations have had to shut down—outpatient clinics or discretionary care offerings. And the extent to which hospitals rely on outpatient care for their revenues, again, varies considerably from 34% to 88%. Some colleagues and I, at the outset of the pandemic, attempted to look at what hospitals seem to be the most at risk financially given all of these indicators. And we found that it tended to be smaller hospitals—so those with 50 or fewer beds—hospitals with critical access status and then, in particular, hospitals in rural areas. And I should note that the Government Accountability Office found that there were 19 rural hospital closures in 2019, the year before the onset of the pandemic. There were three closures as of February 2020.

So what do we know about effects? Well, health services revenue overall in the U.S. was about 1% lower in 2020 compared to 2019. There was a significant drop in the second quarter of 2020 and then a bit of a rebound in the quarters thereafter. But I think, importantly, that average annual effect belies some heterogeneity across practice settings. And so what we can see here is that in 2020, relative to 2019, there was a significant decrease in health services spending in the outpatient setting—in physician offices and in outpatient care centers, whereas, on average, hospitals were actually up about 0.1%. Again, that’s on average. And that—I think that correlates with other measures of hospital utilization. And so we saw that, again, sort of after the initial surge of the pandemic in March and April of 2020, there was a significant decrease in hospital admissions. But then they went up to about 94% of baseline by December 2020. And that is responsible for some of the financial trends I showed you in the last few figures.

I think one important component of hospitals’ ability to weather this storm is whether they’re able to provide telehealth services as a substitute for in-person care. And this figure from the Kaiser Family Foundation looks by week, March to September of 2020, at telehealth visits in green as a proportion of total visits in blue. And you can see that, again, there is this significant increase in telehealth offerings at the outset of the pandemic, and that’s been pretty constant in the months thereafter.

So I think the key takeaway No. 2 here is that the financial effects of the pandemic will vary considerably across hospitals, and it’s a function of a variety of different factors—to what extent in the outpatient setting volumes decrease due to practice closures, to what extent hospitals are reliant on outpatient services and to what extent they’re able to pivot to telehealth offerings. I think on the inpatient setting, we’ve seen evidence of both decreased volumes for non-emergent as well as non-COVID emergent care—so lots of evidence that even in the emergency department, we’ve seen reduced volumes for heart attacks and, again, other forms of emergency care. And then, of course, in areas hard-hit by the pandemic, we’ve seen increases in volumes for COVID-related care that unfortunately has had a counterbalancing effect financially.

So there’s been a pretty robust policy response. Under the CARES Act passed in March 2020, Congress established a provider relief fund that has been replenished several times since then and now stands at $178 billion. Those funds have been allocated primarily through two distributions—a general distribution and a targeted distribution. That general distribution allocated funds to hospitals and other providers on the basis of a variety of measures, but the plurality of those funds were allocated on the basis of net revenues historically in Medicare. And then the targeted funds were allocated to specific types of hospitals—so those hard-hit by the pandemic, those in rural areas, those with a safety net orientation, et cetera.

I think an important thing to note, as highlighted by this figure from the Urban Institute that looks at how funds were allocated across these different categories—again, the plurality of funds, 46 billion, were in this Phase 1 distribution that were given to hospitals based on how much they spent in Medicare historically. And I think one side effect of that is that the funding tends to have gone to places that have money, not places that need money. An analysis published this year in Health Affairs found that net patient revenue explained about 46% of the variation in relief disbursements we’ve seen thus far across hospitals. In this work by Colleen Grogan and colleagues, you can see on the right here that we actually saw more provider relief funds go to hospitals with more days of cash on hand—again, that were in a better position financially.

I think there’s also some pretty good evidence that revenue is a poor proxy for need. And so this figure is from work by Pragya Kakani and colleagues who wrote in JAMA last year and looked at structural inequities in the way relief funds were allocated. They found, conditional on receiving the same amount of funding as counties with a low proportion of Black residents, those with a high proportion of Black residents had much higher COVID burden, as shown here, had higher prevalence of chronic disease, as well as more hospitals at risk financially. So you can see here that hospitals in areas with more Black residents had lower operating margins and fewer days cash on hand even though they received the same amount of funding as counties with fewer Black residents, as analyzed in this analysis.

So I want to conclude with a few takeaways for policy and reporting. First, I think in targeting public policies, there is a tradeoff between speed and accuracy. And I think there’s some evidence from the research thus far that the provider relief fund allocations initially overemphasize speed. But I think subsequent and more recent disbursements have been targeted to smaller and rural hospitals more at risk financially. I think, importantly, we don’t know quite yet what the total effect of those disbursements will be.

I think these data highlight the potential for closure and compromised access to care, particularly in rural areas, and suggest the need for additional attention on that issue, both from policymakers and from reporters.

And then lastly, I think they highlight the need for greater antitrust enforcement and surveillance. And there’s lots of concern among policy observers that the financial effects of the pandemic will incentivize hospitals and other provider organizations to engage in mergers and acquisitions. The evidence is very clear that when entities, particularly hospitals, that are in the same markets merge, that only has the effect of increasing prices for consumers and, at best, does not hurt quality and, in some cases, may actually do so.

I should highlight one newsworthy item. As of a couple hours ago, the Department of Health and Human Services announced that providers who—whose relief fund payments exceeded $10,000 are now required to notify HHS if they engage in a merger or acquisition with another health care entity.

I want to end with a few caveats. One is that the mean changes in performance I highlighted do not reflect the entire distribution, and I think we should be particularly concerned about how the pandemic affects outlier hospitals. And then lastly, hospital financial data are released at a lag. We’ll know a lot more in the next few months. So I’m going to end there. Thanks so much. I look forward to engaging during the Q&A.

[0:36:29]

RICK WEISS: Thank you, Dr. Schpero. We have just had a firehose of information from these three panelists. I’m so appreciative to get all that across. And we will start the Q&A session here. I generally start these briefings with one question from the moderator. And I’ll do that now. And I’m just going to ask each of you if you could in turn—from your having just watched the news media cover what’s been going on over the last year and a half plus—to hospitals and health care workers—what have you seen that either has impressed you and that you would like to encourage reporters to keep up on, or maybe something that you feel like reporters are missing the mark on and that a little bit of advice could help them do a better job as they cover this complicated beat. And, John, I will start with you.

[0:37:18]

JOHN HICK: Great. Thanks, Rick. I think one of the key things that’s been a success is the media has consistently delivered excellent messages about the effectiveness of vaccination and the safety of vaccination, you know? There’s been very little that I’ve seen that has been, you know, problematic there. And that’s been wonderful. You know, I think one of the areas where we’ve struggled is to connect people with relevant stories, you know, in that domain where, you know, it has an impact. And in some ways, that’s a little bit beyond reason. I think the thing we really need to kind of turn to, again—and this has come up in all of the presentations—is equity.

You know, we really can’t expect, you know, private organizations to solve equity issues because it’s not profitable. And if you’re, you know, maintaining a negative net margin, you know, operating in areas that serve underserved communities, that’s not sustainable. And so how do we create the public-private partnerships, how do we create that drive, you know, to really begin correcting some of these structural issues that we need to look at as far as access goes? And I think the media can really help that over time, you know, with the type of storytelling and investigative journalism that gets done. I’ll point to Sheri Fink’s, you know, excellent article about the situation in Los Angeles and some of the disparities in care between, you know, the county-operated—the publicly operated hospitals and the privately operated hospitals is just an excellent example of that. Thank you.

[0:38:36]

RICK WEISS: Thanks, John. It’s one of the things that has struck me the most as you were making your presentation earlier, too. I don’t think I’d ever thought about the fact that, really, this is a huge, public—public—health emergency that’s being handled by private entities that were not designed to really function to cover this kind of thing. So it’s a super interesting premise to start from. Jessi?

[0:38:57]

JESSI GOLD: Yeah. Thank you for asking. I mean, I gave some ideas of what I thought was missing. I think I’ll point out some people I think who have done a very good job of this. So the Guardian is—did a whole series where they actually investigated how many health care workers have died of COVID. Without them, the numbers are much smaller from the CDC because hospitals don’t want to say how many people died related to their hospital because that’s complicated. And so the numbers are very different. So the Guardian’s numbers are much more realistic. And I think that was a really good investigative—like, use of investigative reporting.

Ed Yong has done a bunch of pieces that actually focus on health care workers and the outcomes to them. So what is it like to have a hospital bed shortage on health care worker mental health? What is it like to have long COVID as a health care worker? And I think it’s important, when you’re looking at these stories, to always know that—I will argue there’s mental health in everything, no matter what. But when you’re doing stories about the hospital system, everything that’s going on in health care, to pause and go, how does this affect health care worker mental health? And how can I be thinking of it from that perspective? Even if it’s just one line in your piece, it means a lot to people to actually validate that their experiences make sense, and that what they’re experiencing is what everybody else would be experiencing in those circumstances.

[0:40:16]

RICK WEISS: Great. Thank you, and especially in light of the stats you provided earlier. It’s a huge part of the U.S. workforce that we’re talking about here. It’s not just some small job category. Great. And, Will?

[0:40:29]

WILL SCHPERO: So perhaps this is inappropriate to say on a panel focused on how COVID has impacted hospitals. But I actually think there could be more attention paid to, when it comes to the financial impact of the pandemic, how it’s affecting outpatient practices and outpatient care, you know? Those practices, obviously, when they’re not part of large health systems, are much smaller. They have fewer resources to be able to withstand long periods during which they don’t have access to consistent revenues. And I think, again, it’s an equity issue where those practices that disproportionately care for Medicaid beneficiaries and other low-income Americans are probably less able to be open and to, again, sort of weather the storm financially. And the CARES Act funding wasn’t just for hospitals. A lot had also went to other provider organizations.

But I think there’s really the potential for practice closures in the coming months and years that, again, could exacerbate existing disparities in access to care and health outcomes. And I think that, I think, deserves additional attention from the reporting community and also from policymakers. I should mention, in terms of a relevant reporting angle, there have been various entities that I think have been experimenting with ways to support outpatient practices during the pandemic. So most notably, one that comes to mind is Blue Cross Blue Shield North Carolina, which has tried to, basically, provide a set fee per patient per month to many of its primary care practices and sort of catalyze a movement away from the traditional fee for service reimbursement mechanism we rely on in the U.S. in most settings as a way to both sort of move that evolution forward, but also to, again, help these practices stay open as they see decreased volumes during the pandemic.

[0:42:35]

RICK WEISS: That’s fascinating. Any reporters on today from North Carolina, if there are other state-led, sort of evolutionary experiments like that going on. I would recommend that reporters think about reaching out to Will and see if there’s something in your area that might be relevant.

OK to get to some questions from reporters, let’s start with a question here from Kris Mamula from the Pittsburgh Post-Gazette. Could Dr. Hick elaborate on the disparities in care between rural and urban hospitals and the transfer of patients between hospitals and skilled nursing facilities? Are staffing problems at nursing homes, for example, necessarily creating backups at urban hospitals?

[0:43:21]

JOHN HICK: Yeah, great question. And no question, you know, there is a backup that’s occurring because hospitals can’t get patients out to long-term care. That’s not universal, but it’s very frequent nationally and something worth looking into because that is a substantial burden in getting people out. The biggest problem on the coming in side is that, you know, a lot of times—let’s say you get a critically ill patient in—and we’ll just say they have COVID, but it certainly doesn’t have to be that. So you get a critically ill patient sent to the emergency department, and you put a breathing tube in. They’re on a ventilator. Maybe they’re getting medications to support their blood pressure.

And you start calling around to the major facilities that usually take those patients, and they’re all already boarding some of those similar patients in their emergency departments. And a lot of times, you don’t even need—you don’t even get to talk to a physician. You just get a no from the operator. We’re not taking any transfers. So, you know, that’s leading to major delays. We’re talking hours to days before those patients can get a bed. And in the meantime, the nursing and physician staff in those facilities are just not equipped to deal with those, you know, type of illnesses. It might be a dialysis patient, and you don’t provide dialysis. It might be a person with a GI bleed, and you have two units of blood in the hospital. There are certain things you just shouldn’t be taking care of in a small rural hospital, and yet those hospitals are getting saddled with those patients, you know, for days at a time, waiting for beds to come available in a tertiary care center when, in fact, if that patient was in a tertiary care center, they would be likely to getting a lot more expertise and a lot more resources.

You know, as was mentioned, telehealth is a bit of a, you know, problem-solver here as we can certainly consult with and recommend changes in ventilator settings and drips and things like that. But at the end of the day, we can’t telehealth blood. We can’t telehealth dialysis. We can’t telehealth surgeries. There’s a lot of limits to that. And we need to do better, especially for those hospitals that are not part of a health care system already. They’re getting left out in a lot of states.

[0:45:20]

RICK WEISS: You know, a follow-up on that for you, Will. You had mentioned some stats on rural hospital closures. Looked like the data kind of ended right around the beginning of the pandemic. Do we know yet whether rural hospital closures really will prove to be higher than pre-pandemic?

[0:45:36]

WILL SCHPERO: That’s a good question. I don’t think we know yet. You know, I think one of the best entities tracking rural hospital closures is in a rural health center at the University of North Carolina at Chapel Hill. They do a lot of work in this area and pretty actively follow this. I think, last I had checked in 2020, it seemed like it was on par with recent years. But I think, to be honest, it’s tough to construct an appropriate counterfactual. What is the counterfactual number of hospitals we would expect to have closed in absence of the pandemic? I’m an economist. A lot of what I focus on is creating those sorts of counterfactuals, and I think that’s very, very tough to do here.

So I think time will tell, and, you know, I think it’s worth, you know, thinking about, what are steps that states and federal regulators can take to really keep an eye on rural hospitals? You know, I think the evidence is quite clear that when rural hospitals close, there are real mortality effects. And I would recommend some recent work on this subject by Caitlin Carroll, who’s a health economist at the University of Minnesota. And so I think it’s deserving of significant attention, again, from policymakers and others.

[0:46:48]

RICK WEISS: Great. Question for Dr. Gold. You mentioned that the baseline mental health state of health care workers pre-pandemic was not great. Are there efforts underway to address that underlying problem, steps that would put health care workforce in a better position to handle a COVID-like crisis in the future?

[0:47:07]

JESSI GOLD: That’s a very good question. I mean, I think that this is something that if you talk to health care workers about, they wish that somebody started doing something a long time ago. There are these jokes about how all they used to do for mental health was give us pizza parties and a lecture on burnout, and we’d just like to go to sleep. And I think that that still exists.

But the real problem, I think, when you think about kind of planning mental health—and it’s the same problem in the whole country, even outside of health care—is we have a big problem, but it’s not tangibly a problem right now. Whereas people coming in who are sick with COVID that people can see and that they’re dying, that means something, like, tangible, right? Whereas mental health feels really far in the future to people. But at the same time, the ERs are full with people, and they’re going to be—mental health providers don’t have space and their waitlists are three, four months. So, like, we have a lot of problems, right?

And so hospital systems are trying to figure that out, but their money, which we just talked about, too, can’t really be used for that yet. I think they’re trying as best they can to stop all the bleeds at once, right? But I think mental health often gets put below the things that need to happen urgently. And so for my hospital, it’s a lot of advocating for, like, this isn’t just right now. This is going to be long-term. Can we invest in this long-term? What does that look like? And really getting people access to care, at least, even though that’s not even close to prevention. That’s treatment, right? So that’s—it’s a little bit late on that end.

[0:48:37]

JOHN HICK: Rick, can I just tag onto that really briefly?

[0:48:39]

RICK WEISS: Sure.

[0:48:39]

JOHN HICK: And Jessi knows a lot more about this than I do. But I think one of the, you know, biggest contributors to burnout and PTSD symptoms is a powerlessness. And I think that’s what an awful lot of our providers are experiencing right now. And, you know, as Jessi mentioned, there’s no way to fix that right now. I mean, we’ve got to have all hands on deck. But it feels like you’re drinking from a fire hose with no ability to control that flow. And that puts us in a very vulnerable position physically and mentally.

[0:49:05]

RICK WEISS: Got it.

[0:49:07]

JESSI GOLD: While people are screaming at you and telling you, you don’t know anything, right? So it’s like a fire hose in a setting that hates you. So it’s just very complicated. I can’t count the number of people who’ve said, like, I want people to get vaccines. And even when they’re in the hospital, I can’t give them to them. And I am so lacking of every feeling about this. And I don’t know how to keep doing my job when that—I just feel very despondent that no one’s listening, which is what I keep saying. Like, meaning, purpose, control—all those things we just don’t have.

[0:49:39]

RICK WEISS: It seems to me that would be especially intense for a field where, you know, health care workers—especially physicians, I think—have felt like they’ve been in a very powerful position until recently, a lot of respect. Question here from Hilary Brueck from Business Insider. This is directed initially to you, Dr. Hick. At the end of your talk, you said omicon, in a way, may be the last chapter in the pandemic. Can you talk a little more about that? Is it largely because anyone who hasn’t been vaccinated and boosted is likely to be infected with omicron?

[0:50:10]

JOHN HICK: Yes. We’ve got to be really careful because this is still very preliminary. But at some point, we need a virus that is, one, more transmissible than the native, wild-type virus was, two, less severe or less virulent and, three, induces immunity towards the other SARS-CoV viruses. Remains to be seen whether omicron is going to meet those, you know, categorizations. But if it does, that means we’ve got a virus that then becomes part of the general coronavirus community, you know, setting where it’s going to circulate. And people are going to get it. But they’re not going to be hospitalized and die at rates that are going to compromise the health care system. And if it winds up providing us with a refresher in our immunity every year or two when we get it or similar variants, so much the better. But if no other variants that are worse can outcompete omicron in the community, if it’s that contagious, then that sets us up for, actually, a pretty good situation. But, again, a lot remains to be seen. But that would be the best Christmas gift ever.

[0:51:12]

RICK WEISS: A question here that I’ll throw to you first, Will. Others may want to weigh in on this. But it notes that in many places, health care workers are leaving institution-based roles for higher paying travel gigs. What are the implications for hospitals and, maybe, for patient outcomes?

[0:51:30]

WILL SCHPERO: That’s a great question. And I’ll say, it’s certainly not an area of expertise for me. So I’ll certainly start off with an answer and then, you know, defer to John and Jessi if they have additional thoughts. So I think Jessi alluded to the evidence earlier. There is evidence that folks are leaving health care. We’ve seen employment go down across most health care settings. My sense is the most recent data has shown us it has rebounded in most settings, the one exception being long-term care, where it continues to go down. And so I guess I’m not certain that we should expect major labor market effects impacting patient outcomes in most inpatient and outpatient settings except in the long-term care setting, where, again, I think we do see very significant employment decreases with little evidence of a rebound. And so I think that’s where, you know, perhaps, the story should be and where the policy focus should be.

And, you know, I think, as my two fellow panelists alluded to earlier, you know, that does have significant implications for inpatient care to the extent that it becomes less possible to transfer folks out of the hospital setting. I will say that to the extent some of the decrease in unemployment or—sorry—employment that we’re seeing is a function in general of the tight labor market and folks requesting higher wages. There is some evidence showing that when health care workers receive higher wages, they deliver higher quality care. And so if this does encourage some health care organizations to increase wages, particularly for low-wage workers, you know, I do think there’s reason to expect that might improve patient outcomes.

[0:53:20]

RICK WEISS: Interesting.

[0:53:21]

JESSI GOLD: I just piggyback on that, which is to say, you can absolutely not talk about nursing shortages, nursing—travel nursing without talking about mental health because nurses, if they’re the people who’ve been in the hospital system for a really long time and know the hospital system, actually are getting paid less than the people who are coming in as travel nurses. And it’s not their specialty. So the people who’ve been there forever are teaching people how to work. And those people are getting paid more. That is very hard mentally. And it really convinces people to go take travel jobs, because why would you stay in a job when you’re training people who don’t know what you know and they’re getting so much more? And if you look at those salaries in places, I mean, they’re very enticing. It’s hard if you are in nursing especially to look at that and go, I don’t want to do that. So I do think you’re going to see mental health impacts of that. And I’ve heard mental health impacts of that on the nurses who have stayed. And it’s not an easy task.

[0:54:23]

RICK WEISS: Great point, important dynamic. Want to try to squeeze one or two more questions in in our hour here. Here’s a question from Sarah Lehr from WKAR Public Media in Michigan. What sources do you recommend for finding vaccination rates among health care workers, particularly if we’re looking to localize the data to hospital systems in our area? Is there a localizable source that any of you would recommend?

[0:54:50]

JOHN HICK: I would start with your state health departments and then with your major health care systems. But the state health department, you know, ought to have reasonable data on that. There’s just a question of how long it’ll take you to get it—you know, easily available versus not as easily. But that would be the place to start.

[0:55:06]

RICK WEISS: Great.

[0:55:08]

WILL SCHPERO: The one additional source I’d mention is the Department of Health and Human Services releases a weekly dataset that includes information at the hospital level on COVID-related hospitalizations and bed use, but also in recent months, vaccination rates among workers. The one very serious caveat is that while hospitals are required to report their COVID case numbers, they are not required to report their vaccination data. And so there is significant missingness (ph), and not all hospitals and health systems are reporting it in that data set. Frankly, I think that distillery in and of itself—I think there are many hospitals that are not being as transparent as they could be about their vaccination rates. And I think there are, you know, a number of cases where they’re not voluntarily reporting those data.

[0:55:59]

JESSI GOLD: From a journalistic angle, I’d also add that people get very frustrated when every story is about the health care workers who do not get vaccinated. So there are lots of journalistic angles that can cover why people choose to, why somebody chose to get it when they were pregnant and we didn’t know a lot about the COVID vaccine, why people put their kids in trials. Name a health care worker whose child is not in a trial. I think the entire first trials were almost all health care worker kids. And I think that those stories are really important, especially to the morale of health care workers, to not just be saying, like, here are the nurses who are protesting and leaving, and those are the people that we should be focusing our attention on.

[0:56:38]

RICK WEISS: Fascinating. Here’s a question any of you could weigh in on. It’s from Beth Skwarecki reporting for Lifehacker. Besides following recommendations like getting vaccinated, do you have any advice for the general public on how to navigate health care systems, given the current situation? This is really important for local reporters who are providing, you know, news you can use to their readers and viewers. How can people navigate their health care systems in the current circumstances?

[0:57:10]

JOHN HICK: It’s a great question. You know, I think the No. 1 thing is, get your usual care. You know, and we’re seeing many, many complications of people who have, you know, neglected their usual primary care, who have neglected their health, you know, during COVID. So, you know, make sure that you’re getting your usual medical care, that you’re getting, you know, your blood pressure managed, your diabetes managed. And if you think you’re having acute symptoms, you know, do not hesitate to call 911 and get evaluated. It’s really important that we don’t miss your heart attack or miss a complication that then winds up being something that we’re going to struggle, you know, to deal with later on down the line.

And then take care of yourself mentally and physically. You know, make sure you’re making time to get exercise, to, you know, find things that create peace for you, and leverage those as much as you can. A lot of us—our rhythms are completely disrupted by COVID, and so finding new rhythms and new ways that you can feel comfortable, you know, especially around the time of the holidays when tradition and the absence of some of those traditions is so problematic for a lot of people, you know, finding quality, you know, quality things that may become new traditions or new opportunities is really important, and doing so in a way that mitigates some of the risk that we may see around the holidays with omicron and delta variants continuing to spread. Thank you.

[0:58:36]

RICK WEISS: Anyone else want to answer that question before we wrap? OK. So we’ve got just one minute left, and I’m going to ask you each in about 15 seconds each one take-home message that you want the reporters to think about as they think about covering what’s going on in our hospital systems and health care systems today. John, quickly to you.

[0:58:59]

JOHN HICK: Been practicing for 25 years in the emergency department, and every shift I’m working these days is like the worst shift in my career. You know, you have intermittently shifts that are bad, but we have never seen sustained bad the way we have in the last couple months. I’ll just say that. It’s unprecedented what we’re going through.

[0:59:19]

RICK WEISS: That says a lot. Jessi.

[0:59:22]

JESSI GOLD: Yeah. I mean, health care workers are human. As much as you want us to keep going and everybody else is over it, it’s just not something we can stop and just fold in the towel and be done with, you know? I think we’re human. And that’s really important to emphasize in anything that you’re thinking about because we forget it sometimes, too.

[0:59:43]

RICK WEISS: Will.

[0:59:44]

WILL SCHPERO: So I think this is a pandemic that we know has had disparate impacts and I think in the long run will have disparate effects. And I think we’ve an obligation both to highlight those disparities, but also to identify organizational and policy levers that may compound them or may help to ameliorate them. And I think, you know, that’s where we need to focus lots of our attention going forward.

[1:00:10]

RICK WEISS: Great. I want to thank our panelists so much for just a hugely information-rich and really emotionally rich presentation of the situation on the ground right now. Want to remind the reporters on the line here that the slides will be up fairly immediately. Video will go up very soon, transcript soon after. Get in touch with us if you need a videotape sooner. Do follow us on Twitter @RealSciLine. Please, reporters, if you can take half a minute to answer the three-question survey at the end of this briefing, it really helps us do a good job as we keep coming up with topics and opportunities for you through this avenue. And just finally, again, thanks to you, Dr. John Hick, Dr. Jessi Gold, Dr. Will Schpero, for a fantastically important and informative briefing today. See you all at the next SciLine media briefing.