Earlier this year, The Seattle Times reported that the University of Washington medical complex had lost just short of half a billion dollars during the first several months of the COVID-19 pandemic. The University’s response included a strategy to furlough physicians and other health care workers (HCWs) and accelerate plans to shutter the building holding their psychiatric patients.
A month earlier, Virginia Mason had confronted its own massive revenue losses following its suspension of non-essential medical procedures by reducing physician salaries and placing some HCWs on furlough. At the time, I was optimistic. I thought VM’s smaller size, engaged leadership, and idealistic, hardworking and passionate HCWs would allow us to be nimbler than the competition.
I remember glibly sharing with one of my colleagues in a group text that the business of medicine was like that of many other businesses — and just like local restaurants, health clubs, and barbershops, we too should recognize that we would be inconvenienced by market strains. Only after I had texted this message did I learn that my colleague had just been placed on furlough. Suddenly, what seemed like a somewhat distant and abstract future had taken on a far more immediate and personal consequence.
Now, eight months since the first case of COVID-19 was reported in Washington state, the pandemic has led to profound changes in medicine—from restrictions on who and when people can visit hospitals, to how HCWs connect with patients, to how and where we practice medicine. How long these changes persist remains to be seen but, broadly, medical providers seem destined to operate in a healthcare system altered by extreme financial stress, technology, and other changes prompted by the pandemic.
Healthcare across the U.S. and here in the Northwest has been consolidating for years, as organizations such as Providence and Kaiser have sought to grow larger and strengthen their financial bases. VM began a partnership with Yakima Memorial a few years ago, after efforts to work more closely with Group Health failed to materialize. Estimates prior to COVID suggested that 8% of U.S. hospitals were on the brink of closing and that another 10% were at risk of closing due to financial insolvency. Now, COVID-19 has placed even more pressure on healthcare organizations, from hospitals to independent primary care clinics. As VM celebrates its 100th anniversary we employees wait anxiously to see how an impending partnership with CHI Franciscan will impact both our patients and our work.
The pandemic and its restrictions on elective procedures and outpatient visits have resulted in a dramatic decline in hospital revenues. The American Hospital Association estimates that COVID-19 has collectively cost U.S. hospitals more than $50 billion per month since March. Since January 2020, at least 20 U.S. hospitals have closed, including Astria’s Regional Hospital in Yakima.
In a recent commentary in the New England Journal of Medicine, the authors wrote, “In the aftermath of COVID-19, there will be significant pent-up demand for healthcare services, and a significant loss of providers could reduce the system’s capacity to the point where it is impossible to catch up on the accumulation of deferred care while also meeting ongoing demand.”
COVID-19 has financially harmed 97 percent of 724 medical practices, according to a recent survey conducted by the Medical Group Management Association. What’s more, 6 percent of 558 U.S. primary care physicians indicated in late spring that their practice had shut its doors, and many of these practices will not reopen. Whether treating patients on the front lines or facing a dramatic reduction in patient volume, medical practices are struggling to survive.
Several years ago, I suggested to VM leadership that we adopt virtual consultations for some of our non-cancer-related hematology cases. At the time, this suggestion gained little traction. My understanding was that since we were not widely serving the needs of rural populations, we could not be easily reimbursed for these efforts and that there existed too many obstacles to pursue this effort. Now, among the positive innovations that have taken place due to the conditions of the pandemic has been the use of telemedicine. When the federal government relaxed telemedicine reimbursement rules in response to the pandemic, the use of virtual care skyrocketed. Within a few short weeks, VM was among a burgeoning group of providers and healthcare networks adopting this technology.
Telemedicine enables HCWs to connect with patients through enhanced access. Patients who are connected to the internet — but hate the idea of driving to a medical center, paying a large parking fee, and braving the safety restrictions put in place as they try to navigate the medical center maze — prefer this option.
However, telemedicine has also made it more challenging to connect with our patients on an emotional level. Technology is imperfect—screens freeze, and facial cues can be more difficult to read. The importance of touch and the art of the physical exam are lost as we seek to develop “virtual” skills to compensate for this. With the addition of masks, even in-person care has been impacted in similar—but perhaps lesser—ways. Will reimbursement rules allow virtual care to continue growing? Congress will decide this, but reversing course seems unlikely in this new “normal.”
Like the work meetings of many other industries, many of our physician and nurse meetings and tumor boards are now virtual as we, too, have become increasingly comfortable with Zoom and other virtual platforms for day-to-day functioning. Such forms of communication are more impersonal and erode camaraderie but, in the health care industry there will be greater pressure to become more efficient and cost-conscious, so these newer platforms will likely gain permanence, even after the COVID pandemic wanes.
Hospitals and clinics will likely reinforce COVID-era operations—including visitor restrictions and other protocols—well after the pandemic: Medical waiting rooms will be virtual instead of physical, patients will register online rather than when they check into the doctor’s office, and efforts to minimize infection risk—such as are currently in place with drive-through Coronavirus testing and flu vaccinations—will continue after the pandemic. Buildings themselves will likely evolve, too.
Faced with an influx of cases, such as is occurring in Wisconsin, at-risk hospitals are learning to flex their emergency departments and critical care units as they prepare for new surges. Modular construction will also dominate plans, where emphasis is placed on patient care areas that can be assembled rapidly during periods of stress and disassembled easily when not in use. For its part, the CDC has advised medical practices to “make long-term changes to practices and procedures,” including no longer using porous materials for seating, no longer leaving doors open, and upgrading ventilation systems. Patient-facing work areas have consequently never been cleaner, a good step.
Disruption to essential medical supply chains has emerged as one of the most frustrating aspects of the pandemic, inhibiting patient care and physician workflows alike. Blue state governors have not been the only ones appealing to the federal government for enhanced support—HCWs have pleaded for adequate PPE, ventilators, and medications, and have done so at the peril of their own jobs. Recall the case of the Bellingham emergency room doctor who was fired after warning patients of his hospital’s unsafe conditions. There will also be more coherent standards that do not vary from hospital-to-hospital regarding what constitutes adequate PPE. The use of specific masks, goggles, and gowns will be based on efficacy data, rather than what is available in one hospital versus another.
It remains to be seen how the pandemic will affect hospitals, clinics, and HCWs in the long term. But clearly, some of the effects will become permanent. In some ways, that’s good news; Who doesn’t want patients to have increased access to virtual care, less infection-prone clinics and hospitals, and needed supplies? In other ways, the pandemic’s footprint on health care—in urban and rural areas alike—will be devastating, as large swings in the workforce take place and some providers take early retirement or are downsized out of jobs. Job stability—long taken for granted in healthcare—will be irrevocably altered.