COVID-19 causes unusual financial risk for rural hospitals — underutilization

Liv Paggiarino/For the DemocratAaron Kliethermes puts on a fresh pair of gloves on  Wednesday at Capitol Region Physicians Primary Care Clinic. After every coronavirus test, he and coworker Nikki Troesser changed out their gloves and sanitized their hands.
Liv Paggiarino/For the DemocratAaron Kliethermes puts on a fresh pair of gloves on Wednesday at Capitol Region Physicians Primary Care Clinic. After every coronavirus test, he and coworker Nikki Troesser changed out their gloves and sanitized their hands.

Although the spread of the novel coronavirus, COVID-19, has come with more dramatic consequences in urban areas, it's effect on rural hospitals has been just as chilling.

COVID-19 has been a disease that - at minimum - first was addressed in urban areas, said Dave Dillon, the Missouri Hospital Association vice president of public and media relations.

That was a logical outcome. But a lot of people became infected before protocols went in place.

Steps taken to prevent rapid spread, like that in cities, have been effective, but difficult for rural hospitals.

"The nature of this virus is that it's clearly very easily transmissible in highly dense populations," Dillon said. "What we've seen is in Missouri's urban areas, we've seen hotspots - like Los Angeles and New York City. Because of population density, we saw more people infected and more hospital utilization."

Rural hospitals and hospitals in smaller cities have seen very little of that, he said. Not unlike urban hospitals, they placed a "hard stop" on elective procedures, diminishing their inpatient and outpatient procedures. To save resources and not overtax themselves, hospitals canceled all their elective procedures early in the pandemic.

Those are procedures that bring revenue into hospitals - all hospitals, including those that may already have been struggling to make ends meet in rural communities.

Additionally, people are avoiding hospitals.

Beds, made vacant to assure they'd be available if necessary, aren't being used.

"The absence of demand for health care services right now is creating a difficult situation for hospitals," Dillon said. "You're obligated to taking care of your community's health, but you're seeing a drastic drop in services."

Missouri is watching as other communities - that the pandemic struck earlier and harder - are trying to overcome hurdles posed by those challenges.

"Right now, the challenges for (Missouri's rural) hospitals aren't that they are being overwhelmed. They are being underwhelmed," Dillon said. "And they're facing financial challenges associated with that."

Typically, 50 percent of operational costs for a hospital come from staffing.

Some hospitals in the state, Dillon said, are doing things they'd rather not be doing - furloughing and laying off employees and delaying payments to suppliers.

Late last week, Capital Region Medical Center announced it was offering voluntary furloughs to some employees, according to Lindsay Huhman, the hospital's director of marketing.

"Due to the evolving COVID-19 pandemic that is impacting lives and economies across the world, CRMC has seen a shift in patient volumes similar to other health care organizations across the country," Huhman told the Jefferson City News Tribune. "As concerns for spread of the virus grew, CRMC made the prudent decision to reduce elective procedures, postpone well or routine clinic visits and adopt TeleVisit technology to see patients virtually.

"While implementing these changes helps protect patients, the community, providers and employees, the result is a reduction in demand for staff. To help manage the reduction in volumes, employees working in departments with the most dramatic impact were given the opportunity to voluntarily take a furlough."

The hospital will maintain benefits for the affected employees and has promised to bring them back on board when it returns to normal operations.

The option to return is not as readily available for staff from rural hospitals.

There are significant problems with laying off staff, particularly in rural communities, Dillon said. If rural hospitals lay off employees, it is difficult to regain them. It costs more to recruit replacements. And replacements generally cost more than their predecessors.

"Nurses and therapists are those people who are necessary," he said. "If they start disappearing from rural hospitals, it is more difficult to replace them."

Hospitals brace for uncertain future

There are few guesses about when Missouri lives will reach a new normal after the pandemic.

Medical professionals and scientists are crunching data accumulated during the pandemic.

Hospitals were not alone in making changes to their daily activities in order to prepare for and slow the spread of the pandemic.

Governments have ordered gatherings be limited to fewer than 10 people, causing many businesses to close.

And as it became apparent that the pandemic was going to spread across the country, local and state governments asked residents to practice social distancing.

The 100-year-old strategy for preventing the spread of a virus is working, Dillon said. He said the modern-day approach of "super social distancing" takes the approach further - not just staying 6 feet away from each other people but also closing down businesses, using drive-thru windows, working from home or working remotely.

"The data seem to indicate that we may have plateaued. You don't really know that until you have a larger data set to look at," Dillon said.

Missouri Gov. Mike Parson on Thursday announced extension of a statewide stay-at-home order through May 3. At the same time, he said, the state will monitor public health data and stay ahead of the pandemic.

Nationwide, the United States may be turning a corner on the pandemic, Dillon said. And experts are trying to determine when it will be safe for businesses and communities to begin returning to their new normal.

"We are going to need to be able to do additional testing - not just testing, but fairly rapid testing," Dillon said. "We'll have to assure the (medical equipment) supply chain is open enough to address the problematic gaps we've seen."

Parson on Thursday called on the state to be able to conduct at least 10,000 COVID-19 tests daily.

And, some communities may possibly begin modified versions of social distancing.

"We're more than a month into this, and every day, we see additional progress along many of the factors that are important to reopening," Dillon said.

The health community doesn't want to look back and see that efforts to "flatten the curve" (or blunt the surge in disease exposures) have been reversed, he said.

Failure to flatten the curve could have disastrous results. Early projections for the pandemic showed dire results if communities didn't slow the spread of the virus.

Several projections created about a month ago warned the virus could have significant negative effects on hospitals and community health.

They said, should the COVID-19 pandemic continue as it was, and depending on how high a percentage of the population it affected, hospitals could have run far short of bed space to manage the crisis.

That troubling situation was already a reality for some metropolitan "hotspots," and if it weren't for social distancing and closures of schools and businesses, could also be true for communities in rural America.

Projections from the Institute for Health Metrics and Evaluation, an independent global health research center at the University of Washington in Seattle funded through the Bill & Melinda Gates Foundation, projected total COVID-19-caused use of hospital beds and invasive ventilators in the United States and for each state.

Early projections were alarming, with states running short on the much-needed equipment. However, as states began implementing social distancing, the organization revised its estimates downward.

Projected peak use of ventilators for Missouri went from May 11 to April 28.

And, where once beds were expected to run short, the Missouri estimate looks comfortably far from having shortages, according to the projections (at covid19.healthdata.org).

Other health experts have weighed in on the capacity for the global pandemic to cause chaos in the United States. The Harvard Global Health Institute, ProPublica and the New York Times collaborated to consider several worst-case scenarios.

The model looked at bed capacity for each of 306 U.S. hospital markets - called Hospital Referral Regions (HRR). The regions represent regional health care markets for tertiary (or highly specialized, complex) medical care. For example, Jefferson City falls within the HRR served by hospitals in Columbia.

Data projected that anywhere from 56-773 percent of hospital beds in the HRR would be needed for patients, depending on how quickly the pandemic spread and to what percentage of the population was infected. The researchers looked at how infections in 20 percent, 40 percent and 60 percent of the population would stress hospitals if they happened over six-month, 12-month or 18 month time periods.

The federal government on Thursday recommended, as criteria for easing stay-at-home guidelines for states, that they show declines in documented cases for 14 consecutive days, that hospitals can treat all patients without crisis care and that there is a robust testing system in place (including testing for health care workers). DHSS Director Randall Williams said Friday during the governor's daily COVID-19 briefing that testing is providing data that will help health care leaders make decisions.

If the state is to begin to restart its economy, it must have the capacity to absorb any surges in the pandemic that may occur, he said.

"We want to make sure that we have plenty of hospital beds," Williams said. "We have been very fortunate throughout the state - as I've said many times, we have about 2,100 ventilators, and we have about 1,100 available."