IN WASHINGTON, hospitalist Farshid Rafatnia, MD, views the efforts to keep hospitals from being overwhelmed by covid patients as something of a double-edged sword. While aggressive social restrictions put in place by the state helped prevent an outbreak that would have overwhelmed his hospital, the attention being paid to covid has decimated his hospital’s census.
Dr. Rafatnia, chief hospitalist for Sound Physicians outside Seattle, says the outbreak in greater Seattle has been relatively contained. The problem: Noncovid patients who would normally be coming to the ED and being admitted for acute conditions haven’t received that message.
“Most of the news you see is from New York City where they haven’t had enough beds or PPE,” Dr. Rafatnia says. “I think that’s scared patients off.” Like in hospitals across the country, the significant drop in his group’s daily census can’t be explained by the suspension of elective procedures.
“I think people are just afraid to come.”
~ Farshid Rafatnia, MD
Instead, the increased acuity he finds among the patients who do come has convinced him that they are simply staying home, trying to tough their way through acute symptoms.
“When we do see them, it’s usually much later in the hospital course than we would traditionally see,” he explains. “At that point, our interventions won’t help as much.” By the time STEMIs end up being treated now, he points out, they are no longer STEMIs but heart failure. One patient who stayed home with what was originally a simple pneumonia finally came to the hospital a month later— with empyema.
“It should have been a short hospital course or even a discharge home from the ED with antibiotics,” says Dr. Rafatnia. “Instead, the patient was admitted for more than two weeks with a chest tube.”
One argument proposed to possibly explain the dizzying drop in medical patients is that social distancing has produced fewer triggers for strokes and MIs. But Dr. Rafatnia isn’t buying it.
“These disease processes take many years before they culminate in an acute event,” he says. “I think people are just afraid to come.”
That reluctance has been so pronounced that, as states tentatively restart some elective procedures, state hospital associations—as well as regional hospital systems— are launching media campaigns to try to convince patients that it’s safe to come back to the hospital. And given the disappearing census and revenues, some hospitals hemorrhaging money have turned to furloughs and/or pay cuts to stanch expenses.
“We expect a huge influx of summer visitors. That’s the wave of possible covid that we worry about.”
~ Jennifer Ashley, MD
St. Charles Health System
Since hospital medicine was launched, hospitalists have been able to take advantage of being too scarce to meet demand. But the coronavirus era has some hospitalists wondering if they should start expecting pay cuts—or even layoffs.
Volumes offset by complexity
A hospitalist at Overlake Medical Center in Bellevue, Wash., and a co-principal of Nelson Flores Hospital Medicine Consultants, John Nelson, MD, finished residency more than 30 years ago.
“I’ve never seen hospitalists—and hospitals—get walloped by an economic downturn like this,” Dr. Nelson says. “I’ve always assumed that health care was somewhat recession-proof. But, oh my gosh, not this time.”
Dr. Nelson expects the patient reluctance that cratered hospital volumes this spring to persist for some time. “If we went months where covid wasn’t in the news and nobody was getting it, people eventually would go back to interacting with hospitals as they did previously. But I think it would be prudent to figure that it’s not coming back 100% for a long time.”
According to Dr. Nelson, however, the shrinking volumes that have been a financial disaster for hospitals have helped the hospitalists treating patients with coronavirus.
“Total volumes came down, but that was offset by the complexity of treating covid,” he points out. Clinicians needed time for long phone conversations with families who couldn’t visit, to don and doff PPE, and to keep up with protocols that changed, he says, “every eight hours. Our census numbers were lower, but our number of work hours stayed the same.”
“If there was ever a time to have one or two too many on staff, this is the time.”
~ Martin Buser, MPH
Hospitalist Management Resources
In Boone, N.C., Lisa Kaufmann, MD, director of hospital medicine at Appalachian Regional Healthcare System, says that her hospital has yet to treat a single coronavirus patient. (That was in early May, and she expects that to change, given that a poultry processing plant is located in the next county.)
Still, the census in the two hospitals her group staffs fell 50%. For the hospitalists, Dr. Kaufmann says the drop was “a welcome breather. Until this, our visit numbers have been steadily going up for more than 18 months.”
A spike in summer census
The low census also allowed the hospitalists to prepare for a possible surge. They helped transition an old coronary care unit to a negative-pressure ICU, pulled together surge staffing plans, came up with covid order sets for both the floor and the ICUs, and did Webinar training.
And, Dr. Kaufmann points out, they are getting ready for their normal summer spike when the population in their county almost doubles. “Many are retirees,” she notes. “They have above-average incomes but a lot of chronic health problems.”
In May, that summer influx had already begun early. “People from out of state perceive that it’s safer here, and they are supposed to self-quarantine when they get here. But we expect to see more covid cases coming.”
Across the country in Bend, Ore., Jennifer Ashley, MD, the hospitalist director for St. Charles Health System, also expects her area’s standard wave of summer tourists to hit. Her hospitalist program staffs two hospitals. Even though Oregon is sandwiched between Washington and California, which both had outbreaks, her state has largely been spared so far.
“We may continue to see cases in our community for at least the next 18 months.”
~ Stephen Behnke, MD
MBA MedOne Hospital Physicians
But the summer tourists who travel to Bend come predominantly from those two states. “We expect a huge influx of summer visitors,” says Dr. Ashley. “That’s actually the wave of possible covid that we worry about.”
As part of her hospital’s preparations for a surge this spring, Dr. Ashley hired locums and scheduled three tiers of back-up providers per shift among her own hospitalists. When that surge didn’t materialize, she was able to let most of the locums scheduled to work in April and May go.
Preparing for a potential surge this summer, however, “we still plan to have one person on back-up every day,” she says.
As for the past eight weeks, the hospitalist census dropped to half its typical volume. “We asked for volunteers to take weeks off, and a few people took me up on that.” But most group members still hold out hope of traveling with their families this summer. “For the most part, they don’t want to give up their shifts now.”
In response, “we’re not forcing anyone to take time off,” Dr. Ashley says. “We’ve kept our full schedule, even though our docs are sometimes seeing only 10 patients a day.” Facility-wide, some nurses have flexed into different roles, including to staff testing tents. But there have been no furloughs.
The Appalachian Regional hospitalists are riding out low volumes with several staff members who are over age 65 taking voluntary leave, says Dr. Kaufmann. The health system has also launched what it calls “covid leave” where employees take time off and still keep their benefits.
“Layoffs for hospitalists are not very likely.”
~ John Nelson, MD
Overlake Medical Center
The system has not furloughed any employees, and it has created a flex pool that allows those who want to continue to work to do so in different departments. “We’ve had pharmacists taking temp checks,” she says, “and nurses helping environmental services with extra cleaning.”
As for the hospitalists, “some have chosen to take time off. They’re paid by the shift, so if they don’t work, they don’t get paid,” she points out. “We figure that at some point this year, we’ll need extra help. So everybody is very comfortable that if they take time off now, they’ll be able to make it up later.”
Paring back physicians on staff
For hospitalist groups that have spent these months treating coronavirus, Martin Buser, MPH, founding partner of Hospitalist Management Resources (HMR) LLC, a national hospitalist consulting firm, points out that they may have unfortunately seen some members become infected and quarantined.
“If there was ever a time to have one or two too many on staff, this is the time,” says Mr. Buser. His clients have also been telling him how time- and labor-intensive it is caring for covid patients, “so each physician should really be treating no more than 10 or 12 patients a day.”
But he’s also received calls from group leaders and hospital administrators who are trying to cope with unprecedented financial losses, with the government’s disaster relief only “a drop in the bucket.” Some bigger programs, he notes, “have actually needed to call off some of their hospitalists.”
For groups in that predicament who have exhausted voluntary reductions, he advises first letting all locums and then part-timers go. If programs actually need to furlough or lay off full-time clinicians to reach staffing goals, they should use a rational system based on seniority. “Take off the least senior first—and when you bring them back, go in reverse.”
“We may not see as much influenza in the over-65, hospital-prone population as we usually do. I’m hopeful it won’t be as much of a double blow of flu and covid as it could be.”
~ Lisa Kaufmann, MD
Appalachian Regional Healthcare System
Some groups paid on productivity alone have simply cut everyone’s number of shifts so they all share the pain. But some hospitals and health systems that implemented across-the-board cuts—in April, for instance, a major system in the Midwest announced it was cutting all its physicians’ pay this year by double digits—have faced a backlash, with their physicians being interviewed on national news.
“Unless the group voluntarily decides that everyone will take a reduction in shifts, you would be better off furloughing or laying off a few,” Mr. Buser says. “That way, everybody isn’t coming to work angry.”
But Mr. Buser also says that out of his company’s hundreds of clients, he’s heard from only a few that need to resort to physician furloughs or layoffs. After all, doctors and nurses who are laid off would have no problem finding jobs elsewhere once the pandemic is over.
Plus, hospitals having a lull right now may be slammed with a covid surge later this year or next, or both. Overlake’s Dr. Nelson says that while he expects that some hospitals will ask hospitalists to voluntarily take time off now, “layoffs for hospitalists are not very likely.”
In Columbus, Ohio, Stephen Behnke, MD, MBA, CEO of MedOne Hospital Physicians, a private group, says his group’s number of covid cases has remained pretty constant across the five hospitals they staff. At the same time, the noncovid census took a 50% hit—and those missing patients weren’t replaced by the coronavirus cases coming in.
While the census has since come up to about 80% of baseline, Dr. Behnke says the group first asked for volunteers among its 75 physicians and 55 advanced practice providers to skip some shifts. Then in May, “we had to begin to ask people to not come in and to furlough themselves for a day.” That ask, he adds, was across the board.
Fortunately, as a private practice, Dr. Behnke’s group qualified for a loan through the government’s Paycheck Protection Program. That’s enabled the group to give its members some compensation for furloughed shifts or for volunteering to take time off.
While that pay isn’t as much as physicians make working a shift, it should be enough to help cover their expenses. He hopes the group can continue to use that program well into the summer.
In Dr. Nelson’s group, lower census has, as elsewhere, translated to hospitalists producing fewer RVUs. His health system has agreed to compensate hospitalists for the same number of RVUs they produced last year, “even if our actual generation this year is 20% lower. It’s protection against a drop in income from having to be on the front-line.”
And Dr. Rafatnia with Sound Physicians says his company’s size and reach make it possible to shift clinicians to different roles and/or sites rather than consider furloughs or layoffs. During these covid months, “the company has done a phenomenal job standing up telemedicine services,” he notes. Physicians have also shifted into doing more research and into staffing transfer centers.
Ohio’s Dr. Behnke believes that treating covid will be hospitalists’ new clinical normal for the foreseeable future. “Unless the disease is somehow affected by warmer weather, we may continue to see cases in our community for at least the next 18 months,” he says. “We don’t expect a vaccine for quite some time.”
With covid in the community, Dr. Kaufmann with Appalachian Regional expects many older patients to continue to shelter in place, no matter what restrictions are lifted. As a result, “we may not see as much influenza in the over-65, hospital-prone population as we usually do,” she says. “I’m hopeful it won’t be as much of a double blow of flu and covid at the same time as it could be.”
If—and it’s a big “if”—hospitals can ensure adequate testing and PPE, HMR’s Mr. Buser thinks that surgeries will come roaring back this fall, up to 120% of their previous volume. “A lot of pent-up, elective-surgery demand could materialize over the next six months if patients feel safe returning to the hospital,” he says. If so, hospitalists engaged in comanagement will see volume pick up significantly.
“Surgeons right now are dying on the vine and want to get back into the OR,” he points out, “and hospitals are seeing staggering losses.” He does expect “belt-tightening to be draconian,” and he advises hospitalists to lower their expectations for compensation increases this year. At the same time, he doesn’t believe administrators will think it’s smart to cut hospitalist pay either.
But that all depends on how well covid is or isn’t contained. If catastrophic outbreaks like New York’s continue and everyone once again has to go underground?
“I don’t think the government will be able to print money fast enough to keep all hospitals afloat,” he says. “If there’s a significant second wave, all bets are off.”
What changes to keep?
IN CONFRONTING coronavirus, hospitalists have had to deal with unprecedented change. Group leaders say they’ve adjusted physician schedules almost daily, while compensation formulas have likewise been tweaked.
But what are some changes ushered in by covid that should become permanent? Farshid Rafatnia, MD, chief hospitalist for Sound Physicians outside Seattle, says he’s very glad to finally see a ban on handshakes in the hospital, hopefully for good. He sees that as a benefit for patient safety and health.
“I grew up in Sweden and went to medical school there,” Dr. Rafatnia says. “In Sweden, they teach you to avoid shaking hands with patients for public health reasons, and that’s considered best practice.” He also hopes, like after the 2009 H1N1 pandemic, that meticulous hand hygiene continues to be maintained.
“We’re now much more cognizant of hand hygiene and of proper sneeze and cough etiquette,” he says. “We need to rethink how we’ve done things in the past.”
In Bend, Ore., Jennifer Ashley, MD, the St. Charles Health System hospitalist director, appreciates how quickly she and her colleagues developed the use of iPads in the hospital. That’s led the two hospitals in the system to purchase several hundred iPads.
“Going forward, we can have one in each patient room so that every patient can FaceTime with family,” says Dr. Ashley. The plan is to have the iPads interact with the EHR so patients can see their treatment team and use the tablets for patient education. “Some of the work we’re doing now will lay the groundwork for much broader use of iPads in the future.”
She also hopes the collaboration that’s taken place across departments, which produced covid care pathways that are updated weekly, continues. As part of that collaboration, the hospitalists have been very diligent about seeing patients in the ED and getting them out of what she calls “that high-risk zone” and up to the floor as soon as possible, or discharged home.
“Covid was so insidious, and we didn’t have enough testing, and there was fear lurking behind every patient,” Dr. Ashley says. “I hope this critical assessment of who needs to be hospitalized and who doesn’t persists after this crisis.”Published in the June 2020 issue of Today’s Hospitalist