Some hospitals throughout the country are barely managing to survive given that many avenues of their revenue have been shut down during the COVID-19 pandemic. Most hospitals have cancelled elective procedures and routine care which represent over half of all hospital revenue in order to ensure that there are enough beds and critical care resources for the potential surge of COVID-19 patients. How did this occur?

During the late winter, The World Health Organization in conjunction with the Department of Health and Human Services and the Centers for Disease Control and Management developed a “Hospital Preparedness Checklist” for US Hospitals that included the following to plan for the projected surge in COVID-19 patients:

• Elimination of all non-essential visits and procedures (including elective surgeries) and
• Elimination of routine care for those with chronic and/or stable medical conditions

The intention was sound, particularly based upon the Italian experience where the death rate was significantly higher from COVID-19 due to lack of availability of essential critical care services and personnel.

The predictions were right and wrong. Many high-density population centers like New York City and New Orleans experienced the ‘surge’ and desperately acquired additional personnel and equipment. However, many parts of the country (particularly more rural states like New Hampshire) did not. As a result, many healthcare organizations saw a significant drop in volumes and revenue as hospital productivity plummeted.  In addition, the cost of treating COVID-19 patients was not adequately covered by either public or private payers which further depleted revenues. This has had serious consequences for hospitals and healthcare systems everywhere with:

• Significant fall in revenue (40%-60%)
• Deteriorating margins to invest in needed equipment and personnel
• Furloughs for long standing employees
• Higher cost of capital with impaired bond ratings
• Depletion of days cash on hand with several NH hospitals predicted to be cash depleted by early summer

Thus, hospitals need to quickly pivot and change course in order to avoid a threat to the very viability of the essential healthcare services upon which their communities rely.

What are the solutions?

1. Rapidly expand telehealth and virtual capabilities. Healthcare, like every other industry is digitalizing so that patients and consumers can receive routine and necessary services VIA I-phone or Android 24/7 at a low cost. Some organizations like Stanford University Health Center in Palo Alto, California are far down this path and provide over 1/3^rd of their total routine primary care services virtually. Most healthcare organizations have barely put their toes in the water. The good news is that the cost for these services is 95% less than the traditional face-to-face model. The advantage of creating a virtual healthcare delivery platform is that it can be done locally, regionally, or outsourced all together with little capital investment. Individuals with chronic conditions (e.g. diabetes, hypertension, heart disease etc.) should not have their care curtailed as this will only make their ongoing conditions worse.

• Resume elective procedures safely. Elective procedures constitute the revenue ‘life-blood’ of a healthcare organization and enable other critical care and necessary services to occur. These can be done during a pandemic utilizing either a ‘hospital within a hospital’ or ‘parallel organization’ model where there is complete segregation of COVID-19 positive (or possibly positive) staff/patients from those who are definitively negative without symptoms or who have established COVID antibodies. Every healthcare organization is obligated to screen and stabilize potential COVID-19 patients; however, there is no obligation to provide definitive treatment at each and every facility and the care of COVID patients should be regionalized and systematized so that once a COVID-19 patient is identified, screened and found to be high risk (requiring either hospitalization or ICU care), they are transferred to a regional COVID center where there is dedicated personnel and critical care equipment to address their needs 24/7 with intensivists.

• Expand or reduce COVID and non-COVID services based upon rapidly changing demand over time. According to the Centers for Disease Control and Prevention (CDC), COVID-19 is likely to have several peaks and quiescent periods over a one to two-year period. This means that hospitals and healthcare systems cannot be held hostage by the pandemic indefinitely but must be able to rapidly adapt to changing demand based upon local and regional spread or containment of the virus.

In order to achieve these goals, the State of New Hampshire through the Governor’s Task Force will need to establish a New Hampshire COVID-19 Supply Chain to ensure sufficient supplies,  testing and personal protective equipment (PPE)  which will require direct  contracting with corporate entities willing to sell directly to our State due to the depletion and inflated cost of federal supplies and tests.

This pandemic has revealed a fundamental tension: public safety v. a failing economy. Hospitals, like every other business in America, will have to balance ensuring that the public is safe from unnecessary exposure to COVID-19 with its primary mission to maintain essential healthcare services to the communities they serve. It is not an either/or and we must develop a more nuanced and adaptive model for our hospitals to screen and care for COVID patients while maintaining innovative ways to preserve their core business so that along with the communities they serve, they will survive the pandemic as well.