Kevin Tabb, MD (President & CEO, BILH) discusses how COVID-19 has impacted the system and how hospitals are still ready to safely take care of patients.
Boston Globe – June 13, 2020
Hospitals are trying to coax you back — and convince you that it’s safe — as the COVID-19 outbreak eases
For the first few months of the pandemic, reports from hospitals around Massachusetts were grim: medical workers in spacesuit-like protective gear scrambling to care for infected patients, many on ventilators.
Now, with the number of coronavirus cases falling and health care providers resuming routine and elective care, hospitals are trying to coax back regular patients — and reassure them that it’s safe. Hospital halls are starting to bustle and return to their pre-pandemic rhythms, losing some of the feel of lurking danger during the surge.
As part of the new normal, hospitals have reconfigured spaces to reduce crowding and ensure everyone entering wears face masks and is screened for symptoms. Appointments are staggered. Waiting room chairs are far apart. At many hospitals, all admitted patients are tested for COVID-19.
Meanwhile, hospitals are keeping a portion of beds empty in case of a second wave of infections.
“We understand that some people may have concerns about safety, given what they’ve seen on the news or what they may know about COVID,” said Dr. Paul Biddinger, director of emergency preparedness for the Mass. General Brigham hospital network. “Our data show that throughout the entire pandemic, we’ve been able to safely deliver care to thousands and thousands of patients who did not have COVID.”
During the surge in COVID cases, hospitals were forced to cancel scheduled non-emergency procedures, which pay a significant chunk of their bills, to make room for infected patients. Now, they need to urgently ramp up non-coronavirus care, both for their patients’ health and for their own financial security. Many have instituted pay cuts, furloughs, and other measures as they face both diminished revenues and the increased costs of coronavirus testing and protective equipment.
The state’s hospitals usually generate about $30 billion in revenue a year, or $2.5 billion each month. Those earnings plummeted by $1.4 billion — more than half — in each month of the pandemic, according to the Massachusetts Health & Hospital Association. Nationwide, health care revenues fell 45 percent, according to a study published Wednesday.
“We’re really facing some pretty extraordinary financial pressure,” said Dr. Kevin Tabb, CEO of Beth Israel Lahey Health, who has taken a major pay cut himself, along with other executives. The system has lost hundreds of millions of dollars, he said, and the federal stimulus dollars “haven’t anywhere near covered the staggering losses.”
At Brigham and Women’s Hospital this week, the lobby resembled a socially distanced airport security line, with staffers directing people where to enter and exit, or stand in marked areas to be screened for the virus. Patients stood on navy blue circles spaced 6 feet apart that read, “We’re stronger together 2020.”
Clerks handed each person a surgical mask and asked whether they had recently experienced symptoms of COVID-19 such as a fever, cough, or loss of smell. One man tried to enter the wrong way, prompting an employee to shout, “Sir!”
Elsewhere in the building lay 61 patients infected with COVID, and others who were awaiting test results. It’s a juggling act that hospitals across the state are dealing with as they ramp up non-COVID care while managing a total of 1,334 COVID patients, down from nearly 4,000 in late April.
In the radiation oncology department, Kenton Fabrick, 66, of Salem, surveyed the lightly populated waiting room, where rows of chairs had vanished to leave just a few. In the month he has been coming to the Brigham for radiation treatment for prostate cancer, he said, he felt safer at the hospital than at Walmart or Target.
“This is so much better, so much more controlled; everybody’s following the rules, it’s immaculately clean,” said Fabrick, a substance abuse services manager. “To save my life, it’s been absolutely terrific.”
Not all patients are so sure about setting foot in hospitals during a pandemic. During the surge, ER visits for some serious emergencies fell sharply across the state. Beth Israel Deaconess Medical Center reported a 33 percent decline in heart attack patients and a 58 percent drop in stroke patients hospitalized in March and April.
“It is far more risky to defer your care than it is to come in and get care,” given the many safety measures in place, said Tabb, of Beth Israel.
At Boston Medical Center, the city’s safety-net hospital, the emergency room went from seeing about 400 people per day before the pandemic, to 150 in mid-April. Now, around 250 come in daily, which means the hospital “still has a big hill to climb” in making patients feel comfortable, said Dr. Ravin Davidoff, chief medical officer.
One patient came in six days after his stroke because he feared contracting COVID, Davidoff said, making it too late for him to fully recover. He believes many patients’ fears will ease as they see BMC’s strict precautions and that they’re being “as safe as one can be.”
This week, Governor Charlie Baker said the state had made enough progress in reducing the risk of the virus to enter Phase 2 of reopening the economy. That allows hospitals to resume “nonessential” elective procedures such as knee replacements, colonoscopies, and hip surgeries. During the first phase, which started May 18, medical centers had been able to bring back patients with more urgent needs, such as those requiring cancer surgeries.
For patients whose care had been delayed, that was a relief.
“I was sitting there from March 11 to May 15, just kind of waiting, knowing I still have cancer in me and I want it out,” said Krista Petruzziello, 49, of Lowell, who was diagnosed with breast cancer right before the pandemic hit.
Normally, her tumor would have been surgically removed as soon as possible. But because of the shutdown, her doctors at Dana-Farber Cancer Institute and Lowell General Hospital believed she could safely delay the surgery and start hormone therapy to shrink the tumor for some months before removing it.
Throughout the lockdown, Dana-Farber and other medical centers never stopped performing surgeries for cancer patients whose lives depended on it, said Dr. Harold Burstein, a medical oncologist there.
“For everyone, in everything we do, life has been disrupted, turned upside down, and cancer patients are included in that,” Burstein said. “The goal of care during the pandemic was first and foremost to protect the safety of patients.”
Now, hospitals are working to schedule a backlog of cases, and choosing who goes first based on their medical needs. Specialty departments in many cases ranked which patients’ care seemed most urgent to protect their life or to alleviate severe pain or immobility. The state urged hospitals to use telemedicine wherever possible and ensure equitable access to care for all patients, regardless of their insurance.
Key to maintaining safety is being aware of who is infected and contagious. Some hospitals are keeping COVID patients on dedicated floors or units, while others don’t feel that’s necessary. None are sharing rooms with non-COVID patients.
Many hospitals are testing all admitted patients for the coronavirus, including any women giving birth and people having most other procedures.
Visitors remain limited across the state, but policies vary among hospitals. Often one companion is allowed during a birth or end-of-life for non-COVID patients. Because of the need to preserve protective equipment, visitors often aren’t allowed for COVID patients.
The prospect of a second wave of infections looms as the state reopens. To ensure sufficient capacity, the state requires each hospital system to keep at least 20 percent of its beds open.
Hospitals use models to determine whether they need to keep even more regular or ICU beds open, while also juggling the need to bring back scheduled surgeries that also could take up those beds. Boston Medical Center exceeded its ICU capacity during the pandemic surge and had to transfer nine patients, Davidoff said.
“It’s always anticipating what tomorrow might bring by looking at today’s information,” he said.
Hospitals expect patient volume will remain lower for the rest of the year, but the uncertainty of how much lower affects financial planning.
In Western Massachusetts, the BayState Health hospital network expects to see a 20 percent drop in patients from its pre-COVID volume over the next year because of people’s fears of coming in and because of the convenience of telemedicine, said the system’s CEO, Dr. Mark Keroack.
“I don’t know a single [hospital] CEO anywhere who thinks they’re going back to the same volume as six months ago,” Keroack said. “It’s really anybody’s guess.”
Brigham’s radiation oncology unit has actually ramped up volume, seeing about 50 percent more patients than usual, to get through its backlog of cancer treatments.
“Cancer doesn’t wait,” said Dr. Daniel Cagney, a radiation oncologist. “Initially in March and April, there were significant unknowns, but we’ve been living with this for a few months. … I feel very confident that we will provide the best care for patients and it’s safe for them to come into the hospital.”