COVID-19 is draining health care providers' finances and leaving some patients in limbo
As hospitals prepare for a surge of patients ill from COVID-19, physician and dental offices across Arizona are sitting empty, patients are learning that upcoming surgeries are canceled, and some health care workers are facing job cuts and furloughs.
Emergency room traffic is down, patient volumes are down, and for hospitals, expenses are way up — they've been ordered to increase their bed capacity, and they're scrambling for supplies. Leaders at Northern Arizona Healthcare say the cost of a single N95 mask prior to the pandemic was 69 cents. Now, they're $8 each.
What's going on in health care right now is what Phoenix internal medicine physician Dr. M. Zuhdi Jasser calls a "perfect storm" of stress on the health care system because of the expected COVID-19 patients and an economic shutdown that has affected businesses everywhere, including the health care infrastructure. Regular health care in Arizona has all but ground to a halt.
Jasser recently spent 30 minutes fighting to get an angiogram for a patient with coronary artery disease — fallout from a March 19 executive order from Gov. Doug Ducey that hospitals and clinics halt non-essential surgeries.
"He's not going to wait two or three months in order to not have a heart attack," Jasser said of his patient. "It took quite a bit to prove that was not an elective procedure. Regular things that are slam dunks, that would take me 10 minutes to get scheduled, are taking me 30 to 60 minutes to get scheduled because of the obstacles in place."
Non-essential or elective surgeries are ones that can be delayed “without undue risk to the current or future health of a patient,” according to the governor's order. Doctors are told to use their best judgment in determining whether a surgery is elective. A surgery is not elective if delaying will be life-threatening or cause permanent physical dysfunction, impairment or hospitalization.
Elective surgeries and procedures are still important, and patients say they’re struggling with the delays.
Gilbert resident Danielle Gregorich, 36, has dealt with health challenges for several years, including a stroke, kidney cancer and cardiac ablation. Now, she desperately needs a hysterectomy to alleviate her pain from endometriosis. But it’s considered an elective surgery, so her “horrendous” pain will continue until at least the fall, she said.
“I saw the light at the end of the tunnel and now I feel like I've been put back 300 feet," Gregorich said.
Gilbert resident Stephanie Brooks, 35, is now going without medical treatment for her stomach ulcer. After extreme pain and vomiting two weeks ago, Brooks finally went into the emergency room and was told by her doctor she needed an endoscopy as soon as possible.
As the coronavirus situation escalated, the endoscopy became impossible to schedule. She's been told that unless her ulcer becomes a pressing emergency or she begins vomiting blood, there’s nothing to be done until COVID-19 restrictions ease. She manages pain with over the counter medications and a bland diet, but she’s eager to be examined.
'It's really a medical opinion whether something is emergent, urgent or elective. The gray area is in those urgent procedures," Jasser said. "We have to be careful not to delay urgent procedures."
Jasser is trying to schedule surgery for another patient who has a severe hip problem. She is in her 40s, and her hip is so bad right now that she can't walk.
"I'm advocating for her as her primary care doctor, but it's hard if the hospital is not doing elective procedures," Jasser said.
Mayo Clinic will furlough some employees
On Friday, the Mayo Clinic, which has health facilities in Minnesota, Florida and Arizona, announced that after April 28, "temporary furloughs of some staff and salary reductions will be required." Because the details are still being worked out, officials with the Mayo Clinic in Arizona could not provide a number of affected employees in Arizona.
"There are no plans for permanent staff layoffs," Dr. Richard Gray, Mayo Clinic in Arizona CEO, said in an emailed statement. "We will work with our teams in the coming weeks to ensure that our staff are supported, that the duration of this disruption is as limited as possible, and that all staff are quickly welcomed back as we are able to resume more care that is not directly related to our COVID-19-response."
The health system said that halting elective surgeries — something Mayo began prior to Ducey's order — was the right decision, but that it eliminated most revenue at a time when Mayo is making investments to develop and expand testing, conduct research to help stop the pandemic and realign facilities and care teams to treat patients ill with COVID-19, which is caused by the new coronavirus.
On April 2, leaders at the Santa Cruz Valley Regional Hospital in southern Arizona said they'd have to shut their doors without immediate economic relief. The cause, they said, was lost revenue from the cancellation of elective surgeries combined with the expense of preparing for a COVID-19 patient surge.
Dr. Robert Trenschel, Yuma Regional Medical Center president and CEO, wants his hospital to be allowed to restore some of its elective surgeries and procedures. He believes Ducey should allow individual hospitals to decide for themselves how much they can handle.
Trenschel said he is doing everything he can to avoid furloughs for the 2,400 employees at his 406-bed hospital. The hospital typically has about 80% of its patient beds occupied, yet now is less than half full. Right now, it is treating two patients who have tested positive for the new coronavirus, which causes COVID-19 illness, and several other patients who have suspected COVID-19 infections.
"We are not getting the number of cases here that other areas are seeing. We are under tremendous financial pressure," Trenschel said. "It's a $400,000 loss in net revenue per day."
Jasser is struggling to keep his small practice of three providers financially afloat, too. For his practice, Ducey's March 30 stay-at-home order provided the real economic blow, Jasser said. Patient visits to the Jasser Center for Comprehensive Care "decreased overnight" by about 30% to 40%, and as of Wednesday volume was down by 50%, he said.
He doesn't want to furlough any of the practice's 18 employees, though it may be a necessity. There's also the issue of patient health, he said. He put in an application for a small business loan and hopes it comes through soon.
Telehealth has provided some help for patients, but Jasser is worried about patients who have chronic health conditions and are avoiding necessary trips to the doctor's office. His office, like most others, is screening patients for signs of COVID-19 before they are allowed to go inside, and everyone wears masks.
"It's not just about fighting a virus. It's about keeping Arizonans healthy," Jasser said. "The perception that we can put everything on hold while we're fighting the virus is a bit absurd because if someone has diabetes, or emphysema that gets out of control, they are going to become more at-risk."
At Kingman Regional Medical Center in northern Arizona, patient volumes are down about 30%, and hospital officials said the impact of the COVID-19 pandemic equates to losses of about $8 million per month. At the same time, the 235-bed hospital is trying to get ready for a projected surge in patients ill with COVID-19 later this month. Ducey has asked hospitals to increase their bed capacity by 50 percent.
"Just putting policies and procedures in place, like standardizing how we are going to intubate patients," said Brian Turney, Kingman Regional Medical Center CEO. "We have an incident command center trying to get all these things in place so that we are as prepared as possible. ... All of those types of things take a lot of time and effort."
Turney said the hospital has repurposed some employees' jobs, and some have had hours cut. The Kingman area has had about 12 positive cases and the hospital has treated four COVID-19 patients, he said.
"We've got about 120 days cash on hand, so we could go on for a period of months, but obviously that would have a long-term financial effect on our abilities to do other things in the future — what kind of services we could offer, how much we could expand and grow," Turney said.
On April 8, Ducey announced that the Arizona Health Care Cost Containment System, which is the state's Medicaid program, will work with its provider partners to make available more than $50 million in accelerated hospital payments and advances and extend an additional $5 million in new COVID-19-related funding to critical access hospitals throughout the state.
A critical access hospital is a rural acute care hospital located more than a 35-mile drive from any other hospital.
"That's going to help from a cash flow standpoint," Turney said. "It's basically advances on business we'll do in the future. At least from a cash-flow standpoint, it helps. But it doesn't really offset your losses long-term."
Becker's Hospital Review this week reported at least 80 hospitals across the country are furloughing workers because of pressures from COVID-19.
"I can't imagine there is a hospital that is not impacted financially by what is going on," said Julia Strange, a Tucson Medical Center spokeswoman. TMC is the largest hospital in Tucson. It has 600 licensed beds and a workforce of about 4,000.
"Our surgeries are 50% to 60% less than what they were at this time a year ago," she said. "Our billable charges are between 40% and 45% less than a year ago. When you drop that dramatically it's very difficult to maintain the workforce. We estimate the drop in volumes to be about $20 million per month that we've lost."
Hospitals operate on slim margins. At TMC, it's about 2% per year, Strange said. Federal relief from the CARES Act is expected, but hospitals don't yet know exactly how the payments will roll out or if it will be enough.
An analysis by the Arizona Hospital and Healthcare Association shows Arizona hospitals are reporting revenue losses of 30% to 40% due to cancellation of elective procedures and a reduction in emergency department visits. Statewide, that equates to a revenue reduction of $430 million to $575 million per month, and hospital officials don't know how long the COVID-19 crisis will continue here.
"We're working very hard to work with local, state and federal partners to get relief into the system," Strange said. "We are not looking for anything more than what we need to continue with our mission as a community hospital. A majority of our patients in the hospital do not have COVID-19. We want to keep our patients safe, keep our staff safe, and provide an environment where people can heal from all kinds of illnesses."
Cancer patient can't see specialist
Patients are skipping mammograms, colonoscopies, blood work and annual physicals — aspects of medicine that are frequently touted as contributing to longevity and overall health. Of more immediate concern, patients are also avoiding the emergency room, Tucson Medical Center's Strange said.
"We got the stay-at-home message out so well that we are concerned about people with emergent health needs, like signs and symptoms of a heart attack or stroke, or people in a diabetes crisis, that they are not coming to the hospital when they need to," Strange said. "Hospitals like TMC have gone to great lengths to ensure patients will be safe while in our care. The hospital is not a dangerous place."
Not wanting to risk leaving their homes, patients with chronic diseases and serious illnesses are skipping important appointments too.
Gilbert resident Stephanie Kempf, 41, has a rare form of cancer called aggressive fibromatosis desmoid. She has a malignant tumor that requires an MRI every three months to monitor its growth and make sure it isn’t attaching to bones or organs. If it does, she could lose arm movement or a kidney, she said.
The MRI has to be done at her specialist’s office in Nashville. Because of her weakened immune system from recent chemotherapy, Kempf barely feels comfortable going out to get the mail, not to mention flying to Nashville. She was going to have an MRI in May to examine a newly developed tumor, but that’s now delayed indefinitely.
“This situation isn’t making things any easier for me or my husband or anyone with this condition,” Kempf said. “It’s super stressful knowing that I have to go an extended three months without any measurements or knowing if we have any growth or any change.”
Kempf has also been laid off from her job, leaving her without health insurance for a short period, she said.
"We can't approach this through the tunnel vision of how many people are infected, how many people are critically ill from the virus," Jasser said. "This has to be a total picture, not only from a total picture of health but also economically for Arizonans. If the shutdown goes on much longer, are unemployed patients going to be able to pay for their insulin, pay for their heart failure medication? We can't ignore them."
The executive orders to halt non-essential surgeries and to stay at home have had an economic effect on a range of health providers.
Many dental hygienists have no work because there are no routine cleanings going on, and most dental practices are operating at only a fraction of their normal staffing levels, said Sean Murphy, executive director of the Arizona Dental Association. Most dental offices are taking emergency cases only, and emergency cases make up a very small fraction of what most dental practices provide to patients on a daily basis.
"In my office, that has reduced our patient load by probably about 98%," said Arizona Dental Association President Dr. Jennifer Enos, whose dental practice is in Chandler. "On an average day, we might see 30 to 40 patients and we are now seeing one to two patients a day, for emergencies."
Many dental offices have had to furlough or lay off employees due to the pandemic, Murphy said.
Reach health care reporter Stephanie Innes at Stephanie.Innes@gannett.com or at 602-444-8369. Follow her on Twitter @stephanieinnes.
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