While the pandemic has undeniably stressed the area’s health care institutions, some good has come out of it, says Rochester Regional Health Chief Medical Officer Robert Mayo M.D.
Though COVID-19 appears at least for the moment to be in retreat, health care systems could, like some COVID patients, face lingering symptoms, what Mayo calls sequelae, a medical term to describe conditions that arise as the result of a previous disease or injury.
Forced by circumstance to step up their game, the region’s hospitals, nursing homes, elected leaders and public health officials strengthened existing lines of communication and developed new ones, Mayo told local reporters late last week.
On the upside, says Mayo, “the pandemic has really been a stimulus for improving communication and partnership across our community, between Rochester Regional Health, the University of Rochester, the county leadership and the city leadership. Those have all been great things. We’ve really been able to accomplish some important work.”
On the other hand, he adds, “There are plenty of things for us to work on, big things that existed before the pandemic and (have been) highlighted by the pandemic.”
In the immediate term, area hospitals are facing a backlog of elective surgeries that piled up as health care systems were forced to cancel non-urgent but still important procedures like diagnostic procedures and surgeries as COVID patients, many of whom were unvaccinated, claimed acute and intensive care beds.
The elective-procedure backlog, says Mayo is “a lot. It’s a lot of people who have been waiting for procedures, some of which are follow up of known diseases and some are routine screenings.
“We are now pleased that we are beginning to ramp up our elective surgeries again. The planning process for that began last week. Those schedules are starting to roll forward. Patients should be starting to hear from (physicians’) offices.”
Still, patients waiting for a diagnosis or wondering whether a planned procedure’s delay could have unintended negative consequences will have faced some degree of unease.
Hospitals’ sequelae, meanwhile, include the financial consequences of being forced to temporarily forego profitable procedures that in less fraught times help them offset costs. These costs include providing charity care to indigent patients and writing off bills that go unpaid because patients lack insurance or refuse to pay, and to help make up for the gap between what government insurance like Medicaid pays and the actual costs of care.
The resumption of electives is not yet moving full steam ahead. It could take a while for hospitals to resume pre-COVID levels.
“It will take us (at least) a few weeks and probably a few months to catch up,” Mayo says.
Staff shortages—already acute before the pandemic and greatly exacerbated as the pandemic wore on—remain as another lingering problem for area hospitals.
As the Rochester Beacon previously reported, health care systems during the pandemic saw an acute shortage of nursing staff as stressed frontline workers quit the profession or abandoned regular employment to work for far higher wages at agencies supplying temporary nursing help.
UR Medicine’s Strong Memorial Hospital was seeing an unprecedented 25 percent turnover among nursing staff, Strong Chief Nursing Executive Karen Keady said in January. Paying higher rates to travel nurses would in the long term be financially unsustainable, Keady said.
RRH’s Mayo says some of his system’s units are currently seeing a nursing staff vacancy rate of 25 percent; others are seeing even higher rates.
RRH, says Mayo, is “still working through understaffing. We anticipate that it will take some time to refill those positions.”
In the meantime, he adds, paying higher rates to travel nurses to backfill short-staffed units has added “a huge premium” to RRH’s staffing costs over the past year and a half, while hitting the system with a sort of double whammy as nurse-staffing agencies “have hired away some of our staff.”
To woo back disaffected staff or attract new nursing hires, RRH has raised pay rates and added other incentives, strategies Strong Memorial’s Keady said UR Medicine is also employing.
In the longer term, says Mayo, area health care facilities are facing problems “that have been highlighted during the pandemic (but) are systemic.”
Electronic medical records are one example. Such systems cost institutions like RRH “hundreds of millions of dollars” to install and maintain.
But, says Mayo, while EMR systems “are part of the solution, giving caregivers advantages like virtually instant access to patients’ medical histories, (they) are also part of the problem. If the system isn’t designed just right for some unique circumstance, it creates some laborious actions to get things customized.”
While hospital bed shortages were greatly exacerbated during pandemic peaks, they are by no means a new problem for this area, particularly in the city and its near suburbs, which have typically been overfull since 2001, when Genesee Hospital abruptly closed, taking out 286 beds. Since then, RRH’s Rochester General Hospital, UR Medicine’s Strong and RRH’s Unity Hospital have typically run occupancy rates of more than 100 percent.
Inability to discharge patients who are too unwell to be left to themselves but not sick enough to require full hospitalization has long been a choke point for this area’s chronically overcrowded hospitals, keeping acute care beds that could be used for patients in more immediate need occupied. While that has been a problem for area hospitals for years, if not decades, the pandemic’s extreme bed shortages made it an even more acute ill.
In January, Keady described Strong’s setup of an alternative level of care unit that would primarily be staffed by aides, a setup that would free more nurses to provide care to acutely ill patients. She had hoped that the ALC unit would only be needed as a temporary measure but weeks later it remained in operation.
Mayo says the ALC choke point illustrates another of the U.S. health care system’s systemic issues, that it “creates financial incentives that aren’t always aligned.”
He explains: “Each institution works to ensure that it survives (financially) and to pay its employees properly. Sometimes those incentives are at odds with other institutions.”
Nursing homes are far more reliant than hospitals on Medicaid reimbursement, which pays less than the actual cost of care, a situation that can make skilled nursing facilities’ budgeting a challenging task.
Skilled nursing patients can require expensive medications that hospitals can more easily afford than nursing homes, notes Mayo. He traces some nursing homes’ denial of admittance to some hospitalized patients to the skilled nursing facility’s inability to afford medications the patient needs.
While the cure for such problems would seem to lie in legislative and regulatory moves, especially on the federal level, no such action appears to be on the immediate horizon.
Still, Mayo believes, such problems can be better addressed at the local level through greater efficiencies and greater cooperation among institutions.
“There are legislative and regulatory solutions, financial solutions,” says Mayo, “but there’s enough opportunity to go around. There are also process solutions. There are many layers of knitting together these complex systems to be sure that they are efficient and that patients move through the system of care as efficiently and productively as possible.”
And on the need to implement such measures, says Mayo, seeing some silver lining in the COVID-19 cloud, “the pandemic has shined a light.”