Staff shortages, deferred treatment driving changes in care models

Patients previously considered low-risk became sicker and health disparities likely widened because of clinical staff shortages and volume surges during the COVID-19 pandemic. As a result, care delivery models need to evolve to make up the backlog and meet the ongoing needs of those whose ailments manifested or became more severe because they couldn’t receive treatment.

The pandemic, along with the healthcare system’s response, have had a disproportionate effect on older and sicker patients as well as people from underserved communities that’s going to linger. The public health emergency also highlighted and exacerbated staffing shortages, leaving a smaller, exhausted workforce to deal with the clinical consequences of deferred care. The pandemic eventually will go away, but the patients who didn’t get the treatment they needed will not.

The impact of delayed care on patients is still being empirically explored, but a general consensus has emerged: Many became sicker and diseases progressed undetected as preventive care and screening went by the wayside. Wellness visits declined 69%, breast cancer screenings dropped 88% and childhood vaccinations for measles, mumps and rubella fell 60% as people stayed clear of the healthcare system in 2020, according to data from UnitedHealthcare.

Hospitals are grappling right now with how to optimize their workforces to face these challenges by reconsidering how care is delivered. Telehealth and value-based care will play critical roles.

Crisis standards of care

The number of hospitals that entered crisis standards of care during the pandemic hasn’t been counted, and the ways they deployed—or didn’t deploy—resources changed over time. By last year, hospitals had expanded surge capacity and supplies of ventilators and personal protective equipment but became increasingly short-staffed. As of last month, 27% reported critical shortages to the Health and Human Services Department.

During crisis levels in the early phases of the pandemic, mortality rates spiked as hospitals rationed care. One-quarter of COVID-19 deaths between March and August 2020 were attributable to overstretched hospitals, according to the National Institutes of Health. Patients with the most serious non-coronavirus illnesses suffered under the same conditions.

To advise triage decisions, some states resorted to previously developed guidelines on allocating workers, beds and equipment during times of scarcity. By definition, this meant turning away patients who otherwise would’ve received treatment.

Tennessee, for instance, at first excluded patients with specific chronic disabilities, severe dementia, end-stage organ failure and other diseases under pre-pandemic guidance for times when resources were short. But HHS’ Office for Civil Rights determined that policy violated federal anti-discrimination laws. By June 2020, Tennessee rescinded those guidelines to allow such patients to receive treatment.

That left hospitals to figure out how to prioritize resources at their own discretion but it didn’t necessarily translate into better access for chronically ill patients. Not only were providers in the Volunteer State and elsewhere still swamped, but those internal decisions led to similar outcomes as the guidance that was deemed illegal by the federal government.

HHS recommended that providers use the Sequential Organ Failure Assessments score, which evaluates organ function to determine patients’ likelihood of mortality if they were to receive treatments or beds. Those most likely to die go untreated and often are diverted to palliative care.

This example underscores how difficult decisions during emergencies can harm the most vulnerable, said Matthew Wynia, the director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus in Aurora.

The Sequential Organ Failure Assessment may be inappropriate because it’s designed to be used quickly and it stacks the odds against patients with chronic health conditions, which disproportionately affect marginalized communities and the elderly, Wynia said.

“Mortality rates for Black people during the pandemic have been higher,” Wynia said. “What really got people’s concerns raised was you could have a perfect scoring system that was really accurate, and it would end up preferentially taking resources away from Black people.”

Both broad and narrow triage methods lead to similar outcomes: The oldest and sickest are first to see life-saving treatments halted and deaths among those demographics skyrocket, Wynia said. “We had very few places that ever acknowledged that they were making those kinds of triage decisions,” he said. “You can see it in the data, even if people won’t talk about it. You can see that during surges when ICUs were really crammed full, mortality rates for older people with COVID went way up.”

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Nursing shortages

Nursing represents the biggest workforce problem for most hospitals. The total number of registered nurses declined 2% and the number of nursing assistants fell 9% between 2020 and 2021, according to the Bureau of Labor Statistics.

In September, the American Nurses Association asked HHS Secretary Xavier Becerra to declare the shortage a national crisis because it jeopardizes patient care. As of this writing, he hasn’t. Some states had to mobilize the National Guard to fill out hospitals’ clinical teams, and approximately 95% of hospitals reported using nurse staffing agencies.

A robust body of research shows that having fewer nurses is linked to worse patient outcomes. Mortality and adverse health events rise, as do costs, when patients spend more time in hospitals and are more likely to be readmitted. This contributes to burnout and moral injury among clinicians, which can lead to declining patient satisfaction and lower Medicare reimbursements.

To mitigate patient volumes when there aren’t enough workers, hospitals halted or delayed care for lower-acuity patients. This freed up beds and specialists to care for COVID-19 patients and others with more severe illnesses, but it denied necessary care to many patients.

“You try and shed the things that are the lowest risk, like a knee surgery or coronary artery bypass graft,” Wynia said. “There are things you can defer, but you can’t defer them forever or they do start to become dangerous.”

Consider people who have kidney disease. End-stage renal disease patients are among those affected by deferred care because of staffing shortages and other reasons. The number of U.S. residents with kidney failure had more than quadrupled since 1990, only to fall in 2021 because 18,000 more of them died than projected, largely as a result of the pandemic, a ProPublica investigation found.

More than one-quarter of the kidney care visits projected for last year didn’t happen, lab surveillance of creatinine levels dropped 30%, and 8% fewer kidney failure-related prescriptions were filled during the pandemic. Those findings are based on an analysis of claims from January 2019 to August 2021 conducted by Duke University School of Medicine, OptumLabs, the National Kidney Foundation and the Icahn School of Medicine at Mount Sinai. Providers haven’t caught up, which means those patients are at higher risk of hospitalizations, advanced kidney treatments, uncontrolled diabetes and hypertension, the study found.

“The system wasn’t designed to make up for the deficit that has developed,” said Dr. David Cook, senior vice president at OptumLabs, who co-wrote the report.

The nephrologist shortage predates the pandemic, while the number of medical students choosing this specialty has steadily declined. Like other clinical disciplines, these kidney doctors face a care backlog at the same time there are fewer professionals to provide services.

Deferred care and burnout

The industry is aware of the implications for patient health. Hospitals are seeing unprecedented front-line worker burnout and record retirement among veteran caretakers, the Federation of American Hospitals said in an open letter to federal policymakers last November.

Providers are also facing pent-up demand, the need to resume preventive care, as well as preexisting factors such as the aging population, according to the federation. “Talk to any hospital administrator across the country and they will describe the difficult decisions they face daily to ensure capacity can be met with the current workforce,” the letter says.

On the patient side, greater demand will create a bottleneck that could worsen socioeconomic and racial health disparities if the industry isn’t mindful about ensuring equity. People who live in high-poverty or rural areas—or who are Black, Brown or LGBTQ—are more likely to feel disconnected from healthcare providers and put off care longer as a result. People of color or who identify as LGBTQ often face structural barriers to care and discrimination that influences their relationships with providers.

“There are all kinds of reasons why people who are less connected with the healthcare system might end up being deferred longer,” Wynia said. “Now that we’re trying to make up the backlog, those people could get worse care because they don’t have those connections and don’t feel empowered within the healthcare system.”

To address this universe of issues, healthcare industry leaders are looking to new models that more fully incorporate things like telemedicine and value-based care, Cook said.

“There has to be a reenvisioning of how we’re delivering this care that increasingly needs to be delivered through primary care. The way you manage a shortage of specialists is either to develop a new model or start to empower and educate primary-care providers to do some of these services,” Cook said. “Even in primary care there is going to be a shortage of providers, so reorganizing the way that care is delivered, I think, is going to be one of the major trends.”

Value-based care models can help by promoting greater involvement by specialists such as dietitians and behavioral health professionals, which makes patients less dependent on physicians and enables providers to personalize care plans and coordinate resources, Cook said.

“That’s how you deal with a physician shortage,” he added. “Those wraparound services will allow us to manage people with conditions longitudinally with high touch and frequency. You develop and apply other assets in healthcare and assemble in such a way that they get paid for.”

The current labor situation could be an opportunity for providers to invest in a modernized workforce that addresses population health—and there’s federal money on the table.

The American Rescue Plan includes $12.7 billion for home- and community-based services, $8.5 billion in the Provider Relief Fund, $7 billion for recruitment and retention in public health, $1.55 billion to expand critical care programs in underserved communities and $250 million for the behavioral health workforce.

Key priorities include training the next generation of healthcare workers, more equitably distributing clinicians to regions with the biggest needs and promoting well-being and resilience among today’s workforce, according to an article by healthcare labor experts published last September in Health Affairs.

Furthermore, the educational pipeline must be stocked with students who match the racial, ethnic and cultural attributes of the patients they will serve. Current professionals need more training on unconscious bias and the intersection of medicine and racism, the authors wrote. Better access to maternity care, more primary-care clinicians, investments in mental health and substance use disorder treatment, improved long-term care and commitment to addressing inequities and the social determinants of health should be among the goals, they wrote.

“It is imperative that these public funds be used wisely to build a workforce that responds to the urgent and enduring healthcare needs of society, rather than the interests of healthcare organizations, health insurers or professional groups,” the article says.