Hospitals added beds to treat coronavirus patients. Will they keep them?

Plenty of hospitals reacted to early forecasts warning about waves of coronavirus patients by adding more staffed beds, despite having spent years pushing more and more services into outpatient settings.

Once the pandemic subsides, the question of what to do with that greatly expanded capacity will be top of mind for health system leaders.

And cutting staffed beds could be tougher than it sounds. “People’s jobs might depend on those beds now,” said Dr. Thomas Valley, assistant professor of pulmonary and critical-care medicine at the University of Michigan. “When you’ve increased ICU staff, it’s hard to let people go. When you’ve built something up, it’s hard to contract that down to what it was before.”

Compared with their original plans for 2020, 27% of health systems increased the number of beds they have up and running, according to the results of Modern Healthcare’s 44th annual Hospital Systems Survey, completed by about 50 health systems.

In interviews, executives said they added beds to prepare for an influx of coronavirus patients, which in some cases has not materialized in their respective communities.

Another 12.5% of respondents said their staffed beds declined this year compared with their plan, and the majority—58%—said their current staffed-bed count matches their plan for the year.

The fate of that added capacity will likely depend on the severity of the COVID-19 outbreak in each system’s coverage area, said Chris Plance, a healthcare expert with PA Consulting. Hospitals in New York and New Jersey, some of which were overwhelmed with coronavirus patients at the pandemic’s early peaks, might keep 80% of their beds staffed—compared with 60% to 70% in normal times, he said. Areas like Western Pennsylvania, which saw very little COVID-19 activity, might staff fewer beds than normal for a period of time while they work to recover financially from lost patient revenue during the pandemic.

“It’s going to be very asymmetric: What you see providers doing in one location is not going to look like what others do,” Plance said. “Whereas in the past, it used to be symmetric. All providers across the U.S. kind of behaved the same. I don’t think that’s going to be the case for at least the next few years.”

Spectrum Health, a Grand Rapids-based system with 11 hospitals across western Michigan, added intensive-care unit and general medical-surgical beds in anticipation of a COVID-19 surge. But western Michigan hasn’t experienced near the number of cases as the eastern side of the state, where Detroit alone has had nearly 12,000 confirmed cases. At its height, Spectrum was treating about 100 COVID-19 patients across its hospitals. Today, that’s fewer than 30.

Spectrum is unusual in that even before COVID-19 hit, the not-for-profit health system had planned to increase ICU beds at its largest campus by 25%. The idea is to increasingly move services into outpatient or home settings that otherwise would have been inpatient and transform the hospitals “to be more like large ICUs,” where only the sickest patients go, said Dr. Darryl Elmouchi, president of Spectrum Health West Michigan.

“COVID just lit a fire under that, in terms of, ‘We absolutely recognize the need and are trying to do that more quickly,’ ” he said.

In Valley’s mind, what happens to hospitals’ additional staffed beds is vital, especially ICU beds, which is his specialty. When a hospital has a surplus of ICU beds, its staff tends to use them, even in cases where patients don’t need that level of care. And ICUs often end up treating all patients with the same high level of intensity, including invasive procedures and heavy antibiotic use, he said. “That’s not even mentioning the ramifications from a cost standpoint,” Valley said.

Valley argued in a recent Intensive Care Medicine article that reducing the number of available ICU beds would constrain ICU use, lessen the urge to expand the critical-care workforce and would not negatively affect clinical outcomes. He also argued it could improve population health if hospitals direct that money to things like primary-care interventions.

But there’s also a risk associated with reducing ICU beds. It’s not easy to bring that capacity back once it’s scaled down because intensive care requires specialized staffing and higher staffing ratios, and treating coronavirus patients involves special equipment like ventilators and negative pressure rooms.

Sioux Falls, S.D.-based Sanford Health added about 20 beds earlier this year as it braced for the worst-case scenario. The system’s hospitals had been running at 75% to 90% capacity already, which made adding more rooms important. None of the system’s markets were ultimately overwhelmed, said Dr. Luis Garcia, president of Sanford Health Clinic.

“We were overprepared, let’s put it that way,” he said.

Sanford hasn’t decided what it will do with the extra capacity once the pandemic subsides. Garcia said that depends on what happens in the next six months to a year. Being a rural provider—the largest city in South Dakota has about 190,000 people—Sanford is limited by the number of providers, especially critical-care specialists, it can hire to staff its beds.

The pandemic accelerated a trend that’s been happening at Sanford over the past four years: More care is moving outside of the hospital, assuming it can be done safely and for less money elsewhere. One example of that is home oxygen monitoring.

When Sanford providers diagnose patients with COVID-19 but they’re not sick enough to require hospitalization, the patients take home an oxygen monitor with a sensor that allows providers to track their oxygen levels 24/7, Garcia said.

That program has worked out so well that Sanford is now exploring using it with its congestive heart failure or chronic obstructive pulmonary disease patients.

“Those people in the hospital that weren’t quite as sick, they won’t need to be here anymore,” Garcia said.

Modern Healthcare’s survey results also highlighted a widely predicted trend: the pandemic leading to more consolidation.

Almost 67% of health systems that responded to the survey said they plan to employ more physicians next year. About 31% said they don’t plan to change the number of employed physicians, and just 2% said they will employ fewer physicians next year.

The 50 health systems that responded to the survey employed almost 65,000 physicians collectively, or an average of 1,300 physicians each, at the end of fiscal 2019, which was about the same as in the prior year.

Private physician groups reported in-person visits dropped up to 60% in March, a decline that was only partially offset by virtual visits. For some, going it alone will no longer be an option. The CEO of North Carolina’s largest multispecialty physician group said in May he might eventually need to sell the practice to the local hospital.

RWJBarnabas Health employed about 1,000 physicians in its medical group at the end of 2019, up 8% from the prior year, and plans to hire even more next year. The West Orange, N.J.-based health system is working to fill service gaps, especially in specialties like endocrinology and rheumatology, said Dr. Andy Anderson, CEO of RWJBarnabas Health Medical Group.

The system is also looking to hire more primary-care providers.

Anderson said RWJBarnabas prefers to hire physicians over launching joint ventures and other arrangements because it can then align quality metrics with compensation, giving physicians incentives to improve their performance. It also enables better patient care coordination, especially once RWJBarnabas transitions to using a single electronic health record systemwide.

RWJBarnabas was among the majority of systems—68%—that said hiring more physicians last year did not materially affect financial performance. While physician practices themselves don’t tend to make money in the current healthcare reimbursement model, they do draw screenings, imaging, testing and surgeries to be performed in hospitals Anderson said.

Sanford also plans to hire more physicians next year, although Garcia said the health system is always in recruitment mode, especially for medical and surgical specialties. Once doctors start working at Sanford, they tend to stay, officials there say, but it’s difficult to attract them to the mostly rural areas of Minnesota, North Dakota and South Dakota that the health system serves.

Sanford budgeted to add a significant number of doctors this year, and Garcia said leadership made a conscious decision to enhance recruitment during the pandemic, not pull back.

“For us it’s an opportunity,” he said. “While others are firing people, while others are closing practices, while others are stopping recruitment, we actually did the opposite.”

Throughout the pandemic, Garcia said Sanford has not furloughed or laid off any of its employees, and even gave bonuses to hourly workers.

“We wanted to send a message that you’re part of a family,” he said. “We take care of you.”

SURVEY: Hospital Systems: 2020