Category: Healthcare

Originally published on Healthcare Dive.

A movement health systems have been dreading is gaining speed, as commercial and government payers are implementing more and more policies that restrict reimbursements for services that can be performed outside a hospital. Anthem’s recent announcement that it will no longer pay for MRIs and CT scans performed at a hospital in an outpatient basis could be a harbinger for what’s to come.

Several hospitals and health systems have already taken steps to recapture revenue lost to these demands for pushing patients outside their walls whenever possible. But with the industry already suffering from reduced patient volumes and lower reimbursements in general, policies restricting the services hospitals count on for steady cash flow could be a major disruption.

Anthem’s new rule

Anthem plans to implement the policy in 13 of its 14 states by March 2018, with only New Hampshire exempt from the new policy. The payer has already implemented it in nine states.

Hospital officials are predictably concerned about what this could mean to their margins. Higher in-hospital reimbursement for MRIs and CT scans made them profitable, even though they’re not a major service for hospitals. One estimate said some health systems collect more than half of their profit from imaging services.

Anthem’s new policy is part of a payer movement to reduce healthcare costs by pushing patients to get care at locations less expensive than hospitals. That’s also true for another controversial Anthem policy to stop paying for Emergency Department (ED) care it deems unnecessary.

Trying to cut healthcare costs is nothing new for insurance companies, or the industry in general. For many years, payers and employers have created health plans that reward members for getting care at less expensive locations. That benefit design has resulted in patients paying more to go to specialists rather than primary care physicians and going to EDs rather than places like urgent care centers. Payers have also nudged members to get more services as an outpatient and avoid being admitted to a hospital.

Those cost-cutting efforts seem to be working. Altarum’s Center for Sustainable Health Spending’s recent Health Sector Economic Indicators reported overall national health spending growth decreased in the second quarter. A major reason for the slower spending growth was connected to hospital spending growth, which was only 1.3% rather than the expected 4% growth rate. Hospital spending growth was the slowest major healthcare category over the past year. Hospital spending increased in June by 0.8%, which was the slowest growth rate year-over-year since January 1989.

While payers have looked for passive ways to re-direct patient care in the past, Anthem’s two new policies extend beyond benefit design and go to the heart of hospital funding. In recent years, hospitals overcame lower Medicare reimbursements by making more on imaging and ED services, which have been steady profit centers. Now, hospitals in 13 states will see that funding dry up.

Anthem said its new Imaging Clinical Site of Care program dovetails with the Institute for Healthcare Improvement Triple Aim Initiative, which seeks to improve the patient experience, improve population health and reduce per capita cost of healthcare.

Anthem subsidiary AIM Specialty Health is administering the program to identify when hospital outpatient services for services like MRIs and CT scans are medically necessary. Lori McLaughlin, Anthem communications director, told Healthcare Dive getting services in a “clinically appropriate setting” like a freestanding outpatient clinic or imaging center is less expensive and clinical research shows those locations are safe.

Anthem said the policy will result in lower healthcare costs for members and the healthcare industry overall. Imaging services in a hospital can cost $1,000 more than a freestanding clinic, and that cost could fall to the patient if they haven’t met their plan’s deductible.

Anthem said AIM Speciality Health will only review the level of care if there are at least two alternate freestanding imaging centers nearby. So, imaging would be approved in rural areas that might not have more than one option for an MRI or CT scan, according to the payer.

McLaughlin said Anthem doesn’t know how much it has saved or how many hospital scans it has reduced because the plan is still so new. With the imaging policy set, McLaughlin said Anthem will continue to look for more ways to save healthcare costs.

“Anthem’s primary concern is to provide access to quality, safe and affordable healthcare for our affiliated health plan members. We’re always looking at new approaches to ensure clinical quality and improve affordability and we are committed to reducing overall medical cost where possible when the safety of the member is not put at risk,” she said.

Will other payers follow suit?

Anthem is a major insurer in more than a dozen states, so any decision will have a ripple effect in those areas and beyond.

Lea Halim, senior research consultant at Advisory Board, told Healthcare Dive other payers will likely watch how Anthem’s policy plays out.

“Will Anthem get a lot of pushback from patients and employers? Will hospital lobbies succeed in getting state governments to force Anthem to roll back the policy? If Anthem does not face, or successfully overcomes these types of challenges, other payers may very well follow suit,” Halim said.

Payers are working to bring down costs in other ways, too. One example is insurance companies buying surgical centers, said Gregory Hagood, senior managing director at SOLIC Capital Advisors, which works with hospitals on mergers and acquisitions. Another example is payers creating networks that encourage members to use alternative (i.e., less expensive) services.

Hagood expects payers will continue to look for more ways to cut costs, including reviewing elective services performed in hospitals. “We’re seeing all insurance companies trying to create an alternative network where, theoretically, the quality of these centers are what you get in the hospital, but at a lower rate because you don’t have all the overhead of hospitals,” he told Healthcare Dive.

Private companies like Anthem aren’t the only payers creating policies that cut costs and affect hospital finances. The CMS also recently announced a proposal to make costs more site neutral. With this change, CMS would pay services at off-campus hospital outpatient departments by 25% of regular outpatient rates (while increasing outpatient payments overall by 1.75%). The CMS expects the proposal would save about $500 million this year. The American Hospital Association has spoken out vociferously against the proposal.

Medicare is also proposing hip surgeries in surgery centers in addition to just hospitals. Knee and hip surgeries have the highest margins for hospitals, but Medicare is pushing more volume to outpatient services.

“Those are huge dollars you’re talking about there,” Hagood said. “It’s another where a hospital’s lucrative services like joint replacement and imaging are starting to get squeezed from both sides — from CMS and private payers.”

Impact to hospitals

Anthem’s size and importance in the 13 states where it is active means its imaging policy will affect hospital finances. However, Paul Keckley, healthcare researcher and managing editor of The Keckley Report, told Healthcare Dive many hospitals are already competing with freestanding and physician-owned facilities. So, though Anthem’s policy will affect hospitals, Keckley said those facilities are already “accustomed to the downward pressure on their margins.”

Hagood estimates that MRIs and CT scans make up only 5%-10% of a hospital’s business, but those services are profitable and have huge profit margins for hospitals.

Hagood said an MRI for a knee or shoulder would cost about $500 on average in a physician’s office, but that would swell to somewhere between $1,000 and $2,000 at hospitals in many markets. This means hospitals are making an average of $1,000 more on each procedure, he said.

Spread over a year, that’s about $800,000 more profit for hospitals, which these facilities stand to lose with Anthem’s new imaging policy.

Halim said hospitals stand to lose the reimbursements from Anthem, but those with their own freestanding imaging facilities that bill at a lower rate already should be able to capture a portion of the lost revenue.

Beyond hospital finances, the policy change would impact patients both positively and negatively. Anthem patients in a high-deductible plan will pay less out-of-pocket for an MRI or CT scan at freestanding facilities. However, patients not in a high-deductible plan and who may not pay much out-of-pocket anyway, may feel inconvenienced if they’re told they can’t get the services at their local hospital. Plus, if the ordering physician doesn’t direct the patient to a freestanding facility and the person gets the services at a hospital, Anthem could deny the claim and the patient will get stuck with the bill, said Halim.

What will hospitals do?

Hagood doesn’t think hospitals will make up the lost funding in other areas. Instead, he expects staffing cuts and hospitals squeezing vendor contracts for supplies and maintenance.

One way hospitals could respond is by working with the payer to get a little more money for imaging than a freestanding imaging center, but much less than what Anthem has been paying hospitals. Hagood said hospitals may get a “modest premium,” such as maybe get another $100 or $200 for a scan instead of the extra $1,000 Anthem has been paying them.

Halim said hospitals may accept the outpatient payment rate for hospital-based facilities in exchange for a policy waiver. Plus, they may invest more in their own freestanding imaging centers.

“If Anthem represents a significant portion of their revenue — and if the new policy sticks — that may lead some hospitals to consider investing in freestanding facilities so that they can still capture Anthem’s outpatient imaging business,” Halim said.

Originally published on Healthcare Dive.

Payers and providers have for decades stayed in their silos, leading to a more fractured and adversarial healthcare system. That relationship, however, is starting to soften for many in the industry. Payer-provider partnerships put the two groups on the same team in hopes of reducing costs and improving care and outcomes through sharing data and better communication.

A major driver of these partnerships is the move away from fee-for-service payments and toward valued-based payments and population health management.

Originally published on Healthcare Dive.

Republican plans targeting federal funding for health coverage have drawn ire from Americans in all corners of the country, but some of the loudest voices are coming from parents. They have cornered members of Congress at town halls to ask how the slashed budgets will affect some of society’s most vulnerable.

Suggested cuts to Medicaid and the Children’s Health Insurance Plans (CHIP) would throw millions of Americans off insurance and leave hospitals that are already teetering financially facing more uncompensated care. Children’s hospitals, safety net hospitals and rural hospitals will be most affected, and disabled children will face devastating cuts in coverage.

The funding decreases have been proposed in bills making their way through Congress and separately by President Donald Trump. They would shift the cost burden further onto states, many of which have seen success in expanding Medicaid, which is also on the chopping block.

“Children, the elderly, the disabled, and others from our most vulnerable populations would all be affected by these deep budget cuts,” Joanna Hiatt Kim, vice president of policy at the American Hospital Association, told Healthcare Dive. “For hospitals, this could mean more uncompensated care as millions continue to seek needed healthcare without any coverage. For the patient, this could mean delayed care or foregoing care altogether.”

Impact on children’s healthcare

More cuts to Medicaid and CHIP would reverse the trend of fewer uninsured Americans, including children.

Congress created CHIP 20 years ago when 15% of children were uninsured. CHIP, the Affordable Care Act and Medicaid expansion provided more insurance offerings and now only about 5% of children are uninsured. CHIP, which is a federal/state partnership, includes free well-child visits in many states and also provides prescription coverage, inpatient and outpatient care and emergency services.

While suggesting a two-year CHIP extension in his budget plan, Trump proposed a 20% CHIP cut over the next two years. His budget also seeks a $610 billion cut from Medicaid over 10 years, despite early promises to leave the program alone.

Studies have shown that CHIP helps reduce hospitalizations and child mortality, and improves quality of care. The program has bipartisan support. However, HHS Secretary Tom Price voted twice against expansion when he was a congressman.

CHIP is up for reauthorization by Sept. 30 and governors recently spoke out in favor of expanding it. In his budget proposal, Trump proposes a two-year extension of CHIP, but also suggests program cuts, including the matching rate for states.

Jim Kaufman, vice president of public policy at Children’s Hospital Association (CHA), told Healthcare Dive that CHIP helps children’s hospitals.

“CHIP is good for kids, and that makes it good for children’s hospitals and children’s providers,” Kaufman said.

Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities, told Healthcare Dive that the cuts would shift costs to states and reduce benefits. He said Trump’s budget would eliminate a 23-percentage-point increase in each state’s federal CHIP matching rate, which is in effect until 2019. That would mean $3.5 billion cut from the program.

The budget would also cut CHIP funding for children with families that have incomes above 250% of the federal poverty line, which would affect 28 states and Washington, D.C. that provide CHIP coverage to children above the income threshold, according to Park.

This will mean states will need to pick up more of the CHIP program costs if they want to maintain the current coverage level. Park said he believes Congress will reauthorize the program, but questions remain about CHIP’s funding and benefits.

Children are about half of Medicaid’s enrollment

The CHA released a report in May that said changes to Medicaid will hurt children, who are the largest group covered under Medicaid. Disabled children will feel the brunt of the pain.

Park said Trump’s proposed budget goes well beyond the Medicaid cuts included in the American Health Care Act (AHCA). The House plan would cut Medicaid by 24% over 10 years. Trump’s budget would reduce the Medicaid budget by 45% in that period.

Park said children make up about half of Medicaid enrollment, but cause very little in costs. Seniors and people with disabilities make up about one-fifth of enrollment, but about half of costs.

Forty-five percent of children with special healthcare needs are on Medicaid. If those children don’t get insurance elsewhere, hospitals would feel the financial burden of caring for those higher cost children without getting reimbursed by Medicaid.

The House approved the AHCA in May, which proposed Medicaid per capita caps starting in 2020 that would be based on 2016 federal Medicaid spending. In a study earlier this year, KFF said that creating a Medicaid block grant or per capita cap “would shift risks and costs to states, enrollees, and providers and could result in reductions in coverage for children.”

Children’s hospitals would be affected more than many other hospitals. The average children’s hospital pay mix is about 54% Medicaid, so children’s hospitals are especially vulnerable if there are large cuts to Medicaid and CHIP at the federal and state levels. Uncompensated care has dropped since CHIP and Medicaid expansion. Kaufman estimated that uncompensated care is an average of about 2% now.

“Since Medicaid is the largest payer of children’s healthcare services and the largest payer for children’s hospitals, the proposed Medicaid cuts included in the AHCA would have a significant impact on the more than 30 million children covered by Medicaid,” said Kaufman. “The states would cut coverage, benefits and access to care. Cuts of this magnitude will have a negative impact on all children’s healthcare.”

The Congressional Budget Office predicts 23 million Americans would lose their health insurance by 2026 under the newest version of the AHCA.

Park said the CBO score confirms the House bill isn’t fixable. “It’s clear just from the cost shift that kids would certainly be facing cuts if the House bill was enacted,” he said. “And that would be particularly problematic for kids who need Medicaid coverage that isn’t provided by private insurance.”

Originally published on Healthcare Dive.Originally published on Healthcare Dive.

Nurses across the country are stressed, burnt out and thinking of leaving the profession. Surveys, polls and studies of all kinds point to nurses with longer hours, more work and less time to care for patients and unwind from the intense stress of the job.

A University of Phoenix College of Health Professionals 2016 poll found that four out of five nurses are playing a larger role in patient care management than two years ago and 84% of registered nurses believe non-doctors will play an even larger role in patient care management in the next five years. That means more work for nurses.

A recent Kronos Incorporated survey showed that 90% of nurses are thinking about leaving their hospital for another job because of a poor work/life balance. Also, most of the surveyed nurses (83%) said hospitals are losing good nurses because other employers offer a better work/life balance. “Nurse burnout is real, although some like to avoid or downplay it,” Elizabeth Scala, author of Stop Nurse Burnout, told Healthcare Dive. “In fact, there is often a stigma related to nurse burnout. Nurses fear that if they speak up, they will not be heard or worse . . . will be retaliated against in some way.”

What’s causing burnout among nurses

A nurse’s workload, work/life balance and a nursing shortage are all contributing to stressed nurses. An RNnetwork study earlier this year found that 70% of nurses feel burnt out and half of the nurses have considered leaving the profession. Also, nearly half of nurses surveyed said their workload has increased.

Kronos Incorporated’s survey found that many nurses said they skipped breaks and didn’t get enough sleep in between shifts. One-quarter of those surveyed said a change from eight- to 12-hour shifts exasperated burnout.

Half of the nurses in a new CareerBuilder study said they feel “tired all the time.” Staffing isn’t expected to improve anytime soon. CareerBuilder said nursing job vacancies are “increasing at an accelerated rate.”

But hospitals and health systems are struggling to find enough qualified nurses to fill the jobs. CareerBuilder reported that hospitals posted a job listing for registered nurses an average of 10 times on different sites in the first quarter of this year, which points to a “highly competitive hiring environment” for hospitals and health systems.

This employment crunch can lead to larger workloads and longer hours for nurses.

But it’s not just more work and longer hours that is causing stress. Technology can also create a barrier between a nurse and a patient. Scala argued technology like electronic health records (EHRs) systems can make a nurse feel disconnected from patients.

EHRs can help improve care coordination. However, nurses may worry that they are simply inputting information and not making a difference for their patients, Scala said. “While the nurse went into the profession of nursing to provide relationship-based care and impact patients, the computers and charting can make it difficult for the nurse to feel as though they have the time to spend with the patient and family in front of them,” Scala said.

Nurses used pen and paper when Lisa Radesi started in the profession 38 years ago. Now, they have to spend a lot of their time on computers and using other technologies. Radesi, who currently serves as the academic dean at the School of Nursing at the University of Phoenix, told Healthcare Dive that computer and technology literacy are a relatively new skill set in nursing. “They have to be computer savvy and electronically savvy. Fifteen or 20 years ago, you didn’t have to be,” she said. “That’s a big role change for them.”

Nurses are also playing a larger role in the overall management of patient care. They are providing more care coordination, post-discharge management and pre-discharge work. Many nurses are taking on more leadership roles in health systems. Nurses have a great influence in patient care and often take on more roles, which can lead to overwork, according to Radesi.

How burnout impacts nurses, patient safety and a hospital’s finances

Studies have found that nurse burnout can impact patient infections, patient satisfaction and quality of care.

“Nurse burnout affects patient care negatively,” Scala said. “If a nurse shows up to work and is feeling tired, disengaged and unappreciated, then they are not going to provide their best care. They may make a mistake, such as forgetting to check in on a PRN medication or overlook a crucial lab value.”

Patients and families can pick up when a nurse is burned out, which leads to lower satisfaction, Scala added.

Burnt out nurses can also have a financial implication on hospitals. Nurses leaving the job means hospitals have to recruit, hire, train and orient new nurses. That costs a lot of money — not to mention what constant turnover can do to staff morale.

“In today’s healthcare environment, organizations are finding that nurses are leaving clinical roles in less than two years’ time,” Scala said. “The constant turnover can be costly to the organization’s bottom line.”

What hospitals can do to help nurses

An increasing number of surveys and studies point to a nurse burnout problem. But what can a hospital or health system do to help nurses who feel stressed out?

Lower nurse-to-patient ratios are one way to help. Implementing those types of levels can reduce stress levels while improving patient care, according to Radesi.

One the two approaches has a cost connected to it, while the other may require making changes to the way nurses perform their work.

What does a health system or hospital do if it can’t afford to add more nurses or doesn’t have buy-in for hourly rounding? Here are three low-cost tips:

Watch for signs of stress

Spotting burnout isn’t easy, Scala noted. Nurses may come to work trying to hide their stress because they’re afraid of a reprimand.

A clear sign of burnout is less enthusiasm for the job. Other examples are a usually social nurse, who starts avoiding colleagues, and a team player who withdraws from team activities, such as projects and committees, according to Scala.

Ross argued hospitals monitoring changes in engagement and attendance can get a view on nurses’ stress levels. Nurses who miss shifts, leave early, complain more or disagree more with co-workers might need help.

Claudia Douglas, administrative director of the Institute for Evidence-Based Practice and Nursing Research at Hackensack University Medical Center, told Healthcare Dive that her facility conducts anonymous surveys to get feedback from staff and specifically runs a nurse satisfaction survey to get feedback from nurses. “The results are benchmarked against a national database,” Douglas said. “For areas indicating opportunity for improvement, leaders are required to complete an action plan.”

Stephen Young, research scientist of leadership insights and analytics at the Center for Creative Leadership, who co-authored “How Nurse Leaders Can Reduce Burnout: Focus on Mental Energy!” told Healthcare Dive that hospitals need to measure employees’ “mental energy levels and adopt initiatives that will most effectively enhance where energy is low within the organization.”

Staff with low mental energy may need a work shift scheduling change, while low emotional energy may “indicate a harmful interpersonal environment,” Young said.

Annual surveys aren’t enough, Young added. Instead, give employees game-based apps to use daily to examine their energy. That kind of energy assessment tool “can help you to objectively measure your organization’s human energy crisis and determine how severe it is,” according to Young’s report.

Teach self-care strategies

Scala, who teaches self-care strategies in her Burnout Proof Live training, argued it’s important for nurses to learn how to separate work from home life. Nurses need to learn how to leave work at home.

“Teaching individual nurses burnout prevention tools is one piece of this complex puzzle,” she said.

Young said engaging workers on their energy levels on a daily basis raises their self-awareness. With that data, a hospital could teach individualized strategies, such as coping and break scheduling.

“Nurses, like any human beings, are a diverse group,” Scala said. “Each nurse needs to find the self-care technique that works best for them. A variety of tools must be offered. The best thing an organization can do is to assess what the nurses want/need to cope and prevent burnout. And then to listen to the feedback, implementing a variety of strategies to support their nursing staff.”

Make wellness a priority

Surveys have found that nurses often work through their breaks. Nurses not having any time off during a shift can lead to higher stress levels.

Hospital leaders need to make sure their nurses are taking enough time off during their shift so they are alert.

One way to show the importance of wellness is to create wellness teams. Radesi believes having wellness teams can keep health front of mind for nurses and staff. Some ideas could be offering nurses massages during a shift, holding departmental group sessions to talk about health and creating a reward program connected to wellness, such as giving a prize to the staff member who walks the most.

Another example is setting aside space for wellness. Douglas Hackensack University Medical Center has respite areas with comfortable seating and soothing lighting. The areas promote mental, emotional, spiritual and social opportunities, Douglas said.

Employees often follow their leader — and wellness is no exception. Nurse leaders should model behaviors that can reduce burnout, such as practicing mindfulness, Young said.

By putting each employee’s wellness in the forefront, hospitals can improve morale and lower stress levels.

All of these tips go back to the same thing — get to know your nurses. Hospitals should look to improve communication with nurses and involve them in the decision-making process. Also, explain changes when they’re made. Nurses crave professional development, Radesi argued.

“The more they know, the easier it is for them to do their job,” Radesi said.

Hackensack University Medical Center’s leadership team holds Town Hall meetings on various shifts to help foster better communication, according to Douglas. “Hospital leadership must be engaged with their team members,” Douglas said. “They must be attuned to the challenges team members may face. Collaboration, partnership, active listening, and open and continuous lines of communication are essential.”

Originally published on Healthcare Dive.

Public health officials agree that the next major pandemic will be influenza. Are U.S. hospitals ready for it?

The U.S. Department of Health and Human Resources (HHS) estimates that an infectious disease pandemic could infect 90 million Americans and kill as many as 1.9 million people. This kind of pandemic would put a strain on the country’s healthcare system, sicken hospital staff and stretch hospital resources to their limits and beyond.

An influenza pandemic would go well beyond the normal seasonal flu virus. Patients’ immune systems won’t be able to cope with a pandemic flu, and it will spread quickly across the globe.

This isn’t just the stuff of science fiction. There have been multiple pandemics over the past century.

The Spanish Flu of 1918 caused more than 50 million deaths. Between 20% and 40% of the world became infected. The late-1950s saw the Asian flu, which killed about 2 million people, including 70,000 in the U.S. In recent years, the H1N1 virus in 2019 killed 17,000 people worldwide.

Billionaire Bill Gates spoke about the pandemic threat earlier this year during a security conference in Munich.

“Imagine if I told you somewhere in this world, there’s a weapon that exists — or that could emerge — capable of killing tens of thousands, or millions of people, bringing economies to a standstill and throwing nations into chaos,” Gates said. “Whether it occurs by a quirk of nature or at the hand of a terrorist, epidemiologists say a fast-moving airborne pathogen could kill more than 30 million people in less than a year.”

Hospitals across the country are now planning and testing models to implement when an infectious disease pandemic eventually hits the U.S.

Are we prepared?

A 2015 report “The Next Pandemic: Hospital Management” examined how a pandemic could impact the healthcare system, the state of preparedness of hospitals and special considerations for them during a pandemic.

The authors of the report, Robert E. Falcone, vice president of clinical policy and population health at the Ohio Hospital Association and clinical professor of surgery at Ohio State University, and Andrew Detty, quality and population health analyst at the Ohio Hospital Association, warned that a severe pandemic like the 1918 flu could: infect 90 million Americans, hospitalize 9.9 million and kill 1.9 million.

To put that into perspective, the H1N1 virus in that impacted the country from 2009 to 2010 increased emergency department (ED) visits by 18% over the baseline in from 2005 through 2008 with individual hospitals and health systems seeing much higher rates.

Part of the issue with H1N1 was not so much that people were infected, but that they were afraid that they or their children had the H1N1 virus and rushed to EDs, according to the 2015 report. That caused a major drain on the healthcare system.

Preparing for a pandemic

The National Strategy for Pandemic Influenza involves three parts: preparedness and communication; surveillance and detection; and response and containment.

Over the past decade, the federal government has sounded the alarm about a potential pandemic. The Centers for Disease Control and Prevention (CDC) created a free program for hospitals called FluSurge 2.0 to figure out the number of hospitalizations, intensive care unit (ICU) admissions, ventilators needed and deaths caused by an influenza pandemic.

Hospitals and health systems, in turn, have employed full-time incident coordinators, created pandemic preparedness committees with clinical, support and senior administrative representatives and participated in regional hospital planning.

Colin Bucks, medical director for the office of emergency medicine at Stanford Health Care in Stanford, CA, tells Healthcare Dive Stanford has a standing committee of 20 people that includes specialists in disease prevention, infection control and infectious diseases. The group meets quarterly to review plans, monitor infectious disease and bioterrorism updates, look for potential outbreaks, implement infection control procedures and decide when to start screening methods to prevent infections from spreading.

They also promote patient education, such as communicating with at-risk populations, informing patients about when to go to the hospital and educating people about proper disease-prevention hygiene so that they take the proper precautions to prevent infectious diseases.

Bucks says the health system also learns by reviewing how other health officials respond to crises, such as the SARS outbreak in Toronto in 2003 and the Ebola pandemic in 2014 and 2015, which he saw firsthand.

“It’s good to take the path that’s been tread before,” Bucks says of learning how healthcare facilities have tackled other emergencies. “Let’s learn from folks who have gone through major events.”

Preparing for a pandemic isn’t cheap. A 2006 report called “Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science” estimated a 164-bed hospital would need to spend $1 million to prepare for a pandemic, including $200,000 for a pandemic plan, $160,000 for staff education and training, $400,000 for stockpiling minimal personal protective equipment (PPE) and $240,000 to stockpile basic supplies.

Joan Ivaska, senior director of infection prevention at Banner Health, based in Phoenix, Ariz., tells Healthcare Dive she’s not able to put a dollar amount on how much the large health system has spent on influenza pandemic preparation. Banner, which has 28 acute care facilities in six states, has committed resources to emergency management and infection prevention programs for any emergencies.

“Banner Health takes an all-hazards approach to preparedness for an influx of infectious disease patients,” Ivaska says. “We maintain plans for responding to an influx of infectious patients, whether from influenza or some other disease,” she adds.

Staff education and drills

It’s one thing to put down a plan on paper. It’s quite another thing to put it into action. Education and training drills help hospital staff, and administrators get more comfortable with a plan before there’s an influenza pandemic.

The Occupational Safety & Health Administration recommends that staff education and training include infection control precautions, how to report pandemic influenza to hospital and public health officials, proper PPE usage, hand hygiene, training of infection control monitors and tabletop simulation exercises.

Banner Health reviews emergency response plans on a routine basis and conducts staff training and drill exercises every year, says Ivaska.

“We have staff with expertise in infection prevention and control and emergency management who coordinate these activities as part of their ongoing responsibilities,” she says.

Stanford Health Care tested an ED “drive-through” a few years ago to rapidly evaluate patients outside of the hospital environment to prevent cross-infection during a pandemic. In the test, hospital staff evaluated patients still in their vehicles or next to their vehicles.

The hospital tested the feasibility of the external influenza clinic and measured throughput times of simulated patients. Stanford Hospital used 38 patient charts from people treated during the H1N1 outbreak in 2009 to simulate the scenarios. It found that the medical length of stay was 26 minutes and physicians were able to identify the patients admitted and discharged during the real ED visit with 100% accuracy.

The ED drive-through and other programs that look to limit the spread of infectious disease focus on patient screening. They also seek to protect staff who meet patients first, including administrative staff, clerks, greeters, and security, as well as doctors, nurses and housekeeping staff. Stanford Health Care makes sure there are hand-washing supplies, masks, and other PPEs to protect them from infectious illnesses.

Stanford Hospital officials said the drive-through model is a “feasible alternative to a traditional walk-in ED or clinic and is associated with rapid throughput times. It provides a social distancing strategy, using the patient’s vehicle as an isolation compartment to mitigate person-to-person spread of infectious diseases.”

Bucks says Stanford hasn’t needed to test or implement the ED drive-through model again, but it’s in the emergency plan when needed. However, Stanford has needed to readapt the model because of changes to buildings or new facilities in the system, such as the new Stanford Hospital, which is slated to open in 2018.

“We haven’t had to activate that in anger, but it’s still a standing part of our response procedures,” says Bucks.

Bucks says the ED drive-through works for Stanford Health Care and other hospitals can start a similar program with proper planning and testing. “I think others can look at this and implement it, but I wouldn’t be under the illusion it could happen as a just in time,” says Bucks about the need for planning and testing the plan.

Stanford’s model is one of many that tried to limit potential exposure. Another example is triage telephone lines. The Minnesota Department of Health collaborated with health plans and hospital systems to establish MN FluLine.

MN FluLine uses standardized triage protocol and registered nurses talk to patients about their symptoms, when to seek medical care, and offers prescriptions to high-risk patients who are advised to stay home. MN FluLine believes the program has prevented about 11,000 face-to-face healthcare encounters. The CDC is looking at similar triage phone lines to see if it can reduce the spread of infectious diseases.

Shortages

An influenza pandemic would quickly fill EDs and ICU beds and could cause staffing, ventilator and PPE shortages if hospitals aren’t prepared.

A 2010 study found that there were a little more than 62,000 full-feature mechanical ventilators in U.S. acute care hospitals. That’s about one for each ICU bed.

The SARS outbreak of 2003 in Canada is an example of what happens to supplies when hospitals are overwhelmed with an infectious disease. In Toronto, one 1,300-bed hospital used 3,000 disposable isolation gowns, 14,000 pairs of gloves, 18,000 N95 respirator masks, 9,500 ear loop masks and 500 pairs of goggles daily during the peak of the outbreak. The HHS recommends that hospitals stockpile disposable N95 respirators and surgical masks, face shields, gowns and gloves in case there’s a pandemic.

Banner maintains an inventory of essential supplies and equipment in the event of an influx of infectious patients, according to Ivaska. The health system would also partner with public health partners for specific needs if there’s a pandemic.

In terms of staffing, hospitals may need to bring in more staff to help with patient care and hospital upkeep to minimize the spread of the virus.

Hospital staff would also likely become sick themselves. One estimate suggests 40% of hospital staff would be absent during a pandemic because they’re sick, caring for a sick family member or they may even refuse to come to work for fear of getting sick.

Hospitals may need to call in volunteers, medical students, nursing students and retired healthcare workers to help hospital staffing during a crisis.

There is also the issue of staff, patient and community well-being. In “The Next Pandemic: Hospital Management,” the authors pointed to the 2003 SARS outbreak as an example of what happens to staff during a health crisis.

Quarantine during the SARS outbreak “caused fear, anger, loneliness, and boredom among isolated patients, and the fear of becoming infected and restrictions on activity caused discomfort for uninfected patients,” the authors wrote. “Healthcare workers expressed fear and resentment in the face of the danger of infection and constantly changing information; social isolation exacerbated their anxiety, as did concern about infecting loved ones.”

There is also the issue of hospitals needing to segregate flu patients to reduce spreading the disease. In case of a pandemic, a hospital may need to move patients to specific parts of a hospital or even to off-site locations.

Bucks says Stanford Health Care has used external facilities at times and the system would likely need to implement a similar plan if there is a flu pandemic.

Banner Health takes a whole system approach if there’s an influx of infectious patients or other healthcare emergencies, Ivaska says. How specifically the system would respond to a specific emergency depends on a number of factors, including a facility’s location, infrastructure, capabilities and staffing, she adds.

Planning for a pandemic in the current political climate

The federal government helps hospitals and health systems prepare for a possible health crisis through training and grants, such as $850 million in Hospital Preparedness grants.

But there is concern that federal money may soon dry up. In his budget outline in March, President Donald Trump proposed cutting nearly 18% from the Department of Health and Human Services budget. The president also proposed cutting almost $6 billion from the National Institutes of Health and another $400 million from training programs for nurses and other health professionals.

The Obama administration spent $1 billion on the Global Health Security Agenda, which focused on global health security, including preventing pandemics. That funding ends in fiscal year 2019, and the Trump administration hasn’t said whether it will continue.

Congress will ultimately decide on the actual budget, and will likely ignore many of Trump’s proposed health services cuts. In response to the president’s proposed cuts, Rep. Tom Cole (R-OK), who chairs the House Appropriations subcommittee on labor, health and human services, education and related agencies, called the health agencies “the front lines of defense for the American people for some pretty awful things.”

“If the idea of a government is to protect the United States and its people, then these people contribute as much as another wing on an F-35, and actually do more to save tens of thousands of lives,” he said, referring to Trump’s plan to increase military spending while decreasing money for health services.