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Auburn health administration experts take on COVID-19 series

Pictured, from left: Cathleen Erwin, Haneen Ali, Geoffrey Silvera, and Lori Redding.

Health care in the United States is compiled and provided by many different organizations, which often leads to confusion and challenges on an ordinary day. Since these are extraordinary times, we asked some of our health services administration faculty to take on some of the complex questions we are all facing during the COVID-19 pandemic. 

Due to the complicated nature of health care, we asked a few of our health services administration faculty to share their expertise. We spoke with Cathleen Erwin, associate professor and program director of health services administration, Haneen Ali, assistant professor, Geoffrey Silvera, assistant professor, and Lori Redding, lecturer and internship coordinator in the health services administration program. Below are their responses. 

What are the financial implications/repercussions to healthcare as a result of the pandemic?
Erwin: The COVID-19 pandemic is putting an enormous strain on our healthcare system, both in terms of capacity as well as finances. A recent study projected that without significant financial assistance both in terms of federal relief and increased reimbursement for services, many hospitals will exhaust cash supplies within 60 to 90 days and will have to resort to significant cost-cutting measures. We are already seeing thousands of healthcare workers being furloughed in the U.S. by both large and small healthcare organizations. Healthcare has been a job-creating industry in the U.S. for decades but lost 42,000 jobs in the month of March alone according to preliminary unemployment numbers released by the Bureau of Labor Statistics. The majority of the job losses occurred in the ambulatory arena (e.g., dental practices, physician offices, outpatient facilities). 

In addition to addressing immediate concerns, healthcare leaders must consider the long-term impact on their organizations’ operations as we move past the pandemic. One of the most impactful changes from a financial perspective has been the suspension of elective and non-emergency procedures. According to financial experts, health care organizations are dealing with a disease that places a serious cost of care burden without sufficient financial reimbursement. And, on top of that they have had to suspend one of the main drivers of revenues, I.e., elective procedures. This will have serious financial implications for healthcare organizations in terms of cash flow, and leaders are challenged with forecasting volumes and revenue in a time of uncertainty and should be developing contingency plans for whatever happens in the future.

Healthcare organizations will be eligible for financial relief through several government sources, so it is important that HCOs are tracking all expenses and lost revenue. According to financial experts, HCOs need to have a team in place to document expenses and lost revenue, identify funding sources, prioritize funding applications, and ensure that documentation is in place so that funds aren’t clawed back later due because of improper use. HCOs should be seeking guidance from financial consultants and professional associations as they navigate these unchartered waters.

How might the pandemic be impacting the quality of healthcare being provided during these unprecedented times?
Silvera: It is first important to recognize that quality takes on a new definition in times of crisis. This is true in any form of national disaster, but especially true in these unprecedented times of a global pandemic. Typically, quality conversations center around not only the health outcomes of patients, but also their safety, their experience, and the processes that care delivery teams implement. These are all important considerations in evaluating care delivery, however, these considerations have likely taken a back seat to the consideration of capacity. It is no longer a matter of if providers can give patients the highest quality of care to meet their needs and preferences, it is about whether they can see patients in need of care at all. This is not to suggest that poor quality of care is being delivered, by any means. It is just not the priority right now, and frankly, as a healthcare quality researcher, it is my belief that it should not be. For at least 20 years, the entire U.S. healthcare system has been orienting care delivery towards the needs and preferences of patients and their families. At this point in history, we have to hope that those lessons of compassion, patient centeredness, and evidence-based practice are leading our healthcare providers to do what is right for their patients, and I have every confidence they are. 

That being said, there is cause to be concerned about the long-term effects of this crisis on a keystone workforce in healthcare, nurses. It is widely known in the healthcare quality world, that nurses are the cornerstone of delivering high-quality healthcare in hospitals. Prior to this crisis, there was concern about the impending effects of a longstanding shortage of nurses globally. The question before this crisis was whether we could continue to deliver high-quality care with an increasing nursing shortage due to aging Baby Boomers who would undoubtedly need more medical care as they age. In a shortage, the concern is mainly that when short-staffed, nurses are likely to work longer hours and more shifts. The effects of being overworked can have implications for nurses, hospitals, and, ultimately, patients. Nurses can become burnt-out leading to leaving either their position, or in many cases, the profession. But, nursing burnout is not only felt by the nurses. Hospitals have higher levels of turnover when nurses are burned out (which is costly), and nurses who are burned out are more likely to make medical errors which can endanger patients. All of this was already a concern before the coronarvirus (COVID-19) pandemic. 

Based on reports of the working conditions at the front lines, and the high stress situation that nurses find themselves in right now (some describing it as like being in a war zone), I suspect these issues are only going to be exacerbated in the immediate future. It is my opinion, that without an intervention to increase the nursing workforce over the next decade, we will see similar capacity issues that we are seeing now, not because there are not enough hospital beds, but because we do not have enough nurses. Hospitals are going to have to redouble their efforts to recruit and retain high-quality nurses in order to provide high-quality care for their patients and communities. 

Redding: Over the last several decades, healthcare has always been an industry with rapid change and growth, thus requiring its clinical professionals to follow suit. During the COVID-19 pandemic, we have seen an immediate demand for our clinical staff to perform work in different nursing areas or in slightly different roles. For example, surgical nurses are being reassigned to work in departments treating COVID-19 patients, which requires nursing skills but within different processes and in a different capacity. Furthermore, often a nurse or hospital professional may be reassigned to work a different shift than they have routinely work. Both of these adjustments in hospital staffing help to alleviate the nursing or hospital staffing demand, however, it leads to increase in staffing costs due to possible overtime hours and necessary training. The most expensive line items of a healthcare organization is its personnel costs.

While healthcare professionals are ready to meet the demands of their patients, often times their employees’ needs are heightened. We’ve seen some hospitals create peer-to-peer counseling to provide emotional support to their hospital staff due to the increased demands in their schedules.  

We’ve seen some healthcare organizations providing a food pantry for their staff to meet physical needs, once they step away from the bedside and refocus their attention to their individual and family needs. Healthcare organizations meeting the physical and emotional needs of their staff helps to reduce their stress levels, thus enabling them to focus while at the bedside.

Erwin: Because of the urgency of the situation, we are seeing improvisation and fast-tracking innovation to meet immediate needs. However, only time will show the impact of these innovations – both positive and negative. New tests and technology are being implemented without the usual and customary prototyping and testing. Questions remain about whether or not this is adequate, to what degree should we trust these devices and are the devices safe enough to be used. For example, it has been reported that some hospitals are having to use one ventilator for two or more patients. Was this tested before? How will providers adjust the ventilator based on the patients’ lung capacities when having two patients using the same ventilator. I think at this point in a time of crisis most health care organizations have to focus more on “do no harm” rather than how do we deliver or improve the quality of care. 

How is healthcare technology and innovations playing a role in the fight against the pandemic?
Erwin: Throughout history, healthcare has made significant advancements during times of national and international crises. As the old saying goes "necessity is the mother of invention.” This is certainly true during the COVID-19 pandemic. We are seeing improvisation and innovation in our health care organizations as they scramble to diagnose and treat patients and to keep their healthcare care professionals and patients safe. We are seeing more widespread use of telehealth as regulatory barriers are removed, reimbursement is expanded, and as both clinicians and patients become more accustomed to utilizing video and mobile technology. We are also seeing a response from various types of manufacturing companies that are now ramping up to design and build needed medical equipment and supplies. 

Ali: Innovation and technology should be recognized as the best in equipping us to handle the sudden spread of the COVID-19. We should look out of the box, above the wall, and beyond the traditional old methods and strategies to be able to adapt successfully to any public health crisis. We already started to see/witness a significant shift in healthcare delivery around the country the same as the educational sector, shifting to virtual workplace models and the use of video-conferencing and other virtual tools. Telehealth and virtual care have both been growing in the past few years. We also saw a slow growth of Remote patient monitoring (RPM) and home monitoring in the last few years. Still, with the current shelter-at-home recommendations/restrictions, those methods have been highlighted by healthcare leaders to monitor patients at home, especially patients with chronic conditions that we need them to stay home because of the higher risk. A significant increase in the telehealth visits was recorded already. Data and the ability to share data, Artificial Intelligence (AI), Simulation, Geographic Information Systems (GIS), and the use of social media platforms and smartphones to communicate, deliver, and share information. All are helping in identifying, tracking, and forecasting the spread. I also expect to see growth in robot design and applications during pandemic risks, mainly because it isn’t susceptible to the virus. So, it can be implemented to reduce human-human interaction and deployed for tasks such as medicine, food, sterilizing, handling bio-hazardous waste (some are already in use at Stanford Medical Center for example).

How can healthcare providers and companies rebuild trust in our healthcare system and its infrastructure?
Silvera: I think it will come down to how we respond after the crisis. Everyone is pining for a return to normalcy. But before we move on to the next series of headlines, we need to recognize the men and women who are serving us at the front lines of this pandemic, the doctors and the nurses, of course, but also, the scientists working to develop a vaccine, the administrators working tirelessly to get resources to the frontlines, and government officials for (eventually) making the right call on social distancing interventions. We have a long road ahead of us in rebuilding trust in our systems, but the best efforts we can make in that goal is to support each other in the midst of the crisis. No one asked for this, and we all are doing our best.

Redding: Nurses and physicians who are near retirement are reporting they are ready to leave now but don’t because their patients need them. But some are already filing retirement paperwork ahead of their planned retirement projections, so that once the pandemic slows they will exit the industry. This could worsen the impact of an already forecasted nursing and physician shortage. Healthcare leaders who lead their organizations through this pandemic with compassion for their workforce while listening to their needs could inspire professional trust. While other leaders may find their workforce leaving their organization or pushing them out of the industry altogether.

Erwin: Going forward, I think that there will be much attention paid at the federal level to shoring up the healthcare supply chain in light of the issues we have faced during this crisis. This will probably include ramping up domestic production so that we are not as heavily reliant on imported goods.

Ali: I agree, it’s more trust in the federal government and trust within the organization- Hospitals are threatening medical staff to be terminated if they talk to the media about a lack of gear, supplies, and protective equipment. Working conditions are just so bad in some places that nurses are either dying or leaving.

Can any of you help to clarify what the federal government is paying for (and what they aren’t paying for) with regards to Coronavirus testing?
Erwin: Healthcare providers submit claims to insurance companies for reimbursement for COVID-19 testing just as they do for other types of diagnostic testing. Insurance companies determine the amount of reimbursement for the providers. On March 12, Vice President Mike Pence announced that insurance companies (e.g., private insurance, Medicare or Medicaid) will cover the cost of testing for their beneficiaries.

The federal government pays for COVID-19 testing as an insurer through reimbursement of claims submitted for Medicare patients. Patients with Medicare Part B do not have to pay out-of-pocket for a Coronavirus test ordered by their physician or other health care provider. Individuals with Medicare Advantage plans have the same benefits. The Center for Medicare and Medicaid Services (CMS) has a webpage dedicated to keeping Medicare recipients informed on Coronavirus. 

Individuals without health insurance face significant more challenges in the face of Coronavirus. The Emergency Medicine Treatment and Labor Act (EMTALA) requires hospitals to screen and stabilize patients with emergent conditions; however, it does not require hospitals to provide the care at no cost for patients who cannot pay and they are not required to provide treatment for non-emergent conditions. The Families First Coronavirus Response Act signed into law on March 18, 2020, gives states the option to expand Medicaid coverage to uninsured individuals to provide coverage for COVID-19 diagnosis and testing with 100% federal financing. The coverage is limited to testing services free of charge to the individual. The legislation does not address coverage for COVID-19 treatment costs for people who are uninsured. Alabama is one of the states that has not yet expanded Medicaid coverage, and it is unknown at this time whether or not the state will take advantage of this new opportunity to provide coverage for COVID-19 testing for uninsured individuals. House Bill 447 introduced on March 12, 2020, seeks to expand Medicaid and is currently pending review by the House Ways and Means General Fund Committee.

What should people expect if they visit healthcare professionals during the pandemic?
Erwin: If you have a routine visit scheduled with your provider, you should first determine if this can be delayed to later in the year. If not, then it is important to contact your provider to determine how they want to handle your visit. Providers are utilizing telemedicine to a greater extent than ever before, and it may be possible for you to have virtual visit with your provider. Providers should be able to instruct their patients on how to access their offices so it is important to call for specific instructions while we are practicing social distancing. It is especially important during these extraordinary times that you understand the type of care that you need (emergency, urgent, routine) so that you can safely access the appropriate services.

Ali: There is a growing concern about the ability of the United States healthcare systems to meet the needs because of the availability of resources. A very high percentage of beds and ventilators are already in use, and there is a serious conversation about "life and death decisions" at this stage. Hospitals and healthcare facilities are facing a major crisis as 50% of confirmed cases in February were healthcare professionals (according to the CDC). They are widely affected by the virus, and this pandemic will continue to affect them. The impact of an infected caregiver will extend to everyone. This means fewer providers, longer waiting times, and longer time to manage the disease or infected individuals. There is a debate regarding medical appointments though: if people should postpone or keep them. My thoughts on this are people should be prohibited from visiting any hospitals unless it is an absolute necessity, and the recommendations suggest all routine and non-critical appointments must be delayed or postponed, and the individual's and personal risk factors should be considered. Patients with cardiovascular disease or lung or immune disorders should postpone their appointment and communicate with their providers via other ways of communication. Patients, in general, should consider factors such as what the appointment is for, the recommendations of their provider, and run a simple cost-benefit analysis, or maybe risk-benefit analysis in this case. Making a trip to the physician, is it worth the risk?  

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