Beyond the Pandemic Part 1

Shifting patterns of care

During the pandemic, many people put off cancer screening, elective procedures, and even maintenance care for chronic conditions. This explains why patients post pandemic put a clear strain on the healthcare system and hospitals. Hospitals are seeing sicker patients who require more care, making longer stays more common.

Reports show the patterns:

• According to a survey of primary care physicians, “37% said that their patients with chronic conditions were ‘in noticeably worse health resulting from the pandemic.’ In addition, 56% of physicians noted they had seen an increase in negative health burdens due to delayed or inaccessible care.”¹
• The journal Cancer found “in just three months in 2021, there was an 80.6% decrease
  in screening for colorectal cancer, 69% decrease in screening for cervical cancer and 55.3%
  decrease in screening for breast cancer.”¹
• The British Medical Journal found that “every month of delayed cancer care could result in a 10% increase in risk for mortality, which for breast cancer in the U.S. alone could lead to 6,100 avoidable deaths over a three-month period.”¹

Meanwhile, hospitals are seeing a drop in ED visits for non-COVID related illness and a shift to lower-acute sites and telehealth options. While this is likely related to patients wanting to avoid COVID infections, it is nevertheless creating new behavior patterns:

• “The decline in ED visits experienced during the pandemic was sharp but is expected to plateau with a decline in demand projected at
  -2% over the next 10 years. ED visits will remain significantly below 2019 volumes as a result
  of lower acuity volumes shifting to alternative care sites including virtual triage.”³
• Patients with certain illnesses that may have worsened due to delayed care are returning to the ED. However, this trend may not last even though current ED patients are often sicker. A 2022 report showed that “as pandemic-era protocols decline, infectious diseases such as asthma, chronic lung disease and cystic fibrosis are expected to return with a 3% increase this year in ED visits,” but went on to predict that ED visits overall will decrease 10% by 2032.3 ⁴

The shifting care patterns have created a bottleneck:

• Beds are being occupied by patients with greater acuity, longer stays and intensified treatments. Those patients finally admitted for long-awaited elective procedures are proving to need more care than previous patients undergoing non-emergency procedures.
• Delayed elective procedures can become less elective when they are delayed as conditions worsen over time, adding to the ALOS. “Between 2019 and 2021, overall patient acuity, as measured by the average length of stay, was up nearly 10%.”1
• As illustrated below, hospitals are seeing the diversity, complexity and severity of patient illnesses – the CMI rate – grow, possibly due to delayed care.

The effects are evident in the emergency department as well:

• Patients who arrive in the ED are increasingly sicker and are more often requiring admission. This can result in more patients being held in the ED waiting for beds occupied by elective patients and sicker inpatients.
• “Once elective surgeries were no longer on hold, the influx of cases placed a greater demand on inpatient beds. Increased ED admission rates and acuity has been another factor. One health system reported overall admission rates across its EDs have increased from 16% to more than 20%.”⁴
• This cycle becomes a self-fulfilling prophecy because longer LOS in the ER of admitted patient waiting for beds is linked to further delays in care and worse outcomes.

"ED boarding is the start of a vicious cycle. Boarding patients ties up ED beds, creating waits and longer lengths of stay for all other ED patients. Boarding also impacts clinical outcomes, since boarders experience higher morbidity and mortality rates and higher inpatient LOS than nonboarders. Longer stays place a higher demand on inpatient beds, reducing functional bed capacity. Additionally, longer inpatient stays cost hospitals more money. Lastly, boarders typically report lower HCAHPS scores, further eroding the bottom line."⁴

Increased patient acuity increases hospitals’ labor, drug and supply costs, creating financial challenges.

• Hospitals require more staff with increased patient acuity. With the workforce shortages in critical areas such as nursing and respiratory care, hospitals often must turn to high-cost contract labor. According to June 2022 data from Kaufman Hall, “labor costs are up over 12% for hospitals from 2021.”¹
• Sicker patients require more expensive drug treatments. Specialty drugs such as Humira used to treat rheumatoid arthritis, “experienced a 21% price increase between 2019 and 2021. At the same time, patients hospitalized with rheumatoid arthritis had an 89% increase in ALOS, further compounding this cost increase. Overall, hospitals have experienced double-digit growth in drug costs compared to pre-pandemic levels and that growth continues to exist in 2022. In fact, between just May and June 2022, hospital drug expenses grew 4.1%.”¹
• “As hospitals treat sicker patients, they often need more intensive care that requires the use of more supplies and equipment from surgical masks to high-cost ventilators and surgical instruments. As a result, supply costs between just May and June 2022, increased nearly 5%.” ¹

Summary

“Patients who are sicker and more expensive weigh heavily on hospitals’ operating margins, putting a strain on both expenses and revenue,” said Erik Swanson, senior vice president of data and analytics at Kaufman Hall. Beyond the bottom line, we would add that the strain extends to staff and available beds.² Hospitals are now working to understand what is happening, to determine the root causes, and look for strategies to lessen the impact as predictions for 2023 and beyond do not show much improvement.⁸

Read Part 2 of our Beyond the Pandemic compendium of research addressing solutions to this shifting landscape.

All source notes provided in the download document.