Nebraska health care providers adapted during pandemic

OMAHA -- Freddie Warner Jr. couldn't take it anymore.

His hip hurt, which caused him to put more pressure on his knee. That made his back hurt. He couldn't sit or stand for long periods. The 51-year-old Omaha man gave up his job in lawn care, his occupation since high school.

On Dec. 1, Warner underwent surgery to replace his left hip. On Feb. 7, he had surgery on his right knee.

While hundreds of joint replacement surgeries are performed every day across the country, Warner's operations came during a surge in COVID-19. At the time, staffed hospital beds were in short supply, and many elective surgeries like Warner's had been postponed or canceled.

Instead of keeping Warner at least one night in the hospital after his surgeries, which had been the more common practice, his surgeon sent him home the same day.

After some physical therapy and exercises at home, Warner was able to start a new lawn-care job at the end of March.

While a shift to more outpatient or same-day surgeries had been underway for some time, health system leaders say the pandemic accelerated it. It similarly sped the expansion of telehealth, which gave people access to clinicians when clinics were closed and many patients were leery of in-person encounters. It also provided remote support to staff at smaller hospitals, allowing them to keep more patients closer to their homes.

The pandemic also exposed the challenges facing the health care workforce and the gaps between the demand for such workers and educational programs' ability to produce them. And just as worker shortages have helped drive wage increases in industries from transportation to food service, health systems also are seeing increased labor costs.

"It's about making sure we're competitively paying people for the work they're doing," said Cory Shaw, chief operating officer for Nebraska Medicine. " ... We have to make sure we pay competitively for the difficult jobs they've got."

Steve Goeser, president and CEO of Methodist Health System, said some health care workers have retired or left the profession as a result of the pandemic. Others have moved to less stressful jobs. Some have left for more lucrative traveling medical jobs.

"So, yes, it's really accelerated salaries," Goeser said. "It's put a real strain on finances. I think we're fortunate in the staffing that we have and the people that stayed with us."

Shaw said Nebraska Medicine already has begun alerting insurers to its increased costs. Reimbursements from Medicare and Medicaid, which make up 60%-70% of a typical hospital's business, fall well short of cost increases in a normal year and will lag even more as health systems seek to cover increased costs.

"It's going to force us to revisit with our health insurance partners and employers what they're paying for health care," Shaw said. That likely will eventually translate to higher premiums and out-of-pocket expenses.

Dr. Cary Ward, chief medical officer with CHI Health, said the cost of health care has gone up dramatically and will stay that way for some time. CHI Health spent $8.7 million on traveling nurses in February alone. Pre-COVID, that tab was about $1.8 million a month.

At the same time, the recent decline in the number of COVID patients, while good news, has meant a reduction in reimbursements for their care. And the cost of supplies and pharmaceuticals also has gone up.

"It's a very expensive time in health care," Ward said.

For many consumers, health care already was costly. Premiums for employer-sponsored family health coverages rose 4% in 2021, according to the Kaiser Family Foundation's annual survey, with workers on average contributing $5,969 toward the cost of family coverage. Since 2011, average family premiums have increased 47%, more than average wages — at 31% — or inflation — at 19%.

The federal government has taken steps during the pandemic to ease the financial impacts of the pandemic on Americans:

* Federal funding has covered out-of-pocket costs of COVID testing, vaccines and treatments.

* The public health emergency kept tens of thousands of people enrolled in Medicaid regardless of changes in their eligibility.

* The American Rescue Plan Act increased premium tax credits available through HealthCare.gov, the federal insurance marketplace. The number of Nebraskans enrolled in the marketplace increased by 12% to roughly 99,000, according to CMS.

What happens next, however, is up in the air. Federal funding for testing, vaccines and treatments for the uninsured is running out. An effort to provide an additional $10 billion in COVID assistance remains in flux. A Senate measure would allow the Biden administration to purchase more vaccines and therapeutics but would not replenish the program that pays for testing, treating and vaccinating the uninsured.

Meanwhile, the Biden administration has extended the public health emergency until mid-July. An earlier end could have caused thousands of Nebraskans who remained on Medicaid during the pandemic to lose that coverage, Nebraska Appleseed says. The expanded tax credits are scheduled to expire at the end of the year, although efforts are underway to include them in future legislation.

Health system leaders say the pandemic drove greater collaboration within and among the state's health systems. Smaller hospitals, they say, managed patients with more serious conditions than they had before.

"Big or small, you still have to have those partnerships," said Kelly Driscoll, president and CEO of Faith Regional Health Services in Norfolk. "Those are key roles to provide the health care that we all want to provide."

The pandemic also required health systems to adapt quickly.

Goeser said Methodist staff knew the value of negative airflow rooms in preventing the spread of pathogens but never fathomed they would create whole floors with negative airflow for treating patients with COVID. Doing so meant nurses and other caregivers could gown up once for a shift rather than changing between each room.

Like other health systems, Methodist quickly expanded its intensive care unit to other areas and used pre- and post-operative areas for overflow. The health system set up a call center over a weekend to triage patients and send them to a designated COVID clinic to avoid overburdening its emergency rooms.

Ward said the acceleration of outpatient and same-day surgeries was a positive development that came out of the pandemic. When done with the right patient who has adequate support at home, it's better for patients and lowers the cost of care.

"It's great," Ward said, "and we hope that will be a trend that will continue."

Dr. Clayton Thor, an orthopedic surgeon with CHI Health, said most of his hip and knee replacement patients before the pandemic spent at least one night in the hospital. Now, roughly 80% to 85% go home the same day, as Warner did.

"COVID did the shift for me," Thor said. "We had to cancel inpatient surgeries for such a long period of time, and multiple periods of time … to where patients were hurting bad enough, the only option was to do it that way."

Thor said he started shifting to same-day dismissals with younger, healthier, more active patients and gradually expanded his list. Patients with other significant health issues, such as cardiac histories or oxygen use, still are kept overnight.

Warner said he was happy to skip a night in the hospital. He had set a goal of getting back to work by May, which he beat by about a month. "I didn't think it would be this early," he said. "I feel brand new, like I have a lot of energy to go out and do things."

Shaw said Nebraska Medicine performed 24,000 surgeries five years ago, 10,000 of them inpatient procedures and 14,000 outpatient ones. For the fiscal year that ended June 30, the numbers stayed about the same but shifted to 15,000 outpatient surgeries and 9,000 inpatient ones. He expects the shift to continue during the current fiscal year.

One reason for the shift, which Shaw said was highlighted during the pandemic, was to make sure hospital beds were available for those who really need them.

And just as schools and businesses flipped to remote sessions on Zoom, health systems and clinics quickly expanded their telemedicine offerings to provide clinical and behavioral health visits and offer online consultations with other, smaller hospitals.

Faith Regional's respiratory therapists, for instance, trained staff at smaller hospitals to use BiPAP machines, Driscoll said. A noninvasive form of ventilation, BiPAP became an important treatment for COVID patients.

Shaw said telehealth made up a sliver of Nebraska Medicine's clinical activity before the pandemic. At the peak, it comprised 80% to 90%. Now it's back to 15% to 20%. Health systems with a greater share of primary care may be higher, he said.

Methodist peaked at about 250 virtual visits a week when some clinics were closed and now has dropped under 100, Goeser said. But the health system maintains robust virtual outreach to other hospitals and in behavioral health.

Ward said 32% of CHI Health's visits during the peak of the pandemic were virtual. That has since declined as patients have returned to more in-person visits. But Ward said virtual care still offers an alternative for many, such as those who don't feel well enough to come in and patients who live far from clinics.

"I think telehealth will play an increasingly important role in the future of health care," he said.

Drive-up care also caught on during the pandemic, Ward said. Three new CHI Health family health centers, one near CHI Immanuel in Omaha, one in Elkhorn and another in Lincoln, will have heated drive-thru bays that patients can access.

Dr. Michael Romano, chief medical officer for the Nebraska Health Network, said the shift toward more virtual care and outpatient procedures generally is a good thing because both are done in lower-cost settings. The cost pressures in health care, he said, will create incentives for providers to look at how they can do things differently.

"I don't necessarily look at the cost pressures as being a bad thing," Romano said. "I think we ultimately end up doing things better because the cost pressures have forced us to do things better."

The data on outcomes from virtual care, however, still is a few years away. "My gut feel is there are lots of situations where it's very effective, some others not so much," he said. "We need to be a little selective in how we use it."

Lee Handke, the network's CEO, said patient satisfaction with telehealth is high, which will make it difficult to reverse course. The health network, which formed in 2010, includes physicians in Nebraska Medicine, Methodist Health System and Fremont Health.

Eventually, Handke said, health plans will begin to steer members to providers and facilities with lower costs. What's still missing from that equation, however, are easy-to-use tools to help customers compare and shop. Recent federal pricing transparency rules require health systems to post pricing information. That raw data will become easier to use once software developers create new tools tapping the information.

Romano added that employees still will need some incentive, such as being able to share in the savings on out-of-pocket costs, to shop around.

Meanwhile, health system leaders say they're working to increase efficiencies.

Methodist, for instance, began using artificial intelligence to automate billing and claims in 2019 and since has increased the use of the technology. Jeff Francis, vice president of finance, said the automation saves about 1,400 hours of work a month that once was done by staff in claims alone.

Nebraska Medicine and the University of Nebraska Medical Center are developing an 18- to 25-bed inpatient unit on their campus as a futuristic setting where they can test different care team models and technologies. The goal is to have patients in the unit beginning in 2024.

Ward said CHI Health has looked at several different models of care intended to increase cost effectiveness and adjust to staff shortages.

One model, called iCARE, or Interprofessional Collaborative Alignment Resulting in Exceptional Patient Care Teams, involves bringing pharmacists onto floors to help nurses administer some medications, such as complex antibiotic infusions, and having occupational therapists assist nurses with tasks such as walking patients and strength training.

Shaw said the delaying of care during the pandemic is likely to have long-lasting effects. If patients avoided or didn't have access to cancer screenings, they later might be diagnosed with a more advanced disease that will cost more to treat than if it had been detected earlier.

Because of such concerns, health systems have been encouraging people to get in for screenings and other preventative care.

Handke said the health network worked with providers during the pandemic to focus on the most vulnerable patients during the pandemic. As an accountable care organization, the network's goal is to take good care of Medicare patients in order to improve their health and lower costs. Wellness visits for those patients during 2021 remained high.

Romano said some national data indicates that more strokes and heart attacks have occurred since the pandemic began. Cancer screenings and new diagnoses of cancer have fallen off, although it may take a few years before that impact is clear. "I don't think we know how that's going to hit," he said.