A Post-Crisis Crisis: Pending loss of emergency status is a concern to health systems

When will the COVID-19 pandemic end?

Science says the pandemic ends when the disease becomes endemic – which is to say when people have developed enough immunity that it becomes a normal recurring illness, such as the flu.

But in addition to the scientific answer, there is a bureaucratic one. A COVID-19 public health emergency, or PHE, was declared by President Donald Trump in January 2020, and it has been renewed, first by Trump and then by President Joe Biden, for 90-day increments since then – most recently on April 12.

In Missouri, Gov. Mike Parson declared the state to be entering the endemic phase effective April 1.

The Biden administration has promised to give 60 days’ notice before allowing the federal public health emergency to expire, as a chance for health care agencies to prepare for the changes.

A ray of light: COVID-19 cases are waning locally. An April 14 news release from the Springfield-Greene County Health Department noted the county’s seven-day rolling case average had dropped below 10 per day for the first time since 2020. Just three months ago, the seven-day rolling average was 476 cases per day.

While the viral emergency lessens, the looming expiration of the PHE could bring a different kind of emergency to hospitals: a fiscal one.

The PHE has offered myriad financial assistance to hospitals treating COVID-19 patients, including a 20% payment increase for Medicare patients and certain liability immunities related to vaccines.

Building pressure
Dave Thompson, the Tulsa, Oklahoma-based senior vice president of strategic integration for Mercy, said hospitals are facing tremendous pressure right now, but it’s important they continue to work to increase coverage for Medicaid-eligible patients.

“We have to continue to see that coverage improve,” he said.

Thompson said whether government relief systems continue or not, hospitals must remain focused on patient care.

“We can’t let this PHE expiration just further exacerbate our abilities,” he said. “There’s a continuity of care risk here. We’ve got to closely monitor it and do everything we can to help those who might fall through the cracks.”

Steve Edwards, CoxHealth president and CEO, noted even with the PHE, hospitals have been struggling.

Referring to CoxHeath’s operating margin, he noted that in January the hospital lost about 4%, and in February, it lost about 3%.

“In my career, I don’t recall seeing two months of losses,” he said.

He said hospitals were strained in those months because they had a high COVID-19 census but a low number of high-billing surgical cases, and medical cases like COVID care are expensive to treat.

“That’s not necessarily a motivating factor, but it’s got to be a concern,” he said. “We’re in better shape today than we were two months ago.”

Kaufman Hall’s National Hospital Flash Report for March backed up Edwards’ concerns, noting 2022 is off to a bad start for U.S. health systems. It states most organizations are experiencing declines in margins, revenue and inpatient volumes following the omicron surge.

Despite steep declines in COVID-19 cases, outpatient care has been slow to return, and inpatient volumes have receded, the report states.

What’s coming down the pike with the end of the emergency orders? Without further action, many people will lose their Medicaid eligibility – an estimated 13% of those currently enrolled, according to the Kaiser Family Foundation.

The foundation adds that COVID-19 testing and vaccines will no longer be free, and costs of treatment will rise. And telehealth options will likely be curtailed.

Cautiously prepared
Jordan Valley Community Health Center serves a large number of Medicaid patients. According to Alexis Brown, executive director of clinics, the biggest impact for patients will be the need to renew their Medicaid enrollment information for the first time in years.

Many patients have moved to a different address and will not receive information that is mailed to them from the state.

“The struggle is going to be getting awareness out to them and helping them to re-sign up in a timely fashion,” she said.

According to the Medicaid website, as of November 2021, Missouri had enrolled 1.13 million people in Medicaid.

The federal emergency orders stipulated that patients not be removed from Medicaid rolls, even if they receive a boost in income that makes them ineligible.

An April 12 article in Becker’s Hospital Review notes that millions of people will need to complete renewal applications to determine if they can remain in the program, and that process will be complicated by staffing shortages at state Medicaid agencies.

Brown said the staff at Jordan Valley is ready to meet the problem head-on, and in fact has been meeting it all along.

“We work with the Medicaid population on a daily basis, and many of our staff are trained to do Medicaid applications,” she said. “We prework our schedule so we can tell if people are inactive.”

Hospitals on alert
Edwards said he is concerned about continuity of coverage for several reasons. One is that the insured who do not qualify for Medicaid but have received Medicaid-like coverage will lose their insurance.

“It obviously affects hospital finances, and it also creates reluctance for people to receive care,” he said, adding when patients obtain treatment later in the course of a disease, the outcomes are usually not as favorable.

One aspect of the crisis Edwards anticipates is that illnesses went undetected during the COVID-19 pandemic.

“We know the rate of cancer hasn’t gone down during the pandemic; it’s just gone underground,” he said.

Prostate screenings, colonoscopies, breast imaging – these were put off during the pandemic, and when patients discovered they had cancer or other diseases, it was more advanced than it would have been otherwise, he said.

Thompson shares Edwards’ concerns and more.

He said COVID-19 cases have significantly declined, but some aspects of the PHE have been hugely impactful in a positive way to people served by Mercy. Thompson indicated he would like to see some of the provisions adopted permanently.

“Frankly, many of those waivers have had a tremendous impact on the future of the health care delivery model,” he said.

He enumerated what he called major benefits that resulted from the PHE, including paying for vaccinations for the underserved, telemedicine and detailed administrative support around post-acute care and managing transitions of care.

He does not want to see hospitals go backward after making such strides during the pandemic.

“We’re constantly focused on this idea of delivering the right care at the right time in the right setting,” he said. “Keeping a lot of these PHE supports in place is just crucial for that.”

He said he does anticipate the PHE will eventually expire, and some funding already has.

“We still have to stay focused on providing care in all our communities,” he said.