Empty beds, pay cuts: What happened to local providers as Sacramento ‘crushed the curve’
Northern California is absolutely “crushing the curve,” reining in the spread of the new coronavirus through social distancing and improved hygiene, said Dr. David Lubarsky, the CEO of UC Davis Health.
And, his voice rings with fervor, even though his Sacramento-based hospital sat at one point with a couple hundred empty beds and the emergency room was treating half the patients it typically serves.
Not far away, Dr. David Kosh also has been managing a drastic drop in patient visits, even though his small family practice in south Sacramento lies well outside the hospital environment where physicians are treating patients with the worst cases of COVID-19. Associated Family Physicians lost 90 percent of their volume when Gov. Gavin Newsom issued his stay-home recommendation in late March.
“The patients are scared to come,” Kosh said. “Instead of having providers work every day, we’re having them work just three days a week. There’s not enough patients for providers to work every day. We have employees who aren’t working right now. We were able to call some back to work but not all.”
Northern California is so far winning the campaign to ensure there are enough beds, equipment and personnel to treat the sickest COVID-19 patients, but that, in turn, is causing a financial upheaval among hospitals and private-practice physicians as revenue and cash flow fall short of meeting expenses for labor and infrastructure.
This financial quagmire is an “unexpected consequence” of the response to the COVID-19 crisis, said Gerald Kominski, a professor of health policy and management at the University of California, Los Angeles. The respiratory illness has overwhelmed providers in some areas of the country but has left hospitals relatively unscathed in other regions, especially those like California which took early and aggressive action.
“A month ago, we were looking at and preparing for what would be the equivalent of a tsunami or a flood of possible admissions to hospitals all over the country,” Kominski said. “The flood has not been quite what we anticipated, which is good news, but the down side of that is you’ve got hospitals that have lost a lot of revenue.”
This extends beyond hospitals, Kominski said, into the broader health care system.
“We’ve gone through this period of pretty intense fear, to put it bluntly,” he said. “How do we move back from that to a sense of (normalcy)? Everybody wants to get back to a normal sense of life, the way things used to be, and ... I think most people know that’s not going to happen immediately. But when will it be safe?”
A surge that never came
Hospital administrators report that the virus surge they had anticipated at this point has not arrived. In early March, state epidemiological predicted that California hospitals would be in the thick of it by late April.
To give Placer County an edge, leaders of Sutter Roseville Medical Center asked construction crews and staff to pull out the stops to get their expanded ICU open a month early to meet the demand. State inspectors and regulators also worked with the hospital to make it happen.
But as state residents heeded calls to stay home and to practice social distancing when on essential errands, the tally of suspected and confirmed COVID-19 cases peaked in hospitals statewide at nearly 5800 on April 7 and then began dropping. That same day, Sacramento County posted its highest number at 77 hospitalized cases, but by April 27, that number was down to 46.
“We have a very limited number of COVID-19 patients in our hospitals, thank God,” said Lubarsky, “and very few infected people in our community.”
As of Thursday, Sacramento County ranked 10th among California counties in the number of people with COVID-19 who have been hospitalized. Ineed, most counties in the area from which Sacramento hospitals draw most of their patients have among the lowest rates of hospitalization: Sacramento County, 43 per 100,000 residents; San Joaquin County, 24; Solano, 12; Placer, 5; El Dorado and Nevada, 1; and none in Butte, Amador, Sutter, Yolo and Yuba counties.
Southern California has been hit much worse, with Los Angeles reporting 1,962 residents per 100,000 seeking hospital care; San Diego, 276; and Riverside, 215.
“Here in Los Angeles,” Kominski said, ‘we still have half the deaths in the state. We don’t have half the population. We have a quarter of the population Things are a little more severe here in this county than they are in the rest of the state.”
As The Sacramento Bee has reported, rural counties have by and large reported fewer cases and fewer deaths from the virus. Yet no matter where hospitals were based, they were all urged by the U.S. Centers for Medicare & Medicaid Services, the Surgeon General and the American College of Surgeons to stop any elective procedures that weren’t considered urgent to preserve equipment and beds for patients who had the new coronavirus.
“Hospitals more or less complied with this,” Kominski said. “They kept the capacity there, expecting that there was going to be this tsunami of COVID patients and we were going to need hospital beds. ... Otherwise, people were literally going to be dying in the hallways.”
Deferred pay, canceled shifts
Doctors, nurses and other health care providers in the Sacramento region prepared to be overrun as their colleagues had been in Seattle, New York, New Orleans, Detroit. Instead, many report finding themselves being forced to sit out work because the number of patients at their hospitals is so low.
Davis resident Irina Okhremtchouk founded the group Med Spouses Unite to provide resources and community to spouses of frontline health care workers. Her husband is a physician whose patients include people with COVID-19.
The Med Spouses group now has roughly 200 members, and in an informal poll, Okhremtchouk discovered that many physicians are losing pay and bonuses, even as they work to save the lives of people severely ill with this respiratory illness.
Doctors with Kaiser Permanente Medical Group are being asked to burn down vacation time, she said. Paid time off often accrues as a liability on a company’s books.
Sutter Medical Group is deferring about 15 percent of pay for its doctors, nurse practitioners and other providers, regardless of whether they work on the front lines against COVID-19 or not, Okhremtchouk said, and retirement contributions have also been deferred.
“In a nutshell, in Sutter’s case, deferred pay is going to those who aren’t working now,” she said. “Doctors, nurse practitioners and physician assistants who are seeing patients now are not only providing care for COVID-19 patients but also supporting cash-flow for the regional medical system.”
Mercy Medical Group has cut a number of bonuses for both osteopathic and medical doctors, regardless of whether they are working, Okhremtchouk said.
A registered nurse and certified nursing assistant at Dignity, who spoke on condition of anonymity out of fear of retaliation, noted that some wards in the company’s local hospitals have been closed, and they and their colleagues are not getting enough hours for full pay. Instead, the nurse said, company officials have told them they can use a combination of paid time off, unpaid leave or unemployment.
Dignity Health officials said they are staffing in line with patient volumes, and if there is work suited to the employees skills, they will be able to float and temporarily perform the work at a Dignity facility within the company’s Sacramento division.
Many nurses and other health care workers, however, work on a contingency basis and do not accrue paid time off and, in some cases, unemployment benefits.
The financial upheaval in health care is by no means limited to the Sacramento region. The Service Employees International Union-United Healthcare Workers West sent out a news release Monday, noting that Stanford Health is requiring workers to take 12 furlough days over the next 10 weeks. That amounts to a pay cut of 20 percent, the union said.
“We have been putting our lives on the line treating COVID-19 patients and Stanford Health is thanking us by cutting our pay and harming our families,” said Chuck Fonseca, a nursing assistant and SEIU-UHW member. “We had no warning that this was coming and there was no discussion. They just sent us an email out of the blue — and most of us are in shock that they would treat us this way.”
Despite managing a sharply lower patient census, Lubarsky said he doesn’t know of any UCD Health staff who have had salaries or hours cut as a result of the low patient census at the medical center.
Todd Stenhouse, a spokesman for AFSCME 3299, a union representing patient care workers at UC Davis Health, said this union’s contract prohibits such measures but that workers may not get a chance at the overtime pay they have come to rely upon to make ends meet.
Kosh’s Associated Family Physicians and many other primary care physicians have remained open to serve all their patients, including those fighting nasty bouts of COVID-19 at home, but office visits have dropped so low that they, too, are cutting shifts for workers.
The Primary Care Collaborative, an industry trade group, released results from a national survey showing that six in 10 clinicians were uncertain whether their practices would remain open as a result of combined pressures from difficulty sourcing PPE, clinician and staff illness, and lost income.
Conditions not seen in a career
Many hospitals across the state are operating below their normal patient census, said Jan Emerson-Shea, a spokesperson for the California Hospital Association.
“We believe this is primarily because there have been widespread cancellations of elective procedures over the past several weeks as hospitals responded to the state’s request to prepare for a surge of COVID patient,” she said. “While the governor on (April 22) announced plans to increase access to care, the details are still being worked out.”
These financial hits come at a time when health care workers are being stressed in other ways, Kominski said.
“These are conditions that most health professionals have not faced in their careers,” he said. “Everybody who walks in could potentially be a carrier, so you’ve got to treat everybody as if they have COVID, and as a result, you have to be especially cautious, and we’ve all seen that the PPE (personal protective equipment) that are necessary to provide a sense of safety isn’t always there to the extent necessary.”
In many instances, Kominski said, health care workers are wearing the same mask all day, not taking it off out of concern for either losing a tight seal or coming into contact with any pathogens on the mask surface.
In addition, he said, doctors often are quite literally ministering to patients in their final hours of life because safety protocols prohibit clergy and family from coming to the patient’s bedside.
“People are dying in some cases after being on the ventilator for weeks,” Kominski said. “They’re dying alone. ... It’s a highly difficult situation.”
‘Patients are scared to come’
Since April 22, when the governor urged residents not to delay their necessary care, hospitals and doctors in private practice said they have seen traffic pick up.
“We’re maybe up to 30 percent (of normal traffic), but we still have providers and staff who aren’t working because there’s no patients,” Kosh said “I mean, we have patients, but they’re scared to come right now. Other doctors offices have had that, too. I know in Elk Grove there’s been a couple doctors’ offices that have shut down completely. ... Whether they’re going to reopen after things quiet down, I don’t know.”
At UC Davis Medical Center, Lubarsky said that patient volume has picked up dramatically since Newsom’s announcement. “About half of our empty beds have already been filled,” he said.
But what he and several other hospital leaders say they’ve seen is that, amid the COVID-19 crisis, local residents have been delaying care to the point that they are coming in with severe health issues.
“People are presenting to the emergency rooms later and with more advanced symptoms,” Lubarsky said, “so the fact that we were able to so quickly fill our beds is bad, too, and it’s bad because what it means is that a lot of people who came to our emergency room needed to be admitted.”
He and Sutter Roseville CEO Brian Alexander urged residents to seek the care they need, stressing that emergency rooms are safe because they segregate patients who have symptoms of COVID-19 such as coughing, fever and shortness of breath.
Lubarsky said his hospital also has converted one floor to create a COVID-19 ward, and all rooms use negative air pressure to prevent air from escaping. “Air only comes in and doesn’t go out (into the other floors),” he said, and before the air is exhausted into the environment, it is fully 100-percent scrubbed of any potential virus.”
When it comes to exposure to the new coronavirus, It’s safer to come to UC Davis Medical Center than it is to go to the grocery story, Lubarsky said.
Kosh said his practice also has instituted changes, arranging to see patients with coughs in only first-floor exam rooms and after hours.
“We give them a mask that they put on before they leave the car,” he said. “We escort them into a side entrance. We keep them on the first floor in isolation, away from the second floor where we see other patients.”
Even though California avoided the big surges like the ones in New York and Louisiana, Detroit and Philadelphia, Kosh said, people still seem to be quite devastated by the impact of COVID-19.
“Half the patients I see are scared and fearful about what’s going to happen,” he said.
What can’t be put off a year?
Kominski said this fear might be the hardest thing for hospitals and the health care system at large to overcome. People are hearing conflicting messages from health care unions and hospitals, he said, so out of an abundance of caution, many are choosing to follow the stay-home recommendation.
Certainly, California is on a downward slope in terms of the number of new cases and the number of deaths from the disease, Kominski said.
“People need to be reassured,” Kominski said. “I don’t know whose responsibility it is to do that. ... It might be that hospitals need to do a little advertising and say, ‘We’re open for business. It’s been a difficult two months, but we’ve got capacity and it’s safe.”
In Sacramento County, Public Health Officer Olivia Kasirye noted Wednesday as part of her order extending the stay-home directive, that visits to physicians or dentists for chronic conditions or preventive services are now considered an essential activity.
Emerson-Shea said that the California Hospital Association has launched a social media campaign that encourages those who may be experiencing a health emergency to seek immediate care. Hospitals also have been sharing similar messages on their social media.
Many of the patients who need this messaging may not be social media users, however. Kosh pointed out that his practice’s Medicare-age population are the ones who seek medical care most often.
“They’re the ones who have the breathing problems and the heart problems,” he said. “They’re more likely to come than the younger people. And, they’re also the ones worried most about getting sick (from coronavirus).“
The next stage for hospitals will be resuming elective procedures and other services, and hospital leaders said they’re working with state leaders to develop criteria that will allow them to do so. Without a vaccine, Lubarsky said, nothing is really going to change, so UCD is currently looking at what procedures, surgeries and preventive care can’t be put off for a year.
“How long can you put off well child visits when they don’t get their vaccines, right, and you can’t send them back to school? How long can you put off doing a person’s mammogram? You don’t have to have your mammogram tomorrow, but you certainly shouldn’t delay it for six months,” Lubarsky said. “How do we accommodate that while keeping careful checks on the impact of increasing our volumes and still being prepared for a second-wave surge?”
This story was originally published May 1, 2020 at 11:23 AM.
