Challenges emerge for the US healthcare system as COVID-19 cases rise

COVID-19 has caused ongoing challenges for health systems across the United States throughout 2020. Recent increases in cases and hospitalizations, however, reveal that pressure may be more widespread in the coming months, with less resiliency across the country to support surges in demand for care. Early in the pandemic some providers relied on resources, such as supplies, from other parts of the country to manage demand, and postponed “elective” care to free up resources for COVID-19 patients.¹Ansari T and Prang A, “Nurses travel from coronavirus hot spot to hot spot, from New York to Texas,” Wall Street Journal, August 9, 2020, wsj.com.²Matthews K and Villeneuve M, “Cuomo orders shift in ventilators to overwhelmed hospitals,” Associated Press, April 3, 2020, apnews.com.

However, potential widespread health system demand may limit the ability of providers to shift resources to emerging “hot spots.” Increasing acuity resulting from delayed care may limit the ability of providers to unlock additional capacity and resources when needed. Given the unique challenges that are evolving across the country, health systems and public health leaders will need to rapidly adjust to prevent potential COVID-19-related crises and save lives.

Considerations to mitigate these challenges include 1) developing plans to increase effective capacity of acute care beds to meet COVID-19 demand in addition to urgent and elective care needs; 2) proactively managing supply and demand for personal protective equipment (PPE) in advance of potential shortages; and 3) strengthening plans to support the provider workforce by cross-training, creating contingency staffing models, and increasing ancillary support for frontline workers. These supports might include childcare services and mental health services.

COVID-19 cases and hospitalizations are rising and demand for care is now more widespread than ever before

More than 1,750,000 people across the United States were diagnosed with COVID-19 in the first two weeks of November. As of November 22, the number of new cases each day continues to climb across almost every state.³Coronavirus Resource Center, COVID-19 data in motion,” Johns Hopkins University, last visited November 22, 2020, coronavirus.jhu.edu. Despite many public health measures and COVID-19-related restrictions, the prevalence of the virus is now greater and more widespread than at any point since the pandemic began. While the country has continued to increase testing capacity, there is also a rising percent of tests with positive diagnosis results across most states (Exhibit 1). Hospitalizations have been steadily rising for weeks, indicating the disease is becoming more prevalent (Exhibit 2).⁴The COVID Tracking Project, “Our data,” The Atlantic Monthly Group, last visited November 22, 2020, covidtracking.com/data.

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Since the beginning of the pandemic, some variables have decreased the burden on the health system. Admission and mortality rates have fallen as older populations have represented a smaller proportion of new cases in recent months. For example, the median age of new cases was 38 years at the end of August compared to 46 years in May.⁵Boehmer TK et al., “Changing age distribution of the COVID-19 pandemic—United States, May–August 2020,” MMWR Morb Mortal Wkly Rep, 2020, Volume 69, pp. 1404–9, cdc.gov. In addition, the evolution in treatment protocols has decreased reliance on ventilators, lowered overall hospital length of stay, and decreased clinical and demographic-adjusted mortality rates.⁶Horwitz L, “Trends in COVID-19 risk-adjusted mortality rates,” J Hosp Med, published online first on October 23, 2020, journalofhospitalmedicine.com.⁷“CDC COVID data tracker,” Centers for Disease Control and Prevention, last visited November 22, 2020, covid.cdc.gov.

However, as case growth climbs and over 80,000 patients are currently hospitalized with a COVID-19 diagnosis, pressure on hospital systems is starting to mount again—but this time large systems are seeing pressure in multiple locations simultaneously. As of November 22, 33 states had at least 10 percent of all hospital beds occupied by a patient with a COVID-19 diagnosis, and 34 states had more than 20 percent of all adult intensive care unit (ICU) beds occupied by a COVID-19 patient (Exhibit 3).⁸U.S. Department of Health & Human Services, “COVID-19 reported patient impact and hospital capacity by state,” Department of Health & Human Services, last visited November 22, 2020, healthdata.gov. This compares to nine states having more than 10 percent of beds occupied by COVID-19 patients on April 15, and 11 states on July 23, when the country reached the two prior peaks of around 60,000 patients hospitalized. Hospitalizations continue to rise, as all 50 states had an increase in the number of patients hospitalized with COVID-19 in the second week of November. In addition, many of the locations with the highest relative pressure are located in more rural areas of the country and may have relatively fewer resources nearby to support patients compared to major metropolitan areas that experienced surges early on in the pandemic (for example, North Dakota has 11 staffed ICU beds per 100,000 population, while the United States average is 27 staffed ICU beds per 100,000 population).⁹U.S. Department of Health & Human Services, “COVID-19 reported patient impact and hospital capacity by state,” Department of Health & Human Services, last visited November 22, 2020, healthdata.gov. North Dakota, for example, announced on November 9 that healthcare workers with asymptomatic cases could continue to work in COVID-19 units in order to alleviate staffing concerns.¹⁰Turley J, “With North Dakota hospitals at 100% capacity, Burgum announces COVID-positive nurses can stay at work,” Grand Forks Herald, November 10, 2020, grandforksherald.com.

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Continued increases in COVID-19 volumes may soon overwhelm hospitals. Currently, 11 states have more than 80 percent of all hospital beds occupied, and 18 states have more than 80 percent of all ICU beds occupied. If current transmission and hospitalization rates continue, and length of stay is not reduced, 13 states may exceed their current ICU bed capacity in the next few weeks if additional beds are not brought online or if existing capacity is not freed up, for example by decreasing elective admissions. Six states may surpass 100 percent of their total ICU and med surg occupancy for all inpatient beds (Exhibit 4).¹¹McKinsey COVID-19 epidemiology model. Potential occupancy rates are based on current occupancy rates in addition to potential growth in COVID-19 patient volumes. Current occupancy rates are based on data reported by the Department of Health and Human Services on November 16, and potential growth in COVID-19 volumes assume that current COVID-19 transmission rates remain constant for the next month. Potential occupancy rates do not account for any additional beds that may be activated, or any potential decrease in non-COVID-19 patient volumes. Certain micro-regions within some states may face even greater pressure, as several cities (for example, El Paso and Milwaukee) have already reported that hospitals were entirely full in early November.¹²Borunda D, “El Paso COVID-19 patient hospitalizations break records; county enforces shutdown, curfew,” El Paso Times, November 2, 2020, elpasotimes.com.¹³Kirchen R, “Covid-19 hospitalization spike challenges hospital capacity in Milwaukee, statewide: Dr. Weston,” Milwaukee Business Journal, November 3, 2020, bizjournals.com.

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Prior health system responses to managing COVID-19 surges may not be as effective due to new challenges

As outlined in “Critical care capacity: The number to watch during the battle of COVID-19,”¹⁴Singhal S, Finn P, Kumar P, Craven M, and Smit S, “Critical care capacity: The number to watch during the battle of COVID-19,” March 30, 2020, McKinsey.com. hospital leaders could consider certain actions to help alleviate potential pressure, such as decreasing elective care, stockpiling supplies, and cross-training staff. However, continued and widespread pressure, combined with new challenges (for example, raw material shortages and severe caregiver burnout) will limit the effectiveness of approaches that providers deployed earlier in 2020, such as:

Capacity

Early in the pandemic, many hospital systems postponed elective care in order to free up additional capacity for COVID-19 patients. As the pandemic has progressed, this has continued to be an effective technique used by many states and providers to help ensure sufficient capacity.¹⁵Platoff E, “Texas bans elective surgeries in more than 100 counties as coronavirus hospitalizations keep climbing,” Texas Tribune, July 9, 2020, texastribune.org.¹⁶Miller NS, “HCA hospitals in Central Florida halt elective surgeries again,” Orlando Sentinel, July 14, 2020, orlandosentinel.com. For example, providers across the state of Arizona decreased non-COVID-19 inpatient volumes by around 40 percent from June 13 to July 6, largely because providers halted elective admissions.¹⁷Associated Press, “Spikes of COVID-19 prompt some Arizona hospitals to halt elective surgeries,” KVOA Television, June 25, 2020, kvoa.com.¹⁸“Data Dashboard—Hospital bed usage & availability,” Arizona Department of Health Services, last visited July 2020, azdhs.gov. However, multiple recent reports suggest that the acuity of care is increasing, and care that was once deemed to be elective may now be more urgent in nature.¹⁹Feldman N et al., “A snapshot of emergency department volumes in the ‘epicenter of the epicenter’ of the COVID-19 pandemic,” Am J Emerg Med, August 2020, S0735-6757(20)30751-8, advance online publication, doi.org/10.1016/j.ajem.2020.08.057.²⁰Motley Fool Transcribing, “HCA healthcare (HCA) Q3 2020 earnings call transcript,” The Motley Fool, October 26, 2020, fool.com. Therefore, decisions to halt elective care may have a relatively smaller impact than the same decision might have had in the period of March to July. In addition, some patients also may have forgone seeking medical treatment for life-threatening conditions. For example, in the first 10 weeks of the pandemic, hospitals saw a 23 percent reduction in heart attacks and a 20 percent reduction in strokes, which led to fewer emergent admissions between the March to May time period.²¹Lange SJ at al., “Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions—United States, January–May 2020,” MMWR Morb Mortal Wkly Rep, 2020, Volume 69, pp. 795–800, cdc.gov. Lastly, many alternative sites of care were built early on in the pandemic. However, many of these facilities have been disassembled, and the ability or willingness to erect new alternative sites of care may be more limited moving forward.

Supplies

The demand for PPE and testing supplies continues to be well above baseline levels as society grapples with trying to safely resume “normal” activity in light of strong virus resurgence. Our latest Consumer Health Insights survey found that 90 percent of respondents reported masks and testing as their most important factors in supporting return.²²McKinsey COVID-19 Consumer Health Insights Survey, October 2020. The increase in PPE use across all healthcare settings, as well as in schools, businesses, and public spaces has exacerbated demand-side pressure. The most recent FDA report has identified shortages for 20 critical supplies (including N95 respirators, surgical gloves, gowns, testing supplies, and ventilators).²³“Medical device shortages during the COVID-19 public health emergency,” Food & Drug Administration, last updated September 24, 2020, fda.gov. Further, sustained pressure on the global supply chain could result in higher costs (for example, raw materials, labor, and capital expenditures) and persistent supply shortages.

Workforce

COVID-19 has strained the clinical workforce for more than nine months, and the continued pressure is leading to increased risks and new challenges moving forward. Recent reports have shown that healthcare workers face a greater risk of acquiring COVID-19 compared to workers in other sectors, and are experiencing longer working hours, fatigue, and psychological stress.²⁴“Coronavirus: Doctors, nurses, and health workers ‘burning out’, warns WHO” Euronews, October 29, 2020, euronews.com.²⁵Shah ASV et al., “Risk of hospital admission with coronavirus disease 2019 in healthcare workers and their households: Nationwide linkage cohort study,” BMJ, 2020, Volume 371, p. m3582, bmj.com.²⁶Nguyen LH et al., “Risk of COVID-19 among front-line health-care workers and the general community: A prospective cohort study,” Lancet, September 1, 2020, Volume 5, Number 9, pp. e475–83, thelancet.com. As a result, many physicians and nurses have been unable to work due to exposures or infections, which are likely to continue.²⁷“Hospitals competing for nurses as coronavirus cases surge” Modern Healthcare, November 2, 2020, modernhealthcare.com. Potential infections of family members along with disruptions to school and childcare arrangements have also led to higher-than-normal call-out rates, and delayed paid time off (PTO) is starting to pose potential liabilities for organizations moving forward.²⁸Webber T, “Hospitals competing for nurses as US coronavirus cases surge” ABC News, November 2, 2020, abcnews.go.com. Early in the pandemic, many heroic physicians and nurses moved across the country to “COVID-19 hot spots” to provide additional support as necessary. However, as the COVID-19 burden is now rising across the country, the ability for providers to be shifted across regions may become more limited.²⁹Yong E, “No one is listening to us,” Atlantic, November 13, 2020, theatlantic.com. Many states still have mandatory quarantine requirements in place for visitors, which may impact providers considering travel assignments, particularly around the holiday season.³⁰Schwartz K, “Thinking of traveling in the U.S.? These states have travel restrictions,” New York Times, updated November 24, 2020, nytimes.com.

The increased stress on healthcare workers is leading to longer-term concerns as well. Some providers have seen an increase in early retirements (compounding existing increased retirement rates driven by baby boomers, especially nurses).³¹Health Affairs Blog, “How should we prepare for the wave of retiring baby boomer nurses?,” blog entry by Buerhaus P, Auerbach D, and Staiger D, May 3, 2017, healthaffairs.org. Many nursing and medical schools have delayed clinical rotations which may decrease the number of new graduates available in the next year.³²Twachtman G, “COVID-19 spurs telemedicine, furloughs, retirement,” Medscape, April 29, 2020, medscape.com.³³“Changes to nursing programs’ clinical requirements in response to COVID-19,” NurseJournal, October 28, 2020, nursejournal.org.³⁴Health Affairs Blog, “How should we prepare for the wave of retiring baby boomer nurses?,” blog entry by Buerhaus P, Auerbach D, and Staiger D, May 3, 2017, healthaffairs.org. Lastly, some staff who were furloughed have found new roles outside of healthcare.³⁵Fadel L et al., “As hospitals lose revenue, more than a million health care workers lose jobs,” NPR, May 8, 2020, npr.org. Altogether, the potential exists for workforce shortages to limit effective capacity in the coming months, and it will be important to consider solutions within, rather than across, markets.

Health systems may consider developing new COVID-19 strategies to manage novel challenges and ensure sufficient resources

As the prevalence of COVID-19 continues to rise, providers could consider establishing or reinvigorating “command centers” in order to support agility in operational decision making. Having a centralized view of potential challenges, supported by real-time data, may be able to help leaders mitigate potential capacity, supply, and workforce issues before they arise. Below are several actions that health systems could consider across these three dimensions:

Capacity—Develop thoughtful plans to increase effective capacity of acute care beds to meet COVID-19 demand in addition to urgent and elective care needs.

As highlighted in “Understanding the hidden costs of COVID-19’s potential impact on US healthcare,” hospitals across the country have faced significant financial pressures throughout 2020, in part due to a reduction in elective procedure volume, which typically drives a disproportionate share of revenue and margin for hospitals.³⁶Hutchins Coe E, Enomoto K, Finn P, Stenson J, and Weber K, “Understanding the hidden costs of COVID-19’s potential impact on US healthcare,” September 4, 2020, McKinsey.com.³⁷“Hospitals and health systems continue to face unprecedented financial challenges due to COVID-19,” American Hospital Association, June 2020, aha.org.³⁸Berlin G, Bueno D, Gibler K, and Schulz J, “Cutting through the COVID-19 surgical backlog,” October 2, 2020, McKinsey.com. Therefore, as the pandemic continues, providers may be increasingly hesitant to cease elective procedures for financial reasons. At the same time, providers recognize the need to prepare for potential increases in COVID-19 volumes.

However, leaders should not always view this as an “either-or” decision.³⁹Liss S, “How Banner Health is using AI to keep electives going,” Healthcare Dive, October 19, 2020, healthcaredive.com.⁴⁰Evans M, “Hospitals balance COVID-19 care with more-lucrative services during latest virus surge,” Wall Street Journal, October 26, 2020, wsj.com. Health systems could consider the following actions to help balance capacity conservation for COVID-19 patients, with the ability to concurrently provide routine care as long as possible:

• Leverage real-time data and forward-looking models to understand potential demand and capacity of med surg and ICU beds across all facilities
• Establish occupancy thresholds which may necessitate slowing down elective admissions, with criteria to determine which types of care may be safest to postpone first
• Explore opportunities to leverage virtual care (for example, remote monitoring and tele-ICU) when medically appropriate and in accordance with legal and professional standards to increase acute bed availability
• Increase the number of acute or critical care beds by converting existing space (for example, conversion of operating/perioperative rooms) or considering double occupancy rooms when medically appropriate
• Optimize inpatient throughput to increase effective capacity
• Create community-wide plans for utilization of alternative care sites (for example, use of alternative care sites for post-acute care)
• Develop effective triage processes to cross-level demand and route patients to nearby facilities with bed availability (potentially involving partnerships with other providers)
• Proactively ramp up elective care volumes when COVID-19 demand is low to prevent unnecessary deferral of care (which may help to mitigate non-COVID-19 demand in subsequent months)

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Supplies—Revisit supply and demand mitigation plans to prepare for crisis scenarios.

Proactively managing supply and demand in advance of potential shortages may help to prevent another acute shortage. As such, health systems should consider the following actions to help manage COVID-19 resurgence:

• Utilize real-time dashboards to track projected demand and supply inflow, with demand management thresholds set for key supplies
• Cross-level supplies with nearby facilities
• Codify and syndicate contingency and crisis demand management protocols for supply conservation across the system, including protocols in patient and non-patient areas to conserve supply as needed
• Expand sourcing channels and explore appropriate alternatives for supplies, including direct to manufacture sources
• Coordinate with internal (for example, central emergency response team) and external (for example, state government) stakeholders to ensure efforts are integrated with the broader system and risk is managed appropriately

Workforce—Strengthen plans to support the provider workforce by cross-training, creating contingency staffing models, and increasing ancillary support.

Given the new workforce challenges outlined above, many novel strategies may be required in the months ahead to prevent workforce shortages. Potential actions to consider include:

• Model potential demand and supply of providers by site of care, role, and specialty to identify locations with the greatest relative risk
• Establish contracts with temporary staffing agencies or increase hiring with expedited HR and onboarding processes
• Engage with recently retired providers and identify potential ways to leverage their expertise (for example, providing virtual mentoring/assistance to less tenured providers)
• Shift providers from nearby facilities or markets, if feasible (either within a system or in partnership with external providers in other regions of the country with lower relative COVID-19 pressure)
• Increase availability of rapid COVID-19 tests for employees to limit potential spread of the virus and decrease call-out rates⁴¹National Center for Immunization and Respiratory Diseases Division of Viral Diseases, “Considerations for use of SARS-CoV-2 antigen testing in nursing homes,” Centers for Disease Control and Prevention, last updated October 23, 2020, cdc.gov.
• Strategically stagger PTO and provide incentives (financial and non-financial) to work during peak times and holidays
• Provide personal wellness and mental health support to prevent provider burnout
• Provide cross-training and upskill personnel to fill critical roles (for example, critical care nurses)⁴²Veenema TG et al., Recommendations for improving national nurse preparedness for pandemic response: Early lessons from COVID-19, Johns Hopkins Center for Health Security, June 10, 2020, centerforhealthsecurity.org.
• Develop plans to shift to contingency or crisis staffing ratios once other options have been explored
• Increase programs for caregivers designed to support them in and outside of work with childcare (including homeschooling), providing meals for them and their loved ones, and anything else to reduce some of their burden
• Explore ways to get new grads and cross-training caregivers up to speed more quickly and partner with local schools to enable continued clinical requirements and avoid seeing major gaps in talent availability

Providers across the country have shown tremendous resiliency in response to unprecedented challenges throughout 2020. However, new strategies will be required to manage this latest uptick in demand, which may end up being the greatest challenge to date in the COVID-19 response. Health systems that proactively prepare for worst case scenarios, and develop thoughtful strategic and operational plans to mitigate upcoming challenges, will be best positioned to prevent crises and save lives.