key: cord-0821323-41d7haes
authors: Huffman, Alan
title: COVID-19 Surges Then Crickets and the Impact on the Emergency Department Workforce
date: 2022-02-16
journal: Ann Emerg Med
DOI: 10.1016/j.annemergmed.2022.01.028
sha: 005f39dc024f2797e92109771af424eddcddbefc
doc_id: 821323
cord_uid: 41d7haes

nan

W hile clinicians are buffeted by alternating surges and declines in patient volumes as a result of COVID-19, emergency medical staff have faced more than the obvious challenges involving treatment, potential exposure, and pandemic fatigue.

Staffing issues have added professional uncertainty to the mix-in some cases, accelerating trends that were already underway, such as an oversupply of emergency physicians, corporate staff reductions, and less-predictable work schedules. Clinicians have tended to ramp up during periods of patient overload, then lay off, reassign, or reduce shifts when surges subside.

How individual practitioners are affected depends on which business model their emergency department (ED) follows. If it involves directly employing doctors and other medical staff, they may be called on to work overtime and then laid off during downturns. If the model uses independent contractors, they may be given more shifts when the ED is barraged with patients and moved to the areas of greatest need, then assigned fewer or shorter shifts when volumes fall.

In both cases, the fluctuations are directly absorbed by the medical staff. Emergency physicians have been laid off or had their hours cut after working to the brink of exhaustion, intubating scores of patients, and being compelled to inform family members their loved ones were dying and that they could not be with them to say goodbye.

For anyone who works in emergency medicine or is preparing to enter the field, these dynamics raise questions about the future of the profession that many providers are reluctant to discuss. Among the providers contacted for insight into how patient fluctuations have affected their operations, logistics, business models, and future planning, many declined to comment for this article, citing concerns about the potential for controversy. This is illustrated by articles such as this one 1 from ProPublica, headlined "Hospitals Face a New Crisis: Staffing Firms Are Cutting Their Doctors' Hours and Pay," which noted that staffing companies had cut hours for thousands of emergency physicians, physician assistants, and nurse practitioners, resulting in lower pay.

Mark Reiter, MD, MBA, the residency program director of emergency medicine for the University of Tennessee and past president of the American Academy of Emergency Medicine, said many EDs that have experienced staff cuts as a result of declining patient volumes have not returned to appropriate staffing as patient volumes have rebounded or even surged.

Reiter said these moves have added financial strain on the physicians, and "it makes it more challenging to optimally staff an emergency department and successfully run an emergency medicine practice." Jody Crane, MD, chief medical officer for the medical staffing company TeamHealth, which is owned by the private-equity firm Blackstone and employs more than 15,000 health care professionals and advanced practice clinicians, cautioned that the issue of how clinicians respond to such fluctuations is sometimes painted with too broad a brush and that everyone in health care has been affected.

"We've had wild fluctuations from day to day," Crane, an emergency physician who leads his company's pandemic response, said. "High patient volume days are typically Mondays and taper off through the week, but during the pandemic, a Friday could be out of control. It didn't seem to correspond to historical patterns."

Such fluctuations have occurred in almost every US state, particularly in COVID-19 hotspots, he said. Following the pandemic shutdown in March 2020, patient volumes were down by as much as 50%, which, he said, had "devastating" effects on clinicians and hospitals. "During the first three waves, we saw an inverse relation between ED volumes and surge. People tended to hunker down in their homes and not seek care." It was during this period that ProPublica reported TeamHealth had asked anesthesiologists to take voluntary furloughs and reduced hours for ED staff in some areas.

After the first wave passed, Crane said, patient volumes gradually returned, though to varying degrees regionally and from county to county. By the time the delta variant hit, "EDs had come back quite a bit," he said, but the new wave again disrupted the cycle. In some parts of Florida where TeamHealth is a provider, patient volumes were down 20%, then up 20% within a matter of a few weeks.

"We were scrambling," Crane said. "In our case, it was all hands on deck. Anybody who wasn't maxed out on hours came to work. We hired up. We offered jobs and shift bonuses."

The problem, he said, was that due to hiring intervals, "Once we got these people on board, volumes were trailing." Staffing was then scaled back. "Everybody was at 80 percent [staffing], then surged to 110 percent, then we dropped back to a normal staffing level," he said. As of late autumn 2021, ED volumes for TeamHealth were down from 5% to 10% from prepandemic levels, he said.

"The biggest challenge," Crane said, "has not been effectively solved. You have a two-month window, and the only way that's solvable is if you have a workforce working at 70 percent. It causes a whiplash effect on the workforce. We could be more effective if we had six months. But you can flex-shift for the durations. Nurses have historically been good at that. Doctors haven't traditionally done that." He said that when patient volumes are down, physicians typically go home early. With flex shifts, a 6-hour shift might last 10 hours, Crane said. "We don't like it, but that was one of the strategies we implemented."

The spread of the omicron variant has again inundated EDs with patients, with some hospitals reporting jumps in patient loads of up to 200%. 2 An added complication with omicron is that it is far more transmissible, which can undermine staffing goals as physicians and allied workers are sickened.

Another question is how these changing dynamics will affect volumes of in-person care in the long term and whether patients who have opted to rely on telemedicine will continue to do so after the pandemic fades. The stock 3 for publicly traded Teladoc, billed 4 as the first and largest telemedicine company in the United States, has been up and down during the pandemic but, overall, has significantly increased in value. The company, which declined to comment for this article, is considered a bellwether in the field. The stock advisory site Motley Fool noted that enthusiasm for its publicly traded stock "cooled down significantly" 5 following reduced revenue projections in November 2021 but that the company was still included in buy recommendations. One analyst told 6 Motley Fool that Teladoc has opportunities "to disrupt so many aspects of the traditional healthcare visit model."

When asked if he expects telemedicine to play a greater role, Crane noted that ED volumes had gone up each year until 2019 but had dropped by about 1% before the pandemic hit. Reiter said he did not foresee a major shift from EDs to telemedicine.

"Some very low acuity complaints may be amenable to care via telemedicine," he said. "However, most emergency department visits are higher acuity and require a complete physical examination, diagnostic tests, patient monitoring, medications, and/or procedures that simply cannot be done via telemedicine." Envision Healthcare, a medical staffing agency that employs nearly 25,000 clinicians at 650 facilities, provided a prepared response to questions about its responses to patient surges and declines. The statement noted that Envision has "expanded and accelerated its virtual health capabilities" during the pandemic and provided almost 300,000 telemedicine visits since March 2020. Beyond that, the statement said only that Envision "will continue to offer virtual health options to patients into the future."

A spokesperson for Envision, which was bought 7 by the private investment firm KKR for almost $10 billion in 2018, also provided a white paper that noted 911 callers may now be given the option, covered by the Centers for Medicare & Medicaid Services' Emergency Triage, Treat, and Transport (ET3) program, 8 to use telemedicine rather than visit an ED. According to the report, paramedics who arrive at the scene of a 911 call follow clinical protocols that dictate transporting the patient to an ED or an alternative care destination or treating the patient in place using telemedicine (the patient retains the right to choose to go to an ED).

The paper also noted: "One of the main challenges in promoting the adoption of the ET3 model is that health systems focusing on patient volume could be disincentivized from participating. However, with the rise of advanced and alternative payment models, hospitals will receive additional incentives to eliminate preventable returns to the hospital."

Envision declined to make a spokesperson available for an interview but, in its prepared responses, noted that the company supports policy changes that would make it easier for physicians to obtain multistate licensing "to further facilitate the national matching of supply and demand"-ie, to enable the free movement of clinicians to the areas of greatest need. The company supports making permanent licensing waivers granted under the ET3 program during the pandemic and noted that the Centers for Medicare & Medicaid Services previously "had significant geographic and place-of-service restrictions on reimbursement for the clinicians delivering care via virtual health."

Envision has also cut staff hours during patient lulls, according to ProPublica, but in its prepared response, the company said it has responded to fluctuating staff needs by creating "new critical care teams" to operate in ICUs, with the capability to increase the standard physician-to-patient ratio of 1:15 to 1:30 or beyond during surges. Since the start of the pandemic, Envision reported having sent multispecialty teams of more than 500 physicians and advanced practice providers to hotspots across the country.

Moving staff to the areas of greatest need has been a common response to patient surges, raising questions about whether the practice will continue in the postpandemic era.

Though staffing companies quoted in the ProPublica article said they were not cutting physicians' hourly rates, the outlet noted that "by assigning fewer hours to doctors and other providers such as physician's assistants and nurse practitioners, the companies are effectively paying them less. It also means that some hospitals have fewer clinicians working in the ER at a time."

According to the article, Team-Health initially said it was "not instituting any reduction in pay or benefits as our emergency physicians face current challenges," but that the reality was that reducing hours represented a de facto cut in pay. A TeamHealth spokesperson told the outlet the company had reduced hours in some markets but was maintaining staffing above the current demand in anticipation of a future surge of COVID-19 patients.

Cutting hours and benefits were among the cost-cutting measures some staffing companies undertook early in the pandemic. STAT News reported 9 in April 2020 that privateequity-backed Alteon Health had cut its doctors' benefits, even as many of them worked to treat patients infected with COVID-19. The company announced it would suspend paid time off, matching contributions to employees' 401(K) retirement accounts, and discretionary bonuses, according to an email obtained by STAT. The company also said it would reduce some clinicians' hours to the minimum required to maintain health insurance coverage and that it would convert some salaried employees to hourly status for "maximum staffing flexibility." The article attributed the cuts to the forced cancellation of nonurgent medical procedures, which reduced hospitals' and private physician practices' revenue streams.

Crane, with TeamHealth, said flexible shifts are a logical response to dramatic swings in patient volumes. He noted that although most providers now have adequate stockpiles of personal protective equipment that was once in short supply, "You can't stockpile physicians. Service is perishable. That's the fundamental difference between service versus the supply side. There's no effective way to save up hours." Similar problems have developed with nursing, technician, and medical assistant staffing, he said.

Health care has been grappling with significant financial consequences, as illustrated by this analysis, 10 released by the American

Association, which projected that an average of 39% of US hospitals would operate in the red during 2021 in a best-case scenario, with median hospital operating margins down 10.5% from prepandemic baselines. Under the study's worst-case scenario, half of all hospitals, on average, would operate in the red, with median margins down 80% from prepandemic baselines. The picture was even gloomier for rural hospitals, with median margins projected to be down from 38% to 100%. The analysis noted that labor expenses were up 14% due to the costs of contract staff, hazard pay, and other expenses for maintaining a workforce.

As for the long-term planning for such fluctuations and what it might mean for health care professionals, Crane said, "Every expert has been wrong a lot during the pandemic, including me." He said that although he has "no crystal ball," he expects the virus to become endemic, with "less frequent, lower-amplitude waves," and hopes it will no longer be necessary to plan for such dramatic fluctuations in patient volumes by late 2022, though there will still be a need to address short-term variations and to prepare for a potential future pandemic.

"We have done this our whole, entire life, responding to fluctuations," he said, adding that although he does not see major systemic changes ahead, "potential countermeasures that would ultimately come out of this" could include the closer tracking of patient volumes, such as "looking at patternsthe science of predicting. If COVID hadn't reared its ugly head, we could have mapped out two years, but now there's going to have to be more planning in the future in a reactive manner."

During future fluctuations, shifts will need to be adjusted and some staff will be sent home, but overall, Crane said he expects the ups and downs to result in an overall 80% full-time staffing level.

"Let's say I'm a third-year resident, thinking of the future of emergency medicine," he said. "Year one, I can probably expect a bit more flexibility with scheduling and more tolerance for surging up or down. The practice of emergency medicine probably doesn't change that much." Likewise, he said he does not foresee "material changes in job availability."

Section editors: Truman J. Milling, Jr, MD, and Jeremy Faust, MD, MS Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist.

The views expressed in News and Perspective are those of the authors, and do not reflect the views and opinions of the American College of Emergency Physicians or the editorial board of Annals of Emergency Medicine.

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