The American Hospital Association, led by Rick Pollack, has been at the forefront of the COVID-19 battle, helping ensure the federal government provides economic support and adjust regulations for the crisis, as well as connecting sources of crucial supplies with hospitals and health systems in need. Rick has likely spoken with more hospital executives than anyone else in America during this pandemic. He took time from his incredibly busy schedule to share his observations from the field and the AHA’s efforts to support hospitals. I extend my personal thanks to Rick and the AHA for the essential work they are doing.
— Ken Kaufman
This interview was conducted April 11, 2020.
Q: What is your general assessment of the current situation with hospitals and COVID-19?
A: The spread of COVID-19 is a national emergency and has reached crisis levels in many communities. Certain areas like New York, New Jersey, New Orleans, and Detroit are considered hotspots, but the situation on the ground is quite varied, different for different regions across the country. Other areas, like Chicago for instance, anticipate becoming hotspots and are preparing, while a community like Seattle may be closer to the other side of the surge. This situation is highly variable and could change at any time depending on factors such as how successful we are at social distancing, as well as the availability of personal protective equipment.
In many respects the COVID-19 situation is likely going to make certain problems within our healthcare system worse. We knew there were challenges around behavioral health before; we're going to have new issues. Existing disparities and inequities in care will increase as vulnerable communities are being heavily impacted by the pandemic. The concern around resiliency, or clinician burnout, is another example. If we thought we had a problem there before, it's likely going to be exacerbated further. Also, the amount of preventive care being deferred will have consequences that will be significant. There will certainly be learnings for all of us as we come through this situation, but I anticipate that we will see existing challenges that have gotten bigger.
Q: Could you review the economic challenge of hospitals shutting down non-emergent procedures?
A: Like other sectors across the nation, hospitals and health systems have experienced an economic decline due to the COVID-19 pandemic. There is incredible pressure on hospitals from an economic perspective with the shutdown of regular operations because of restrictions on elective, or rather, scheduled or non-emergent procedures. To a great extent, this occurred because guidance from the American College of Surgeons (ACS) was misinterpreted by certain federal government officials. The thoughtful approach taken by ACS on how to approach situation did not say to stop all non-emergent procedures. Fortunately, we were able to work with CMS to put out guidelines on how to address this matter, and other national hospital associations have joined us to support the guidelines. CMS provided a balanced approach, suggesting tiering different types of procedures depending on clinical need leaving ultimate decisions up to physicians, patients and hospitals at the local, community level. Unfortunately, several states have layered on top of those guidelines a categorical stoppage of everything deemed elective.
In looking at how we adjust to the economic pressures of this situation, we need go back to the CMS guidelines. That would not only help our patients get the care they need, but also help address some of the economic challenges that we face
Q: What has this pandemic shown us about the healthcare supply chain and what might need to change in the future?
A: One lesson is the supply chain’s vulnerability in terms of being too dependent on any one particular country. This is literally a matter of national security. We have also learned that the stockpiles are not a reliable source in their current state. Providers are having to jump through hoops to access those stockpiles, items are then reportedly not functioning or have passed their expiration date but could still be viable. In some cases, we have worked with the government successfully to get waivers—for example, masks that still functioned but whose elastic was snapping—this could be fixed.
When we get to the after-action learning, I think the issue of the stockpile will be at the top of everybody’s list: how we handle it in the future, whether it has enough inventory, how we replenish it, and how we make sure that it’s up to date.
Q: What are some of the positive effects that could potentially come from this crisis?
A: There is no question that telehealth is going to emerge as being more useful than ever before. In addition, we’re hopeful that the regulatory relief provided through a series of waivers can remain in effect beyond the emergency period. For example, these critical tools will help ensure hospitals and health systems can provide the right treatment for patients in the right location. This includes providing care in non-traditional settings, remotely through telehealth and in appropriate outpatient facilities through easing of the Stark Law, licensure for advanced practice caregivers and other waivers to enhance flexibility for rural and critical access hospitals, as well as home healthcare just to mention a few certainly need to remain. While many of these changes were designed to give us flexibility to act in a decisive manner during an emergency, they are very necessary to reduce costs and improve care.
We have also seen hospitals and health systems provide tremendous support to their communities, partnering to meet unmet needs—helping people with meals and groceries, manning food banks, providing assistance to the homeless, coordinating with community providers to extend remote or telehealth access, providing behavioral health and wellness check-ins, and serving as a credible source of health information.
Q: Do you have any comment about the adequacy of federal government financial support to date related to the pandemic?
A: Since this pandemic began, the AHA has been sounding the alarm for policymakers and government leaders to make sure our field gets the tools and resources we need to win this war. Congress has prioritized responding to this pandemic and has passed three packages so far, with more likely to come.
The first was to provide more federal funding for vaccine development and public health. Then there was legislation focused on individuals and unemployment insurance, providing help for individuals who were vulnerable. Then there was the CARES Act. We think that the CARES Act was a good first step in addressing the situation for hospitals. It included the $100 billion relief fund, $30 billion of which was released April 10th. We continue to urge the department to release the remaining CARES Act emergency relief funds in an expedited manner and to correct for flaws in the distribution formula that resulted from using a proxy of Medicare FFS that did not account for hot spots or hospitals with high Medicaid volumes for example.
The CARES Act included other important provisions besides the relief fund. It included the suspension of the sequester, a 20% add-on for taking care of COVID patients, and accelerated payments of which, according to the last count from CMS, $51 billion has been released.
Again, these are good steps but there will need to be more. We are already working on that. We need to have more government support to address the pandemic and its effects. COVID-19 is posing perhaps one of the greatest financial challenges in the history of America's hospitals, so there will need to be a CARES 2, 3, and 4. Right now, we're focused on immediate relief in all forms. At some point that will evolve into a recovery, and then rebuilding. We're pleased that we have the government response that we've had thus far. However, there will need to be more, we're already working on the next stage.
Q: What other efforts has the AHA put into action in the face of the pandemic?
A: While we work with the administration, we are taking action on our own. We launched the 100 Million Mask Challenge, a national call to action to increase production of personal protective equipment, which is in critically short supply. Providence started this effort locally when they were in the thick of their surge and running low on PPE, and now the AHA has scaled and expanded the effort. A lot of factories that are idle can produce PPE—gloves, goggles, masks, gowns. We have been working hard to connect companies that are saying they want to help with hospitals and communities that need these supplies. In addition, we have provided an avenue for people who want to donate PPE to hospitals in need
AHA has continued to expand the scope of the 100 Million Mask Challenge to meet the growing challenges and needs of our health care workers as they take on the COVID-19 pandemic. A number of complementary partnerships have been formed to further this effort – all housed under the umbrella of the 100 Million Mask Challenge.
AHA partnered with Microsoft, UPS, Merit Solutions, Kaiser Permanente and consulting firm Kearney to create HealthEquip™. The smart app will coordinate and accelerate PPE supply efforts, matching individuals and organizations donating PPE with local hospitals and health systems in need at health-equip.com
AHA has also joined with The Creative Coalition and the Association for Healthcare Philanthropy to launch the “Protect the Heroes” campaign, which creates an avenue for the general public to make direct financial donations to protect our health care heroes, directed at the hospital or health systems of their choice at protecttheheroes.org.
Then we said, “Let's broaden the challenge.” Can we include doctors and nurses who want to volunteer to go to hotspots? We've begun working with our state hospital association partners to support efforts around the workforce shortage. Next, we are thinking about how we include people who want to provide ventilators. And we're broadening the project to include the Dynamic Ventilator Reserve, a voluntary public-private partnership led by a group of U.S. hospitals and health systems to aid in creating an inline inventory and distributing existing ventilators to high-need areas in the fight against COVID-19.
We have also been focused on cutting through regulatory red tape, and CMS has been extremely responsive in this regard. They’ve issued multiple waivers, many of which we hope will stick for the future because they allow hospitals to take quick and decisive action.
Finally, the AHA has been focused on getting timely guidance out of the “alphabet soup” or the many government agencies we must deal with…working with the CDC in terms of getting the scientific guidance that we all want to follow; with the FDA with regard to emergency-use authorizations, particularly around lab testing in hospitals; with OSHA in regard to worker protections; and with the DEA on drug shortages.
Q: Do you have any thoughts about balancing the desire to reopen the economy with the potential health issues?
A: We have to follow the science. I understand there is a difficult balance here, but at the root this began as a public health problem. We have to follow the expertise of the scientists and physicians, follow their guidance in terms of what the science tells us is the best approach and timing. The way to solve the economic problem is to snuff out the public health problem. The worst thing that can happen is if we prematurely go back to some form of “business as usual,” only to find that a reoccurrence takes us back to square one.
Q: Do you have any other comments to executives of the nation’s hospitals?
A: The American Hospital Association would like to express our incredible respect and admiration for what hospitals do every single day in protecting their communities and serving their patients. And I would like to ask the executives in your audience, on behalf of the AHA, to express our immense gratitude to the doctors, the nurses, and all the healthcare workers who are on the front lines of this battle. We know that with the right tools and resources we will get through this crisis, and we will learn from it.