For months, hospitals large and small have sounded the alarm on a labor crisis that is threatening their ability to maintain care services and jeopardizes their longer-term financial stability.
Nationwide hospital employment has dropped by nearly 94,000 people since February 2020, with about 8,000 of those workers disappearing from August to September of this year, according to the Bureau of Labor Statistics.
Unit turnover has increased from 18% prior to the pandemic to 30%, while overtime pay and the cost of contract workers will likely cost hospitals an extra $24 billion for clinical labor in 2021, according to a recent Premier Inc. analysis.
“For every healthcare leader, every hospital CEO, this is the most important question we are dealing with,” David Zaas, M.D., CEO of MUSC Health-Charleston Division and chief clinical officer of MUSC Health, said during a virtual policy briefing hosted by the American Hospital Association on Tuesday. “We’ve seen the toll. We’ve seen the fatigue. We’ve seen the challenges that it’s taken at work and at home as COVID has impacted our communities.”
As workers either leave the field or depart for higher-paying positions, smaller hospitals are placed in the difficult position of competing with well-funded systems for a limited pool of skilled employees.
“What used to keep me up at night was when I lost a nurse … or I lost a professional to an urban center. There wasn’t really a whole lot I could do,” said Leonard Hernandez, CEO and president of the Susan B. Allen Memorial Hospital, a rural 48-bed facility outside of Wichita, Kansas. “Now I’m losing them to hospitals all over. I’m losing them to critical access hospitals because they’re able to pay more than we are, and obviously [to] the urban hospitals and the contract labor.”
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The situation for front-line workers themselves has also shifted since the early days of the pandemic, noted Advocate Aurora Health Chief Nursing Officer Mary Beth Kingston. Roughly 18 months of extra hours and tense—or even violent—encounters with patients and families over COVID-19 interventions such as masking and visiting restrictions has clinicians worn down to the bone.
“The public support is not as visible and our healthcare workers feel that. The increased divisiveness we see in society we’re also seeing in healthcare,” Kingston said.
The workforce shortages have spilled out beyond the clinical staff and into additional roles such as patient transporters, technicians and nutrition services specialists, Zaas warned. So too has the stress, said Hernandez, who recounted a conversation he had earlier that morning with a clerical worker on the verge of tears.
“What happened? How come we went from being healthcare heroes to now, to the point where nobody really cares anymore?’ They just want to know why we can’t do our job better, why we can’t hire more people, why we can’t take care of the things we used to do pre-COVID?” the worker told Hernandez.
With labor shortages and COVID-19 curveballs unlikely to vanish anytime soon, hospital leaders and legislators alike have “an obligation” to support more programs and policies to bolster the resiliency of their workforces, the executives said.
Compensation may be the immediate focus for many, but bonuses and similar payments are more of a short-term response that does nothing to address the broader workforce supply shortage, they said.
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A more effective strategy is to consider the work environment itself and to tackle any barriers that are complicating healthcare workers’ home lives or preventing them from achieving personal fulfilment during their day-to-day care, the group said. By and large, that means that hospitals need to offer their employees more flexibility with scheduling hours and working remotely, offering more peer support and wellness training or taking a more active role in family benefits such as childcare.
“A high percentage of our individuals in the labor force have children and the whole childcare issue is an essential one,” Kingston said. “We implemented a childcare stipend, whether it was children not being able to go to school or being home for quarantine. This ended up being a very real issue for our workforce.”
Lawmakers hold the keys to faster relief funds, additional training
Most of these workforce resiliency efforts require funds that are increasingly hard to come by. Kingston and Zaas stressed that the new pharmaceutics, personal protective equipment, screening procedures and vaccination programs hospitals have taken on during the past 18 months have placed many organizations in a tight spot financially—and that’s not to mention the slimmer margins and dwindling elective care hospitals are bracing for in the months and years to come.
“Our financial challenges, our labor challenges that we’re talking about are going to last significantly longer [than COVID-19]", Zaas said.
Here, the executives looked back to the uncertainty of 2020, when worker furloughs and service closures led lawmakers to route an unprecedented amount of relief funds to hospitals that Hernandez called “the most influential thing that Congress ever did” for the industry.
The executives said the government is again in a position to offer struggling hospitals a much-needed lifeline. First and foremost, about $25 billion of those relief funds have yet to be handed out to rural hospitals and those whose revenues are still being hammered by COVID-19.
“They talked about it for a week and two weeks later the funds were in hospitals’ accounts,” said Hernandez, whose hospital was pulling on its allotment up through August. “So when you talk about the $25 billion that’s still out there, still available, I don’t see any reason why that shouldn’t be pushed out.”
For smaller hospitals like his, Hernandez said that legislators could revive early pandemic discussions over relaxing or waiving the criteria to qualify as a Critical Access Hospital or similar designations that could “level the playing field” when it comes to reimbursement and, resultingly, hiring on high-cost workers.
But with time being of the essence, he continued, lawmakers should also be discussing whether hospitals would be better off keeping the billions of dollars that have already been distributed through the Centers for Medicare & Medicaid Services’ (CMS') Accelerated and Advance Payment Program.
“In my opinion, the biggest thing that the legislation could do would be to convince CMS to forgive the advanced payments,” he said. “Those funds are already in hospitals, they’re sitting there in accounts waiting to be repaid back over the next two years and they can’t be used for anything else.
“CMS is not going to close if they do not get those funds back—but hospitals could," Hernandez said.
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Outside of relief funds and reimbursement, the executives said that the government could address both clinical and nonclinical workforce supply issues by increasing its support for education programs.
Kingston called for the federal government to direct greater financial support for community colleges, universities and other institutions with nursing or clinical education programs, “particularly in the area of faculty expansion.” Similarly, student loan forgiveness from employers and the government alike could help more trainees and new employees from seeking out other opportunities, she said.
“Training was interrupted for many students and we’re seeing a higher number of nurses leave within their first year,” Kingston said. “Tens of thousands of qualified applicants are being turned away from nursing programs every year due to faculty shortages and lack of clinical sites. I think creating incentives to teach, grants for students, promoting sim[ulation] centers—these are some of the things where the federal and state governments can focus their efforts.”
Alongside legislation like the Dr. Lorna Breen Health Care Provider Protection Act, which aims to reduce burnout, suicide and other behavioral health conditions among healthcare workers, Zaas called for broader support of education and recruitment-focused congressional efforts such as the Resident Physician Shortage Reduction Act and the Ways and Means Committee’s Pathway to Practice Training Programs (PDF).
The Resident Physician Shortage Act stands to add 14,000 new Graduate Medical Education slots, making up for the mere 1,000 that have been added since 1996 despite continual growth in the U.S. population and healthcare system, Zaas said.
The Pathway to Practice Training Programs legislation would be a “complementary” program that awards medical school scholarships to minorities and others living in medically underserved, rural or health professional shortage areas, who then go ahead to complete their residency and practice in those same regions.
“We recognize that the shortage of physicians, the shortage of trainees exacerbates our health disparities,” Zaas said. “It disproportionally impacts our rural and underserved areas where we struggle to recruit physicians in the setting of the shortage. … [Pathway to Practice Training Programs are] really ensuring our physician workforce of the future reflects our communities.”