Arkansas’ health care landscape, like that of the industry across the country and around the world, has been fundamentally changed by COVID-19. From small-town hospitals and rural clinics to the state’s largest and most comprehensive health systems, the people, technology and systems that keep us healthy have been tested to the core by the events of the past 12 months.
As a result, say experts, such institutions have emerged smarter, if more scarred because of it.
“Our whole operation has changed,” says Cam Patterson, chancellor of the University of Arkansas for Medical Sciences (UAMS). “You can’t enter the hospital without appreciating that we have had to change our way of doing business. No. 1 has been the work we have had to do to keep our health care workers safe while they’re providing care. I would say that’s absolutely our No. 1. No. 2, right behind that, is we’ve had to rapidly develop expertise in a disease we’ve never seen before.
“Frankly, if COVID went away today, and tomorrow there was never another COVID-19 patient and we never saw one in the hospital again, the damage due to this pandemic would still continue for decades. The severity with which health care systems have been impacted and the immense damage that has happened to our ability to provide care is going to reverberate for a long time.”
In the July article, “COVID-19 — Implications for the Health Care System,” the New England Journal of Medicine (NEJM) underlined the continuing market pressure and operational inadequacies of the nation’s health care system. As well, the article highlighted how COVID-19 showed the many disconnects between health systems and government, which handcuffed response and added to the difficulty in dealing with the disease.
The piece called for reform in four specific areas — undermined health insurance coverage, financial loss for providers, racial and ethnic disparities in health care and a flawed public health system — considered the leading existential challenges to what the health care industry does and how they do it.
“The novel coronavirus pandemic has spawned four intertwined health care crises that reveal and compound deep underlying problems in the health care system of the United States,” wrote the authors. “In so doing, however, the pandemic points the way toward reforms that could improve our ability not only to cope with likely future epidemics but also to serve the basic health care needs of Americans.”
“YOU DIDN’T KNOW WHAT YOU DIDN’T KNOW”
This summer marks the 40th anniversary of the dawning of the AIDS epidemic, when the U.S. Centers for Disease Control and Prevention (CDC) reported on unusual clusters of Pneumocystis pneumonia in its Morbidity and Mortality Weekly Report newsletter. It was the last time physicians faced a health crisis of such scale and grave consequences of which they knew so little. Until COVID-19.
“With HIV, there was no cure, no treatment. In a lot of ways, COVID-19 is like that, but compressed from a decade down to a couple of months,” Patterson says. “The difference between HIV and COVID, in my mind, putting medical issues aside, is the difference in the societal and political response. There were some political overtones for HIV; Ronald Reagan was criticized for not mentioning the disease. But at the end of the day, whether you’re a Democrat or a Republican didn’t determine whether you wore a condom or not.
“That’s not the case now. Just seeing social discourse driving maladaptive behaviors has been one of the most difficult aspects of my career. There’s never been a situation in my life where there’s been as much bad information around a health care problem as has occurred here. Frankly, we’ve had public voices to adjudicate some of that.”
Misinformation about COVID-19 emanated from a number of angles, not just Capitol Hill. Health care administrators said some of the stiffest challenges in combating the disease early on came from a lack of understanding within the medical community itself.
“Unfortunately, with this virus, you didn’t know what you didn’t know,” says LaDonna Johnston, vice president of patient services with Unity Health in Searcy and the group’s Newport hospital administrator. “The one thing we come back to all the time was ventilators. Initially, it was, ‘You’ve got to have ventilators. Get ventilators. As soon as you know they’ve got COVID, put them on the vent! Put them on the vent!’ And then we learned, ‘Patients don’t tend to do well. Don’t put them on the vent! Don’t put them on the vent!’
“We learned a lot by watching the northern states, and we tried to follow suit, but we just learned things as we went along. What we initially thought would help didn’t and we had to be agile. We had to make some changes. I think [the state and CDC] were trying to communicate with us, but they did not know what to tell us to do.”
Dealing with the scenario gave smaller organizations such as Unity a foxhole mentality in relation to the virus. While there was no shortage of communication going on, health care teams quickly wised up to the fact that reinforcements would be slow in coming.
“For small, rural hospitals out there in states like Arkansas, there was the realization that you’ve got to do this yourself,” Johnston says. “You can’t wait for UPS to drive by and drop off N95s, you can’t wait for FedEx to bring you vaccines. The state’s not doing that for you, the government’s not doing that for you, the magic fairy isn’t going to show up to do that for you.
“We learned quickly that you couldn’t count on typical resources to help you. The agility of [Unity’s] leadership to recognize that and then to perform at that level guided us through last year. Our leaders stepped up and they did not take no for an answer. They just kept bird-dogging until we got what we had to have to not only take care of patients in our community but also take care of our associates and ensure they were safe.”
THROUGH THE MIND’S EYE
The mental health challenges presented by COVID-19 last year were also substantial. Not only did clinics and behavioral hospitals have to implement the same medical precautions as other health care organizations but also consider the pandemic’s impact on their patients’ mental treatment (or lack thereof).
“Our parent company, Universal Health Services, conducted a national survey in Spring 2020 to assess and quantify Americans’ views and perceptions on mental health amidst COVID-19,” says Bruce Trimble, director of business development for The Bridgeway. “The survey revealed one in four people were unclear what action to take if they had a mental health crisis. Fear of virus exposure was the key barrier to mental health treatment during this time, followed by the cost of copay and negative perception of telehealth.”
Trimble says the impact of these considerations was a mixed bag. Some populations showed a marked decrease in the number of people seeking help while other demographics turned out in greater numbers than before.
“Initially, the pandemic precluded some people from seeking help, primarily in the elderly population,” he says. “We experienced a decrease in referrals from nursing homes and assisted living centers and based upon these trends, we suspended our senior care program operations.
“At the same time, we saw an increase in adults with substance use disorders and in June expanded our substance abuse continuum of care by adding an acute rehabilitation program. We now have medical detoxification, partial hospitalization and intensive outpatient programs for substance use disorders.”
In response to patient concerns, the mental health care community began to lean heavily on technology to maintain contact and continue treatment. Trimble says while these tools were relatively easy to implement, the learning curve for patients proved challenging.
“We launched telehealth for partial hospitalization and intensive outpatient programs rather quickly and we adapted it for our mobile assessment team in April. However, we found that many people were unaware of telehealth and the app we use, Zoom,” he says.
“We were talking with people in a mental health crisis and trying to educate them on how to download and use new technology, which was challenging. In response, we developed some downloadable tools that are available on our website.”
This system is expected to remain in place for many in the mental health field, Trimble says, even if it isn’t the preferred methodology for treatment in all cases.
“Now that health care providers have worked with this platform, I expect to see more mental health providers adapt to this technology,” he says. “While telehealth has proven to be a useful tool, I believe most people prefer face-to-face interaction with health care professionals. I think this is especially true in mental health where non-verbal communication is so vital.”
THE POLITICS OF HEALTH CARE
No discussion about the saga of the COVID-19 response can be held without talking about the social and political climate in which it unfolded. Health care workers may have been portrayed as the life-and-death heroes they are, but the institutions where they performed yeoman’s work are still on shaky ground, especially in the state’s rural areas.
It’s a cruel irony for health care systems like Unity, which performed admirably in the heat of battle only to face the same pre-pandemic financial uncertainties due to reduced reimbursements and escalating costs.
“There are 26 hospitals in Arkansas that are open because they’re getting funding either from the county or city level, and there are 18 hospitals in Arkansas that were on the verge of closing before COVID hit,” says Steven Webb, Unity Health’s president and CEO. “Supply costs have gone through the roof as we try to just get the basic supplies of gloves and gowns and masks. Some things have gone up 800 percent in cost. Drugs have gone up.
“Staffing urban hospitals has been very competitive, and that’s made it a real challenge in rural hospitals across the state and across the country. It’s a competitive market a lot of rural hospitals don’t have the financial ability to compete with. Unfortunately, I think it puts more pressure on rural hospitals, and I think it will have a negative impact on our rural facilities across the state.”
Health care systems are also under scrutiny for the manner in which they provide health care to all segments of the community. Such issues are top of mind for Patterson, who says equitable access, treatment and mitigation efforts such as vaccine distribution are paramount to ethical medicine.
“You can’t have health care without having equity. When inequity exists, health care, by definition, doesn’t exist,” he says. “The vaccine is going to be our test of the application of equity, and it’s going to be a challenge for several reasons. One is simply for practical reasons; it’s much easier to vaccinate in one clinic, 1,000 people a day in Little Rock, than it is if you are in Mena. It’s just because of density.
“To the extent that the faster we get more people vaccinated, the quicker this will abate, there’s going to be the temptation to say, ‘That is what we should do first and then, we should go to less-densely populated areas that are going to take us longer, on a per-person basis, to vaccinate.’ We have to be practical, but we have to resist the temptation to overlook areas that are in need, merely based on size.”
It’s not just Arkansas that is struggling with equitable access, particularly in communities of color, as the July NEJM report highlighted.
“Black persons constitute 13 percent of the U.S. population but account for 20 percent of COVID-19 cases and more than 22 percent of COVID-19 deaths, as of July 22, 2020,” the report noted. “Hispanic persons, at 18 percent of the population, account for almost 33 percent of new cases nationwide. Nearly 20 percent of U.S. counties are disproportionately Black, and these counties have accounted for more than half of COVID-19 cases and almost 60 percent of COVID-19 deaths nationally.”
Patterson says, “We have to understand that there are communities across our state, especially African American, Latino and, in Northwest Arkansas, the Marshallese population, that are particularly vulnerable to COVID-19 and more likely to have consequences from COVID-19,” Patterson says. “We’ve got to do the work — and it’s extra work, sometimes, but it’s good work — to make sure that those communities are not forgotten when it comes time to roll up somebody’s shirt sleeve and put a shot in their arm.”
SAME SONG, SECOND VERSE?
Experts say the wider, ongoing impacts of the COVID-19 experience are substantial, from spurring telehealth to attracting more people into the medical field. They also say society at large has changed irreversibly, citing things such as working from home, wearing masks and calling in sick when it is warranted.
But in other areas, the lessons of 2020 are already starting to fall by the wayside. Buoyed by the introduction of vaccines and emboldened by a general desire to get back to life as it once was, the general public has begun demonstrating disturbing trends in behavior, say medical professionals.
“There is some pandemic fatigue that’s going on as we round the corner on our one-year anniversary,” says Dr. Roddy Lochala, Unity Health’s chief medical officer. “People are tired, they’re weary and they may see the cases and hospitalizations have gone down. But the numbers could just as easily go back up; there is concern about the different strains and their higher rates of transmission. We still have finite resources in things like ventilators, not just in our hospital system, but throughout the state.
“We’ve seen the horrific toll that COVID-19 can take, and we continue to take it very seriously. Members of our hospital system have been vaccinated with two shots and we’re still following all the rules, just as if we had never had the shot. We’re not letting our guard down here, and we hope the community continues to stay vigilant and helps increase these vaccination numbers and decrease our hospitalizations.”
“It’s lessons learned,” adds Johnston. “There will be another event. Now, will it be in five years? Will it be in 20 years? I don’t think, in this country, we know what’s ahead of us. We all need to be very mindful that this could happen next year, and it could be another virus. It could be another disease that comes across this country.
“This isn’t going to be the last pandemic. If this country thinks it is, we’re sadly mistaken.”