Last year brought its share of challenges. Finding solutions is the hard work awaiting everyone in the healthcare community this year

2023: Time for Solutions

Last year brought its share of challenges. Finding solutions is the hard work awaiting everyone in the healthcare community this year.

2022 presented all kinds of challenges

for providers, patients and public health professionals. No doubt many of those challenges will linger in 2023, and new ones will arise. However, researchers, providers, public health professionals, lawmakers – and medical sales professionals – can be expected to keep working through the tough issues facing them. In part one of a two-part series, Repertoire examines the following issues: ʯ Respiratory season ʯ Monkeypox ʯ Retail clinics ʯ Inflation ʯ Workforce issues

Respiratory season: In like a lion

Predictions of a tumultuous respiratory season –

fueled by COVID-19, influenza and respiratory syncytial virus – appeared to be coming true at year’s end. Will any of the public-health-related measures society learned during the pandemic ease the damage?

In November, the Centers for Disease Control and Prevention reported that early increases in seasonal influenza activity were continuing nationwide, with the Southeast and South-Central areas of the country hardest hit. The agency estimated that as of Nov. 1, influenza accounted for 1.6 million illnesses, 13,000 hospitalizations and 7,300 deaths (including two pediatric deaths), and the cumulative hospitalization rate was higher than the rate observed in week 43 during every previous season since 2010-2011.

In addition to elevated levels of flu, CDC was tracking rises in respiratory syncytial virus (RSV), Rhino viruses and animal viruses. Children’s hospitals were overflowing with RSV patients.

Long COVID

Although the incidence of COVID-19 had abated by late 2022, the healthcare community still faced a challenging after-effect – Long COVID. Between 7.7 million and 23 million people in the United States could have Long COVID, whose symptoms can linger for weeks, months and even years, according to U.S. government estimates.

The most reported symptoms include fatigue, symptoms that worsen after physical or mental effort, fever, and lung (respiratory) symptoms, including difficulty breathing or shortness of breath and cough.

People who had suffered severe illness with COVID19 were more likely to experience organ damage affecting the heart, kidneys, skin and brain. Abnormalities of the thyroid joined the ever-growing list of side effects attributed to Long COVID, according to research presented at the American Thyroid Association 2022 Annual Meeting in October. Inflammation and problems with the immune system were also said to occur. Effects such as these could lead to the development of new conditions, such as diabetes or a heart or nervous system condition, according to Mayo Clinic.

At year’s end, researchers were still questioning whether Long COVID is a new syndrome and unique to COVID-19. That’s because some symptoms are similar to those caused by chronic fatigue syndrome and other chronic illnesses that develop after infections. Despite the questions, however, the healthcare community continued to learn more about Long COVID, how to treat it, and even how to prevent it.

For example, in November, the U.S. Department of Veterans Affairs released a study showing the medication Paxlovid can reduce the risk of symptoms of Long COVID. The study, which included more than 56,000 veterans with a positive SARS-CoV-2 test, showed that those given the oral antiviral medication in the first five days of a COVID-19 infection had a 25% decreased risk of developing 10 of 12 different Long COVID conditions studied, including heart disease, blood disorders, fatigue, liver disease, kidney disease, muscle pain, neurocognitive impairment and shortness of breath.

Monkeypox: Lessons learned about ‘stigma’ disease

Retail clinics: Nonstop

Monkeypox cases were declining by year’s end, but some observers believe progress could have been swifter.

In the U.S., about 27,635 cases were reported in late October, about 85% down from the peak at the outbreak, reported Demetre Daskalakis, MD, White House National Monkeypox Response deputy coordinator. However, he added, “the outbreak is really concentrated in communities of color, specifically among Black individuals.”

The CDC reported on a clinical consultation for 57 hospitalized patients with severe manifestations of monkeypox, most of whom were Black men with AIDS. Delays had been observed in initiation of monkeypoxdirected therapies. Twelve patients died, and monkeypox was a cause of death or contributing factor in five patients to date, with several other deaths still under investigation.

As a result, CDC advised clinicians to consider early treatment with available therapeutics for those at risk for severe monkeypox disease, particularly patients with AIDS. Engaging all persons with HIV in care remains a critical public health priority.

According to one U.S. epidemiologist, the monkeypox experience demonstrated that the world has made little progress since the 1980s AIDS epidemic. “As with the AIDS epidemic, sluggish responses from governments and international institutions, plus outright homophobia and bureaucratic bumbling, have hampered efforts to contain the outbreak,” wrote Gregg Gonsalves, an epidemiologist at the Yale School of Public Health in New Haven, Connecticut, in a commentary in Nature. “Very often, humanity has the ability to prevent and treat infectious disease; not doing so is a political choice.”

That said, public health officials around the world were applying lessons learned from the AIDS epidemic to monkeypox. “Local staff in the most affected states [in Nigeria] have reported that stigma, connected with commentary from across the world blaming gay people for monkeypox, is discouraging some people from seeking care,” said Dr. Leo Zekeng, UNAIDS Country Director and Representative in Nigeria in August. “State Health officials are working to ensure that staff at health clinics are sensitized to break down such stigma, and not to reinforce it. State Ministry of Health officials are also embarking on community sensitization on monkeypox, emphasizing identification of symptoms, prevention and the need to get tested.”

In September, the U.S. FDA made a significant step forward in early detection of monkeypox by authorizing emergency use of in vitro diagnostics for the detection or diagnosis of monkeypox. These diagnostics may detect the monkeypox virus specifically or more generally detect non-variola orthopoxviruses, which include monkeypox virus.

Repertoire readers know that traditional retailers (e.g.,

Walgreens, CVS Health, Walmart) and some non-traditional ones (e.g., Amazon) have been busy setting up bricks-and-mortar primary care clinics around the country. Expect that trend to continue in 2023.

In November, research and consulting firm Forrester predicted that retail health clinics will double their share of the primary care market. Sixteen years ago, there were 29 retail health clinics; now, there are more than 3,000. From 2019 to 2020, such clinics experienced growth of 21.5%, fueled initially by the need for local, convenient COVID-19 testing sites and sustained by their ability to provide accessible care without appointments. Just five days after Forrester published its report, VillageMD announced its intention to acquire Summit Health-CityMD, giving the combined company more than 680 provider locations in 26 states.

Retail health clinics will double their share of the primary care market in 2023, fueled by patient demand and additional retail companies looking to join the ranks, predicted Forrester. As retail health clinics grow in primary care, the demand for health systems to step up their patient experience game can be expected to increase.

Inflation: The unwelcome guest

Inflation maintained a stubborn presence in 2022.

At press time, the outlook for 2023 looked only slightly less ominous.

For healthcare providers, inflation couldn’t have come at a worse time. Forrester predicted that the economic downturn and consumer behavior could cause hospital bankruptcies to spike by a third. “Inflation, the nurse staffing crisis, labor cost hikes, supply chain disruption, and sourcing shortages are breaking the banks of U.S. hospitals and shutting their doors,” the firm reported. “Over the next 12 months, hospitals that averted financial crisis due to the Fed’s contingency provisions, state-based funding sources, and lender-granted waivers and extensions will succumb to a lack of cash flow.”

Hospital and health system expenses were expected to increase by nearly $135 billion in 2023, driven by a projected $86 billion increase in labor expenses. Backlogs for surgery, imaging and diagnostic services could prevent hospitals from recovering a $20 billion loss of revenue, spurred by the shutdown of elective procedures from March to May 2020. Chapter 11 bankruptcy filings for large healthcare organizations in 2022 were 28% higher than 2021. By the end of 2022 more than 30% of all rural hospitals were expected to be at immediate risk of closure due to low financial reserves or reliance on government aid.

Workforce issues: A stubborn problem

Concerns about the shortage of healthcare workers

and about burnout among those still on the job were expected to linger in 2023 and perhaps beyond.

The percentage of physicians reporting burnout rose from 61% in 2021 to 65% in 2022, according to a survey by Jackson Physician Search and the Medical Group Management Association. When asked to gauge how much their burnout levels changed from 2021 to 2022, 35% of physicians reported a significant increase and 40% reported burnout had increased somewhat. Half of physicians reported considering leaving their practice for a different job in healthcare.

For the long-term-service sector, the workforce situation was even more dire. Nearly 342,000 jobs in the sector were lost from February to December 2020, a 5% decline, according to the U.S. Bureau of Labor Statistics. Jobs in nursing homes declined by 9%, followed by declines in residential care (7%) and home care settings (3%).

Nursing shortages were well-publicized in 2022 and will probably linger in 2023. In April 2022, researchers reported in Health Affairs that the total supply of RNs decreased by more than 100,000 from 2020 to 2021 – the largest drop observed over the prior four decades. A significant number of nurses leaving the workforce were under the age of 35, and most were employed in hospitals.

The shortage of registered nurses was expected to intensify as Baby Boomers age and the need for healthcare grows, reported the American Association of Colleges of Nursing. Meanwhile, nursing schools across the country were struggling to expand capacity to meet the rising demand.

Creative solutions

By year’s end, some providers had already found ways to creatively address the nursing shortage. In Danville, Pennsylvania, for example, Geisinger Health implemented an internal traveling nurse program to offer nurses higher payment rates for traveling within the organization, which comprises nine hospitals, reported HealthLeaders Media. Geisinger also opened its staffing model for flex and per diem nurse roles and is offering recruitment loans to new graduates and retention bonuses to nurses. And instead of conducting exit interviews when people leave, Geisinger was conducting “stay interviews” to help administrators understand what would encourage people to continue working for the system.

The American Hospital Association Center for Health Innovation recommended five ways providers could address staffing issues: ʯ Customize retention strategies. While all nurses seek recognition and compensation for their efforts, many put a premium on flexible scheduling, breaks to recharge, strong management support and open lines of communication, input into decision-making, accessibility to mental health and well-being resources, or help with child or eldercare. Meanwhile, physicians seek increased pay, additional time off, reduced on-call, and paid sabbaticals.

ʯ Fully exercise the skills of advanced practice nurses.

Nationwide, more effective use of nurse practitioners and physician assistants could help alleviate the primary care physician shortage, said AHA. Licensed NPs took on greater responsibility during the pandemic, and their role was expected to continue to grow along with value-based care models in 2023, per McKinsey &

Company. Their ranks also are expanding, increasing 12% in the last year to a record 325,000-plus.

Perhaps it’s no surprise that interest in unionizing has increased, given the rising number of physicians now employed by large healthcare systems.

ʯ Become a destination for millennials and Gen Zs.

As workforce shortages continue, new clinicians can be more selective about where they work. Providers should allow staff to tailor their schedules and create career pathways.

ʯ Integrate workforce planning with strategic plan-

ning. Healthcare providers should strive to create an environment that supports the team through change. As skill sets and capabilities shift, employers can develop strategies to reskill the workforce and strengthen the talent pipeline with new professional development pathways. ʯ Create your own solutions. Some hospitals and health systems are building their own internal supply of clinicians who can be reassigned temporarily during peak need periods. Chicago-based Common-

Spirit Health, for example, found that by creating an internal staffing agency gives, nurses gained more flexibility while remaining in the organization and maintaining seniority.

Union shops

As concerns about workforce shortages grew in the past year, so did interest in unionizing among healthcare workers. Among physicians, perhaps it’s no surprise, given the rising number who are now employed by large healthcare systems. Medical residents might be moving in the same direction.

Ten years ago, in 2012, 60% of physician practices in the U.S. were physician-owned, 23.4% of practices had some hospital ownership, and only 5.6% of physicians were direct hospital employees, according to researchers in a July 2022 JAMA Network article. By 2022 the percentage of physicians employed by hospitals or health systems reached 52.1% and 21.8% by other corporate entities, for an estimated 74% of practicing physicians.

“This rapid transformation has largely followed an aggressive strategy, put forward by hospital and corporate leadership, that seeks scale and exploits market power,” the researchers wrote. “However, it is also a strategy that is increasingly at odds with the interests of the physicians working in these organizations. ... These differences suggest the potential for growing challenges for U.S. medicine.”

Among medical residents, union-organizing attempts were also on the rise, with recent drives at Stanford, the University of Southern California and the University of Vermont. As of mid-2022, roughly 15% of U.S. house staff in more than 60 hospitals were represented by the Committee of Interns and Residents (CIR), which is part of the Service Employees International Union. A smaller portion of residents have created their own local unions or joined one for medical and dental providers, such as the Union of American Physicians and Dentists.

Residents’ reasons for organizing often focus on pay and working conditions. At the University of Washington, for example, the Resident and Fellow Physician UnionNorthwest (RFPU) won pregnant residents the right to reject 24-hour shifts. At the University of Miami Leonard M. Miller School of Medicine, CIR negotiated additional pay and better planning for the extra demands residents face when hurricanes hit.

Unionization is not a slam-dunk decision for providers, however. Some residents worry that it could undermine patients’ and communities’ trust in them. Meanwhile, executives in teaching institutions worry that a collective contractual agreement could limit flexibility in graduate medical education.