Virus Tsunami Could Swamp Alabama’s Health Care, Particularly In Rural Areas

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Nurse at UAB Hospital wears personal protective equipment. Hospitals already are running short on protective equipment because of the demands of the coronavirus epidemic.

The University of Alabama at Birmingham

By Sam Prickett

The COVID-19 pandemic hasn’t hit its peak in Alabama yet, and when it does, it could be a major disaster for the state’s health care infrastructure, according to Dr. Donald Williamson.

“I’m seeing this whole thing as a tsunami,” he said. “Right now, for most of the state, we’re in that pre-tsunami period where the water is actually being pulled out to sea and everything looks quiet. I think you’re already beginning to see the tip of the tsunami in Birmingham and other places, and I think the tsunami will over the next several weeks and months wash over the state, causing great devastation to our health care system.”

As president and CEO of the Alabama Hospital Association, Williamson has watched Alabama’s medical infrastructure deteriorate over the past 10 years.

Seventeen privately run hospitals have closed in Alabama since 2010, with only one of those reopening. Of those, seven have been located in rural areas; Pickens County Medical Center in Carrollton, which closed earlier this month, is the most recent Alabama hospital to shutter its doors.

Many of the state’s remaining hospitals are struggling with financial problems as well, which Williamson said leaves the state in a vulnerable position as COVID-19 continues to spread and demand for hospital beds, ventilators and personal protective equipment dramatically increases.

“In terms of preparedness, we are challenged in some ways by the fragile financial condition of many of our hospitals, especially our rural hospitals, 88% of which have negative operating margins,” said Williamson, who also was Alabama’s state health officer for 23 years. “In that environment, spending money for an anticipated disaster gets to be very, very problematic.”

“Just to Keep the Doors Open”

The struggle of rural hospitals isn’t unique to Alabama. Nationally, the percentage of rural hospitals operating in the red has increased from 39% to 47% since 2015, according to a study from the Chartis Center for Rural Health, a Chicago-based health care analytics firm.

According to that study, 120 rural hospitals have closed across the United States since 2010, with states in the Southeast and lower Great Plains being most affected. The states with the highest number of rural hospital closures nationwide are among the 14 states that have not adopted the Affordable Care Act’s Medicaid expansion, which went into effect in 2014.

Alabama is among those states that has had the most rural hospital closures, with six. Also in the group are Texas (20), Tennessee (12), Oklahoma (7), Georgia (7) and Missouri (6).

“The closure crisis has affected rural hospitals located in non-Medicaid expansion states much more so than in states that have expanded Medicaid,” the study reads. “Our analysis shows that hospitals located in states that have not adopted Medicaid expansion have lower median operating margin(s) and have a higher percentage of rural hospitals operating with a negative operating margin.”

That correlation isn’t a coincidence, Williamson suggests.

“If in fact we did not have 16% to 20% of our adult population uninsured, then we would be in a much better financial situation for our rural hospitals,” he said. “As a result, we wouldn’t be as stressed on a day-to-day basis just to keep the doors open and make payroll.”

Williamson said that Medicaid expansion “may be essential to reconstructing our health care infrastructure” after the coronavirus crisis abates. But he said that now many Alabamians have the more immediate, pressing need for health care at all.

“Clearly for the hospitals that have closed, you’ve removed the resource from the affected community, so that patients who may present with COVID-like illnesses, instead of being able to go to their local hospital, maybe 5 miles away or 10 minutes away, now find themselves having to drive 30 minutes or 45 minutes for the same care,” he said. “That increases the burden on other hospitals in a way that maybe wouldn’t have existed if those rural hospitals were still operational.”

Of Alabama’s 67 counties, 36 have only one hospital, according to the Alabama Hospital Association’s website. Seven counties — Cleburne, Coosa, Henry, Lamar, Lowndes, Perry and Pickens — have no hospitals at all. In the 2010 census, those counties recorded a combined population of just more than 100,000 people.

Many of those hospitals also are afflicted by the same financial hardships that caused others to close.

“Even for surviving hospitals, because of the very severe financial conditions that many of them face, they are challenged with their ability to go out and purchase extra ventilators, to stockpile as much PPE as they might like,” he said. “Of course, that’s compounded by recent and very appropriate decisions to suspend elective surgical procedures, further putting serious financial strain on the hospitals in some cases. Now, those are the right things to do relative to conserving PPE and creating a surge capacity in the hospitals, but nonetheless they do have financial implications.”

Williamson isn’t alone in his worried prognosis of Alabama’s health care infrastructure. Dr. Jeanne Marrazzo, the director of UAB’s division of infectious diseases, told reporters on March 16 that Alabama’s trend of closing rural hospitals could have serious impacts on urban hospitals such as UAB.

“We well know that many rural hospitals have been closing, right?” Marrazzo said. “We’ve been losing a lot of our smaller hospitals. Even those that have remained open may not have a deep staff to take care of critically ill patients. That’s when things do get frightening, and you need to think about expanding your capacity at a place like UAB or a central place. We have contingency plans that we have been discussing … But I want to reassure people, we’re definitely not there. And we will be keeping very close, close track of this and updating you all as it comes on.”

“About the Worst Possible Thing I Can Imagine”

What would it look like if the demand generated by COVID-19 overwhelmed Alabama’s hospitals? A worst-case scenario, Marrazzo said, might look similar to Italy’s response.

“In Italy, they don’t have enough,” Marrazzo said. “They are actually having to make decisions about taking people they believe are not going to survive off ventilators to reassign them to people (who will survive). We do not want to be placed in that excruciating situation. It’s about the worst possible thing I can imagine as a physician, talking to a family about that or dealing with that. I don’t believe there’s any indication we’re going to get there. But again, my assurance is all based on my belief that we can deflect this curve and not be where Italy is right now.”

So far, Gov. Kay Ivey has addressed the potential strain on hospitals by “cutting red tape” for the health care workforce, reducing the degree of supervision required for some health care professionals to practice medicine and allowing out-of-state licensees to practice in the state. Ivey also directed the State Health and Planning Development Agency to loosen its rules to allow temporary expansion of existing health care facilities.

The state currently has an estimated 15,000 hospital beds, though those are unevenly distributed among urban and rural areas. Of those beds, roughly 75% are typically occupied on a normal day, leaving 3,750 hospital beds across the state available to handle the surge of patients caused by the coronavirus.

Whether that will be enough is hard to predict, Williamson said.

“I’ve been working on modeling the epidemic, and there are a couple of challenges here that make projecting readiness very, very difficult,” he said. “The first of those is, what is the attack rate going to be? What percentage of our population is going to acquire infection? The models are all over the place.”

Wuhan, China, where the virus originated, had an attack rate of 7.4%; New York, meanwhile, has a projected attack rate of 10%. “And when you start looking at some of the models being developed by people working for the World Health Organization, you can see estimates of attack rates of 20%, conservatively, to 60% at the high end,” Williamson said.

In Alabama, that’s a difference between 370,000 people and 3 million. If 20% of those patients need hospitalization, which Williamson said is the average percentage, that becomes a range of 75,000 hospital beds to 621,000 hospital beds need over the course of the epidemic.

“This is the best example of why social distancing is so important to flatten the epidemic curve,” Williamson said. “If you have an epidemic of the same size occurring over a period of two weeks, three weeks, then you simply can’t have enough hospital beds to deal with that. If, on the other hand, you’re able to stretch our epidemic out by flattening the curve so that you never get the enormous spikes, it becomes a much, much more manageable problem for your health care infrastructure than it does if you’re dealing with it over three weeks. If you can flatten it out and deal with it over four or five months … you don’t find yourself in the place that Italy was, the place that Seattle and especially New York City now are.”

The models now are just too different to predict which situation Alabama will find itself in.

“I would love to find that our attack rate is actually lower than what anybody else has reported,” Williamson said. “That would be a godsend, it would be a testament to the effect of social distancing, and correspondingly, one could anticipate the death rate being lower. However, you can’t prepare based on the most rosy scenario. Likewise, I don’t think you can prepare on the most dire scenario. I think you have to try to find what is a reasonable scenario to prepare for and then hope that you have built enough reserve into the system so that if things go worse, you have a way to address that.”

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