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The Keckley Report

The Hospital Workforce at the Brink: Can Lessons be Learned?

By March 23, 2020March 1st, 2023No Comments

As the U.S. copes with the coronavirus and hospitals brace for the surge, two immediate issues have surfaced: the shortage of ICU beds, ventilators, N95 masks, personal protective equipment (PPE) and sanitizers in hospitals and the availability and protection of their frontline caregivers.

As of this morning, neither problem has been solved. Here’s where we are:

Shortages of ICU beds, PPE, masks and ventilators are hitting the most impacted markets like New York City, Seattle and San Francisco already. The I-95 corridor from DC to Boston, Atlanta, Houston and Los Angeles are next. Nationally, we have half the capacity of ICU beds needed if the surge is moderate and the current inventories of PPE, masks, sanitizers are adequate to meet demand for the next two-three weeks. Hospitals are already scrambling to accommodate the surge, though projections range widely about how hard the coronavirus hit will be in terms of infections and deaths.

Hospital workforce issues are, in many ways, more problematic. The nation’s 5198 hospitals employ 5.3 million workers. The AHA estimates the coronavirus will mean 4.8 additional admissions. Hospital capacity is limited, especially in urban and academic settings, and the clinical workforce is under intense pressure from insurers, Medicaid and Medicare to reduce cost. Labor costs are 55% of hospital costs. They’re a target. The clinical workforce–doctors, nurses, technicians, pharmacists—and support staff are stretched thin already. Complicating matters in countries like the UK and Italy, 10-20% of those infected are their frontline caregivers.

The reality is this: the surge is certain but how many are infected, and die is unknown. The CDC projects that if no actions are taken to prevent the spread of Covid-19, between 160 million and 214 million American will be infected, with between 200,000 to 1.7 million people dying from it.


For most hospitals in the U.S, pandemic preparedness is not a new concept. Accreditation by The Joint Commission requires periodic review of emergency preparedness every 18 months. 97.5% reported they had a plan in place, but arguably none seem ready for Covid-19. Until February, inter-operability, site-neutral payments, value-based purchasing and physician burnout were their focus of attention.

Likewise, lawmakers in DC labeled the coronavirus a surprise despite warnings from public health officials who estimated 110 million Americans could be infected,7.7 million hospitalized and 575,000 killed in an October 2019 Crimson Contagion planning exercise. Lessons learned from the Ebola, SARS and H1N1 pandemics received scant attention…until now.

So, what happened? Why was our system ill-prepared for the coronavirus given what was known? Hopefully, in time, a national commission will be appointed to identify root causes and long-term solutions sans partisan bickering. Hopefully, it will be constituted by frontline hospital caregivers and support staff instead of academics and pundits who never worked a day in a hospital. Hopefully, it will produce systemic changes that prepare us better for the next pandemic.

For now, hospitals face enormous challenges as the surge nears. They’re rightfully asking lots of questions:

  • Will needed inventories of masks, sanitizers, ventilators arrive in time? Can surplus inventories in less-impacted hospitals be transferred to hotspots? Will manufacturers jack up their prices to take advantage of surge demand?

  • If ICU beds are needed, can hospital beds in hotels, dorms, convention centers and makeshift warehouses beds be used safely for patient care? How?

  • What’s our back-up plan if our nurses and doctors are infected and unable to work?

  • Are vaccines available and treatments safe and effective? Where? When? And how much will they cost? Of the 41 vaccines being investigated by the World Health Organization and 7 medicines being tested by drug companies, which are the most promising, when will they be available and what will they cost? Is Gilead’s Remdesivir our best hope?

  • While focused on coronavirus, how do we manage the other chronically ill and sick populations under our care? And how do the 280,000 physicians and dentists we employ earn a livelihood while all hands are on deck for the pandemic? And what do we do to make up lost revenue from postponed or cancelled elective procedures representing up to 40% of the hospital revenues?

  • Who is paying for all this? Will insurers reimburse care provided their members and who might reimburse for the 28 million who lack coverage?Will Congress allow a one-time Special Enrollment Period (SEP)in the marketplaces so the uninsured can get immediate coverage? How will patients hospitalized as a result of the coronavirus infection handle out of pocket costs estimated at $1300 or more? Will Congress pass emergency relief funding for hospitals and who will decide where it goes? And how will the 7 million who lose their jobs in coming weeks and 28 million who lack insurance coverage access the care they need?

In coming days, we’ll hear lots more about the heroism of hospital caregivers. Rightfully so.

I doubt we’ll hear as much about how the Chief Human Resource officers are scrambling to keep the workforce intact or the Chief Financial Officers who are anxious about debt obligations and payrolls. Or the communication teams who are operating in crisis communications mode and the environmental services and central sterile teams that are doubling down on infection control guidelines and patient safety. They are not interviewed by media but their roles equally vital to how hospitals are responding to the surge.

Most of the hospital workforce do not have huge retirement nest eggs or benefit from stock options. Most don’t have time to follow the recession or comprehend the administration’s $2 trillion bailout. Most are doing their job, delivering care to those most in need or supporting their frontline caregivers as they can.

Today, they’re all at work taking care of patients. And they hope lessons will be learned from this pandemic, so we’re better prepared for the next one.


P.S. Today marks the 10-year anniversary of the passage of the Patient Protection and Affordable Care Act (ACA). Title V “Health Care Workforce” of the ACA sets forth principles for the modernization and preparedness of the healthcare workforce under the auspices of the National Health Care Workforce Commission. (Sec. 5202, 5205, 5301, 5303, 5501, 5506 and 5507). It was an effort to synchronize the federal government’s 72 healthcare workforce development programs. Regretfully, the workforce never received funding from Congress prompting the Government Accountability Office (GAO) to call for its implementation years later but to no avail.

When the dust settles from the coronavirus, industry leaders and elected officials should revisit the aim of Title V in the ACA. The need is paramount, especially in the hospital workforce. They’re the heart and soul of this industry.


Hospital Use

In 2018, America’s hospitals and health systems treated 143 million people in emergency departments, provided 623 million outpatient visits, performed over 28 million surgeries and delivered nearly 4 million babies. Inpatient admissions decreased by 1.7 million from 2008 to 2018 (AHA)

Hospital Census

There are 5198 community hospitals (2937 not-for-profit, 1296 for-profit, 965 state/locally owned). 1821 classified as rural vs. 3377 urban; 3491 system affiliated59% of hospitals under 100 beds affiliated with a multi-hospital system (AHA)

Hospital Capacity

The U.S. had an estimated 728,000 medical and surgical hospital beds available to the public in 2018, or 2.2 hospital beds per 1,000 people. On a typical day, 36% of the 728,000 beds were unoccupied, leaving 0.8 beds per 1,000 people. (Urban Institute)

Hospital Workforce

As of February 2020, 5,257,900 are employed by hospitals—up 7900 (1.4%) from January, 2020. In the past 10 years (2009 to 2018), 586,000 new hires in hospitals—a 13% increase since ’09. Each hospital job supports almost two additional jobs, and every dollar spent by a hospital supports roughly $2.30 of additional business activity in the economy. Overall, hospitals support 17.3 million jobs, or one out of nine jobs, and $3.3 trillion in economic activity. Note, this does not include clinicians and staff for 280,000 physicians and nurses employed by hospitals or staffing for 8000 skilled nursing beds owned by hospitals.  (US Bureau of Labor Statistics, AHA)

Hospital Labor Costs

Staffing represents 54.9% of hospital’s overhead:  64.4% are wages and salaried; 35.4% is benefits (10.7% health insurance, 4.8% retirement, et al) (HFMA)

Patient Out of Pocket Cost for Hospital Admission

The average hospitalization for COVID-19 will likely cost more than $20,000, and patients will be responsible for approximately $1,300 of that total. (HFMA)

Coronavirus Hospitalization Rate

40% of hospitalized patients in the U.S. are 20-54 and 20% are 20-44, but the mortality rate remains highest for those over 60. (CDC)

ICU Capacity

46,825 ICU beds in community hospitals and 14,439 cardiac intensive care beds in community hospitals (AHA)

National Center for Health Workforce Analysis (NCHWA), HRSA

Government Accountability Office “Healthcare Workforce: Comprehensive Planning by HHS
Needed to Meet National Needs” January 11, 2016

American Hospital Association

Sanger et al “Before Virus Outbreak, a Cascade of Warnings Went Unheeded” New York Times March 19, 2020

Gawande “Keeping the Coronavirus from Infecting Health-Care Workers” New Yorker March 21, 2020

Daly “Hospitals innovate to control labor costs” HFM October 1, 2019

Vick et al “Assessment of community hospital disaster preparedness in New York State.” J Emerg Manag. 2018 Jul/Aug;16(4):213-227. doi: 10.5055/jem.2018.0371.

“The Joint Commission suspends all regular surveys amid COVID-19 pandemic” The Joint Commission March 17, 2020

Pelletier “Conquering High Consequence Infections in a VA Hospital” The Joint Commission February 7,2020

Rae et al “Potential costs of coronavirus treatment for people with employer coverage” Peterson KFF Health System Tracker March 13, 2020

Daly “Hospitals face staffing ‘domino effect’ from the coronavirus outbreak, adviser says” Healthcare Financial Management Association March 17, 2020–domino-effect–from-the-coronavirus-out.html

Pancevski “Covid-19 Deaths in Germany Far Below Rates in Other Countries” Wall Street Journal March 22, 2020

Japsen “Calls Grow to Open Special Obamacare Sign-Up As Coronavirus Spreads” Forbes March 21, 2020

Wiseman et al “Whiplash: All at once, a steady US economy screeches to halt” Market Beat March 22, 2020

Ioannidis “A fiasco in the making? As the coronavirus pandemic takes hold, we are making decisions without reliable data” Stat March 17, 2020

Jacobson “The economic rationale for strong action now against Covid-19” Stat March 18, 2020

Shulte “The novel coronavirus is a serious threat. We need to prepare, not overreact” Stat, March 16, 2020;

Glanz “Coronavirus Could Overwhelm U.S. Without Urgent Action, Estimates Say” New York Times March 20, 2020;

DePillis et al “Here’s Why Florida Got All the Emergency Medical Supplies It Requested While Other States Did Not” ProPublica March 20, 2020
“Not-for-profit and public healthcare – US: Outlook changes to negative as coronavirus accentuates cash flow constraints” Moody’s Investors Service March 18, 2020;
Collins et al “What Are Americans’ Views on the Coronavirus Pandemic?” NBC News/Commonwealth Fund Health Care Poll of 1006 adults March 10-15,2020 released March 20, 2020