In Hugo, population 707, where the dominant view is of the water tower, hospital officials with empty beds during the pandemic offered their place as a high-quality respite for city folks on the long road back from the devastating coronavirus.
One woman from Greeley, who before the virus took her down couldn’t put Lincoln County on a map, was so enamored of her attentive recuperation in Hugo — “Not Really Plain . . . But On the Plains!” — that she sent a Christmas card.
In Aurora, at one of the premier academic and trauma centers in the West, doctors clocking in for an ICU shift would study up on the latest COVID-19 treatment protocol, only to literally rewrite them in the computer system within an hour or two. UCHealth’s chief innovation officer said he’s never seen medical innovation happen so fast.
In Denver, nursing homes buckled under the strain and will never be the same. Hospital leaders set up a crisis transfer chain for patients now available for all future disasters. ICU nurses pondered $50,000 bonuses to jump to an understaffed hospital. Opportunistic politicians said the long-term answer is true universal health care.
And all over the state, seeing your doctor on screen instead of in-person is a crossroads that coronavirus put thoroughly, irretrievably in our rearview.
This is part of a weeklong series marking a year since COVID-19 was first detected in Colorado. The state’s first confirmed cases were announced March 5, 2020.
>> READ THE REST OF THE SERIES
The overwhelming, immediate and systemic health care changes wrought by one year of coronavirus in Colorado are largely here to stay, according to medical and governance leaders from border to border. It shouldn’t come as a surprise. Coloradans upended their lives to get out of the virus’ way. So did medicine. So did health insurance. So did long-term care. So did technology.
“The rate of change in medicine and in science has never moved this fast in 100 years,” said Dr. Richard Zane, chief innovation officer for UCHealth’s 25,000-employee system.
Let’s explore just a few of the ways that significant pieces of Colorado’s health care delivery and finance system are likely to change permanently after 2020:
Nursing homes can’t be the same
Coronavirus creating “a new normal” may be a worn phrase, but state officials said it is the best way to look at the future of Colorado nursing homes, and how the state Colorado cares for its older residents.
Forty percent of the 6,000 Coloradans who have died during the pandemic lived in nursing homes when they caught the virus, according to state health officials. In a state with a nursing home population of about 16,000, and about 9,300 of those paid for by state Medicaid funds before the pandemic, that’s an enormous change.
Counts by the state Health Care Policy and Financing Administration show nursing home residents now down about 17% overall, executive director Kim Bimestefer said. That’s an enormous strain for care centers that, whether for-profit or nonprofit, have always struggled to maintain high-quality care.
An Estes Park nursing home, the only one in the area, has already announced it will close, and operators of multiple other nursing homes in the state are unloading their Colorado properties. Meanwhile, state and federal health officials pumped hundreds of millions of emergency payments into Colorado nursing homes to help cover higher costs and resident losses during the pandemic. They also took multiple nursing homes to task for failing to isolate infections among patients and staff, though Colorado’s overall death rates among nursing home residents mirrored the heavy national toll in the age group.
Use of day programs for older Coloradans, often paid for with state and federal funds, is down 50%, Bimestefer added, because of distancing requirements, staffing and concerns among consumers and their families. The state has added “retainer” payments directly to day service operators to keep them afloat, bent on preserving an important piece of improvements to elderly services in recent years.
The ravaging of patients, the fears from patients, families and staff, the return of society’s focus on nursing home life, are all working together to force a rethinking, Bimestefer said. The state has spent years working with disability activists and families to expand Home and Community Based Services that support those who want to stay as independent in their neighborhood as possible, she said, and that will grow further now.
“What’s the new tomorrow look like? It’s an opportunity for us to look at the industry, the needs of seniors,” she said, “and to recognize and try to forecast what does the new normal look like for families, and for seniors themselves making these decisions?”
A revolution in medicine, every day
As the seat of medical teaching in Colorado, and as a regional giant with a dozen hospitals under management, the UCHealth system saw more hospitalized coronavirus patients than any other system in the Rocky Mountains. And since hospitals had to keep out non-covid patients for space and safety, UCHealth also saw a forced-evolution in its overall patient care.
“We’d change treatment protocols for these patients sometimes twice an hour,” said Zane, formerly head of emergency department medicine at UCHealth. Ventilators? Out. Hydroxychloroquine? In, then out. Remdesivir? In, if you could get it, then … maybe. Surface transmission? Mostly out. Aerosolized transmission? Deadlier than ever.
Daily conference calls among the chief medical officers at the Front Range hospital systems, including the renowned independent trauma center at Denver Health, became a key driver of protocol change and better patient care, Zane said. Once medical officers had traded information on what was working best for the largest number of patients, UCHealth would update notes on coronavirus treatment in its electronic record system, accessible at bedsides at all times.
Electronic records, often maligned for failing to fulfill the promise of convenience, showed their long-term worth in systemizing complex, rapidly changing care across hospitals, Zane said. Collaboration among peers who often compete showed similar promise.
“This was a new disease we thought was going to be like an old disease, that turned out to be a new disease,” Zane said. “And small changes made a big difference.”
Clinical collaboration was encouraged and in part facilitated by the hospital trade group, the Colorado Hospital Association. “Learning in real time about things that are going well — from a clinical perspective, that was incredibly powerful,” CHA Vice President of Clinical Affairs Dr. Darlene Tad-y said.
Keeping even chronic-care patients away from the hospital — to avoid infection and to make room for virus cases — also taught UCHealth how to speed up innovation. The system accelerated its efforts to use monitoring devices on patients in their homes to watch for dangerous changes, in lieu of being hooked up to the same devices in a hospital bed.
Care in diabetes, one of the most life-impacting and costly chronic conditions, is a good example, Kane said. Diabetes is both a mathematical disease, requiring intensive measurement and monitoring, and a broad disease cutting across endocrinology, diet, nutrition, eye care and more. Under traditional models, it can take 18 months for a newly diagnosed patient to consult every specialist, discuss tests results on followup visits, come up with a treatment plan and then go through the intensive education required.
By scheduling that serial diagnosis, education and care with remote telehealth, the same intake can be done in a few weeks, Zane said. Longer term, he said, UCHealth will find a “happy medium” between remote care and its still-growing bricks-and-mortar Anschutz Campus. “There’s just not enough endocrinologists or psychiatrists in Colorado, among others, and this allows us to reach that needed scale,” he said, “by better use, and more facile use, of care.”
Speeding rural change
Once Kevin Stansbury figured out that federal coronavirus support was going to keep the tree-bracketed front doors of Lincoln Community Hospital open, the executive director could start looking for the long-term bright side in the Eastern Plains farming community.
Many of Colorado’s small rural hospitals were hit hard by the virus long before positive test results showed up in their distant communities. State orders locked out non-emergency, non-coronavirus patients, and put off the kinds of procedures that pay the bills. Meanwhile, they spent good money to adapt ventilation, entrances and more to accommodate COVID-19, while stocking up on expensive PPE.
The first rounds of congressional relief shored up finances for Hugo and others. Then Lincoln County got cases. By this winter, Lincoln County had one of the highest ratios of infection in the state, at 20% of the population, while 65 out of 140 of Stansbury’s employees got sick. Lincoln has a 35-bed nursing home attached to the hospital, and eventually 15 residents got COVID-19.
Under arrangements promoted by the state and the Colorado Hospital Association, intensely sick patients from Lincoln County or other hospitals with small or nonexistent ICUs could be transferred easily to bigger Front Range hospitals. For both patient care and financial reasons, the smaller hospitals sought a trade: Send recuperating patients who still need a hospital to rural towns for personal care and restful recovery.
That woman from Greeley, discharged from a northern Colorado hospital, fell in love with the Hugo staff, Stansbury said. She stayed for a week and a half. Her Christmas card to Lincoln Community said, “You people changed my life.”
Lincoln Community also started sending out EMTs and paramedics, when not on emergency calls, to make home visits to chronic care patients or those who might otherwise have gravitated toward the hospital in non-pandemic times. That system has prevented costly hospital stays and offered better service to the community, Stansbury said, and will stay in some form.
Also permanent: Hugo hospital staffers as Facebook Live stars. Lincoln Community has been hosting hour-long Facebook sessions every Thursday, rotating in doctors, nurses, Stansbury, the marketing director and others. They’ve talked to the community about why families were shut out of the nursing home wing, why virus testing was crucial, and whether the new vaccines were safe.
Several hundred people have watched at a time, Stansbury said, in a county of 5,585 people. The recordings are available afterward, and some have gotten more than 1,000 hits. The live events gave families an outlet to challenge decisions and get information from people they trust, avoiding fights over masks and other compliance that have plagued some towns.
“The community has been overwhelming in their support and thanks,” Stansbury said. “I’m very proud of this community.”
The bills will keep coming
While the pandemic clearly changed health care itself, it also was changing how Coloradans pay for their health care, and will continue to long after the virus departs.
In December, when, if all goes well, the Coloradans who want it will have been vaccinated, there will be 300,000 more state residents insured through Medicaid (Health First Colorado) than in March 2020, when the virus first arrived. That will be 1 in 4 Coloradans in the joint federal-state public insurance program.
State health officials are planning their 2021-22 budget, which begins July 1, with one eye on the U.S. Supreme Court. Still due is a decision on the future of the Medicaid-expanding Affordable Care Act, argued in front of the justices last fall. A total of 500,000 of current Medicaid enrollees in Colorado qualified because of the ACA expansion, with the federal share of the joint program picking up the great majority of additional costs.
States received additional boosts to the Medicaid match through federal coronavirus relief acts. A high court decision is expected by May, said Bimestefer, the HCPF chief. “We’re incredibly interested in that,” she said.
Some of the people who lost employer-paid insurance coverage in the pandemic went to the subsidies on the Connect for Health Colorado exchange. Many more went to Medicaid, where there are no premiums at all. “It’s an interesting way of making sure people can afford care during a pandemic, in a recession,” Bimestefer said.
Those pushing for a further expansion of publicly financed health insurance think America’s experience with the pandemic will bring them more support. Colorado Democratic U.S. Sen. Michael Bennet and co-sponsor Sen. Tim Kaine, D-Virginia, are renewing their past drive for “Medicare X,” which would create a federal public option modeled on the popular over-65 Medicare program. It would also expand private insurance subsidies to more people on state exchanges.
One of many things the pandemic revealed, Bennet said during a national online news conference in February, was the unequal impact of disease when people of color and lower-income residents couldn’t afford to see a primary care doctor for their symptoms. Many communities were also left vulnerable by historic pollution impacting lung health, and other social determinants of health.
Conversely, the performance of Colorado’s health care system during the pandemic may have some fence-sitters thinking twice about fully implementing a state-based public health insurance option, which some legislators are vowing to pursue this year. Early work on the public option has focused on the state negotiating or mandating lower hospital prices to create a more affordable premium.
Hospitals “have been in the crosshairs of the Polis administration, in terms of cost savings in the system,” said Michele Lueck, executive director of the Colorado Health Institute, a nonpartisan analytic nonprofit. Yet rapid buildup of hospital capacity and technology in recent years was likely a boon for many patients, she added.
“The pandemic has not strained our capacity in the way other states have been constrained,” Lueck said. “We were quote-unquote overbuilt, but at the same time, that allows us to avoid the hardships we’ve seen in California or New York.”
High touch, high tech
Someday soon children will wonder why so many picture books are about “going to the doctor.”
The pandemic forced long-unfulfilled predictions of providing more health care remotely to finally come true. UCHealth talked of cramming three years of telehealth adoption into three weeks last spring. State Medicaid promoted telehealth to keep hospitals clear, and saw usage go from 5% of all visits before the pandemic to 20% between March and August, Bimestefer said. The peak was 32% of visits in mid-April.
The Medicaid shift to telehealth moved the state system closer to a long-sought goal, of reducing expensive and unnecessary ER visits among patients who didn’t know where else to go. Medicaid cites huge costs for people using highly staffed, high-tech ERs for simple colds and sniffles, minor fever and headaches. It’s much more efficient, Bimestefer said, for patients to know they can talk directly to a nurse or doctor from their home via phone or video link.
Telehealth addresses problems for many groups Medicaid tries to elevate, she added. It’s easier access for patients with disabilities, seniors, working families with school-age children, rural patients far from clinics, and for those overcoming the stigma of mental health care.
All those telehealth advantages were only amplified by the pandemic, Bimestefer said. Older Coloradans most vulnerable to the virus avoided exposure during health visits. Families shut out of school clinics found alternatives online. Mental health needs, from job loss stress to sick relatives to child behavior, were met far more often through phone consults and video sessions.
“We’re trying to emphasize and exacerbate the new normal,” Bimestefer said, “so that we can bring a better tomorrow for care.”