The line of cars told the story. For a few days in March, they stretched out of Cleveland Clinic and University Hospitals drive-thru COVID-19 testing centers. A parking lot near the Cleveland Clinic testing center was full, trailed by a line down the block. The scene was similar in Mayfield Heights, at UH Landerbrook Health Center. Cleveland Clinic and University Hospitals had teamed up to offer testing, and their services were in high demand.
Time has passed since that initial testing surge, but Northeast Ohio hospitals are still bracing for incoming patients. As we all wondered when the peak of cases in Ohio would arrive, Gov. Mike DeWine called on hospitals to act as a team, with “one plan, one voice.”
“The most important thing is that we cannot get through this by each hospital doing its own thing,” DeWine tweeted March 28.
One senses that the governor is well aware of the challenges in bringing together hospital systems that are fiercely competitive.
In Cleveland, cooperation at the institutional level has never come easily. The Cleveland Clinic and University Hospitals have been busy for decades growing their footprints through acquisitions, new construction and expansion into new markets. Even the MetroHealth System, rooted as the local public hospital, recently moved to capture a larger share of the regional market with expansion outside Cuyahoga County.
The Clinic-UH rivalry is legendary, and at times has been cutthroat. Cleveland’s MedCity News, which covers the health care business, noted in 2011: “In an era of big health care, and when economic development is now a bar-stool discussion, hospital rivalries like Cleveland Clinic-University Hospitals are the hottest local feuds going.”
That said, there are signs that the global coronavirus crisis has triggered a necessary and dramatic shift in hospital relations.
Health systems are cooperating like never before. With acute shortages of equipment, beds and staff, they have no choice.
The idea of cooperation is not completely new. After the 9/11 terrorist attacks, hospitals began working together on regional disaster preparedness under the Center for Health Affairs, the Cleveland-area hospital association. With a federal grant, they accumulated a stockpile of supplies, ran drills and simulations, and agreed to share resources, says the Center for Health Affairs’ Lisa Anderson.
“We’ve been doing this for 18 years,” Anderson says. “They are competitors, but in this situation, they all pull together.”
The coronavirus pandemic is putting all that disaster planning to the test, and in ways never imagined. Cooperation on a large scale is critical, says Thomas Campanella, associate professor of health economics at Baldwin Wallace University. It’s not just hospital beds, protective gear and ventilators that are in short supply. Hospitals may be pressed to share expertise, equipment and technology.
They also will need to partner closely with public health authorities and share clinical information that typically they would not. “We have to leverage all our resources to address the need,” Campanella says. “There should be no boundaries.”
That’s necessary because no single health system has the capacity to handle a sudden surge. Hospitals run lean and mean. The number of beds has shrunk for years, as more procedures become outpatient-based. They can normally handle a spike. But if the number of patients overwhelms, there could be a shortage of ventilators or intensive care beds.
The workforce situation is also perilous. No one hospital has a deep enough bench to deal with an onslaught. Significant numbers of frontline health workers will be infected over time. Already, before coronavirus entered the picture, the Center for Health Affairs projected a severe shortage of about 2,850 registered nurses in Northeast Ohio by 2020. In late March, Gov. DeWine signed a bill allowing nursing school graduates to go to work with a temporary license.
An early sign of cooperation came when the Clinic and UH partnered, temporarily, on drive-thru testing. Area hospital medical chiefs have also been meeting regularly, Anderson says. In Akron, Grace Wakulchik, president and CEO of Akron Children’s Hospital, tells me that hospital leaders have been on the phone every day talking about testing, personal protective equipment and clinical protocols (Full disclosure: I write freelance content for Akron Children’s).
Hospitals have canceled nonurgent and elective procedures too, freeing up beds, equipment and staff. Calls for more hospital capacity grow more urgent by the day. There’s talk of using empty hotels and dorm rooms to house patients, health care workers and first responders.
It’s hard to forsee just how bad things will get. It may be some comfort to know the region is blessed with a strong health care infrastructure. With regard to capacity, Northeast Ohio is in better shape than many parts of the country. More than half of U.S. counties have no intensive care beds, according to a new Kaiser Family Foundation report. Compared to other counties with ICU beds, Cuyahoga County has three times as many ICU beds per capita than the U.S. average among residents 60 and older — the people most likely to need them.
Our health systems have also come together in the past on certain initiatives, such as research, some areas of clinical care and community health projects, such as infant mortality and the opioid epidemic.
But data sharing has been a frequent stumbling block. Rita Horwitz, president and CEO of the nonprofit Better Health Partnership, brings together health care providers to share data-driven best practices in primary care across Northeast Ohio. The model has been a success. Research published in Health Affairs in 2018 showed how data-sharing reduced hospitalizations for targeted conditions and saved millions of dollars.
To be effective though, the program requires transparency. But since Better Health Partnership’s beginning in 2007, it hasn’t always been easy to get buy-in. Some providers have been less willing to share patient-level data. Some, including the largest systems, only share aggregate data for certain conditions or initiatives. That limits the ability to identify hot spots and target interventions.
A data-sharing infrastructure across systems and sectors would be helpful during this crisis. But we’re not there. “If you establish that as a norm, then it’s not such a big lift in a crisis,” Horwitz says. “All in, all of the time. It’s about the greater good.”
Transparency among health systems is also vital for the most harrowing decision a doctor might have to make. A recent story by Plain Dealer medical writer Ginger Christ noted that providers must be transparent in how they choose who receives the benefit of a ventilator and who doesn’t.
Whatever unfolds in the weeks and months ahead is certain to redefine parts of the health system. The financial impact of the pandemic will be significant. When life returns to normal, hospitals will again put on their game faces. But it’s not unreasonable to believe the crisis will open new lines of cooperation. That can only be good for patient care, and it will better prepare Cleveland for its health care future.