Hurdles to Health

Access to high-quality health care is an essential element in fostering healthy and prosperous communities and families. Moreover, the capacity of a health care system can make or break the growth and development of a given state. In reality, no one wants to move to, raise a family or start a business in an area without access to quality health care.

The state of health care in West Virginia is a complex and nuanced issue riddled with challenges compounded by policy decisions and environmental and socioeconomic factors beyond the control or scope of health care professionals themselves.

In the past several years, the health care industry has faced challenges unlike any other in recent memory. Compounding the effects of the opioid epidemic throughout much of Appalachia, the COVID-19 pandemic put additional pressure on resources already stretched thin. The pandemic exposed many shortcomings and pitfalls in our health care systems across the nation, with many hospitals and clinics being brought to their knees by staffing, infrastructure and supply chain issues. The domino effect tipped off by the pandemic has yet to be fully realized and it’s shaking out in the health care industry in a myriad of ways.

The pandemic pushed many workers in the medical field to leave their jobs completely as a result of trauma and subsequent burnout. This heartbreaking cycle, coupled with a nationwide shortage of health care professionals, has led to an even sharper decline in access to quality medical care in rural areas, home to some of the most vulnerable populations.

“From nurses to paramedics, people are overwhelmed and overworked,” says Dr. Ayne Amjad, acting state health officer/commissioner for the West Virginia Department of Health and Human Resources (DHHR) Bureau for Public Health. “Some solutions are to offer better pay and ways to move up in current roles for career advancement, as well as offering and introducing more educational opportunities at a younger age in hopes of inspiring career development.”

In West Virginia, the health care rankings are disheartening. In 2021, West Virginia ranked 47th in health care in a report by U.S. News and World Report. The report looked at access to care, quality of care and the overall health of the population as key indicators. The same report ranks West Virginia last in public health after evaluating six metrics: mortality rate, suicide rate, smoking rate, mental health, infant mortality rate and adult obesity rate.

So, what are some of the main factors contributing to the challenges the West Virginia health care system is facing?

Jim Kaufman, president and CEO of the West Virginia Hospital Association, explains one of the biggest challenges all health care providers face in West Virginia is the state’s payer mix. Payer mix refers to the percentage of revenue that comes from private insurance companies versus government insurance programs like Medicare or Medicaid. In West Virginia, 1.2 million of the 1.8 million total population are covered by government health insurance programs, including Medicare, Medicaid and the Public Employee Insurance Agency (PEIA). For the average West Virginia hospital, that translates to three out of every four patients who are covered by these government health insurance programs, all of which pay less than the cost of care, with Medicare paying roughly 85% of the cost.

“Around the country, employer-sponsored health insurance plans pay higher rates to health care providers to help subsidize the underpayment of their state’s government programs,” Kaufman says. “PEIA is particularly problematic in that the program pays providers half of what Medicare pays while in other states their state employee health insurance plans are similar to other employer-sponsored plans.”

Kaufman adds that PEIA currently pays out-of-state hospitals nearly five times more than West Virginia hospitals for the same service. This is because, in West Virginia, policymakers set the payment rate for hospitals and providers, but for out-of-state, PEIA negotiates with providers through United Health Care, the largest insurance company in the nation.

“This payment differential puts West Virginia providers at a severe disadvantage as these out-of-state providers can recruit our nurses and doctors away by offering higher pay,” says Kaufman. “The sad part is they are doing this with West Virginia dollars.”

The problem of a nursing shortage isn’t unique to West Virginia, either. Nationally there are more than 250,000 vacant nursing positions, according to Kaufman. As West Virginia competes for the limited number of health care professionals nationally, the state’s greater reliance on government payers and what they pay to hospitals limits their ability to offer competitive salaries and benefits.

While the focus has centered around the nursing shortage, Kaufman adds that West Virginia hospitals are also reporting shortages in every clinical and non-clinical area, with shortages in laboratory services, radiology and respiratory therapy, as well as high turnovers in environmental services and food service staff.

“These areas are particularly important because while a restaurant can limit its hours, a hospital cares and feeds not only its staff, but patients and families, 24 hours a day, seven days a week,” Kaufman says. “What this means for patients is longer wait times for services. To put things into perspective, while West Virginia hospitals are licensed for roughly 6,700 hospital beds, in August 2022, we were only able to staff approximately 4,750.”

According to Kaufman, even from August 2022, West Virginia hospitals have seen a decline of roughly 15% in staffed hospital beds.

In rural West Virginia community hospitals, the strain of the worker shortage hits even harder. As smaller communities continue to see population losses, especially of young people, the staffing issue is especially challenging. Since the staff at these hospitals are much smaller, the loss of just one nurse can have a major impact.

“This is why we need everyone—caregivers, patients, families and the broader community—to work with health care providers to help us ensure access to care is there for everyone who needs it,” says Kaufman.

The staffing shortage has meant that patients are waiting longer for services, especially non-emergency services, and the consequences of delays have been felt particularly hard in mental health, especially for children.

“Over the past few years, we have seen children and teens in our emergency rooms awaiting care and transfer to psychiatric hospitals or community-based services,” Kaufman says. “Acute care hospitals generally focus on medical conditions and are not the right place for these children needing mental or behavioral health services. However, because of a national shortage of mental health providers, these children are brought to emergency rooms awaiting care for days and weeks.”

To help address the crisis, hospitals are working with the state to improve the systems of care, expanding the awareness of community resources with an effort to reduce the need for crisis intervention, while also working to expand capacity for pediatric mental health services in West Virginia.

Dr. Angie Settle, CEO, DNP, APRN, BC, FNP, of West Virginia Health Right Inc., added that the COVID-19 pandemic only exacerbated behavioral and mental health disorders.

“Those who were controlling their anxiety suddenly found themselves unable to manage due to the overwhelming fear of the unknown caused by the COVID pandemic,” she says. “The sky is falling feeling paired with the need for many medical facilities to focus on emergency care only led to feelings of detachment to their medical provider lifelines.”

Settle believes that the most important policy initiatives West Virginia needs to focus on are addressing behavioral health and substance use disorder care needs.

“These issues go hand in hand with the foster care crisis,” says Settle. “So many individuals grew up in a home where using drugs was the norm and history often repeats itself with the children growing up to become drug dependent also. We must intervene and break these cycles early to end years of family turmoil tied to drug use.”

Amjad echoed Settle’s sentiments about the mental health crisis and need for preventive care at a younger age.

“West Virginia children have been mentally and physically impacted due to the loss of social interaction and disruption in education during the pandemic,” Amjad says. “Mental health is key to being able to adjust socially and enjoy life. Focusing on preventive holistic health care at a young age is extremely important. This includes physical health, nutrition and mental and environmental health. Working on policies to improve prevention will have long-lasting effects.”

To help provide better care for West Virginia, the DHHR promotes mental health resources, including the 988 Suicide and Crisis Lifeline, HELP4WV and its Children’s Crisis Referral Line and the Kids Thrive Collaborative, for behavioral health resources for children and families.

The cascading ripple effects of the pandemic have been widespread and deeply felt by almost everybody. While the public has felt the implications of the 8-9% rise in inflation sparked by the economic downturn of the pandemic, hospitals are seeing significantly higher inflation rates. General supplies and staffing costs have increased by approximately 20% and pharmaceutical costs have risen by as much as 40%.

West Virginia Health Right—a free and charitable clinic providing more than 42,000 medically underserved, uninsured and underinsured adults in West Virginia with free comprehensive care—has seen the long-lasting hardships of the pandemic fall on the backs of its patients.

Due to the rise in inflation and drug prices, the clinic now purchases some medications for the patients it serves, while others are received through drug programs.

“Economically, the pandemic added insult to injury for many of our 42,000 plus patients who were already struggling financially,” says Settle. “The sudden closure of many businesses due to lack of foot traffic tied to lockdowns put many out of work. We have seen large increases in patients needing our services due to a sudden drop in income.”

West Virginia Health Right does not qualify for heightened reimbursement for Medicaid patients like at Federally Qualified Health Centers (FQHC), despite its patients being low-income, uninsured or having Medicaid or Medicare. The reimbursement the clinic receives for all patients and facilities is less than 7% of its total annual budget.

“This necessitates us to aggressively seek countless private and state or federal grants to meet our budget every year,” Settle says.

“Settle urges that these issues need to be addressed on the federal level, first to control drug pricing and second to give free and charitable clinics the access to reduced, 340B drug pricing the FQHCs and critical access hospitals have.”

Despite all the discouraging news, there are resilient and dedicated health care professionals and researchers who are working every day to improve health care and the well-being of people in the Mountain State.

Kaufman reminds us that hospitals in West Virginia offer state-of-the-art, quality care with an array of services. While there are certain services for which patients must travel outside of the state to receive care, those are unique and rare conditions.

Recently, the West Virginia Economic Outlook report noted the new WVU Medicine Children’s Hospital has not only created a centralized state-of-the-art facility for children with a wider range of conditions, but those expanded services will allow those children to be treated in the state compared to traveling out of state to larger cities like Pittsburgh or Cleveland. The new facility will also support future pediatric medical research to help attract researchers and clinicians, ultimately creating a building block for other economic opportunities in biomedical research and development.

Beyond these economic opportunities, though, Kaufman notes that there is tremendous individual opportunity in health care as hospitals are recruiting for every clinical and non-clinical position imaginable.

“While everyone talks about the need for nurses, we need EMTs, laboratory and imaging techs, IT experts, facilities managers and budget analysts,” Kaufman says. “While some of these jobs require advanced education, others require high school education with some training, so, there are great opportunities to start and grow a career. These are not only great paying jobs with benefits but meaningful professions that allow people to give back to their communities.”

In addition, the DHHR continues efforts to enhance its workforce at state-operated facilities with initiatives such as the nursing workforce program, which provides incentives to retain and recruit LPNs, nurses, nurse practitioners and nursing directors. The program provides an in-state relocation bonus, an out-of-state relocation bonus and a retention and hiring incentive.

Kaufman also says the recent trend in West Virginia hospitals merging into systems is beneficial for patient outcomes. Hospital mergers enable hospitals to improve clinical care, lower costs, upgrade facilities and offer new and higher quality services by spreading costs across hospitals and reducing overall health costs.

For example, electronic medical record systems are very expensive, but if you have a larger patient base, the cost per record is lower. Additionally, hospitals and providers can work together to purchase goods and services, buying in bulk to reduce overall costs.

By joining a health system, hospitals are better able to direct necessary resources, restart planned projects, recruit and retain talented clinical staff and personnel and upgrade facilities. Mergers also increase geographic coverage through clinical affiliations. If a smaller hospital does not have the patient volume to support cardiac services, it can partner with another hospital to share a cardiologist.

“This clinical affiliation and sharing of providers expand services into smaller, rural communities, while better utilizing the limited number of specialists and helps to retain costs by avoiding duplication of services,” Kaufman says.

Health care is often only associated with in-patient care and emergency services, but beyond the walls of the hospital, the staff offers important health screenings, educational training, child care and community fairs to support preventive care.

There are also other opportunities to improve the health care industry in West Virginia that haven’t been explored yet. Kaufman says there is a great opportunity to explore alternative models of care not only in rural communities in West Virginia but across the country.

“With the aging of our population and tremendous advances in technology, how can we improve health care access to services right in peoples’ homes, and how can we use data to improve people’s health thereby reducing the need for medical care?” Kaufman says. “Those are the opportunities we need to capitalize on in the future.”