Drastic increase in hospital labor costs led to a sustained financial loss for an academic vascular surgery division during the coronavirus disease 2019 pandemic

Abstract

Objective: The financial effects of the coronavirus disease 2019 (COVID-19) pandemic have fundamentally changed the healthcare environment, with hospitals expected to have lost billions in 2021. A preexisting nationwide nursing shortage became drastically worse during the pandemic amid dramatically increasing labor costs. We examined the evolution and financial effects of these changes during repeated pandemic surges within a vascular surgery division at a tertiary medical center.

Methods: Operating room, inpatient unit, and outpatient clinic financial data were examined retrospectively. The monthly averages for a 14-month control cohort before COVID-19 (January 2019 to February 2020) were compared to the averages for seven interval groups of sequential, 3-month cohorts from March 2020 through November 2021 (groups 1-7).

Results: The monthly relative value unit (RVU) generation had returned to the mean before the COVID-19 pandemic (2520 RVUs) after an isolated decrease early in the pandemic (group 1; 1734 RVUs). The RVUs ranged from 2540 to 2863 per month for groups 2 to 5, with a slight decline in groups 6 and 7. The average monthly RVUs in the COVID-19 period (2437 RVUs) were nearly equivalent (P = .93) to those for the pre-COVID-19 cohort. An analysis of payor mix demonstrated an increase in commercial and Medicaid payors, with a respective decrease in Medicare payors, during COVID-19. The contribution to indirect, or profit, from inpatient hospital and outpatient clinical revenue showed a drastic decrease in group 1, followed by a swift rebound when the government restrictions were eased (group 2). The total monthly vascular nursing unit expense demonstrated a marked increase with each sequential group during COVID-19, with an average monthly upsurge of +$82,171 (+47%; P < .001). An increase in the nursing labor expenses of +$884 per vascular case (from $1630 to $2514; +54%; P < .001) was observed in the COVID-19 era. The nursing labor costs per patient day had increased from $580 to $852 (+$272; +53%; P < .001). The nursing labor cost per RVU had increased from $69.5 to $107.7 (+$38.2; +55%; P < .001). On a system-wide level, the agency-related nursing costs had increased from $4.9 million to $13.6 million per month (+178%; P < .001) in 2021 compared with 2020.

Conclusions: The COVID-19 pandemic has had severe, nationwide effects on healthcare delivery, exacerbating the deleterious effects of an existing, critical nursing shortage. To the best of our knowledge, the present study is the first detailed analysis of this phenomenon and its effects on a surgical division. Our results have demonstrated a progressive, drastic increase in nursing labor costs during the pandemic, with a resultant sustained erosion of financial margins despite a level of clinical productivity, as measured in RVUs, equal to the prepandemic standards. This precarious trend is not sustainable and will require increased, targeted government funding.

Keywords: COVID-19; Cost; Margin; Medicare; Nursing labor; Pandemic; Profit.

Fig 1

Traditional determinants of surgical net revenue, monthly case volume, relative value unit (RVU), length of stay, and U.S. Centers for Medicare & Medicaid Services (CMS) case mix index (CMI) did not change significantly when the two major cohorts were compared. COVID, Coronavirus disease 2019.

Fig 2

Vascular surgery total operating (hospital and outpatient clinic) profit margin (contribution to indirect [CTI]). Data in thousands of dollars. Significant decreases in hospital margin were observed after an initial rebound increase in groups 2 and 3 after the removal of national and regional restrictions on elective cases in the first months of the coronavirus disease 2019 (COVID) pandemic (group 1).

Fig 3

Total vascular surgery nursing unit expenses ($). A nearly continuous and severe escalation in nursing labor costs occurred seen during the coronavirus disease 2019 (COVID) pandemic.

Fig 4

Total vascular surgery nursing unit expenses ($) standardized as a function of admitted patient day. Escalating nursing labor expenditures were analyzed against the control of admitted patient day (length of stay), demonstrating sustained and significant increases as the coronavirus disease 2019 (COVID) pandemic has continued.

Fig 5

Total nursing expense as a function of relative value unit (RVU; $/RVU). To eliminate the potential effect of shifting payor mix on the calculated total margin, total nursing expenses were analyzed on a per RVU basis, demonstrating a dramatic conglomerate increase during the coronavirus disease 2019 (COVID) era.

Fig 6

Total vascular nursing expense, vascular (Vasc) relative value unit (RVU), and vascular surgery margin during coronavirus disease 2019 (COVID-19) surges in a repeat pandemic epicenter. Increasing total nursing expenses (solid red bar) directly and proportionally followed repeated COVID-19 surges (blue spikes) in New Orleans, leading to a decreased profit margin (solid green bar) despite sustained RVU production (green line).