Patrick Charmel, the president of Griffin Hospital in Derby, Conn., keeps his office door open. Alex Balko, the chief financial officer, raced in from across the hall. “Oh man, this is really not good,” Balko said, not bothering to take a seat. “This could be devastating to us.”
Four days before, Griffin had admitted its first patient with telling symptoms, and people were starting to show up to be swabbed. With the novel coronavirus perhaps already within Griffin’s walls — and certainly hovering nearby — doctors were getting ready to cancel the mammograms, hernia repairs and all the other not-so-urgent care that provides the hospital’s main income.
“Pat, this is not sustainable,” Balko said. “What are we going to do?”
In the weeks since their first fretful conversation the third Thursday in March, the answers have been aching for the small hospital that has been a fixture of Connecticut’s lower Naugatuck Valley for more than a century.
This springtime at Griffin is a metaphor for the wounds the pandemic is leaving on the places that Americans sickest with covid-19 turn to in hope of being healed. Across the industry, as the coronavirus has caused elevated expenses and suppressed revenue, a new report estimates U.S. hospitals will have lost a total of $50.7 billion a month from March through June. Some are better buffered to absorb a financial shock than the 115-bed community hospital on its own in working-class Derby, Connecticut’s smallest-size city.
Griffin and Derby are intertwined, part of the hospital’s focus on its neighbors’ health as well as their sicknesses. It runs “mini med school” — 10 weeks of free lectures each fall for anyone who wants to learn how the body works. Off the main lobby is a medical library for the public. In a token of reciprocity during the pandemic, a deli is giving sandwiches to the exhausted hospital staff. The mayor drops off Italian food.
To care for people of the valley who would get infected, Griffin invested in expensive preparations as the virus approached. During three weeks in March, the hospital spent $1.7 million — more than half its capital budget for the year — including for a crash renovation of East B, a shuttered medical unit. The 13 rooms were converted to negative pressure, with air-handling ducts flown in from Wisconsin snaking out windows, up the beige brick walls and onto the roof.
The hospital made these investments as the usual patients were vanishing. Visits to Griffin’s physician practices fell to 2,300 from mid-March through mid-April from 4,200 the month before. Endoscopies were down 90 percent in April. Even trips to the emergency department plummeted from a normal rhythm of about 120 a day to three dozen on a good day.
The bottom line: Griffin is missing $6 million of its usual $15 million in monthly income.
“How long can you sustain those kind of losses?” Charmel said. The answer, he knows, is six months at the most.
Whether such losses will continue to eat away at Griffin’s financial foundations is impossible to know. The trajectory hinges on how many of the billions of dollars that Congress devoted to shoring up the nation’s coronavirus-damaged hospitals arrive in Derby. On whether the state government pitches in. On how long the virus lingers in Connecticut, now burdened with the country’s fifth-highest case rate.
If the losses roll into the fall, Charmel said, “you can’t cut enough to make up for this shortfall. That’s why this is so nerve-racking.”
His deeper fear is that Griffin — which has resisted merging into a larger health system, anchored in a belief it can respond to its community best by itself — might become unable to hold out.
“There’s no way to hide from that,” Charmel said. “I like saying the independence of the hospital is at risk [rather] than the survival, though there’s some of that, too.”
‘This is real’
Daniel Tuccio was born at Griffin 71 years ago. He has worked there for 15 years as a liaison between the doctors network and the hospital, and he likes riding the elevator that carried him as a newborn.
The day after Easter, he was recovering from a knee replacement, working from his spare bedroom on a marketing plan. The phone rang.
It was an administrator calling to say Tuccio’s job had been chosen for an indefinite furlough. His work cellphone would be disconnected.
He sent Charmel a note. He was going to keep working anyway, he wrote. Besides, the cell was his only phone. Charmel let the phone stay on but said Tuccio must stop working.
“I knew they had to focus on the essential workers,” Tuccio said. “But I can tell you, the word ‘essential’ is both powerful to me and hurtful to me.”
Furloughs are the kind of pain that has seeped through Griffin this spring to help it keep going. Balko, the financial officer, knew they were necessary. Charmel knew they clashed with the hospital’s values. “We talk about being a family, about everyone being a caregiver, whether you are working with patients or not,” Charmel said. He hesitated to say “part of the family had to go home.” He finally made the decision at home, late on a Saturday night.
A coordinator for medical students. An exercise specialist for cardiac patients. A social worker for cancer patients. Three cooks. A mail clerk hired 46 years ago. In all, 102 of about 900 workers.
The furloughs aren’t even saving that much money. Griffin is self-insured for unemployment benefits, meaning it pays as much as $648 a week in claims for each out-of-work employee, depending on salary, Balko said. The net effect is savings of about $300,000 each for April and May out of the $6 million gouge in Griffin’s revenue.
Tuccio is okay on money, with hospital unemployment plus a weekly $600 check from the government for being out of work in the pandemic. Harder are the well-meaning calls from doctors he works with — somehow feeling like salt in a wound.
And the solitude, living alone a decade after a divorce. Out back, he plays bocce by himself. Inside, he does not speak some days, except to say to his Google home system, “Hey, Google, what’s the weather for tomorrow?”
Carrie Hale, a supervisor for hyperbaric oxygen therapy in the outpatient wound center, was near the end of her second week of furlough when her supervisor called. Would she be willing to come back as a respiratory therapist with covid-19 patients?
Hale, 57, was born at Griffin, too. She started to work there in the kitchen when she was 16, before going off to college. She trained in respiratory therapy, returning for a job at Griffin. But it had been 23 years since she had worked in critical care.
“Oh, okay,” she replied, but she admitted, “I’m very nervous.”
She is one of 70 Griffin employees who have been redeployed to care for virus-infected patients.
During the past four weeks, she has learned to write patient notes on a computer, rather than by hand, and to understand the sophistication of today’s ventilators. She is on all four units where infected patients are, putting them on CPAP machines to help them breathe for the night, giving nebulizer treatments, prepping the ventilators.
She was in East B, the renovated unit, when a pulmonologist first asked her to put a patient on 100 percent oxygen. The patient was Candace Quinn, the nursing director at a nearby nursing home with covid-19 cases. She was sliding downhill, soon to be moved to intensive care.
Quinn was weak, feverish, coughing. “It hit me, this is real,” Hale said.
Behind a yellow gown, a mask, a face shield, she sees her patients’ fear. Holding their hands, she wishes they could see her face, not just her eyes.
And she worries about bringing the virus home to her husband, who retired last year after 18 years as the police chief of Ansonia, the town next door, and her daughter, home from graduate school. Hale keeps a can of Lysol in her car and sprays herself head to toe before she gets in, then sprays herself again in her garage, where she takes off her clothes before rushing inside to the shower.
When her own fear creeps in, she said, “I just try to think of the patients and say to myself, ‘You’ve got this.’ ”
A shared legacy
Derby sits at a narrow point in southwestern Connecticut where the Naugatuck River empties into the Housatonic as it flows toward Long Island Sound.
“The history of America has been written here,” said Jack Walsh, who ran the local United Way for nearly 30 years before retiring. Derby started as a trading post in the mid-1600s, and by the 19th century, the water power from its rivers made it an Industrial Revolution hub. The area was known as Brass Valley for the factories that manufactured brass buttons and, by early in the 20th century, accounted for two-thirds of the nation’s brass products output.
A brass worker was the first patient admitted when Griffin Hospital opened in 1909, but by the time the local brass industry faded in the 1970s, Derby was suffering. As for Griffin, one-third of local residents said in an early 1980s survey that, if they ever needed a hospital, they would avoid the aging facility in a region with six other hospitals within a dozen miles in any direction, including high-powered Yale-New Haven Medical Center.
Charmel started out at Griffin 41 years ago as a college intern. He was a junior administrator in the mid-1980s when the board of the financially strained hospital considered closing its maternity unit. Instead, the board handed him a chance to revive it. He and the marketing director toured hospitals around the country posing as an expectant couple, the marketing director stuffing a pillow under her skirts, to search out innovative, homey childbirth services.
Griffin opened an early birthing center — the first of its steps to translate the jargon, “patient-centered care,” into practice.
But at Thanksgiving 1997, Charmel was let go. As chief operating officer at the time, he disagreed with the CEO’s focus on building an HMO. Employees started an underground newspaper to lobby for his return, and workers and community members wore yellow ribbons; the mayor fastened one to City Hall. Within three months, Griffin’s board fired the CEO and brought back Charmel.
He has been in charge ever since and has weathered other crises — among them, the pandemonium in 2001 when a 94-year-old woman from rural Oxford, Conn., arrived after opening an envelope containing lethal spores, becoming the nation’s fifth and final death from the anthrax attacks.
Today, at the far end of the parking lot, hospital staff have planted a community garden, with fruits and vegetables that local residents may pick. Parking valets greet patients, often knowing their names. A grand piano is in the lobby, classic rock in the stairwells.
But for all its ambiance, even before a pandemic came along, Griffin’s finances have not been especially strong.
‘Waiting and waiting’
The Metropolitan Transportation Authority’s New Haven line runs from Grand Central Terminal in New York through New Rochelle, trains stopping along Connecticut’s wealthy Fairfield County until ending 12 miles east of Derby.
So when New Rochelle had a coronavirus outbreak in early March, the Griffin staff understood it was only a matter of time before the virus arrived. Unlike New York’s hospitals, they had a little time to get ready.
Griffin set up a call center in mid-March for anyone with questions about the coronavirus. Two days later, it opened drive-through testing, erecting a white tent near the community garden.
With drive-through testing and tests for a dozen area nursing homes, Griffin has identified 861 positive results out of 3,298 people tested.
The hospital, though, loses money on every test. At first, it sent specimens for analysis to Quest Diagnostics, which charged $69 a test before raising its price, or Jackson Laboratory, which charges $99. The insurer that pays the most, Aetna, gives Griffin $60.35 per test. Medicare gives $35.09.
With results at first taking up to a week to come back, Griffin bought Cepheid equipment that cost $169,000 and, on April 13, began running the tests in 45 minutes in-house, using test kits that cost $38.50 apiece. But the hospital still cannot get enough kits, so it has to send many out.
In March, Connecticut Gov. Ned Lamont (D) was asking hospitals to expand their ability to take in infected patients. Griffin heeded guidelines the Centers for Disease Control and Prevention issued Feb. 21, telling hospitals that patients thought to have covid-19 should be placed in rooms with negative pressure. By the time the CDC softened its guidelines April 13, saying hospitals needed only to keep such patients’ doors closed, the renovation of East B was finished, more than doubling Griffin’s negative pressure rooms with 21 added beds.
During the rapid-fire renovation, Marya Chaisson, a pulmonary critical care physician who has run the intensive care unit for 15 years, was reading everything she could find about treating covid-19 — figuring out how the small hospital could handle what was coming.
Griffin had seven ventilators. Chaisson took an inventory throughout the hospital, finding a few anesthesia machines that could be used in a pinch and CPAP machines typically used for sleep apnea. Administrators scored 15 more ventilators from the outside.
Starting out with less sophisticated equipment than big, fancy hospitals, the ICU spent $16,000 on a video laryngoscope to help safely intubate patients who could not breathe enough on their own. Extension tubing so poles for IV medicines could be kept outside patients’ rooms. Expensive disposable leads to monitor brain waves to make sure patients were sedated at proper levels. All the things required for fighting a highly infectious, sometimes fatal respiratory virus.
“We were waiting and waiting, then literally the wave happened,” Chaisson said. The first suspected covid-19 patient tested negative. The next day, March 21, another tested positive.
Griffin has admitted 153 infected patients. Among cases in the United States’ 3,100 counties, New Haven County, with Derby at its western edge, ranks 27th.
On average, a Griffin covid-19 patient uses $23,000 worth of care — more than twice as expensive as the average for other Griffin patients admitted for medical care, Balko has calculated.
“I have to do what I have to do for my patient, and the financial repercussions are the financial repercussions,” Chaisson said. “I know how much the drugs we are using are, the equipment. There’s nothing I can do about it. . . . It gives me some angst.”
Life and death
Lauren Dempsey has been waking up between 4:30 and 5 a.m. It was the hour that her 33-year-old son, a physician assistant in the Griffin emergency department, called her April 18 right after he had gotten a call from the hospital.
After a week in the new negative pressure unit, then a week in intensive care, Dempsey’s 94-year-old father, John Collins, had seemed to be getting better. Before dawn that Saturday, he went into acute respiratory failure. Moments later, his heart stopped. A nurse was holding his hand when he died.
Collins is one of 28 coronavirus patients who have come to Griffin and not survived.
He had lived with Dempsey for nearly a decade, and the virus traveled through the family. Her husband, Marty, got sick in late March. A week later, she had symptoms, and so did her 40-year-old son, who lives upstairs in their two-family Ansonia house with his wife and two children. Her father, who took no medicine except for his thyroid and hadn’t used a walker until last year, had only one symptom: He kept falling to his knees. They called an ambulance. The fever and cough came later.
Collins was a World War II Marine sergeant who came home and turned out to have a talent for bouquet-making in a local florist. He switched to a shoe store until, in middle age, he went into banking, becoming a loan officer. In his 90s, many people in the valley knew him. He loved to go to the movies and the Valley Diner, and to eat cookies off the paper plate Dempsey set out for him before bed. In fine weather, he’d sit on the front porch in a wicker chair, and when the Mister Softee ice cream truck would come by, the driver would give him a free sundae.
Dempsey, a 62-year-old art teacher, always joked with her husband that her father would outlive them both. She never imagined she would talk with him only once by FaceTime in his final days. Or that she, her husband and son — still recovering from covid-19 — would be forbidden from the funeral home, forced to attend a tiny funeral at Pine Grove Cemetery without a Roman Catholic Mass, their priest wearing a mask 20 feet away.
When Quinn, the nursing director from a local nursing home, was transferred to the ICU, she was gravely ill. Chaisson had read about the value of proning — rotating patients onto their stomachs to help them take in oxygen. Unlike bigger hospitals, Griffin does not have automated proning beds, so Chaisson trained the ICU’s entire staff.
Quinn was the first patient Chaisson proned. Her fever was high, her blood pressure low. Organs were failing.
Improbably, Quinn was weaned off a ventilator after 15 days. She is now at a rehabilitation hospital, with exercises to strengthen her mind and her body. “It’s just going to take time, and that’s not something I’m very good with,” Quinn said. “I’m the one to take care of everything.”
Sedated as she was, she does not remember Griffin’s nurses reading aloud the letters her husband wrote every day. She recalls being wheeled out on a gurney on April 30, 21 days after she arrived. Scores of nurses and doctors and others, Chaisson among them, lined the hallways, cheering and weeping.
Over the public address system played what has become Griffin’s covid-19 patient discharge anthem: the Beatles’ “Here Comes the Sun.”
The bottom line
Since he first recognized the coronavirus sweeping north from New York, through the patients who lived and the patients who died, Charmel has believed the federal government and the state would recognize the financial fragility of a small community hospital fighting a pandemic. He has believed they would step up with enough help. Yet as spring deepens, he finds their response tepid.
Three hundred miles away in Washington, Seema Verma, administrator of the federal Centers for Medicare and Medicaid Services, talks often about advances her agency is giving hospitals on payments for patients on Medicare. Griffin applied, and $16.6 million arrived April 8.
What Verma seldom mentions is that hospitals must begin repaying their advances in four months. Starting then, the agency will withhold the money for all the new claims a hospital files until the loan is erased.
At Griffin, the repayment must begin in August. Hospital officials are reluctant to spend the advance, knowing that income from Medicare — which insures more than half of Griffin’s patients — will pause later in the year.
And last month, when the government sent nearly the first third of $100 billion that Congress had just provided for hospitals and other health facilities, Connecticut’s portion was $378 million. Federal health officials, eager to distribute that money quickly, did not take into account how severely the virus had penetrated any state. Connecticut’s portion equates to $14,366 per case, the fourth-lowest in the country, according to federal data Griffin recently analyzed.
Meanwhile, Charmel is leading a team that has talked with Lamont, the governor, making the case that the state’s hospitals are vital to Connecticut’s ability to defeat the virus. The hospitals are asking for some of nearly $1.4 billion that the state has received through a federal Coronavirus Relief Act. So far, Charmel said, state officials are telling him they are waiting to decide until they know how much federal money hospitals eventually get.
Lamont has proposed a four-phase reopening of Connecticut’s economy, with the earliest later this month. Griffin is being cautious in resuming services. It has just begun to invite women at high risk for breast cancer to come for overdue mammograms. Many are staying away, afraid of the virus inside. And, after dropping in recent days, Griffin’s number of covid-19 patients began rising again over the weekend.
Charmel figures it will be at least six months before there is any semblance of normal and the hospital stops hemorrhaging money. So he was eager to find out what help Griffin would get from $12 billion the government was spreading among hospitals in coronavirus hot spots.
The answer arrived in a May 1 email, on a Friday night at the end of a long week. Twelve Connecticut hospitals were sharing $291 million. Griffin was getting none.
Under a threshold Charmel had not known before, hospitals needed to have had 100 cases by April 10 to qualify. Griffin hit its 100th case April 21.