In the early months of the pandemic, masks for medical personnel were in such short supply that providers, states, and the federal government were all bidding against each other to secure them. Gowns were so hard to come by that reports surfaced of nursing home workers using trash bags as makeshift coverings.
The government attempted to alleviate some of the shortages, with the Federal Emergency Management Agency (FEMA) distributing personal protective equipment (PPE) to U.S. nursing homes. Reports quickly emerged indicating that the items were faulty, however — and in any case, the two-week supply officially sent out would have been of limited assistance in a pandemic that skyrocketed the usage and cost of PPE in skilled nursing facilities that historically had never used it in such quantities before.
With COVID-19 surging across most of the country as fall turns to winter, demand for PPE is on the rise again across all health care settings. But for SNFs, there is some improvement in the supply landscape — if they have a relationship with a national supplier.
“For [the post-acute market], if you’re utilizing a national vendor, then you’re in pretty good hands,” Michael Greenfield, the CEO of the post-acute-focused purchasing organization Prime Source Healthcare Solutions, told Skilled Nursing News on November 13. “If you’re using a company like Medline, then you’re doing much better than most other people who are using smaller local regional vendors. And the reason is, because you’ve been a devoted customer of theirs for a long time, you’re on what’s called allocation.”
Planning PPE with predetermined amounts
Allocation has become something of a buzzword among providers, according to Greenfield, who is also one of the co-founders of the Society for Healthcare Organization Procurement Professionals (SHOPP), an organization for long-term care purchasing directors.
Ari Stawis, director of professional services and development at consulting firm Zimmet Healthcare Services Group who leads education on behalf of SHOPP, explained allocation this way in a November 16 interview: A facility would get, as an example, 15 boxes of gloves a month and work that into its operations.
Prior to the pandemic, health care providers could decide how much PPE they needed; allocation eliminates that.
When it comes to COVID-19 outbreak situations, SNFs might need to have more PPE on hand than their original allocation allowed. But national distributors — such as Medline Industries, McKesson (NYSE: MCK) and TwinMed — are making an effort to prioritize facilities that have COVID-19 patients for equipment, both Greenfield and Stawis told SNN.
“I can tell you from case studies that we have that any facility that has COVID-related patients goes on the top of the priority list for the national distributors,” Greenfield said. “So they might go to other facilities and say, ‘Hey, we know we allocated this to you. But you don’t have any COVID patients, we have other facilities that have COVID patients, we need to up their orders and lower yours potentially.’ And they work around it and they prioritize the ones that get COVID.”
In some states, such as New York, SNFs are required to have a stockpile PPE on hand. For Scott LaRue, the president and CEO of ArchCare, the Archdiocese of New York’s health care system, this means having a 60-day supply of PPE onsite at each of ArchCare’s five nursing homes.
In addition, because ArchCare provides several home and community-based programs in addition to nursing home care, LaRue rented a warehouse in New Jersey with a 90-day supply of PPE on hand for the entire system.
It’s a drastic change from the how system used to operate before the pandemic, he told SNN on November 16.
“If you took any one of our homes, there might have been three to five people on isolation at any given time,” LaRue explained. “The amount of supplies that we would normally have would be for roughly three to five people in isolation at any given time, and N95 masks were not something that were used in the nursing home environment pre-COVID.”
TwinMed, which is based in Santa Fe Springs, Ca., works with providers in states that require nursing homes to store PPE and keep a certain amount of inventory — but when it comes its own allocation, it tries to make sure that providers are using the product as much as possible rather than stockpiling, CEO David Blonder told SNN on November 16.
During the height of the pandemic, TwinMed put together allocations based on existing customers’ existing usage pre-COVID, then adding a certain percentage on top of that. The goal was to ensure providers were using the PPE they were ordering, and according to Blonder, no provider that asked for extra product was denied.
“We tried very hard to allow facilities to use the product that they’re ordering, and not just stockpile product,” he said. “That would defeat the purpose and then exacerbate the problem.”
That was during the pandemic’s peak earlier in the year, however, and now almost every PPE category is off allocation except for gloves, Blonder said.
Most — not all — supplies rebound
Gloves remain an area of critical shortage in terms of PPE, for a few reasons, Greenfield explained to SNN. Masks were critically short at the start of the pandemic because of how badly they were needed, but it is much easier to produce masks and keep up with demand for them then it is to produce gloves, he said.
“It’s very difficult to make gloves,” Greenfield told SNN. “You have to have the right material, and you have to have the right machinery, and you have to have the right labor cost and production cost in order to keep up with the market. And gloves are used 100 times more than masks … each nurse has to change their gloves between each patient that they go see. And [they’re] very, very difficult to come by because the entire world is demanding gloves.”
Gloves are also much more regulated, with a Section 510(k) requirement from the Food and Drug Administration (FDA), explained Meyer Greenbaum, who served as executive vice president of business development at TwinMed for 18 years before founding his own firm, Cutting Edge HC.
That means “medical device manufacturers are required to submit a premarket notification if they intend to introduce a device into commercial distribution for the first time or reintroduce a device that will be significantly changed or modified to the extent that its safety or effectiveness could be affected,” according to the FDA’s “510(k) Clearances” overview.
“The barrier to entry is enormous,” Greenbaum explained. “The cost of one production line, which is a high-efficiency, double stack, automatic strip line — it can’t manufacture, if it’s running at full tilt, more than more than 27, to 30,000 cases a month. That’s 300,000 boxes. Now just some perspective: States, facilities, health systems, they’re ordering in the millions of boxes, in the tens of millions of boxes. This is just simply unprecedented.”
There is also a shortage of wipes that are approved by the U.S. Environmental Protection Agency, though there are several varieties of disinfecting wipes available, both Meyer and Blonder said.
Greenfield also pointed to shortages of wipes; and he, Stawis, Blonder and Greenbaum agreed that overall prices are somewhat returning to equilibrium from the spring’s early spikes, though perhaps not entirely back to their pre-COVID levels.
Some reports have surfaced of widespread equipment shortages, but there may be some nuances to these reports. The AARP has reported shortages on a dashboard released in October that provides four-week snapshots on a variety of COVID-19-related metrics. But there’s a lag to the data — the most recent weeks covered are September 21 to October 18 — and a shortage of PPE is defined as “having no supply, or not enough supply of each type of PPE for at least one week for conventional use, for at least one week out of the four weeks in the reporting period.”
Another potential reason some facilities may be short is another facet of the current PPE situation that both Stawis and Greenfield emphasized: While the majority of SNF providers use national suppliers for PPE, there are still a fair number of SNFs who use regional distributors, and these firms have been struggling during the pandemic. Providers in rural areas, for instance, may have a harder time securing supplies, Stawis told SNN.
But overall, PPE supplies have mostly returned to normal, he said, the shortages of specific items like gloves and wipes notwithstanding. In addition, SNFs have made improvements in managing COVID-19 that have, in some ways, made PPE more readily available.
“The biggest change in helping with efficiency is that people have really created COVID units,” Stawis said. “Before, when there was a COVID patient, it would turn into a state of emergency for the entire building, which would turn it completely upside-down. Now, as we’ve sort of progressed and gotten smarter … that allocation can be allocated better, based on the COVID unit.”
Another change for the better, according to LaRue: Supply chains have gone mostly back to how they proceeded before.
“In April, the suppliers were kind of usurped by the state and the federal government,” LaRue told SNN. “Our normal supply chains weren’t even allowed to deliver to us during the height of the pandemic. And that changed and we were able to go back to our normal suppliers. They were able to — with difficulty, I’m not going to say easily — but they were able to fulfill our orders.”
In fact, several of the orders ArchCare placed with vendors in the spring only started to trickle in during late summer and early fall.
“I just received my order of gloves that I placed last the first week of last May. I received these last week,” LaRue noted.
At one point during the early days of COVID-19, ArchCare had to hire a compliance firm to vet potential vendors because of the number of overseas companies offering PPE with little corporate history.
None of these steps were cheap for ArchCare. The federal stimulus funds, FEMA funds, and Small Business Administration loans have kept the system from “a very precarious position,” and its occupancy is down 20% from a normal 99% rate, LaRue told SNN.
But the expenses are not optional when it comes to keeping the residents and the employees safe, he added.
“We’ve had to make organizational adjustments due to the economic reality,” LaRue said. “At the same time, we spent more money on PPE and investments in infection control than we ever had before. We’re talking about millions of dollars here on PPE and infection control investment.”