Rural hospitals stave off mass exodus of workers to vaccine mandate


St. Luke CEO Steve Todd said he was feeling “surprisingly good” about the mandate’s implementation.

“I’m a little bit relieved that we didn’t have a more dire situation,” Todd said. “There was a lot of saber-rattling by staff … I’m pleased that they stepped up.”

The doomsday predictions from some Republican governors and lawmakers, who warned the mandate would lead to a workforce crisis and limit care, particularly in rural areas, have not been borne out.

Hospital officials in Arkansas, Colorado, Indiana, Maine, Montana, Nebraska, Nevada, North Dakota, South Dakota, Tennessee, Virginia, West Virginia and Wyoming said they are still facing significant staffing shortages, the result of longstanding recruitment and retention challenges exacerbated by pandemic-era burnout. Over the last two years, those employees who remain have been subject to increased threats and acts of violence.

And many hospitals are filling the open jobs with traveling hospital workers who are stressing their budgets. Ballad Health, a health system serving parts of Tennessee, Virginia, Kentucky and North Carolina, for example, is paying staffing agencies a rate that comes out to $125 million a year for 400 contract nurses.

But the vaccine mandate, which applies to all health care employees, not just doctors and nurses, is not the wholly encompassing issue two dozen mostly red states envisioned it would be in a lawsuit filed last fall challenging the federal rule. In their complaint, the states said the mandate would “exacerbate an alarming shortage of healthcare workers, particularly in rural communities” and “foreshadow an impending disaster in the healthcare industry.”

Even after the Supreme Court in January allowed the federal health care worker vaccine mandate to move forward, West Virginia Gov. Jim Justice and Virginia Gov. Glenn Youngkin warned CMS that the vaccine rule would have a “particularly acute” impact on rural parts of their states and “access to lifesaving care could be threatened” because of staff lost to vaccine mandates, asking the agency for additional flexibility on the rule’s enforcement in rural facilities.

CMS, in a letter to the two governors last week, asked the states to instead provide a list of facilities they are concerned about and said the agency would contact them directly “to better understand their individual circumstances so we can help them come into compliance.”

Several rural hospital executives said they believe all hospitals should be held to the same standard and that waiving the vaccine mandate for rural hospitals would have done more harm than good.

“These attempted interventions by these two governors appear to be purely political and clearly put patients at risk,” said Mark Nantz, Valley Health System’s CEO. “Losing people in these times is always a challenge but what we found was these folks were … not connected to our mission vision and values and we are much better off without them.”

A bifurcation in enforcement, the rural hospital leaders said, could exacerbate staffing challenges by driving unvaccinated staff from urban to rural facilities.

“Rural health does not want to be known as the place where people who aren’t vaccinated go to get work. We have to have the same standard as the urban hospitals do,” said Kevin Stansbury, CEO of Lincoln Community Hospital in Hugo, Colo., on the eastern plains. “I honestly welcome both the state mandate and the federal mandate for the idea that if we’re all subject to it, just like we are all these other vaccine mandates, it won’t be used as a lever to say, ‘Well, if you don’t let me stay here, then I’m going to quit and go somewhere else.’ It’s a level playing field.”

Not all rural hospital officials support the federal mandate, though. While Alan Levine, CEO of Ballad Health, said the health system has “leaned very heavily” into educating its staff about why they should get vaccinated, he called the federal health care vaccine mandate “clumsy.”

“You can’t treat rural communities the same as you treat urban and suburban communities, and the lack of understanding of those differences is going to create some potential harm,” Levine said. “I can’t believe the federal government would go to a health manpower shortage area and tell us you have to fire people if they don’t get vaccinated. It makes absolutely no sense.”

Even so, Ballad’s vaccination rate has significantly increased in recent days. The number of unvaccinated people without an exemption dropped from 420 at the beginning of the month to 63 as of Friday. Levine attributed the decreases to an education effort as well as bonuses the hospital is awarding to staff.

Some hospital leaders, however, told POLITICO they were only able to come into compliance with the CMS mandate and maintain adequate staffing levels because they granted so many medical and religious exemptions.

Matt Walker, CEO of William Bee Ririe Hospital in a remote eastern Nevada mountain town called Ely, said 28 of his employees have been granted exemptions from the mandate, or about 15 percent of the hospital’s staff, putting the facility’s vaccination rate at roughly double the surrounding community. Twelve employees, he said, would have quit if not for the exemptions, likely forcing the hospital to shut down its OB/GYN unit and, possibly, its operating room.

The next closest hospital, also a tiny rural hospital, is more than a two-hour drive.

“It truly would be devastating for us,” Walker said. “It would’ve been very bad if we didn’t allow the exemption.”

Many hospital leaders said the request for religious exemptions put them in the uncomfortable position of having to judge whether a belief is “sincerely held,” the standard used when determining whether to let someone opt out of immunization.

“That is the between the rock and hard place that you find yourself in,” Todd said. “At the end of the day, it’s a balance of ensuring we’re compliant, ensuring we’re being as safe as we possibly can for our community but at the end of the day we have to be able to provide those services to the community members and patients because it can be a life and death situation.”

Several rural hospital officials that implemented vaccine mandates last year — ahead of the federal requirement — believe any issues hospitals are experiencing now following the mandate are partly of their own making. By implementing mandates on their own timelines, those rural hospital officials said they had the time to engage one-on-one with their hesitant staff and explain to their communities why they were putting a mandate in place.

At Millinocket Regional Hospital, about an hour’s drive from the Canadian border in Maine, CEO Robert Peterson personally combed through medical journals, printed them out and highlighted them to give to a staff member who was worried about getting the vaccine because she was starting a family soon. Peterson’s hospital now has a 100 percent vaccination rate, with no religious exemptions.

“If you’re going to drop a hammer and be heavy-handed, you can do it very quickly. You can just tell people, ‘Look, you need to be vaccinated by such and such a date, and if you’re not vaccinated by such and such a date, you have to look for employment elsewhere,’” Peterson said. “But if you’re going to do it in a less heavy-handed way, then you need to buy yourself some time because we had quite a few people that we needed to sit down with.”

And in Shelton, Wash., Mason General Hospital’s Chief Medical Officer Dean Gushee spent an hour with an employee who he said had been “reading a lot of misinformation.”

“I spent a good hour with her, talking it through and answering the questions, and at the very end of it, she said that she would get the shot as long as I gave it to her, which was the riskiest part of the whole thing since I’m a doctor — I don’t give shots,” Gushee said. “Anyway, she survived to tell the tale, kept her job, and didn’t have to get an exemption.”



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