Nurses care for patients in the COVID-19 unit within the Progressive Care Unit at University Hospital in Columbia (Justin Kelley/MU Health Care).
When Susan Klotz heard the governor had announced he would be allowing the COVID-19 state of emergency to expire at midnight on New Year’s Eve, it sent her and her patients into a panic.
Klotz, a family nurse practitioner, started her own clinic in Ash Grove with her husband during the pandemic. To help deal with a healthcare staffing crisis spurred by the coronavirus, the emergency order waived a requirement that nurse practitioners like Klotz practice within 75 miles of their collaborating physician.
With the waiver, Klotz could collaborate with a physician in Columbia, allowing her to see an average of 30 patients a week — many who require home visits and a intrathecal baclofen pump to deliver medication directly into their spinal fluid.
With the omicron variant fueling a spike in COVID cases and hospitalizations across the state, Klotz expected the emergency order would be extended, at least temporarily. But the day before the waiver was set to expire, Gov. Mike Parson announced that he decided not to extend it — sending Klotz into a scramble to make sure her patients didn’t lose care.
“I just was at a loss,” Klotz said. “I knew it wasn’t an option to discontinue care.”
Klotz wasn’t the only one caught off guard.
Emails obtained by The Independent through an open records request show that in the two weeks leading up to Parson announcing that the state of emergency would be allowed to expire, health care associations, hospitals and lobbyists were urging the governor to extend the order.
If he did decide to let it expire, they pleaded that he give them enough notice to make proper arrangements.
But notice never came.
Emails show the governor’s office remained tight-lipped leading up to the announcement — even as rumors were swirling and Parson’s staff were drafting a press release to unveil the governor’s decision.
“I can’t tell you how disappointed I am in the governor’s decision to do this, especially in light of the increase of COVID cases recently. And I am shocked he would do this with one day notice,” Kyna Iman, a lobbyist who represents the Missouri Nurses Association, wrote to Jamie Birch, Parson’s deputy policy director, hours after the news release was issued.
The governor’s decision came at a time when the state was seeing a wave of COVID cases fueled by the omicron variant. Within weeks, the state was seeing cases and hospitalizations rise to their highest levels for the entirety of the pandemic.
Later that month, a 40-member U.S. Navy medical team would begin arriving in North St. Louis County to aid strained hospitals.
It was a crush of cases that home health providers were also experiencing among their patients and staff, said Carol Hudspeth, executive director of the Missouri Alliance for Home Care.
“That’s why it was such a shock,” Hudspeth said in an interview, noting she found out about the declaration’s expiration the day Parson announced it.
“It’s not that easy to just flip a switch,” she said, “and one day you’re under a waiver, and the next day you can go back to business as usual.”
A broad emergency declaration was first issued in mid-March 2020, and extended five times. In late August 2021, Parson enacted a scaled-back executive order specific to healthcare issues, like staffing shortages and telemedicine.
The order had been set to terminate Dec. 31. The governor’s office issued its news release making the decision public just after 4 p.m. on Dec. 30.
A spokeswoman for Parson did not respond to a request for comment. But in the news release the governor noted that less than half of states still had COVID-19 states of emergencies in effect and that the peak of nearly 600 waivers issued had fallen by 80%.
“It is time to take this final step and move forward as a state,” Parson said in the news release.
‘We are beyond anxious’
In late December, CoxHealth, a hospital system in Springfield, had seen the number of COVID-19 positive patients admitted nearly double from 66 to 110 in just eight days.
Waivers issued under the state of emergency allowed hospitals to exceed their licensed bed capacity, so the hospital had 81 intensive care unit beds and additional step-down beds that were being used to help treat patients.
“If a solution is not discovered, those beds shut down at midnight Friday, throwing our community into a crisis,” Kaitlyn McConnell, a former CoxHealth spokeswoman, wrote to Kelli Jones, Parson’s spokeswoman, on Dec. 29 seeking clarity on the governor’s decision. “We trust and know the staff is working on a solution for this, but we are beyond anxious.”
McConnell anticipated that the state of emergency’s possible expiration would come up at a press conference the hospital was holding later that afternoon. She asked Jones if she had suggestions for how to answer media questions “in a way that demonstrates collaboration with the governor” and even offered for the hospital system’s president and CEO to speak with Parson.
Jones responded to McConnell the following day, saying she had left McConnell a voicemail and could talk if she was still interested. Later that afternoon, Parson’s announcement was made.
In the days leading up to the Dec. 31 state of emergency’s expiration, numerous other healthcare organizations were similarly unsure as to what they should tell their members and implored Parson’s office to keep the declaration in place.
A lobbyist for BJC HealthCare sent lists of specific waivers the hospital system would like to see extended, and statewide associations highlighted the stress their providers were still under as they grappled with inadequate staffing, overloaded hospitals and staff leaving the field.
“The EMT’s and paramedics that serve the citizens of Missouri are exhausted,” Justin Duncan, president of the Missouri Emergency Medical Services Association, wrote in a Dec. 23 letter to the governor.
Jane Drummond, the Missouri Hospital Association’s general counsel and vice president of legal affairs, asked Parson’s general counsel, Andrew Bailey, for a few days notice before any decision was made.
“I am hopeful that with the current level of hospitalizations and the unknowns related to omicron, he will be inclined to keep the status quo in place,” Drummond wrote in a Dec. 20 email. “If for any reason he is not, we would really appreciate a few days’ advance notice so we can be prepared to help our members who are still utilizing waivers figure out how to adapt.”
Even state officials in other departments were unsure.
“I am curious about the waivers and whether they are going to continue after Saturday. Any information you have is appreciated as the executive directors that have waivers are curious,” Sarah Ledgerwood, chief legal counsel for the Department of Commerce and Insurance’s Division of Professional Registration, asked an attorney in Parson’s office on Dec. 30.
It was the second time in three days that Ledgerwood had asked for an update.
“Any update yet?” Hudspeth asked Parson’s legislative budget director on Dec. 29. “My email has been blowing up from providers asking……”
At that point, staff in Parson’s office had already begun working on a draft news release to announce the emergency declaration’s expiration.
Days after the emergency declaration expired, St. Louis hospital leaders said they were “panicked” as they faced the highest numbers of COVID patients they had seen yet. The declaration’s expiration had taken away vital tools, they said during an early January press conference.
The Missouri Hospital Association (MHA) had been quick to criticize Parson’s decision at the time. Looking back, Dave Dillon, a spokesman for MHA, said “our system didn’t break, it managed to bend,” in part because of the quick flexibility the state health department granted to ensure hospitals could still provide the necessary care to patients amid the transition.
The Department of Health and Senior Services granted requests to extend certain waivers that had been authorized during the state of emergency to help providers endure the strain experienced by the virus.
Randy Berger, a spokesman for CoxHealth, said DHSS had approved such a request to continue to operate its 81 intensive care unit beds and an open-ward COVID-19 unit temporarily after the declaration’s expiration while it awaited formal approval, which the hospital system received in early January.
“This let us address our most urgent needs,” Berger said, “which included maintaining our ICU and step-down capacity.”
While some waivers were able to quickly get reinstated, others have fallen by the wayside.
Dillon said state boards have not moved quickly to restore flexibilities that allowed out-of-state clinicians to easily work in the state without a Missouri medical license.
The expiration of a waiver allowing nurse practitioners and physician assistants to order home health services without a physician’s sign-off has created delays in care, Hudspeth said. A bill has been filed for a second year to change state law to make the waiver permanent.
“It’s really unfortunate that who’s suffering in the end is our patients,” Hudspeth said.
The Missouri Nurses Association is similarly advocating to relax restrictions nurse practitioners must abide by, including eliminating the 75-mile geographic boundaries for collaborating physicians.
Lori Croy, spokeswoman for the Department of Commerce and Insurance, said the Missouri Board of Registration for the Healing Arts discussed the regulations with both the Missouri Nurses Association and the Missouri Board of Nursing during its January board meeting, and will once again raise the issue on its February conference call.
For Klotz, things ultimately worked out for her and her patients. But she said the last minute scramble could easily have gone much worse.
When the waiver expired, she offered to put her collaborating physician in a hotel for a few weeks in order to continue treating her patients. After a flurry of calls, she was able to secure an agreement with a Springfield physician three days after Parson’s announcement.
“I just felt like yet again, another health system, another governmental body was ready to let my patients down,” Klotz said, “and was willing to let their quality of life and even their life be put on the line for that.”
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