By Jeff Overley

Law360 (June 26, 2020, 6:54 PM EDT) -- In this edition of Coronavirus Q&A, the Arizona Hospital and Healthcare Association's chief executive officer discusses how a surge of COVID-19 is affecting patients of different ages, policy priorities involving litigation immunity and emergency waivers, and how large urban hospitals are scrambling to shuttle in personnel and serve patients from other areas.

Ann-Marie Alameddin became the association's general counsel in 2015 and assumed the roles of president and CEO in 2019. She shared the perspective as part of a series of interviews Law360 is conducting with attorneys across the country regarding legal, regulatory and business fallout from the coronavirus pandemic, which is suddenly engulfing Arizona and other states across the southern U.S.

Alameddin was an in-house lawyer at an Arizona hospital system before joining the Arizona Hospital and Healthcare Association, which is based in Phoenix and has roughly 60 member hospitals in the Grand Canyon State.

This interview has been edited for length and clarity.

Arizona has been experiencing alarming growth in COVID-19 cases. What do things look like at hospitals, and what work are you focused on?

We are on the wrong end of an increasing trend right now, and we're carefully watching it and trying to provide the support our hospitals need. Since the opening of the economy back in mid-May, we have seen increasing occupancy in both the ICU and inpatient [settings]. It used to be about 80% a couple weeks ago, and now it is 88% statewide.

So hospitals are managing their elective procedures accordingly, per an executive order that was issued at the end of April. We want to make sure there is enough capacity to take care of patients who need critical services. Car accidents, strokes, heart attacks — people still have these events, and we want to make sure we can provide care when patients come to our door.

COVID-19 is increasingly infecting younger people — what are you seeing in terms of patient ages?

In terms of the percentage of positive patients, we are seeing increasing numbers for those who are 20-44 years old. COVID-positive cases for that age group are about half of the positive cases in Arizona.

But then when you go to hospitalizations, more of those are older patients. So it's exactly the population that we have heard about — the vulnerable population, those who are over 65 and those who have comorbid conditions.

Much of the attention on Arizona's situation has focused on the greater Phoenix area. What are hospitals experiencing there?

The Arizona Department of Health Services developed the Arizona Surge Line so that hospital patients in rural areas could be transferred to higher levels of care if they require ICU and specialized services. We had a lot of transfers from the northern hot spots — the Navajo Nation was part of that early wave.

And now we're seeing that ICU beds in metropolitan Phoenix and Tucson are filling. We're seeing ICU occupancy at 88% today. It's an issue. Another issue is staffing — ICU nurses and respiratory therapists are the specialties that are most needed. So we're engaging with staffing agencies to see if we can get more [short-term providers known as] travelers, who perhaps served in New York during its surge, to provide care for patients in Arizona.

You mentioned the Navajo Nation, which has been hard hit. How are other communities outside of dense urban areas doing?

If you look at Yuma County [in southwestern Arizona], that's another area that has had an increase in hospitalizations, as well as Santa Cruz County [in southern Arizona]. So it's certainly not just the metropolitan areas that have seen those increases.

And we do worry about the ability to continue to transfer from rural areas as the ICU capacity of the metropolitan areas is used. Because if you reach your capacity, you're unable to accept transfers. That's the concern, and that's what we hope we stay well under.

Does it feel like hospitals are still pretty far away from the breaking point?

Unfortunately, the answer is that time will tell. We had a really important development with [Republican Gov. Doug Ducey] allowing local municipalities to mandate masks. That was the right move. We needed that from a public health perspective, because masks work.

Frankly, walking around Phoenix a couple weeks ago, it was hard to believe that we were in a pandemic, because there were so many people carrying on business as usual. Now, people are wearing masks, at least in Phoenix, and we have mask mandates across the cities and counties of Arizona.

When I'm walking around grocery stores on the weekend, people are masked, and that's exactly what we needed. So I hope in 10-14 days we're going to be on the decline because we had this really important public health intervention that worked.

Compared to hospitals in the Northeast, hospitals in Arizona had extra time to prepare. How did that help? Were there limits to what preparation could achieve?

It was certainly helpful that we could create surge plans for hospitals to expand their bed capacity; those have been in place since late April.

One challenge is that, if there were travelers who went to New York, a lot of those hospitals are retaining those travelers, not knowing what capacity needs they will have in the future. So we're seeing a tighter market on staffing agencies generally right now. That's a concern for us.

Are we seeing bidding wars between providers in different states for a limited pool of traveling providers?

Certainly staffing agencies are at a premium. But this is their business — they provide a national scope of clinical resources that can be deployed in different geographic areas. It's unfortunate, right now, the number of states that are in need of these services — Texas, California, Arizona.

Certainly the costs have gone up with regard to staffing, which just adds to the financial challenges that hospitals face in this pandemic. It's securing adequate PPE [personal protective equipment]. It's securing staff. It's getting the supplies necessary to meet surge. There are a lot of financial challenges.

The CARES Act funding for hospitals has been crucial. And we are looking for more support, because this is a long-term pandemic. Until we have a vaccine, we will be fighting this pandemic. And we need federal and state support to allow hospitals to do that.

The cancellation of elective procedures has cost hospitals huge amounts of money. What's the status of those procedures in Arizona?

We are currently under an executive order that required a certain level of PPE — for electives to resume, hospitals had to attest that they met a certain level of PPE and that they were not over 80% ICU capacity. And if an ICU did go over 80%, that they would stop and manage those elective procedures accordingly.

And that's where we're at — many ICUs are over 80%, and the statewide average is 88%. So those hospitals in Arizona are responsibly managing their electives at this point. They're doing those surgeries that are necessary to take care of critically ill patients. But if procedures could be delayed for another time, they are being rescheduled.

And I think it's important to allow hospitals flexibility to manage the safety of their patients. Hospitals are very equipped to do this. It depends on community spread in any given city. It depends on the hospital's capacity. It depends on their medical staff — a whole host of variables that are very difficult to mandate with an executive order. So I really appreciated that the governor gave hospitals the latitude to make those determinations. Because it's different in Maricopa County [where Phoenix is located], it's different in Pima County [where Tucson is located], and it's different in the rural counties.

There was hope that by now the pandemic would have stabilized somewhat, but things are getting worse. What does that mean financially for hospitals?

Hospital finances will continue to be strained as we meet the challenges with this pandemic. For all the reasons we talked about: the higher costs of staffing agencies, the prices of PPE and the amount of PPE that's required to take care of COVID-positive patients. The health care industry really needs to be invested in and strengthened by the state and federal policymakers.

So when negotiations begin on the next relief bill in Congress, what are hospitals going to seek?

There's a House infrastructure bill called the Moving Forward Act that has $30 billion for hospitals to increase capacity, strengthen care and modernize facilities to meet the demands of the pandemic. We are in contact with our Arizona congressional delegation, really highlighting the importance of this.

And what we have our eye on most closely at the federal level is the declaration of the public health emergency. That is set to expire on July 25, and with it, all sorts of flexibilities that allow the health care industry to respond.

So we sent a letter to the Trump administration requesting an extension of that public health emergency, and we will be talking to our delegation about that, because we need that continued flexibility and support. It allows us to do things we can't do in a normal situation with regard to regulatory waivers, flexibility on Emergency Use Authorizations, funding through [the Federal Emergency Management Agency], all sorts of things. We need those levers to support the health care industry.

What are the most important things that Arizona policymakers could do for hospitals right now?

Our biggest push this month was really to get a mandate on masks. We're really grateful those mandates happened at the local level and that the governor let the local governments do that — it was crucial.

And then, we need to increase access to tests and make sure that hospital inpatients get their tests turned around [promptly]. If hospitals don't have in-house labs that can run a rapid test, or if there are shortages of the rapid test, it can be four or five days of a patient in the hospital not getting their COVID test results back. That impacts capacity, because you're not able to discharge and you burn up more PPE and patients are left in limbo. So we have got to figure out multiple solutions to the testing problem.

And then the Trump administration has signaled they may not fund some of the federal testing programs. We need the federal support on that. Testing, contact tracing and treatment are the three keys of dealing with the pandemic. We need to increase testing, not pull back.

Arizona's governor, like many other governors and legislatures, granted immunity to health care providers for good-faith actions involving COVID-19. What effects has that had on litigation concerns?

The executive order granting additional immunity to providers was so important, because the state was really asking providers who had perhaps retired, or who have been practicing in other states, to come back and provide health care. You absolutely need to provide some heightened immunity during these really challenging times. You can't expect providers to come back if they are going to be subject to plaintiffs attorneys and litigation for years to come.

And we will be seeking, if we have a special legislative session in July or August, a statutory protection that would provide additional protection beyond what the executive order is able to do in a public health emergency. We want to make sure that we have heightened statutory protection that gives more immunity that providers can rely on.

Anything else you'd like to mention?

For your readers everywhere, in whatever state they might be residing in, we are living in this pandemic and everyone has to remain vigilant in terms of their own safety. That means social distancing. Wearing a mask when you're in public. Washing your hands. Staying home if you're sick.

We all have to be vigilant until we get a vaccine and we can go back to life as normal. But that's a ways off. So everyone has to do their part whether there's a mandate or not. We all have to be responsible for our own health and the health of our family and friends.

It has become very clear that the virus doesn't respect borders.

That's exactly right. And the virus also doesn't respect political views. I don't know why certain elements of this have been politicized. The virus simply seeks a human host. We're all people, so perhaps we should be focusing on our shared humanity, rather than our political views.

--Editing by Emily Kokoll.

Check out Law360's previous installments of Coronavirus Q&A.

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