U.S. Department of Health and Human Services 
Office of Inspector General 
Hospitals Reported That the 
COVID-19 Pandemic Has 
Significantly Strained Health 
Care Delivery 
Results of a National Pulse Survey 
February 2226, 2021
Christi A. Grimm 
Principal Deputy Inspector General 
March 2021, OEI-09-21-00140  U.S. D epartment of Health and Human Services 
Off ice of Inspector General 
 
Report in Brief 
 
March  2021, OEI-09-21-00140 
Scope of the Review  Hospitals Reported That the COVID-19 
This review provides a national snapshot, 
Pandemic Has Significantly Strained Health Care 
from the perspective of front-line hospital 
administrators, on how responding to the 
Delivery 
COVID-19 pandemic has affected their 
capacity to care for patients, staff, and 
Key Takeaways 
communities.  This is not a review of the 
HHS response to the COVID-19 pandemic.   In February 2021, hospitals reported that operating in survival mode for 
These hospital perspectives reflect a specific  an extended period of time has created new and different problems than 
point in timeFebruary 2226, 2021
experienced earlier in the pandemic and exacerbated longstanding 
provided during a pulse survey (brief 
challenges in health care delivery, access, and health outcomes.   
interviews) that OIG conducted with 
320 hospitals nationwide.  The timing was 
Hospital-Reported Challenges.  Hospitals described difficulty balancing 
nearly a year after the World Health 
the complex and resource-intensive care needed for COVID-19 patients with 
Organization declared COVID-19 to be a 
efforts to resume routine hospital care.  They reported that staffing 
pandemic on March 11, 2020. 
shortages have affected patient care, and that exhaustion and trauma have 
First Pulse SurveyMarch 2020 
taken a toll on staffs mental health.  Administrators detailed challenges 
We conducted our first pulse survey of 
associated with vaccine distribution efforts and concerns about vaccine 
challenges that hospitals reported facing in 
hesitancy among staff and members of their communities.  Hospitals also 
response to COVID-19 during the early 
weeks of the pandemic.  At that time,  raised concerns that the pandemic has exacerbated existing disparities in 
hospitals reported that they were largely  access to care and health outcomes.  Additionally, many hospitals reported 
focused on enhancing their capacity to  experiencing financial instability because of increased expenses associated 
respond to the pandemic.  Hospitals 
with responding to a pandemic and lower revenues from decreased use of 
reported challenges such as significant 
other hospital services.  Hospitals indicated that many of the challenges 
shortages in personal protective equipment 
were more severe for rural hospitals. 
(PPE), ventilators, and other supplies as 
demand increased across the country and 
Addressing Hospital Challenges.  Hospitals reported a range of strategies 
around the globe.  Hospitals also spoke of 
to address their challenges and identified areas in which further 
the challenge of needing to rapidly expand 
facility and staffing capacity.  Finally,  government support could help as they continue responding to the 
hospitals reported that, at the time, the lack  pandemic.  Broadly, the areas of government support included enhancing 
of testing capability to detect which  knowledge and guidance on the prevention and treatment of COVID-19, 
patients had COVID-19 negatively impacted 
including safe means to discharge patients with COVID-19; helping to fill 
hospital operations as they tried to prevent 
gaps in hospital staffing, especially for nurses and certain specialists; 
outbreaks among hospital patients and 
continuing financial relief, especially to increase care to rural and 
staff. 
underserved communities; and, encouraging widespread vaccinations to 
Since March 2020, the pandemic has 
reduce the circulation of the virus. 
continued to evolve.  This snapshot from 
2021 provides HHS and other  Looking Forward.  Beyond the immediate needs in responding to 
decisionmakers with updated information 
COVID-19, the pulse survey documents hospitals perspectives about 
on hospital perspectives.  Specifically, this 
longer-term opportunities for improvement to address challenges that 
pulse survey offers hospital administrators 
existed before, and were exacerbated by, the pandemic.  These include 
perspectives on the most significant strains 
that the response to COVID-19 has exerted  reducing disparities in access to health care and in health outcomes; 
on hospitals, as well as their perspectives on  building and maintaining a more robust health care workforce; and 
the longer-term implications of these  strengthening the resiliency of our health care system to respond to 
strains. 
pandemics and other public health emergencies and disasters.   
Report in Brief continued 
 
Report No. OEI-09-21-00140 
Limitations 
How OIG Did This Review 
The hospitals front-line perspectives 
This report is based on a pulse survey conducted during February 2226, 
provide an important voice, among many, 
2021, with hospital administrators from 320 hospitals across 45 States, the 
for HHS and other decisionmakers to 
District of Columbia, and Puerto Rico.  Interviews focused on three key 
consider as they grapple with the challenges 
presented or worsened by the pandemic.   questions: 
However, it is the perspective of hospital 
administrators at a point in time,  1.  What are your most difficult challenges in responding to the COVID-19 
February 2226, 2021.  OIG has not  pandemic right now, and what strategies have you been using to 
independently assessed the merits, costs, or  address the challenges? 
effectiveness of the strategies or areas for 
government support identified by hospitals.   2.  What are your organizations greatest concerns going forward?  
As such, OIG is not endorsing the 
suggestions made by the hospital  3.  How can government best support hospitals? 
administrators.   
Respondent hospitals included special pathogen centers, critical access 
Further, we recognize that HHS, Congress, 
hospitals, and a range of hospitals nationwide of various sizes and 
and other government entities across the 
characteristics.  We spoke with representatives from 320 hospitals that were 
Federal, State, local, and Tribal levels are 
part of our random sample of 397 hospitals, for an 81-percent rate of 
taking substantial actions on a continual 
basis to support hospitals in responding to  contact.  (See Methodology on page 38 for additional information about 
COVID-19.  For example, the recently  how we conducted this pulse survey.) 
passed American Rescue Plan Act of 
2021 provides additional support and   
funding that could help to address some of 
the challenges that hospitals identified. 
     
 
HOSPITAL CHALLENGES: HIGHLIGHTS 
 
 
Health Care Delivery 
Meeting the Health Care Needs of COVID-19 Patients 
Hospitals emphasized the significant clinical challenges in treating COVID-19 patients, some of whom are 
very ill, and patients with longer-term effects after recovering from acute illness.  Hospitals also reported 
difficulty in balancing the care needed for COVID-19 patients with efforts to resume routine hospital care 
and challenges in discharging patients to post-acute settings during their recovery, which strained hospital 
capacity.   
 
Delays in Care Resulting in Patients With More Serious Conditions 
Hospitals reported that patients have delayed or forgone routine health care as a result of the COVID-19 
pandemic, which has led to worsening of patient conditions.  Administrators predicted that widespread 
delayed care could result in higher hospitalization rates and need for more complex hospital care in the 
future.   
 
Increased Needs for Mental and Behavioral Health Care 
Administrators voiced concern that the pandemic has led to greater mental and behavioral health needs 
among patients.  Administrators anticipated that the needs for mental and behavioral health services at their 
hospitals would continue to grow and reported concern about meeting these needs.  
  
Worsening of Longstanding Challenges at Rural Hospitals 
Rural hospitals reported particular difficulty responding to the COVID-19 pandemic and that the pandemic 
had worsened longstanding challenges in staffing, limited capacity, and finances.  Hospitals explained that 
strategies employed by other hospitals, such as sharing clinicians across systems and providing telehealth 
services, may not work for rural hospitals due to remote locations and lack of access to technology.   
 
Concerns about Exacerbation of Health Care Disparities 
Hospitals raised concerns that the COVID-19 pandemic has exacerbated existing disparities in access to care 
and health outcomes.   
 
Benefits and Challenges of Expanded Telehealth Use 
Hospitals reported that telehealth has become an important care delivery model during the COVID-19 
pandemic.  Administrators also reported some challenges in delivering care with telehealth.  These 
challenges are that telehealth, by its very nature, cannot cover all aspects of health care delivery.  They also 
reported that some patients, particularly those in underserved communities, do not have the devices or 
internet access to conduct video calls. 
 
    Staffing 
Staff Burnout and Trauma
Hospitals reported that increased hours and responsibilities, along with other stressors caused by the 
COVID-19 pandemic, resulted in staff being exhausted, mentally fatigued, and sometimes 
experiencing possible post-traumatic stress disorder (PTSD).  Several hospitals reported that 
witnessing COVID-19-related deaths especially weighed on staffs mental health.     
Staffing Shortages Due to High Turnover and Competition
Many hospitals reported that they were experiencing concerning staff shortages, particularly among nurses, 
raising concerns for hospitals about patient safety and quality of care.  Hospitals also expressed concerns 
about the future of the health care workforce as the recruitment pool for nurses and other health care 
workers has continued to shrink. 
Vaccinations 
Diversion of Limited Resources to Vaccine Efforts 
Although hospitals viewed their vaccination efforts as a positive step toward pandemic recovery, several 
hospitals noted that these efforts come at a costfurther stretching limited clinical staff and straining 
hospital finances.  Hospitals reported that differences in government guidance on vaccine eligibility made it 
more complicated for them to determine who is eligible, requiring additional effort for hospitals.  
Vaccine Hesitancy Among Hospital Staff and the Community
Some hospitals reported that some staff and members of the community were hesitant to take the 
COVID-19 vaccine or declined to get vaccinated due in part to safety concerns.  Hospitals reported that 
some staff distrusted the rapid vaccine development and approval process and had concerns that the 
vaccines may not be effective or may pose risks.   
Ensuring Vaccination Access for Rural and Other Underserved Populations
Hospitals reported that vaccinating rural communities presented unique challenges that made it difficult to 
ensure vaccination access for residents.  Hospitals also reported needing to take extra steps to ensure access 
to vaccinations for some senior and low-income populations, such as those who do not have internet access 
or the technology skills to navigate online scheduling. 
Finances 
Financial Instability From Higher Costs and Lower Revenues
Many hospitals reported concerns about their financial stability as the COVID-19 pandemic had 
increased costs and decreased revenues.  They explained that their higher costs were associated with 
patient care, staffing, PPE, and COVID-19 testing and vaccinations; lower revenues stemmed from 
fewer routine and elective services and reimbursement rates that, according to the hospitals, did not 
keep up with increasing costs of care for some COVID-19 patients.     
 
TABLE OF CONTENTS 
 
 
 
 
HOSPITAL LOCATION AND OCCUPANCY  1 
FINDINGS  2 
Health Care Delivery  2 
Hospitals reported significant challenges in meeting the needs of COVID-19 patients and   
uncertainty about future COVID-19 caseloads 
Hospitals reported that the pandemic led to delayed care and feared that an erosion of trust   
in hospital safety would continue to keep patients from seeking needed care 
Hospitals expressed concern about meeting the increased need for mental and behavioral   
health care that has emerged as an outgrowth of the pandemic 
Rural hospitals reported that longstanding operational challenges have worsened during the   
pandemic 
Hospital administrators raised concerns that the COVID-19 pandemic has worsened existing 
disparities in access to care and health outcomes 
Hospitals reported the adoption and use of telehealth was beneficial and a change they want   
to retain despite some challenges 
Staffing  9 
Hospitals reported that increased workloads and the stress of treating seriously ill and dying   
COVID-19 patients have led to staff burnout and, in some cases, trauma 
Hospitals reported that high turnover and competition for medical staff have created staffing   
shortages that in some cases affect patient care 
Vaccinations  12 
Hospitals reported that vaccination efforts were positive steps toward pandemic recovery but   
exacerbated challenges with clinical staff shortages and hospital finances 
Differences in government guidelines regarding vaccine eligibility and prioritization created   
challenges for hospitals 
Hospitals reported that some hospital staff and members of the community were hesitant to   
get vaccinated 
Hospitals reported challenges in ensuring access to vaccinations for rural, senior, and   
low-income populations   
Hospitals reported frustration with the unpredictable and insufficient supply of vaccines   
Supplies  16 
Hospitals reported difficulty maintaining a steady supply of affordable, high-quality PPE   
   
Finances  17 
Hospitals reported that their operational costs have risen dramatically while their revenues   
have declined, threatening their financial stability 
Hospitals expressed uncertainty about rules on repayment of prior Federal loans   
ADDRESSING HOSPITAL CHALLENGES  20 
Hospitals reported implementing strategies to address challenges and described areas in which   
new and continued government support would be helpful 
Enhancing knowledge and guidance on the prevention and treatment of COVID-19   
Providing support to increase care to underserved communities 
Addressing hospital staffing needs and helping to support current staff 
Developing education campaigns regarding vaccines and other public health issues 
Providing ongoing support on financial issues 
Leading a coordinated emergency response 
LOOKING FORWARD  25 
Addressing Urgent and Systemic Challenges Exacerbated by the COVID-19 Pandemic   
SELECTED HOSPITAL STRATEGIES  26 
BACKGROUND  28 
GLOSSARY OF KEY TERMS  34 
METHODOLOGY  38 
APPENDIX: CHARACTERISTICS OF RESPONDING HOSPITALS AND THEIR  41 
COMMUNITIES 
ACKNOWLEDGMENTS AND CONTACT  45 
ABOUT THE OFFICE OF INSPECTOR GENERAL  46 
ENDNOTES  47 
 
 
   
HOSPITAL LOCATION AND OCCUPANCY 
 
Exhibit 1: The 320 responding hospitals were located in 45 States, the District of Columbia, 
and Puerto Rico. 
Source: OIG analysis of 320 responding hospitals using the address listed for their provider number, March 2021. 
Exhibit 2: Some responding hospitals were operating at an over 90-percent adult inpatient 
occupancy and/or an over 90-percent adult intensive care unit (ICU) occupancy. 
45 56
42
40
37 36
33
28 32 31 31
22
20 23
19
13 14
11
8
5
Inpatient Occupancy ICU Occupancy
Source: OIG analysis of HHS Protect data for February 17, 2021.
Note: For adult inpatient occupancy, the total equals 316 responding hospitals because not all hospitals reported data in HHS Protect.  For 
adult ICU occupancy, the total equals 230 because we excluded 86 hospitals that reported not having any ICU beds. 
Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care 
OEI-09-21-00140  Hospital Location and Occupancy | 1   
FINDINGS 
 
HEALTH CARE DELIVERY 
Hospitals reported significant challenges in meeting the needs 
of COVID-19 patients and uncertainty about future COVID-19 
caseloads  
Hospitals are at the forefront of health care delivery during the COVID-19 pandemic, 
and hospital administrators described the strain the pandemic has placed on patient 
care.  In some cases, hospitals reported that underlying problems with health care 
delivery were exacerbated, such as challenges providing care for underserved patients 
and challenges for rural hospitals with limited resources.  
The volume of COVID-19 patients and the complexity of their 
immediate and long-term needs significantly strained patient 
care and hospital operations 
Hospitals reported being overwhelmed by the volume of patients, especially during 
surges in COVID-19 infections.  They explained that this put a severe strain on their 
bed capacity.  Some hospitals reported that they operated at over 100-percent 
capacity during surges, and high occupancy continues for some hospitals.  At the time 
of our survey, 40 responding hospitals had over 90-percent inpatient occupancy and 
56 had over 90 percent of their ICU beds occupied.  (See the Appendix on page 41 for 
more information about the capacity and other characteristics of responding 
hospitals.)  One urban hospital, with a nearly full ICU the week before our survey, 
reported that it would do only urgent surgeries and discharged patients to their 
homes for recovery because of a shortage of recovery areas in the hospital. 
Hospitals emphasized the great clinical challenges in treating COVID-19 patients, 
particularly those with severe illness and comorbidities.  Hospital clinicians have had 
to keep up with emerging treatment protocols, often without sufficient specialty staff, 
such as infectious disease specialists, pulmonologists, respiratory therapists, and 
clinical nurses trained in treating COVID-19.   
COVID-19 patients with longer-term effects will also need complex specialty care.  
Hospitals reported seeing patients with serious post-COVID conditions, such as 
pulmonary issues, pneumonia, heart problems, and blood clots.  One hospital 
described a tsunami of people going forward who they predicted would experience 
long-term effects from COVID-19.   
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Administrators reported challenges in balancing the complex and resource-intensive 
care needed for COVID-19 patients with efforts to resume routine hospital care.  
Hospitals reported having difficulty integrating COVID-19 care into normal 
operations, chiefly because of concerns about infection control.  As hospitals 
reopened more services for patients after the early months of the pandemic, such as 
resuming elective surgeries, they experienced increased challenges in keeping 
infected COVID-19 patients separated from non-infected patients.  Complicating this 
further, hospitals explained that a new patients COVID-19 positivity status may not be 
immediately known.  
Hospitals reported challenges in discharging COVID-19 patients 
during their recovery, which affected available bed space 
throughout the hospital 
Hospitals reported difficulty in discharging COVID-19 patients following the acute 
stage of their illness, resulting in longer hospital stays.  Administrators reported 
challenges in transferring patients to post-acute facilities such as nursing homes, 
rehabilitation hospitals, and hospice facilities.  According to administrators, some 
post-acute facilities were either unwilling or unable to accept patients because the 
facilities were concerned about potential COVID-19 infections.  Others did not have 
bed capacity or staff to care for the patients. 
We have patients in the acute-care setting that really do 
not belong here in terms of what they need clinically but 
cant move on because there is not an available option.   
- Hospital administrator  
Administrators reported that delays in discharge affected available bed space 
throughout the hospital and had other downstream effects.  For example, hospitals 
reported that patient opportunities for specialized post-acute care (e.g., rehabilitation) 
were delayed.  Hospitals also reported that longer stays created bottlenecks 
throughout hospitals, including in ICUs and emergency departments.  As an example, 
one hospital reported that 13 of its 17 emergency treatment rooms were occupied by 
COVID-19 patients waiting to be admitted to the hospital.   
Uncertainty about future COVID-19 caseloads and the 
implications of new virus variants adds to hospitals challenges 
Administrators expressed concern about emerging issues such as new variants of the 
virus and vaccine efficacy.  Hospitals worried that the new variants could bring 
additional challenges and changes to treatment needs, infection control, and best 
care practices.  Administrators also had questions about the long-term efficacy of 
vaccines and worried about the possibility of future COVID-19 surges.  One hospital 
administrator asked, Are we out of the woods or will it come back again?  Another 
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hospital expressed concern that COVID-19 may become a regular seasonal infection, 
like influenza, which could present serious ongoing preparedness challenges given 
that COVID-19 is both more infectious and more deadly than the flu.1   
We are going to have to learn to live with COVID;  
COVID is not going away.  
- Hospital administrator 
Hospitals reported that continuing fluctuations in the number of patients with 
COVID-19 made it difficult to plan for the future.  Hospitals were cautious about 
taking steps toward resuming normal operations.  For example, one hospital not 
treating any COVID-19 patients the week before our survey reported that it was 
hesitant to repurpose its antibody infusion room or to fill rooms designated for 
isolation because of the risk of another wave of COVID-19 cases, despite other 
demands for this space.   
Hospitals reported that the pandemic led to delayed care and 
feared that an erosion of trust in hospital safety would continue 
to keep patients from seeking needed care 
Administrators raised concerns about the public not receiving needed health care 
during the pandemic due to patients delaying and forgoing care, as well as to 
hospitals suspending elective care due to COVID-19.  They reported that lack of care 
and reduced use of hospitals have had significant ramifications for patients and the 
hospitals that treat them. 
Hospitals reported that patients have delayed or forgone routine 
health care, which has led to worsening of patient conditions 
Many hospitals chose, or were required, to suspend elective surgeries and other 
services at different points during the pandemic to preserve resources for 
emergencies and COVID-19 surges, but according to administrators, delayed care has 
persisted past these early suspensions.  As causes of delaying and forgoing care, 
administrators cited patients fear of contracting COVID-19 and practical concerns 
such as difficulty finding transportation during the pandemic.  Hospitals described 
reduced patient volume across hospital departments and services, including 
emergency care, preventative care, chronic condition management, and surgeries.  
Delayed care included preventative and urgent care for serious conditions such as 
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heart attacks or strokes.  One administrator attributed some emergency room deaths 
at their hospital to patients not following up on their prior care needs. 
Things that are elective, if not dealt with over time, 
are no longer elective.  
- Emergency preparedness director 
Administrators predicted that such widespread delayed care would result in higher 
hospitalization rates and a need for more complex hospital care in the future.  They 
explained that when patients miss routine exams and diagnostic tests, such as cancer 
screenings and cardiology tests, serious diagnoses may go unidentified.  One 
administrator reported finding a sharp decline in cancer diagnoses during the 
pandemic, and that patients were not presenting for examination at the onset of 
symptoms.  Another administrator described seeing patients for diabetes and cardiac 
management who were sicker and required more care after postponing prior 
appointments.  One administrator reported, My only concern is how sick our patients 
are.  There was a long period of time where patients were not receiving primary care.  
We see the impact here almost daily with the symptoms patients are presenting with. 
Hospitals reported that public trust in hospital safety and 
credibility has eroded during the pandemic 
Hospital administrators perceived that some in their communities appeared to newly 
question whether hospitals are safe and can keep patients safe.  Administrators 
reported that patients continue to be concerned about contracting COVID-19 in the 
hospital despite the protective procedures that hospitals have put in place to mitigate 
exposure.  Some administrators speculated that this could be in part because of 
confusion over evolving public health guidelines during the pandemic.   
Hospitals voiced concern that some patients were less likely to trust hospital care 
recommendations as credible, possibly because the patients received confusing and 
changing messages about COVID-19 during the pandemic.  Administrators worried 
that lack of trust could contribute to patients further delaying and forgoing care.  One 
administrator said, "Unless we can get everyone on the same page to get routine 
health care, we shudder at the burden of disease that may occur." 
My concern is with our health care image in the community.  
There are people who have lost trust in our health care system.  
Our concern is about re-establishing trust among the community. 
- Hospital CEO 
 
 
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Hospitals expressed concern about meeting the increased need 
for mental and behavioral health care that has emerged as an 
outgrowth of the pandemic 
Administrators voiced concern that the pandemic has led to greater mental and 
behavioral health needs among patients.  They explained that these added needs 
resulted from many factors, including lockdowns, social isolation, and burnout.  
Administrators anticipated that the needs for mental and behavioral health services at 
their hospitals would continue to grow.  Administrators reported concern about 
meeting these needs, and about how mental health challenges can exacerbate other 
health problems.  One hospital reported concern for seniors in particular, observing 
that the elderly may be among the most vulnerable to depression associated with the 
pandemic. 
 In this pandemic, we talk about the death toll...but the 
morbidity that we are overlooking is mental health. 
-Administrator of two hospitals within a network 
Some hospitals believe that they may not have the capacity or resources to meet the 
increased needs for mental and behavioral health care.  For example, one hospital 
closed a psychiatric unit that focused on elderly patients because it needed the units 
staff to help serve COVID-19 patients.  In addition to inpatient care, hospitals often 
serve as a primary mental health provider in communities.  Some administrators 
explained that their role includes conducting mental health screenings and treating 
mental and behavioral health issues as comorbidities to other medical conditions.  
Hospitals reported that there was a need for additional resources and specialists to 
provide this care before the pandemic, and that the pandemic increased the need 
further.  Additionally, administrators reported that it can be more difficult to treat 
COVID-19 patients who suffer from mental illness or behavioral challenges. 
Rural hospitals reported that longstanding operational 
challenges have worsened during the pandemic 
Administrators reported that the COVID-19 pandemic has disproportionately 
hampered operations for rural hospitals.  For example, they reported that the 
pandemic has worsened longstanding challenges in recruiting and retaining staff, 
limited bed capacity, lack of access to specialized services, and financial strain.     
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Some hospitals raised that strategies used by other hospitals to address resource 
challenges, such as sharing clinicians across systems, may not work for rural hospitals.  
One administrator reported that rural hospitals do not have access to back-up 
resources, observing, As a rural community, we have a limited number of physicians.  
If one physician falls ill, were done.  A few rural hospitals reported attempts to 
provide more telehealth services to fill gaps in care, but their patients sometimes 
lacked access to the technology needed to use these services.  They also reported 
that limited patient access to technology, such as broadband internet access, affected 
other aspects of care, such as hampering outreach about vaccines.   
We are essential...If we were not here, I dont 
know where these patients would have gone. 
-Administrator, rural hospital 
Further, administrators reported that a lack of available beds at many larger hospitals 
sometimes prevented them from transferring COVID-19 patients and other critically ill 
patients.  Most rural hospitals are designed to provide urgent and routine care 
services for a wide geographic area and to transfer patients requiring specialty or 
intensive care to other hospitals.  One rural hospital in Louisiana that does not have 
an ICU reported that it was contacting hospitals in neighboring States because they 
had the closest available ICU beds.  Among our responding hospitals, 67 served rural 
communities and 28 of these hospitals operated fewer than 15 inpatient beds.  
(See the Appendix on page 41 for information on the communities served by the 
responding hospitals.)   
Hospital administrators raised concerns that the COVID-19 
pandemic has worsened existing disparities in access to care 
and health outcomes 
Hospitals reported that the COVID-19 pandemic has exacerbated longstanding 
problems with access to care, particularly for rural communities and for low-income 
populations across geographic settings.  Hospitals reported that many rural 
communities face health care provider shortages, transportation challenges that make 
it difficult to access hospitals that may be hours away, and lack of internet service to 
support using telehealth to reduce these barriers.  Many low-income individuals face 
barriers to health care (even in non-rural settings), including lack of health insurance 
or transportation.2  Hospitals also reported that low-income individuals may be 
unable to afford internet service or devices to support using telehealth to reduce 
these barriers. 
In addition, hospitals raised concerns about disparities in health outcomes, including 
higher incidence rates and severity of COVID-19 infections in certain communities, 
concerns raised by the others in the health care community throughout the 
pandemic.  According to the Centers for Disease Control and Prevention (CDC), 
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communities that have high levels of poverty, crowded housing, and other attributes 
associated with higher social vulnerability have been more likely to experience high 
rates of COVID-19.3  Among responding hospitals, 41 were located in counties where 
20 percent or more of the population had household incomes below the Federal 
poverty level, and 113 hospitals serve communities with higher social vulnerability 
than the national average according to CDCs Social Vulnerability Index.  (See the 
Appendix on page 41 for information on the communities served by the responding 
hospitals.)    
Administrators from hospitals in communities with higher social vulnerability reported 
deep concern about worse outcomes for many of their patients.  Hospitals also 
reported clinical challenges in treating patients with certain comorbidities that 
disproportionately affect people of color, such as heart and lung ailments and chronic 
illnesses such as diabetes, and that patients with these comorbidities are at higher risk 
of severe illness from COVID-19.4  These patients may enter hospitals at a more 
severe stage of illness, and require a higher level of care.  In some cases, hospitals 
explained that they lack this advanced care capacity or may lack the resources to treat 
a large number of vulnerable patients.  Hospitals reported that patients who have low 
incomes are also less likely to have access to primary care that could prevent disease 
worsening.   
Hospitals reported the adoption and use of telehealth was 
beneficial and a change they want to retain despite some 
challenges 
Administrators reported that telehealth has become an important care delivery 
modality for their hospitals during the COVID-19 pandemic, increasing patient access 
to care while reducing risk and workload for hospital staff.  Hospitals described a wide 
range of situations for which they implemented or expanded telehealth services, 
including connecting remote specialists to help severely ill patients in ICUs, 
conducting followup visits for patients recovering from COVID-19, conducting mental 
health services, and providing education for at-home care.     
The pandemic created a crisis for us to adopt this 
[telehealth] technology. 
- Hospital CEO 
Although administrators were overwhelmingly positive about the benefits of 
telehealth, they reported three key challenges in delivering care with this method.  
First, telehealth cannot cover all aspects of health care delivery and by its very nature 
lacks the in-person interaction valued by some providers and patients.  Second, 
technology created challenges for telehealth care delivery.  Hospitals reported that 
some patients do not have the devices or internet access to conduct telehealth visits, 
particularly in underserved communities.  One administrator worried that telehealth 
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visits do not work equally well for all communities.  Although some patients are able 
to conduct video calls, others must rely on audio-only telephone calls, particularly the 
elderly and those in underserved communities.  Third, some hospitals reported that 
they received lower payments for some services provided through telehealth than 
they would have received for in-person services, and they did not believe the 
payments reflected the value of those telehealth services. 
 
STAFFING 
Hospitals reported that increased workloads and the stress of 
treating seriously ill and dying COVID-19 patients have led to 
staff burnout and, in some cases, trauma 
Hospitals reported that increased hours and responsibilities, and other stressors 
caused by the COVID-19 pandemic, resulted in staff being exhausted, mentally 
fatigued, and sometimes experiencing possible PTSD.  Hospitals reported that for the 
past year, staff have worked longer hours, extra shifts, and mandatory overtime.  In 
addition, some reported that caring for higher level and critically ill patients who 
might have been transferred to other facilities prior to the pandemic caused 
additional stress on staff who felt ill-equipped to handle such care on a continuing 
basis.  Further, hospitals reported that staff were wearing many hatsbalancing 
multiple clinical and administrative responsibilities to cover the staffing gaps.  Other 
staff were pulled away from their normal duties to complete new COVID-19-related 
tasks.  For example, hospitals reported dedicating staff to meet COVID-19 data entry 
and reporting requirements, with one administrator describing it as very labor 
intensive.  Another hospital reported pulling staff from their regular duties to 
manage the thousands of incoming telephone calls when the community learned that 
the hospital had received vaccine doses.   
Several hospitals reported that the COVID-19-related deaths that staff witnessed 
especially weighed on their mental health.  One administrator observed that, with 
family unable to be present at patient bedsides, it has been heartbreaking for nurses 
to be the last person a dying patient sees.  Further, administrators reported that 
hospital staff experienced COVID-19 deaths among their coworkers, which took a toll 
on those remaining and continuing the work.  One representative from a hospital 
network described a monthly gathering for staff to mourn colleagues who passed 
Long-term solutions for staff fatigue, compassion fatigue, and possible PTSD 
will need to be identified so that we can help our staff be able to care for 
themselves, their families, and our patients. 
-Director of Nursing, hospital at 100% ICU occupancy 
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OEI-09-21-00140  Findings | 9   
away from COVID-19.  Adding to this emotional distress, hospitals explained that 
some staff have had to separate from their families for extended periods to protect 
their family members from infection.    
Administrators at one major teaching hospital (where, the week before our survey, 
nearly 50 percent of ICU patients had COVID-19) reported that treating COVID-19 
formerly involved everyone on staff but now involves only certain staff while others 
get to go back to normal.  The administrators explained that staff still treating 
COVID-19 patients experienced more fatigue attributable to loss of the teamwork that 
existed in earlier months of the pandemic, and a strong desire to return to normalcy 
like some of their colleagues.   
Hospitals reported that high turnover and competition for 
medical staff have created staffing shortages that in some cases 
affect patient care 
Hospitals reported that they were experiencing higher than normal turnover among 
medical staff, resulting in concerning staffing shortages.  Among our responding 
hospitals, 38 reported to HHS Protect that they faced a critical staffing shortage 
during the week before our pulse survey.  Turnover was particularly high among 
nurses, according to the hospitals.  One hospital in a high-poverty and socially 
vulnerable community in Texas (which was operating at 100-percent ICU occupancy 
the week before our survey) reported that its annual average for nurse turnover 
increased from 2 percent prior to the pandemic to 20 percent in 2020.  Hospitals also 
reported losing other types of staff in the past year, including respiratory therapists, 
certified nursing assistants, phlebotomists, laboratory technicians, and other support 
staff vital to hospital operations.   
Many hospitals attributed the increased turnover of staff to stress and burnout caused 
by COVID-19, leading some staff to retire early or seek jobs outside of health care.  
Hospitals also cited competition for health care workers and the opportunity to earn 
more money by leaving a hospital to join a staffing agency.   
Some hospitals reported struggling with the unexpected increase 
in competition for medical staff 
Administrators reported an increase in competition for medical staff, particularly 
nurses, among hospitals and staffing agencies.  Many hospitals reported that they 
were unable to compete with staffing agency salaries, with one administrator 
describing the competition over health care workers as a wage war.  Hospitals that 
lost nurses reported that they often experienced increased staffing costs from the 
higher hourly rates charged by staffing agencies.   
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OEI-09-21-00140  Findings | 10   
The cost [for agency nurses] has gone from $60$70 to 
$200 per hour now.  To get them in here to help has 
become an impossibility. 
- CEO, hospital that reported critical staffing shortages 
Smaller hospitals and rural hospitals reported that it was particularly hard for them to 
compete for staff with large urban hospitals, and that the inability to compete led to 
further shortages.  An administrator from a critical access hospital stated that they 
always had a few nursing vacancies that they could not fill, even with offering 
bonuses.  As another administrator explained, recruiting providers in a rural 
community is always difficult, but had gotten harder during the pandemic.   
Hospitals reported that staffing shortages posed challenges in 
maintaining patient safety and quality of care 
Hospitals raised concerns that the quality of care has suffered as a result of losing 
nursing staff.  Several administrators reported that staffing shortages have forced 
them to assign substantially more patients per staff, such as one administrator who 
reported that their hospital had to cut its staff-to-patient ratio in half for some 
periods during the pandemic, to 1-to-12 from 1-to-6.  Reduced staff-to-patient ratios 
can lead to mistakes when less attention is given to each patient.  Hospitals also 
reported that staffing shortages have resulted in staff having to work longer hours, 
extra shifts, and mandatory overtime for the past year.  Representatives from one 
hospital network reported that it had seen an increase in central line infections, which 
can be life-threatening.  They attributed the increase in these infections to not having 
sufficient staff and reported that staffs fatigue led to process failures.  Another 
hospital reported that feedback scores from patients on communication and quality 
had decreased and attributed that to tired and frustrated staff.   
Some hospital administrators reported quality of care concerns even when they 
bolstered staffing levels with traveling nurses, reporting that these nurses are not as 
familiar with the hospitals particular processes as nurses with longer tenures.  For 
example, one hospital attributed a rise in its hospital-acquired infections to the hiring 
of agency staff not trained in that hospitals infection control processes.   
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OEI-09-21-00140  Findings | 11   
Hospitals expressed concerns that a shrinking recruitment pool 
for nurses could continue to worsen staffing shortages  
Hospitals raised concerns that nationwide shortages of nurses and other health care 
workers, already a concern before the COVID-19 pandemic, had worsened as a result 
of the pandemic.  Administrators from several hospitals believed that the pandemic 
has deterred people from entering the medical profession, with fewer students 
seeking degrees in medical disciplines.  As one hospital administrator said, We cant 
overstate the staffing gap that exists now thats likely to get worse over the next few 
years.  An administrator from one teaching hospital reported that the hospital would 
typically recruit nurses who have completed training at the hospital, but this year only 
100 nurses were expected to graduate and the hospital had 200 open nursing 
positions.   
This [pandemic] has really burnt out the health care industry... 
I am concerned about what we are going to do about making 
people want to go into health care as a profession. 
- Hospital president 
Further, several hospitals expressed concern that, because of the pandemic, newly 
graduated nurses may not have gained sufficient clinical experience with other 
ailments, and that hospitals lacked resources to adequately train new nurses.  One 
administrator explained that some nursing students have been unable to graduate 
because they could not complete their clinical training. 
VACCINATIONS 
Hospitals reported that vaccination efforts were positive steps 
toward pandemic recovery but exacerbated challenges with 
clinical staff shortages and hospital finances 
Hospital staff were among the earliest to get vaccinations, which helped to reduce risk 
of infection to front-line health care workers and to limit the spread of COVID-19 
within the hospital.  Hospitals reported that they have set up the infrastructure 
necessary to administer COVID-19 vaccines to their communities.  These efforts 
include creating mass vaccination sites and reallocating clinical staff to administer 
vaccines.   
Many hospitals reported that they were ready to vaccinate on a large scale as soon as 
vaccine supply became more available.  As one administrator explained, hospitals are 
well positioned to administer vaccines, given that they have the needed space, exam 
rooms, clinical expertise, and workflow processes.  Hospitals viewed their vaccination 
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OEI-09-21-00140  Findings | 12   
efforts as a positive step toward pandemic recovery.  For example, one hospital noted 
that providing vaccinations was important to economic recovery.       
What the public doesn't see is that the same health care workers 
they rely on to provide care are the same ones being pulled to 
distribute vaccinations.  They can't be everywhere at once. 
- Emergency manager  
Some hospitals reported that vaccination efforts sometimes exacerbated existing 
challenges with clinical staff shortages and hospital finances.  Some hospitals reported 
needing to divert clinical staff away from patient care to administer vaccines, which 
has strained an already stressed system as one administrator explained.  Hospitals 
reported shifting nurses from other departments, including ICUs, operating rooms, 
emergency departments, and obstetrics, to administer vaccines, and sometimes at 
remote locations.    
Hospitals reported that it takes a considerable amount of staff time to operate 
vaccination clinics.  One administrator explained that it took 25 staff members 
working an 8-hour shift to distribute 600 vaccines.  Hospitals also reported frustration 
with inefficiencies in required data reporting.  For example, one hospital reported that 
to meet Federal, State, and local reporting requirements, it had to enter vaccine data 
into three separate systems.  It characterized such data entry as cumbersome and 
redundant, noting that none of the three systems are talking to each other, [despite 
the fact that] they are inputting the exact same data into each system.    
[Vaccination] is an immense resource and were happy to 
contribute because it decreases the rates of COVID, but it is 
significant the resource[s] that [go] into that. 
- Hospital president  
Hospitals also reported that costs associated with vaccine administration have 
strained hospital financial resources.  Beyond staffing, hospitals explained that costs 
include equipment for storing vaccines (e.g., freezers) and supplies to administer 
vaccines.  Although a few hospitals reported using the Coronavirus Aid, Relief, and 
Economic Security (CARES) Act funding to offset the expense of vaccinating the 
community, others reported that this support did not cover all of the hospital 
expenses for operating vaccination sites.5  (Note that after our pulse survey, CMS 
increased the Medicare payment amount for administering the COVID-19 vaccine to 
offset costs associated with establishing or operating vaccination sites and hiring 
additional staff.)6   
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OEI-09-21-00140  Findings | 13   
Differences in government guidelines regarding vaccine 
eligibility and prioritization created challenges for hospitals 
Hospitals reported receiving varying information from different levels of government 
about who is eligible to receive the COVID-19 vaccine and when they are eligible.  
Federal, State, and local governments have prioritized different population groups to 
receive vaccines.  CDCs Advisory Committee on Immunization Practices made 
recommendations that prioritized health care workers and long-term care facility 
residents, but States have discretion to adjust the guidelines based on their 
populations, vaccine supply, and capacity to vaccinate.7   
Hospitals reported that differences in vaccination priorities across jurisdictions have 
made it more complicated to determine who is eligible, which can be time-consuming 
and resource-intensive for hospitals.  For example, hospitals serving communities at 
State borders must vary their vaccination approach based on each States priorities.  
One hospital explained, Were near Indiana and Michigan, and depending on what 
side of [the] street youre on, it affects what rules apply.  A further complication is 
that within States, counties and cities may determine their own priority populations 
that can vary across each jurisdiction.  For example, one hospital network noted that 
vaccine 1b eligibility criteria and allocation varies to a great extent across Illinois, 
Wisconsin, Cook County, and City of Chicago.   
Hospitals reported that some hospital staff and members of the 
community were hesitant to get vaccinated 
Hospitals noted that they were struggling to convince some staff of the importance 
and safety of the vaccine.  Administrators from several hospitals reported more than a 
third of their staff had declined to be vaccinated as of the date of our survey.  
Administrators attributed this lack of willingness to take the COVID-19 vaccine to 
multiple causes.  For example, they explained that some staff distrusted the rapid 
vaccine development and approval process and others had concerns that the vaccines 
may not be effective.   
Hospitals also raised concerns about hesitancy among members of their communities 
and reported working to combat misinformation about the vaccine.  Hospitals worried 
that fewer vaccinations would allow the virus to continue circulating longer than 
necessary.  Some administrators reported that the public lacked complete information 
about vaccines, which appeared to increase hesitancy to be vaccinated.  For example, 
one administrator reported hearing a variety of concerns, from questions about the 
long-term side effects of the vaccines to false assertions that vaccines carry 
microchips. 
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Hospitals reported challenges in ensuring access to vaccinations 
for rural, senior, and low-income populations   
Administrators reported that vaccinating rural communities presented unique 
challenges in ensuring access.  Hospitals in rural areas, including critical access 
hospitals, reported that rural areas often have few vaccination sites and lengthy travel 
between sites.  For example, in some rural communities, the hospital may be the 
nearest vaccination site for patients who live hours away.  Hospitals noted that this 
distance can make it difficult to vaccinate residents who do not have reliable 
transportation.  Officials from one critical access hospital noted that many rural areas 
have a higher proportion of low-income residents, who may not have reliable 
transportation for long travel.  Additionally, hospitals explained that those without a 
car have difficulty traveling to mass vaccination sites.   
We feel its important to do more than stand up a 
vaccination site.  We provide education and access.  Part of 
that access strategy is to go out to people. 
- Hospital president 
Hospitals reported taking extra steps to ensure that senior and low-income 
populations could access vaccinations.  Vaccination appointments have been 
commonly scheduled online, and hospitals reported that this creates barriers for 
individuals who lack internet service, devices, or capabilities needed to access and 
navigate online scheduling.  For these patients, hospitals reported needing to use 
different scheduling options, such as calling elderly patients directly to schedule 
vaccination appointments.  Some hospitals also reported going into the community 
to vaccinate, such as by setting up vaccine clinics in parking lots in certain 
neighborhoods.   
Hospitals reported frustration with the unpredictable and 
insufficient supply of vaccines 
Hospitals reported that the supply of vaccines they receive has been unpredictable, 
and they often get little advance notice about changes to shipment quantities.  
Administrators explained that quantities of vaccine shipped to hospitals varied from 
week to week and did not always match the amount they expected.  Hospitals 
reported that this inconsistency led to inefficient use of resources and caused 
hospitals to cancel patient appointments at the last minute.   
There is far more capacity to vaccinate than there 
[are] available vaccine doses." 
- Emergency management director  
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OEI-09-21-00140  Findings | 15   
Several administrators expressed frustration about building infrastructure and 
planning for mass vaccinations only to have that capacity be underutilized due to 
inconsistent supply.  For example, one hospital reported that it has capacity to 
vaccinate 5,000 people a week but received only 2,000 doses a week.  Another 
hospital reported creating three vaccine locations within its system and allocated staff 
to provide 6,0008,000 vaccines a week but had no vaccines at the time of their 
survey on February 21, 2021.  (Note: Since the time of the pulse survey conducted the 
week of February 2226, 2021, the Food and Drug Administration (FDA) issued an 
emergency use authorization for a third vaccine for the prevention of COVID-19, 
helping to lead to an increase in daily vaccinations.)8, 9 
SUPPLIES  
Hospitals reported difficulty maintaining a steady supply of 
affordable, high-quality PPE 
Hospitals reported that they were no longer experiencing the extreme shortages of 
PPE that occurred at the beginning of the COVID-19 pandemic, but some still lacked 
dependable supply chains for PPE.  Hospitals noted that supplies of surgical gloves 
and N95 masks were particularly unpredictable.  One problem reported with gloves 
was that only large sizes could be purchased, often the wrong size for many hospital 
staff.  During the week before the pulse survey, 19 of our responding hospitals 
reported to HHS Protect that they could not order and obtain N95 masks.  Further, 
some hospitals reported sanitizing and reusing PPE to preserve supplies. 
We have been reusing masks and supplies, per CDC 
guidelines, in an effort to extend the life of the supplies 
and reduce costs.  
 -Compliance officer  
Many hospitals reported difficulty in identifying reputable vendors to provide a 
consistent supply of PPE.  As one administrator described, We are routinely changing 
vendors because we cant get [PPE] from our normal manufacturers and vendors.  
Some administrators expressed that it was inefficient for individual hospitals to be 
searching for vendors and that there should be more centralized supply chain 
management.   
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OEI-09-21-00140  Findings | 16   
When hospitals must switch to N95 masks produced by different manufacturers, staff 
often must repeat mask fit-testing, which one administrator reported occurred for 
their hospital four or five times.  Even when hospitals found PPE vendors, 
administrators reported inconsistent delivery, including orders that were cancelled, 
delayed, or incorrect.  One hospital noted that it was difficult to anticipate when their 
orders would be backordered or cancelled.  This made it challenging to build up 
supplies, and hospitals reported concerns about having enough PPE supplies for 
surges or waves of COVID-19 infections in the future. 
Hospitals our size with 300 beds looking for N95s was not 
an efficient use of our time." 
- Hospital president    
Some hospitals reported receiving poor-quality PPE and others reported inflated 
prices.  For example, one hospital reported that when they purchased PPE made 
outside the United States, many of the supplies did not meet U.S. standards.  A few 
hospitals described the PPE that they received as counterfeit or discovered the PPE 
was inadequate for use after testing it.  Some hospitals also indicated that they 
experienced substantial price increases for PPE.  One administrator said, We used to 
pay about $1 per [N95] mask.  Now its $8 to $9 per mask. 
FINANCES 
Hospitals reported that their operational costs have risen 
dramatically while their revenues have declined, threatening 
their financial stability 
Many hospitals identified financial stability as a concern resulting from the COVID-19 
pandemic.  Administrators pointed to a variety of increased costs that their hospitals 
encountered during the pandemic, including higher costs associated with staffing and 
PPE, as well as COVID-19 patient care, testing, and vaccinations.  Some hospitals also 
reported increased administrative costs associated with new data reporting 
requirements for COVID-19 cases, testing, and vaccinations.  Some hospitals 
expressed that the combination of their higher costs coupled with declining revenues 
raised concerns about whether they would be able to remain in operation. 
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OEI-09-21-00140  Findings | 17   
Hospitals that serve disproportionately under- and uninsured populations and rural 
communities reported being particularly concerned about financial instability.  These 
hospitals also tend to serve more patients enrolled in Medicaid, which often 
reimburses at lower rates than private insurance.  Several hospitals noted that they 
faced financial challenges prior to the pandemic and worried that it would be hard to 
recover financial stability after the pandemic ends.  As an administrator of a hospital 
serving a community with high poverty rates described, We were one of the 
[hospitals in] danger of disappearing...now we have to restart in a different world, and 
I dont know if we can get it back.   
Labor costs, supply costs, utility costs, insurance costs 
have all gone up.  Everything on the expense side has 
gone up and the revenue side has not kept pace. 
- CEO, rural hospital 
Hospitals reported a significant decline in revenue resulting from suspending elective 
procedures.  In March 2020, the Centers for Medicare & Medicaid Services (CMS) 
recommended the suspension of elective surgeries and other procedures to help 
conserve PPE and other supplies needed to respond to the pandemic.10  The next 
month, in April 2020, CMS issued additional recommendations to guide practices as 
State, Tribal, and local health care entities considered safely resuming elective 
surgeries and other procedures.11  However, hospitals reported that 
non-COVID-19-related services have remained low, with fewer patient visits for both 
routine and emergency care and fewer elective procedures (compared to before the 
pandemic).  As a result of fewer patient visits, one administrator said their hospital 
was operating at a 25-percent reduction in revenue.  As discussed earlier in the 
report, hospitals surmised that fear of contracting COVID-19 was a main cause of 
patients avoiding coming to the hospital, even for medically necessary treatment.   
Some administrators expressed that, based on their experience, Medicare 
fee-for-service reimbursement did not always cover their costs associated with some 
COVID-19 patients.  For example, one hospital estimated that it was potentially losing 
$3,000 per COVID-19 patient.  Medicare reimburses hospitals a predetermined 
amount based on the COVID-19 diagnosis and any other diagnoses for the patient, 
and provides additional payment increases to hospitals as part of the CARES Act.12, 13  
However, administrators believed that these reimbursement amounts often did not 
cover their added staff and equipment costs associated with COVID-19 patients who 
have prolonged ICU hospital stays.  
Medicare alternative payment models that base payment on value, risk, and outcomes 
presented a different set of financial challenges, according to hospital administrators.  
Although one administrator expressed satisfaction with payments under such models, 
other hospitals noted concerns that they could be penalized under alternative 
payment models, specifically in calculations of future incentive payments.  For 
example, one hospital worried that caring for COVID-19 patients, who often have 
lengthy hospital stays and increased risk of hospital-acquired infections, could 
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OEI-09-21-00140  Findings | 18   
negatively affect their quality metrics, potentially costing hundreds of thousands of 
dollars in missed incentive payments.14  
Hospitals expressed uncertainty about rules on repayment of 
prior Federal loans 
Several administrators expressed concern about whether they would have to repay 
the Federal financial assistance that they had already received.  Hospitals noted that 
loans from the Medicare Accelerated and Advance Payment Programs were essential 
in facing cash flow disruptions during the early days of the pandemic.  However, they 
anticipated problems repaying the loans when the first payments become due 
starting late March 2021.15  Some hospitals also said that guidance on CARES Act 
funds, such as Paycheck Protection Program (PPP) loans, seemed to have changed 
over time, leaving them uncertain about the current rules for repayment.   
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OEI-09-21-00140  Findings | 19   
ADDRESSING HOSPITAL CHALLENGES 
 
Hospitals reported implementing strategies to address 
challenges and described areas in which new and continued 
government support would be helpful 
Hospitals described a range of strategies that they used to address the challenges 
arising from the COVID-19 pandemic.  For example, to ensure that they could meet 
the needs of COVID-19 patients, hospitals reported bringing in expert consultants to 
share best practices for standards of care.  To combat staffing shortages, hospitals 
reported reallocating staff from other departments and offering higher pay and 
bonuses to recruit and retain staff.  In addition, to ensure the success of vaccination 
efforts, hospitals reported leveraging community resources and educating the public 
on the safety and importance of getting vaccinated.  (See the Selected Hospital 
Strategies section on page 26 for more detail on some of the strategies that hospitals 
reported.)  Hospitals expressed appreciation for the financial support and regulatory 
flexibilities that the government has extended to hospitals and noted that the 
assistance has been critical to their continued operations. 
Hospitals also described areas in which new and continued types of government 
support would be helpful in responding to, and recovering from, the COVID-19 
pandemic.  The hospitals front-line perspectives provide an important voice, among 
many, for HHS and other decisionmakers to consider as they grapple with the 
challenges presented or worsened by the pandemic.  However, OIG has not 
independently assessed the merits, costs, or effectiveness of the areas for government 
support identified by hospitals, and as such, OIG is not endorsing them.  Rather, these 
ideas are presented to provide information for decisionmakers.  Some challenges 
identified by hospitals may not be within HHSs authority to address or may require 
legislation.  
Further, we recognize that Congress, HHS, and its partners across government have 
already taken and continue to take action to alleviate hospital challenges.  The 
hospital perspectives reflect a specific point in timeFebruary 2226, 2021.  Since 
then, the American Rescue Plan Act of 2021 was signed into law on March 11, 2021, 
and provides HHS with additional funding to combat and respond to the COVID-19 
pandemic, including programs that support hospitals.16  Further information about 
the American Rescue Plan Act can be found in the Background on page 31. 
Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care 
OEI-09-21-00140  Addressing Hospital Challenges | 20  Enhancing knowledge and guidance on the prevention and 
treatment of COVID-19   
Hospitals described opportunities for government support to help them treat patients 
with and without COVID-19.  These included additional guidance on testing, 
treatment, and infection control that is consistent across government entities and is 
up-to-date with scientific understanding of the virus.  
Hospitals indicated that it would be helpful for government to: 
 Update recommendations for screening (e.g., temperature checks), testing, and
quarantine procedures to accommodate ongoing developments.  For example,
how recommendations should be applied to people who are vaccinated.
 Provide additional clinical research and education efforts regarding the
long-term health care impacts and service needs associated with post-acute
COVID-19 care.  The hospitals indicated that this should include clear guidance
for patients recovering from COVID-19 who may have long-term
complications.
 Provide public health updates to keep hospitals and the public informed on
emerging variants and up-to-date clinical guidance on how to treat them.
Providing support to increase care to underserved communities 
Hospitals described existing disparities in health care access and outcomes for 
underserved communities that COVID-19 has worsened.  
Hospitals indicated that it would be helpful for government to: 
 Address health care disparities and support hospitals efforts to serve
underserved communities, such as with funding and continuing Federal
programs.
 Promote the use of telehealth for specialty services, such as pulmonology and
intensive care, and sponsor infrastructure improvements to support expanded
access to telehealth.
 Consider making policies in the public health emergency waivers permanent
after the emergency declaration ends to take advantage of new forms of
service delivery, for example, telehealth waivers that allow visits to originate in
patients homes, and the waiver allowing out-of-State practitioners to provide
services in a State in which they are not licensed.17
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OEI-09-21-00140  Addressing Hospital Challenges | 21  Addressing hospital staffing needs and helping to support 
current staff  
Hospitals described critical current staffing shortages, particularly among nursing 
staff, as well as burnout and trauma among staff from the COVID-19 pandemic. 
Hospitals indicated that it would be helpful for government to: 
 Assist hospitals in acquiring additional staff during emergency situations,
including the vaccination effort.  As one example of this type of program, one
hospital noted that using the National Disaster Medical System helped some
hospitals in rural areas with additional emergency personnel.
 Assist hospitals, especially rural hospitals, in recruiting professional health care
staff.  For example, the government could increase the Small Rural Hospital
Improvement Grant Program, expand incentives for the National Health Service
Corps to work in rural settings, and provide additional student loan
reimbursement to attract providers to rural areas.
 Implement strategies to encourage more people to enter the health care
workforce, particularly nurses and specialists such as respiratory therapists and
mental health professionals.  These strategies could include innovative
programs between schools and hospitals; initiatives for better education and
training; and financial support such as education grants and loan forgiveness.
 Support hospitals that want to hire international travel nurses by promoting
faster and more efficient placement.
 Address excessive pricing among domestic medical staffing and travel nursing
agencies.
 Assist hospitals in addressing the pressing need for more mental and
behavioral health resources for the health care workforce.  One suggestion
included supporting hospitals to obtain expertise in helping hospital staff avoid
burnout and address PTSD.  Toward this end, the government could create an
online platform of support tools for hospitals that focus on health care workers
mental health and well-being.
Developing education campaigns regarding vaccines and other 
public health issues 
Hospitals expressed concerns about vaccine hesitancy and that the pandemic has led 
to an erosion of public trust in hospitals safety and credibility during the pandemic. 
Hospitals indicated that it would be helpful for government to: 
 Broaden the public education campaign to promote vaccination, focusing on
the safety and importance of getting vaccinated, ensuring that the messaging
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OEI-09-21-00140  Addressing Hospital Challenges | 22  is consistent across government entities and is up to date with the current 
scientific developments. 
 Broaden educational campaigns relaying the importance of using masks and
continuing social distancing measures, even after being vaccinated, until public
health officials determine these measures can be eased.
 Assist hospitals in their efforts to publicly message that hospitals are safe
venues to receive routine care (e.g., preventive screenings) and emergency
care, and reinforce the importance of obtaining routine care to prevent poor
health outcomes.
Providing ongoing support on financial issues 
Hospitals expressed concerns about their financial stability as the COVID-19 pandemic 
had increased their costs and decreased their revenues. 
Hospitals indicated that it would be helpful for government to: 
 Allow hospitals more time to spend Federal relief funds to use the funds to
complete ongoing projects, such as facility improvements and expansions.
 Provide additional guidance on the Medicare Accelerated and Advance
Payment Program, Provider Relief Funds (PRF), and the Paycheck Protection
Program (PPP) relating to how funds can be used and what documentation is
needed to justify expenditures.  Hospitals also asked for loan forgiveness or
longer timelines for loan repayment.
 Continue financial support, as needed, especially for rural hospitals, critical
access hospitals, and hospitals that serve underserved communities.
 Ensure that telehealth reimbursement policies account for the level of
resources needed to provide telehealth services, including services for which
there are provider shortages such as specialty care.
Leading a coordinated emergency response 
Hospitals described opportunities for support from government related to emergency 
planning, preparedness, and response to COVID-19 and future public health 
emergencies. 
Hospitals indicated that it would be helpful for government to: 
 Establish expectations for regional coordination of response efforts (e.g.,
collaboration with neighboring health systems on resource availability) and
institute regional centers for coordination.
 Foster improved management of interhospital transfers and discharge of
patients to places where they will receive the best followup care, such as by
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OEI-09-21-00140  Addressing Hospital Challenges | 23  taking a greater role in facilitating connections between all parts of the health 
care system. 
 Simplify COVID-19 data reporting across Federal, State, and local governments
and eliminate any duplicative or non-essential reporting.
 Oversee national supply chains for medical supplies like PPE to combat price
gouging and substandard products and to ensure greater efficiency and equity.
 Focus on the sufficiency, management, and quality of supplies in the National
Stockpile in preparing for future spikes in demand for PPE and supplies, such
as by supporting private sector domestic suppliers, vendors, or manufacturers
to reduce reliance on imports.
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OEI-09-21-00140  Addressing Hospital Challenges | 24   
LOOKING FORWARD 
 
Addressing Urgent and Systemic Challenges Exacerbated by the 
COVID-19 Pandemic 
This pulse survey offers insights from hospitals into the ways in which the COVID-19 
pandemic has exerted significant strains on their capacity to care for patients, staff, 
and communities.  In late February 2021, nearly 1 year into the pandemic, hospitals 
reported that operating in survival mode for an extended period of time has created 
new and different problems than experienced earlier in the pandemic and 
exacerbated longstanding challenges in health care delivery, access, and health 
outcomes.  Hospitals detailed significant challenges related to health care delivery, 
staffing, vaccination efforts, supplies, and financial stability.   
Hospitals, HHS, and other Federal, State, Tribal, and local entities have taken steps to 
address these challenges.  Additionally, hospital administrators identified areas in 
which continued government support could help in responding to COVID-19.  These 
included: 
 enhancing knowledge and guidance on the prevention and treatment of
COVID-19, including safe means to discharge COVID patients;
 addressing current staff shortages, as well as staff burnout and trauma;
 supporting vaccination efforts, including public messaging campaigns;
 assisting hospitals in managing their financial stability, especially to ensure care
for underserved communities; and
 ensuring a coordinated emergency response to COVID-19.
At the same time, hospitals are grappling with many strains that emanate from 
systemic challenges that the COVID-19 pandemic has both drawn attention to and 
worsened.  Better containment and management of COVID-19 alone will not resolve 
these systemic problems, which warrant further attention.  These include: 
 reducing disparities in access to health care and in health outcomes;
 building and maintaining a more robust health care workforce; and
 strengthening the resiliency of our health care system to respond to pandemics
and other public health emergencies and disasters.
The hospitals front-line perspectives provide an important voice, among many, for 
HHS to consider as it leads and engages in national dialogues and policymaking 
to help solve these foundational challenges. 
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OEI-09-21-00140  Looking Forward | 25   
 
SELECTED HOSPITAL STRATEGIES 
 
 
Hospitals described many strategies that they have employed to help deal with strains placed on them 
by the COVID-19 pandemic.  The following list is not exhaustive of all strategies that hospitals reported 
but includes those that most directly address the challenges described previously in this report.  These 
strategies are self-reported by the hospitals; OIG did not assess their effectiveness. 
Health Care Delivery 
Sharing best practices for patient care 
Hospitals relied on staff training and medical specialists to share current best practices related to 
standards of care.  For example, one hospital described hiring a pulmonology consultant to go on 
rounds with clinical teams and reinforce the latest care standards.   
Facilitating patient transfer and discharge 
Hospitals relied on resource networks and communication with other hospitals to facilitate transfer and 
discharge of patients.  Hospitals that were part of networks or could access regional systems navigated 
capacity challenges by using these systems to identify open beds for patient transfers.  Hospitals used a 
variety of methods to augment their ability to facilitate patient placements, including getting assistance 
from the professional staff at State emergency response centers and the National Disaster Medical 
System and developing relationships with a local hospital network with greater capacity. 
Encouraging patients to resume routine medical care  
Hospitals employed strategies to encourage patients to not delay medical care.  These strategies 
included targeted outreach, such as hospital staff personally contacting higher-risk patients with 
underlying health conditions and prioritizing visits for those patients.   
Rebuilding trust in hospitals 
Hospitals took steps to rebuild the publics trust in hospitals as safe places to receive medical care and 
reduce fear of COVID-19 exposure in the hospitals.  Hospitals reassured the public of hospitals safety 
measures such as testing, isolation, and cleaning.  Hospitals used newspapers, social media, radio, and 
meeting with community groups and leaders to communicate these messages.   
 
 
 
 
 
 
 
 
 
   
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OEI-09-21-00140  Selected Hospital Strategies | 26   
Staffing 
Addressing employee burnout  
Hospitals reported establishing assistance programs and other social supports to help bolster 
employee morale and address burnout.  These efforts included using new or existing employee 
assistance programs and mental health services to share coping strategies.  Hospitals encouraged staff 
to share their experiences through support groups and in one-on-one conversations, such as with 
counselors or chaplains. 
Maintaining sufficient staffing 
Hospitals reported reallocating staff from different departments or supplementing their workforce with 
staff from other hospitals within their networks.  Hospitals reported offering staff higher pay, overtime 
incentives, bonuses, and additional benefits.  Hospitals also recruited new graduates with less 
experience and nurses from other countries to fill vacancies.   
 
Vaccinations 
Leveraging resources to provide vaccinations 
Hospitals partnered with government entities, retired health care workers, and other health care 
providers to staff vaccination sites.  One hospital partnered with area pharmacies to shift the burden 
away from the hospital.  Another hospital collaborated with local homeless shelters and churches to 
increase access. 
Encouraging vaccinations and overcoming vaccine hesitancy 
Hospitals made concerted efforts to provide their communities with accurate, complete information 
about vaccines.  These efforts included coordinating town hall meetings, physician-led talks, press 
releases and one-on-one communication to convey the safety and efficacy of the vaccine.  One hospital 
reported that the direct calls from nurses to patients increased willingness to be vaccinated by 
10 percent. 
 
 
 
 
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BACKGROUND 
 
 
COVID-19 Emergence and Variants 
COVID-19 is a highly contagious coronavirus that can be fatal in some cases.18, 19  
Common symptoms include fever, cough, shortness of breath, fatigue, and new loss 
of taste or smell.20  The first U.S. patient with COVID-19 was reported on January 20, 
2020.21  In late February 2020, a hospital in California documented the first 
community-spread transmission of COVID-19 in the United States, meaning the 
illness was contracted through an unknown exposure in the community.22  On 
March 11, 2020, the World Health Organization declared COVID-19 to be a 
pandemic.23  As of March 18, 2021, there have been over 29 million confirmed cases 
in the United States, with over 530,000 deaths.24 
According to CDC, viruses constantly change through mutation, and new variants of a 
virus are expected to occur over time.25  Several new variants of the virus that causes 
COVID-19 were identified in fall 2020 and have since been documented in the United 
States, with the first being detected in December 2020.26   
Role of Hospitals in Emerging Infectious Disease Preparation 
and Response 
The COVID-19 pandemic has created unprecedented challenges for the U.S. hospital 
system.27, 28  As front-line responders, hospitals have significant responsibilities 
identifying and treating patients with COVID-19.  Hospitals also fill critical roles in the 
vaccination rollout nationwide.  As the pandemic has continued and evolved, 
hospitals have employed both short-term solutions and long-term strategies to 
address the crisis.    
Since 2010, the Office of the Assistant Secretary for Preparedness and Response 
(ASPR) has managed the Hospital Preparedness Program (HPP), which provides grants 
to States and localities to distribute to hospitals and health care coalitions (HCC) for 
improved emergency preparedness and response.29  Under HPP, health care providers 
and public health entities are encouraged to form HCCs that are capable of preparing 
for, responding to, and recovering from emergencies.30  During emergency response 
and recovery, HCCs support health care organizations during emergency response 
and recovery by facilitating information sharing, coordinating of incident response, 
and expediting resource-sharing arrangements.  
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Role of HHS in Emerging Infectious Disease Preparation and 
Response 
HHS is the lead Federal agency responsible for medical support and coordination 
during public health emergencies, such as emerging infectious disease (EID) 
outbreaks.31  HHS operating and staff divisions involved in the Federal response to 
EIDs, including the current COVID-19 response, include the ASPR, CDC, the National 
Institutes of Health (NIH), CMS, FDA, Office of the Assistant Secretary for Health 
(OASH), and the Office of the Surgeon General (OSG).32, 33, 34, 35  HHS also began 
collaborating with the Department of Defense (DOD) in May 2020 to coordinate and 
accelerate the development, manufacturing, and distribution of COVID-19 medical 
countermeasures under a public-private partnership called Operation Warp Speed.36  
ASPR, in addition to managing HPP, coordinates HHSs response to public health 
emergencies and collaborates with hospitals, health care coalitions, State and local 
governments, and other partners to improve readiness and response 
capabilities.37, 38, 39  HHS collaborates with ASPR and CDC, and in coordination with the 
Secretary of Homeland Security, to maintain the Strategic National Stockpile, a 
reserve of drugs, vaccines and other biological products, medical devices, and other 
supplies to ensure the emergency health security of the United States in the event of 
a public health emergency.40   
In response to COVID-19, ASPR is working with its partners to develop medical 
countermeasures and to provide resources to support the U.S. health care systems 
response.  Following the declaration of a national public health emergency on 
January 31, 2020, ASPRs Biomedical Advanced Research and Development Authority 
invested more than $20 billion in 2020 to developing or procuring medical 
countermeasure products to combat the pandemic.41 
Following the Ebola outbreak in 2014, ASPR designated 10 health departments and 
associated partner hospitals as Regional Ebola and other special pathogen treatment 
centers (special pathogen centers) for patients with highly infectious diseases.42  
These centers are required to maintain capability to accept patients with suspected or 
diagnosed illness from special pathogens within 8 hours of notification and to 
conduct quarterly exercises to prepare for an EID outbreak.43  In 2020, ASPR provided 
$350 million to support the National Special Pathogen System, a nationwide 
systems-based network approach that builds on the Ebola-specific treatment network 
to address the needs of hospitals, health systems, and health care workers on the 
front lines of the COVID-19 pandemic.44  The National Special Pathogen System 
includes the 10 special pathogen centers, the National Emergency Special Pathogens 
Training and Education Center, 62 HPP cooperative agreement recipients and their 
State or jurisdiction special pathogen treatment centers, and 53 hospital 
associations.45   
CDC monitors and responds to public health emergencies, such as EIDs, conducts 
research, and provides guidance to health care providers, government entities, and 
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OEI-09-21-00140  Background | 29   
the public.46, 47  On January 21, 2020, CDC launched an agencywide response to 
COVID-19.  Since then, CDC has published more than 180 guidance documents to 
advise health care providers on topics such as hospital preparedness assessments, 
supply planning, and patient evaluation and testing.48, 49  For example, in February 
2021, CDC updated its infection control guidance for health care facilities, including 
hospitals, that details a hierarchy of strategies that health care personnel can use 
when PPE are in short supply or unavailable.50, 51 
CMS oversees hospitals participating in Medicare and Medicaid by requiring them to 
meet Conditions of Participation, a set of minimum health and safety standards.52, 53  
To help address challenges presented by COVID-19, CMS has waived some 
requirements under the emergency authority set forth in Section 1135 of the Social 
Security Act.54  For example, CMS has issued several blanket waivers that grant 
regulatory flexibility to health care providers, including flexibility in providing access 
to telehealth services.55   
In support of vaccine distribution efforts, CMS has updated their Medicare payment 
rates for administering the COVID-19 vaccine.  On March 15, 2021, the rate for a 
vaccine requiring two doses changed from approximately $45 to $80, reflecting 
updated information about the cost of administering the COVID-19 vaccine for 
different types of providers and suppliers.  CMS is also updating its set of toolkits for 
providers, states, and insurers regarding the new rates so that the health care system 
can quickly administer the vaccines.56, 57 
FDA is responsible for protecting public health by ensuring the safety, efficacy, and 
security of human and veterinary drugs, biological products, and medical devices; and 
by ensuring the safety of the Nation's food supply, cosmetics, and products that emit 
radiation.58  FDA is working with hospitals and the medical industry to develop 
vaccines, therapies, diagnostic tests, and other medical devices while monitoring the 
medical supply chain during the COVID-19 outbreak.59  FDA has also issued several 
EUAs for ventilators, testing products, therapies, vaccines, and other medical 
products.60, 61 
NIH, within its National Institute of Allergy and Infectious Diseases (NIAID), conducts 
and supports research to better understand, treat, and ultimately prevent infectious, 
immunologic, and allergic diseases.62  As part of the U.S. Governments response to 
the COVID-19 pandemic, NIAID is conducting and supporting clinical research, 
including clinical trials evaluating therapeutics and vaccine candidates, as well as 
studies of people who have recovered from infection.63 
OASH oversees HHSs key public health offices, including the OSG and the Office of 
Disease Prevention and Health Promotion.64  OASH also oversees a number of 
Presidential and Secretarial advisory committees and 10 regional health offices across 
the United States.65  As part of its COVID-19 response, OASH reviewed individual 
State testing plans and offered technical assistance to help States enhance COVID-19 
testing capacity.66, 67 
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OSG acts as the Nations doctor and oversees the U.S. Public Health Service 
Commissioned Corps, a group of uniformed officers working throughout the Federal 
Government to protect, promote, and advance the Nations public health.68  The 
Surgeon General communicates scientific information and recommendations about a 
variety of health topics, including emerging public health threats, directly to the 
public through advisories, calls to action, and reports.69, 70, 71  For example, in 
December 2020, the Surgeon General encouraged people who have recovered from 
COVID-19 to donate COVID-19 convalescent plasma, which may help infected 
patients suppress the virus using antibodies.72 
Federal Financial Relief 
At the beginning of the pandemic Congress passed the CARES Act, which provided 
grants to hospitals to help offset losses due to the pandemic.73, 74  In addition to these 
grants, the CARES Act included key hospital and health care system provisions that 
affect Medicare and Medicaid, post-acute care, telehealth, vaccine efforts, and other 
areas of emergency preparedness related to COVID-19.75  
Congress, through the CARES Act, and CMS expanded the Medicare Accelerated and 
Advance Payment Programs to assist hospitals and other provider types in minimizing 
the effects of revenue shortfalls.  The Medicare Accelerated and Advance Payment 
Programs, which existed before the pandemic, are designed to provide emergency 
funding to hospitals and other providers facing cash flow disruptions from 
circumstances beyond their control.76, 77  Medicare typically recovers the amounts 
paid under these programs by withholding payments for subsequent claims from 
providers.78  
Through the CARES Act and the PPP and Healthcare Enhancement Act, the Federal 
Government allocated $178 billion in payments to be distributed through the PRF.79  
Qualified hospitals received PRF payments for health care-related expenses or lost 
revenue due to COVID-19.  These distributions do not need to be repaid to the U.S. 
Government, assuming that hospitals comply with the terms and conditions.80   
Some hospitals were eligible for loan programs included in the CARES Act, such as the 
PPP.81  Under the PPP, loans are forgiven if employers do not lay off workers and 
meet other criteria.82  In addition to PPP loans, the CARES Act appropriated $454 
billion for loans to qualifying larger businesses, including hospitals and other large 
health care entities.83   
The American Rescue Plan Act of 2021 
Signed into law on March 11, 2021, the American Rescue Plan Act of 2021 (the Act) 
provides additional support for health care organizations, including hospitals, in their 
COVID-19 response.84  
  
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The Act provides funding for several COVID-19 supply chains.  The bill provides 
$6.05 billion for the research, development, manufacturing, production, and purchase 
of vaccines, therapeutics, and ancillary other medical products and supplies used in 
the COVID-19 response.85  Specific to investing in public health, the bill also provides 
$7.6 billion to qualified community health centers to support their COVID-19 
response, including distribution of COVID-19 vaccines and purchasing equipment to 
conduct mobile vaccinations, particularly in medically underserved areas.86 
To support rural communities, the bill provides $8.5 billion toward payments to 
eligible rural health care providers for related expenses and lost revenues as a result 
of COVID-19.  These include expenses such as purchasing medical supplies and 
equipment, providing for an increased workforce and their training, and providing for 
surge capacity.87  
The bill supports the enhancement of the workforce that is involved in the COVID-19 
response.  In particular, the Act provides $7.66 billion to State, local, and territorial 
public health departments that may be used to cover areas such as wages, 
recruitment, personal protective equipment, and necessary administrative costs and 
activities.88  To address the nursing workforce specifically, the bill also appropriates 
$200 million to support scholarship and loan repayment for nursing students and 
nurses.89 
The Act also provides financial support for mental health and substance use concerns 
in the health care workforce.  The bill provides $80 million in grants that support 
health care providers planning, developing, operating, and participating in training 
activities to reduce and address suicide, burnout, mental health conditions, and 
substance use disorders among health care professionals.90  Additionally, the bill 
provides $20 million to support a national campaign for healthy work conditions and 
the use of mental health and substance use disorder services by health care 
professionals, and $40 million toward grants for health care providers to establish, 
enhance, or expand programs and protocols promoting mental health among their 
health professional workforce.91 
Vaccine Development and Access 
Operation Warp Speed was designed to produce and deliver safe and effective 
COVID-19 vaccines as quickly as possible.92, 93  As of March 1, 2021, the Federal 
Government had awarded more than $19 billion for several vaccine candidates and 
ancillary vaccine supplies.94  FDA issued EUAs for two COVID-19 vaccines, developed 
by Pfizer-BioNTech and Moderna, in December 2020 and issued an EUA for a third 
vaccine developed by Johnson & Johnson on February 27, 2021.95, 96  As of March 19, 
2021, more than 154 million doses of COVID-19 vaccines have been delivered in the 
United States, and more than 118 million doses have been administered.97  
The CDC Advisory Committee on Immunization Practices (ACIP) recommended that 
Federal, State, and local governments prioritize vaccinating health care personnel and 
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OEI-09-21-00140  Background | 32   
residents of long-term care facilities in the first phase of vaccine allocation (Phase 1a).  
ACIP recommended that vaccines should next be offered to front-line essential 
workers and people aged 75 years and older (Phase 1b), followed by people aged 
65 to 74 years, people aged 16 to 64 years with underlying medical conditions, and 
other essential workers (Phase 1c).98  States, Territories, and other local authorities 
developed individual vaccine prioritization and timelines, some of which differed from 
ACIP's recommendations.99, 100, 101  However, all States included hospital personnel in 
Phase 1a of their prioritization plans, and many States allocated and distributed some 
of their initial vaccine doses to hospitals to administer to health care workers.102, 103, 104 
In vaccinating their personnel, hospitals across the United States therefore became 
some of the first providers to administer COVID-19 vaccines.105, 106   
Related Work 
OIG has undertaken extensive oversight work related to COVID-19.  See the OIG 
COVID-19 Portal for more information.   
In the April 2020 report, Hospital Experiences Responding to the COVID-19 Pandemic: 
Results of a National Pulse Survey March 2327, 2020, we outlined challenges that 
hospitals reported facing in response to COVID-19 during the early weeks of the 
pandemic.  At that time, hospitals reported that they were largely focused on 
enhancing their capacity to respond to the pandemic.  Hospitals reported challenges 
such as significant shortages in PPE, ventilators, and other supplies as demand 
increased across the country and around the globe.  Hospitals also spoke of the 
challenge of needing to rapidly expand facility and staffing capacity.  Finally, hospitals 
reported that, at the time, the lack of testing capability to detect which patients had 
COVID-19 negatively impacted hospital operations as they tried to prevent outbreaks 
among hospital patients and staff.107   
In August 2020, we issued a toolkit, Insights for Health Care Facility From OIG;s 
Historical Work on Emergency Response, which contained lessons from OIG reports 
published from 2002 to 2020 about health care facility emergency response.108  A 
related toolkit published in August 2020 compiled Insights for Communities from 
OIGs Historical Work on Emergency Response.109 
In January 2021, OIG contributed to the report Federal COVID-19 Testing Report: Data 
Insights from Six Federal Health Care Programs.  The report, which was issued by the 
Health Care Subgroup of the Pandemic Response Accountability Committee (PRAC), 
examines COVID-19 testing efforts for six Federal health care programs during the 
first 7 months following the declaration of a public health emergency.110 
 
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GLOSSARY OF KEY TERMS 
 
 
Behavioral health: The promotion of mental health, resilience, and wellbeing; the treatment of mental 
and substance use disorders; and the support of those who experience and/or are in recovery from 
these conditions, along with their families and communities.111 
Centers for Disease Control and Prevention (CDC): The HHS operating division that is tasked with 
protecting the public health and safety through addressing emerging health threats, disability, and 
disease.  
Centers for Medicare & Medicaid Services (CMS): The HHS operating division that administers the 
Medicare program and works in partnership with State governments to administer Medicaid, the 
Children's Health Insurance Program, and health insurance portability standards.  
Community spread: Spread of an illness for which the source of the infection is unknown.112  
Coronavirus disease 2019 (COVID-19): An illness of the respiratory tract that is highly contagious and 
can be fatal in some cases.  Symptoms include a cough, a headache, a fever, new loss of taste or smell, 
shortness of breath, and other symptoms.113  Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-
CoV-2) is the virus that causes COVID-19 and is often called the COVID-19 virus; its prior name was the 
2019 novel coronavirus (2019-nCoV). 
Critical access hospital (CAH): A rural hospital that provides outpatient and inpatient hospital services 
to people in rural areas.  CAHs are designated by CMS, and to qualify these facilities must meet certain 
conditions such as: furnishing 24-hour emergency care services 7 days a week, having no more than 25 
inpatient beds, and having an average length of stay of 4 days or less per patient for acute-care 
services.  Until the end of the emergency declaration, CMS is waiving requirements that CAHs limit the 
number of beds to 25 and length of stay of 4 days. 
Emergency use authorization (EUA): A mechanism used by FDA to allow the use of unapproved 
medical products, or unapproved uses of approved medical products, in an emergency to diagnose, 
treat, or prevent serious or life-threatening diseases or conditions.  EUAs are used when certain 
statutory criteria are met, including when there are no adequate, approved, and available alternatives.114 
Emerging infectious disease (EID): Infections that have recently appeared within a population or those 
whose incidence or geographic range is rapidly increasing or threatens to increase in the near future. 
Federal Emergency Management Agency (FEMA): Federal agency under the Department of 
Homeland Security that coordinates responses to natural disasters with State and local governments 
and provides Federal assistance. 
Food and Drug Administration (FDA): the HHS operating division that is responsible for protecting 
the public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological 
products, medical devices, our Nation's food supply, cosmetics, and products that emit radiation.  
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Health care coalition: A group of local health care and other public health organizations that work 
together to prepare for, respond to, and recover from emergencies. 
HHS Protect: On April 10, 2020, the HHS Office of Chief Information Officer (OCIO), in partnership with 
CDC and contractors, launched this new platform to collect health care information to better inform the 
ongoing COVID-19 response.115, 116  In July, HHS announced new guidance for hospitals to report 
requested hospital data to HHS Protect.117  Along with data reported by hospitals report, HHS Protect 
integrates over 200 datasets from State, Federal, and private partners, which includes data on hospital 
utilization, government and industry supply chain, and other information relevant to the current 
pandemic.118   
Intensive care unit (ICU): A specialized hospital or facility department that provides critical care and 
life support for acutely ill and injured patients.  
Medical countermeasures: FDA-regulated products that may be used in potential public health 
emergencies, including a naturally occurring emerging disease.119 
Medicare Accelerated and Advance Payment Programs: Programs that allow CMS to provide 
temporary relief through advanced or accelerated payment to providers and suppliers when they face 
cash flow challenges due to specified circumstances out of their control.  Medicare typically recovers 
the amounts paid under these programs by withholding payments for subsequent claims from 
providers 120   
Mental health: CDC defines mental health as emotional, psychological, and social well-being.  A person 
can experience poor mental health and not be diagnosed with a mental illness.121 
N95 respirator mask: Respiratory protective device designed to achieve a very close facial fit and very 
efficient filtration of airborne particles.  The N95 designation means that when subjected to careful 
testing, the respirator blocks at least 95 percent of very small (0.3 micron) test particles.  If properly 
fitted, the filtration capabilities of N95 respirators exceed those of face masks.  
National Health Service Corps (NHSC): Administered by the Health Resources and Services 
Administration (HRSA), NHSC provides support to health care providers working in areas of the United 
States with limited access to care.  In 2019, HHS announced that it would provide additional money in 
scholarship and loan repayment awards for clinicians and students through the NHSC.122  The NHSC 
Rural Community Loan Repayment Program was designed for providers working to combat the opioid 
epidemic in the Nation's rural communities.  In exchange for loan repayment, award recipients must 
commit to 3-year loan repayment contracts.  The NHSC provides information on how those who have 
already been approved in the program can receive flexibility due to COVID-19.123  
Negative pressure room: A room in a hospital or facility that is used to contain airborne contaminants 
within the room.  
Office of the Assistant Secretary for Preparedness and Response (ASPR): The HHS staff division that 
leads the Nation's medical and public health preparedness for, response to, and recovery from disasters 
and public health emergencies.  
Pandemic: An epidemic that has spread over several countries or continents, usually affecting a large 
number of people.    
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OEI-09-21-00140  Glossary of Key Terms | 35  Paycheck Protection Program (PPP): A program that provides loans to assist eligible borrowers to pay 
certain payroll and operating costs.124  Borrowers may be eligible to have their PPP loan forgiven if they 
meet several criteria, including maintaining employee and compensation levels.  The program is run by 
the Small Business Administration.125, 126   
Personal protective equipment (PPE): Protective clothing, helmets, goggles, or other garments or 
equipment designed to protect the wearer's body from injury or infection.  PPE respirators and face 
masks.  
People of color: A collective term used as an inclusive and unifying frame across different racial groups 
that do not identify as White.127 
Provider Relief Fund (PRF): A fund established by Congress to reimburse, through grants or other 
mechanisms, eligible health care providers for health care-related expenses or lost revenues that are 
attributed to the coronavirus.128 
Pulse survey: A type of short feedback survey, (e.g., quick, point-in-time questions) that are typically 
narrow in scope. 
Quarantine: The separation and restriction of movement of people who were exposed to a contagious 
disease.  Quarantine is used to keep an individual who may have been exposed to COVID-19 away from 
others. 
Regional Ebola and other special pathogen treatment centers (special pathogen centers): Ten 
hospitals designated by ASPR following the Ebola outbreak in 2015 to maintain capability to accept 
patients ill from special pathogens.  They receive annual assessments from the National Ebola Training 
and Education Center, a consortium of several health care facilities that is funded by and directly 
coordinates with ASPR and CDC.   
Respirator: Masklike device that covers the nose and mouth to prevent the inhalation of noxious 
substances.  There are two main types: air-purifying respirators, which remove contaminants from the 
air, and air-supplying respirators, which provide a clean source of air.  (Also see N95 respirators)  
Social distancing: Increasing the physical space between people to avoid spreading illness.  
Recommended measures can include keeping 6 feet away from others, avoiding social gatherings, and 
following guidance from local public health authorities for where a person lives.  
CDC Social Vulnerability Index (CDC SVI): An index of 15 U.S. Census variables that can be used by 
local health officials to identify communities that may need support before, during, and after 
disasters.129  
Special Pathogen: A highly infectious agent capable of causing severe disease in humans. 
Small Rural Hospital Improvement Program (SHIP): HRSAs Federal Office of Rural Health Policy 
administers the Small Rural Hospital Improvement Program.  The purpose of this program is to help 
small rural hospitals with 49 beds or less implement quality and operational improvement efforts to 
align with value-based care.  The Federal Office of Rural Health Policy administers the SHIP award 
through the State Offices of Rural Health (SORH).  Each SORH submits an application to HRSA on behalf 
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of eligible hospital applicants in its State.  The SORH is the official award recipient of record and serves 
as fiscal intermediary for all eligible hospitals within the State.  The maximum funding per hospital for 
June 1, 2019, through May 31, 2023, is $12,000 per year, subject to the availability of appropriated 
funds.130  
Staffed Beds: Physical beds in a health care facility for which staff are available to attend to the patient 
occupying the bed.131 
Strategic National Stockpile: Supplements State and local stocks of devices, medicines, and supplies 
for public health emergencies.  
Telehealth: Use of electronic information and telecommunications technologies to support 
long-distance clinical health care, patient and professional health-related education, public health, and 
health administration.  
Traveling nurse: Nurses employed on a short-term or periodic basis.  They include temporary staff, 
independent contractors, and seasonal hires.132  
Underserved communities: Communities that have historically experienced health care disparities, 
including limited access to health care and worse health outcomes than other communities.  
Communities may be underserved due to geographic conditions, socioeconomic conditions, or a 
combination of both. 
World Health Organization (WHO): An international organization that partners with countries, the 
United Nations system, research institutions, and other entities to direct and coordinate health work.  
WHO has delegates from member countries and an Executive Board that is composed of health experts.  
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METHODOLOGY 
 
 
Scope of Inspection 
For this evaluation we conducted a pulse survey (i.e., quick, point-in-time questions) 
by telephone with administrators from a stratified random sample of 
Medicare-certified hospitals nationwide.  These conversations focused on three key 
issues regarding their COVID-19 response: (1) current challenges in responding to the 
COVID-19 pandemic, (2) their greatest concerns going forward, and (3) areas for 
government support.  We analyzed hospital responses to identify common and 
compelling challenges, concerns, and areas for government support.   
We conducted the interviews during February 2226, 2021.  We spoke with 
administrators who are familiar with the hospitals COVID-19 response.  The positions 
of these hospital administrators were typically the Chief Executive Officer, Chief 
Medical Officer, or representatives from teams and departments dedicated to 
emergency preparedness or incident command.  In some cases, leadership from the 
relevant hospital networks participated in the interviews alongside hospital 
administrators or on the hospitals behalf. 
Hospital Selection and Response 
We had previously selected a stratified random sample of 410 hospitals for an 
October 2018 report examining hospital preparedness for emerging infectious 
diseases.133  We randomly selected the 410 hospitals from 4,489 Medicare-certified 
hospitals with emergency departments in 2016.  The 410 selected hospitals were in 
47 States, the District of Columbia, and Puerto Rico.  The sample was composed of 
two strata: (1) all 10 ASPR-designated Special Pathogen Centers and (2) 400 other 
hospitals with emergency departments. 
For this review, we used the same sample of 410 hospitals but removed 13 hospitals 
that were no longer in operation or no longer providing inpatient care.  This left a 
total sample of 397 eligible hospitals that we attempted to contact.  We received 
responses from 320 of these 397 hospitals, for an 81-percent rate of contact.  Among 
the 77 hospitals that did not respond, 5 chose not to participate, 20 were unable to 
provide the necessary staff to schedule interviews during the 5-day data collection 
period, and 52 could not be reached after a minimum of 3 attempts to contact them.  
Most interview responses were provided directly by an administrator for a single 
hospital.  However, for 51 sampled hospitals, we spoke with administrators from their 
parent corporations.  We considered the interviews with the administrators from the 
parent companies to be responses for each of the hospitals in our sample that were 
Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care 
OEI-09-21-00140  Methodology | 38   
owned by those companies.  These 51 hospitals were spread across 16 hospital 
networks.   
HHS Protect Data 
To supplement the pulse survey responses, we analyzed data from HHS Protect that 
hospitals reported for the Wednesday before our interviews (February 17, 2021).  We 
chose this date because we wanted data as close to our survey week as possible, and 
because certain data are reported only for Wednesdays.  For each responding 
hospital, we identified or calculated the following: 
  number of staffed adult inpatient beds,  
  whether the hospital was treating any patients with COVID-19, 
  adult inpatient occupancy rate, 
  adult ICU occupancy rate,  
  whether the hospital was able to order and obtain N95 masks, and 
  whether the hospital anticipated a critical staffing shortage within a week.134 
See the Appendix on page 41 for the data presentation of this information. 
To complete this analysis, we analyzed HHS Protect data from both the Hospital 
Unified Prioritized Timeseries and Hospital Denominator datasets.  We defined each 
hospital using the CMS Certification Number as reported in HHS Protect.  Our analysis 
is reflective of what hospitals had reported to HHS Protect as of February 25, 2021.  
We did not determine whether hospitals provided updated data after this date.  Four 
responding hospitals had not reported to HHS Protect for February 17, 2021; thus, 
this analysis includes 316 of the 320 responding hospitals.   
CDC and U.S. Census Bureau Data 
We also obtained community-level socioeconomic and demographic data from the 
CDCs 2018 Social Vulnerability Index database and U.S. Census Bureaus 2019 
American Community Survey and the 2010 decennial census.  These data allowed us 
to examine the community characteristics within a 30-minute drive of each 
responding hospitals or within the hospital's county. 
We examined three geospatial variables:  
  urban, mid-size, or rural designation; 
  a social vulnerability index; and 
  the proportion of the population, by county, that had household incomes 
below the Federal poverty level.  
Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care 
OEI-09-21-00140  Methodology | 39   
See the Appendix on page 41 for the data presentation of this information. 
Limitations 
This study has two limitations: (1) hospital responses reflect a point in time 
(February 2226, 2021)since our interviews, some hospital challenges may have 
worsened and others may have improved; and (2) we did not independently verify the 
information reported by hospitals to HHS Protect or to OIG during the interviews, nor 
have we independently assessed the merits, costs, or effectiveness of the strategies or 
areas for government support identified by hospitals.  As such, OIG is not endorsing 
the suggestions made by the hospital administrators.   
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
 
Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care 
OEI-09-21-00140  Methodology | 40   
 
APPENDIX 
 
 
Characteristics of Responding Hospitals and Their Communities 
This appendix describes the 320 hospitals that we surveyed, as well as the communities surrounding the 
responding hospitals.  Please refer to the methodology section for an explanation of the data collected 
and analyzed for this appendix. 
Exhibit A-1: The 320 responding hospitals were located in 45 States, the District of Columbia, 
and Puerto Rico. 
Source: OIG analysis of 320 responding hospitals using the address listed for their provider number, March 2021. 
Exhibit A-2: Among the responding hospitals, some were designated as  
specialized hospitals. 
Special pathogen  Major teaching  Critical access 
centers are designated  hospitals are affiliated  hospitals are smaller 
to treat patients with  with medical schools.   hospitals typically in 
infectious diseases.  We  We talked to 24.  rural communities.  We 
talked to 9.  talked to 95. 
Source: OIG analysis of CMSs Certification and Survey Provider Enhanced Reports data associated with a sample of Medicare-certified 
hospitals as well as data obtained from https://www.phe.gov/Preparedness/planning/hpp/Pages/hpp-pathogens.aspx, March 2021. 
Note: We did not include any of the special pathogen centers in the count of major teaching hospitals. 
Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care 
OEI-09-21-00140  Appendix | 41   
Exhibit A-3: Responding hospitals had a range of bed counts. 
More than 500 beds 21
101500 beds 129
51100 beds 31
050 beds 135
 
Source: OIG analysis of HHS Protect data for staffed, inpatient beds for adults, March 2021. 
Note: Total equals 316 responding hospitals because not all hospitals reported data in HHS Protect.   
Exhibit A-4: About half of responding hospitals were located in urban areas. 
 
Source: OIG analysis of 2010 U.S. Census Bureau data for the 320 responding hospitals using the address listed for their  
provider number, March 2021. 
Note: One dot is equivalent to 10 hospitals. 
Exhibit A-5: Among responding hospitals, 41 were located in counties where 20 percent  
or more of the population had household incomes below the Federal poverty level. 
20% or more 41
1519% 78
1014% 127
Less than 10% 74
 
Source: OIG analysis of 2019 U.S. Census Bureau data for 320 responding hospitals, March 2021. 
Note: Nationally, by county, the average percentage of the population with household income below the Federal poverty level was 
12.3 percent.  See U.S. Census Bureau, Small Area Income and Poverty Estimates: 2019.  Accessed at 
https://www.census.gov/content/dam/Census/library/publications/2020/demo/p30-08.pdf on March 15, 2021. 
Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care 
OEI-09-21-00140  Appendix | 42   
Exhibit A-6: More than one-third of responding hospitals (113) were in communities with 
higher social vulnerability than the national average. 
Highest 10
Medium-High 103
Medium-Low 162
Lowest 41
 
Source: OIG analysis of 2018 CDC data for 316 responding hospitals, March 2021. 
Note: The social vulnerability score uses CDCs social vulnerability index of the community and we calculated this score within a 30-minute 
drive from each hospital.  The index ranges from 0 to 1.0, with 0.5 being the midpoint.  Highest are those above 0.75, medium-high  
are >0.50 to 0.75, medium-low are >0.25 to 0.50, and lowest are those less than or equal to 0.25.  For more information about CDCs Index, see 
https://www.atsdr.cdc.gov/placeandhealth/svi/index.html. 
Exhibit A-7: The majority of responding hospitals were treating adult inpatients with 
confirmed or suspected cases of COVID-19 a week before our data collection. 
Treating patients with COVID-19 234
Not treating patients with COVID-19 82
 
Source: OIG analysis of HHS Protect data, March 2021. 
Note: Total equals 316 responding hospitals because not all hospitals reported data in HHS Protect. 
Exhibit A-8: Some responding hospitals were operating at over 90-percent adult inpatient 
occupancy and/or over 90-percent adult ICU occupancy a week before our survey. 
45 56
42
40
37 36
33
28 32 31 31
22
20 23
19
13 14
11
8
5
Inpatient Occupancy ICU Occupancy
 
Source: OIG analysis of HHS Protect data for February 17, 2021.  
Note: For adult inpatient occupancy, the total equals 316 responding hospitals because not all hospitals reported data in HHS Protect.   
For adult ICU occupancy, the total equals 230 because we excluded 86 hospitals that reported having no staffed ICU beds for adults. 
Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care 
OEI-09-21-00140  Appendix | 43   
Exhibit A-9: Number of Responding Hospitals That Reported Experiencing Staffing 
Shortages and Difficulties Obtaining Supplies 
Number 
Indicator 
of Hospitals 
Staffing Shortages    
Reported that they faced a critical staffing shortage as of February 17, 2021  38 
Reported that they anticipated facing a critical staffing shortage within a week  49 
Difficulty Obtaining Supplies   
Reported that they were unable to order or obtain N-95 masks   19 
Source: OIG analysis of HHS Protect data, March 2021. 
Note: For experiencing staffing shortages, 296 respondent hospitals reported data.  For difficulties in obtaining N-95 masks, 316 responding 
hospitals reported data. 
 
 
Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care 
OEI-09-21-00140  Appendix | 44   
 
ACKNOWLEDGMENTS AND CONTACT 
 
Acknowledgments 
This report is the result of a large team of OIG staff over a short time period, with the 
purpose to provide timely information at an unprecedented time for HHS and the 
nation. 
Rosemary Rawlins Bartholomew and Ivy Ngo served as the team leaders for this study.  
Key contributors included Ariel Arguelles, Emily Borgelt, Anna Brown, Charis Burger, 
Kristen Calille, Tanaz Dutia, Ben Gaddis, Kevin Golladay, Jennifer Hagen, Eunji Kim, 
Sarah Lee, Demetrius Martinez, Kasey Memphis, Sabrina Morello, Petra Nealy, Chelsea 
Samuel, Karl Mari Santos, Anthony Soto McGrath, Savanna Thielbar, Jesse Valente, 
and John Van Der Schans.  
We would also like to acknowledge other significant contributors without whom this 
effort would not have been successful.  Staff from all OIG components contributed, 
including the Office of Audit Services, the Office of Counsel, the Office of Evaluation 
and Inspections, the Office of Investigations, and the Office of Management and 
Policy.  Contributions included planning and conducting interviews, data and 
administrative support, and report production and distribution.  
This report was prepared under the direction of Blaine Collins and Ruth Ann Dorrill, 
Regional Inspectors General for Evaluation and Inspections, and Abby Amoroso and 
Amy Ashcraft, Deputy Regional Inspectors General. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care 
OEI-09-21-00140  Acknowledgments and Contact | 45   
 
ABOUT THE OFFICE OF INSPECTOR GENERAL 
 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-
452, as amended, is to protect the integrity of the Department of Health and Human 
Services (HHS) programs, as well as the health and welfare of beneficiaries served by 
those programs.  This statutory mission is carried out through a nationwide network 
of audits, investigations, and inspections conducted by the following operating 
components: 
The Office of Audit Services (OAS) provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing audit work 
done by others.  Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments of HHS programs and operations.  
These audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS. 
The Office of Evaluation and Inspections (OEI) conducts national 
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable 
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental 
programs.  To promote impact, OEI reports also present practical recommendations 
for improving program operations. 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, operations, and 
beneficiaries.  With investigators working in all 50 States and the District of Columbia, 
OI utilizes its resources by actively coordinating with the Department of Justice and 
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI often lead to criminal convictions, administrative sanctions, and/or civil 
monetary penalties. 
The Office of Counsel to the Inspector General (OCIG) provides 
general legal services to OIG, rendering advice and opinions on HHS programs and 
operations and providing all legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS 
programs, including False Claims Act, program exclusion, and civil monetary penalty 
cases.  In connection with these cases, OCIG also negotiates and monitors corporate 
integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities.
Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care 
OEI-09-21-00140  About OIG | 46   
 
ENDNOTES 
 
 
 
 
1 CDC, Similarities and Differences between Flu and COVID-19.  Accessed at https://www.cdc.gov/flu/symptoms/flu-vs-
covid19.htm#:~:text=COVID%2D19%20is%20caused%20by,can%20be%20contagious%20for%20longer on March 9, 2021.  See 
also, Johns Hopkins Medicine, Health, Coronavirus Disease 2019 vs. the Flu.  Accessed at 
https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-disease-2019-vs-the-flu on 
March 9, 2021.   
2 HHS, OASH, Office of Disease Prevention and Health Promotion, Access to Health Services.  Accessed at 
https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/access-to-
health on March 22, 2021. 
3 CDC, Association Between Social Vulnerability and a Countys Risk for Becoming a COVID-19 HotspotUnited States, 
June 1July 25, 2020. Accessed at https://www.cdc.gov/mmwr/volumes/69/wr/mm6942a3.htm on March 9, 2021.  
4 CDC, COVID-19 Racial and Ethnic Disparities:  Risk of Severe Illness or Death From COVID-19.  Accessed at 
https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/disparities-illness.html on 
March 22, 2021. 
5 HHS, Provider Relief Fund General Information (FAQs).  Accessed at https://www.hhs.gov/coronavirus/cares-act-provider-
relief-fund/faqs/provider-relief-fund-general-info/index.html#vaccine-distribution on March 1, 2021. 
6 CMS Press Release.  Biden-Harris Administration Increases Medicare Payment for Life-Saving COVID-19 Vaccine.  Accessed at 
https://www.cms.gov/newsroom/press-releases/biden-harris-administration-increases-medicare-payment-life-saving-covid-
19-vaccine on March 15, 2021. 
7 Tolbert, Jennifer, Jennifer Kates, and Josh Michaud, The COVID-19 Vaccine Priority Line Continues to Change as States Make 
Further Updates, Kaiser Family Foundation, Jan 21, 2021.  Accessed at https://www.kff.org/policy-watch/the-covid-19-vaccine-
priority-line-continues-to-change-as-states-make-further-updates/ on March 22, 2021. 
8 FDA, FDA Issues Emergency Use Authorization for Third COVID-19 Vaccine, February 27, 2021.  Accessed at 
http://www.fda.gov/news-events/press-announcements/fda-issues-emergency-use-authorization-third-covid-19-
vaccine#:~:text=Today%2C%20the%20U.S.%20Food%20and,SARS-CoV-2 on March 10, 2021.   
9 The number of vaccinations in the United States has increased since the time of the pulse survey.  On February 22, 2021, the 
7-day moving average for new vaccine doses administered in the United States was more than 1,400,000.  As of March 12, that 
average has increased to over 2,100,000.  CDC, COVID Data Tracker, Trends in Number of COVID-19 Vaccinations in the US.  
Accessed at https://covid.cdc.gov/covid-data-tracker/#vaccination-trends on March 17, 2021.   
10 CMS, CMS Releases Recommendations on Adult Elective Surgeries, Non-Essential Medical, Surgical, and Dental Procedures 
During COVID-19 Response, March 18, 2020.  Accessed at https://www.cms.gov/newsroom/press-releases/cms-releases-
recommendations-adult-elective-surgeries-non-essential-medical-surgical-and-
dental#:~:text=Earlier%20today%20at%20the%20White,(COVID-19)%20outbreak on March 9, 2021. 
11 CMS, CMS Issues Recommendations to Re-Open Health Care Systems in Areas With Low Incidence of COVID-19, April 19, 
2020.  Accessed at https://www.cms.gov/newsroom/press-releases/cms-issues-recommendations-re-open-health-care-
systems-areas-low-incidence-covid-19 on March 9, 2021. 
12 In accordance with the CARES Act, CMS increased the Medicare inpatient payment rate for COVID-19 patients by 20 percent, 
and temporarily suspended the 2-percent Medicare fee-for-service sequestration payment adjustment, resulting in an effective 
2-percent payment increase for Medicare claims.  CARES Act, P.L. 116-136,  3709-3710 (March 27, 2020).  CMS Manual 
 
Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care 
OEI-09-21-00140  Endnotes | 47 
   
 
System, Pub. 100-04, CR 11764 (April 24, 2020), accessed at https://www.cms.gov/files/document/r10058cp.pdf on March 9, 
2021. 
13 CMS provided an enhanced payment for eligible inpatient cases that involve use of certain new products with current FDA 
approval or EUA to treat COVID-19.  85 Fed. Reg. 71142 (November 6, 2020).  CMS, New COVID-19 Treatments Add-On 
Payment (NCTAP), accessed at https://www.cms.gov/medicare/covid-19/new-covid-19-treatments-add-payment-nctap on 
March 9, 2021. 
14 CMS has granted exceptions and extensions for many quality reporting and value-based purchasing programs as a result of 
the pandemic.  CMS, Exceptions and Extensions for Quality Reporting Requirements for Acute Care Hospitals, PPS-Exempt 
Cancer Hospitals, Inpatient Psychiatric Facilities, Skilled Nursing Facilities, Home Health Agencies, Hospices, Inpatient 
Rehabilitation Facilities, Long-Term Care Hospitals, Ambulatory Surgical Centers, Renal Dialysis Facilities, and MIPS Eligible 
Clinicians Affected by COVID-19, March 27, 2020.  Accessed at https://www.cms.gov/files/document/guidance-memo-
exceptions-and-extensions-quality-reporting-and-value-based-purchasing-programs.pdf on March 9, 2021. 
15 The Continuing Appropriations Act, 2021 and Other Extensions Act (P.L. 116-159), enacted on October 1, 2020, amended the 
repayment terms so that these loans now start to be repaid 1 year from the date the advance payment was issued.  CMS, Fact 
Sheet: Repayment Terms for Accelerated and Advance Payments Issued to Providers and Suppliers During Covid-19 Emergency.  
Accessed at https://www.cms.gov/files/document/accelerated-and-advanced-payments-fact-sheet.pdf on March 13, 2021. 
16 American Rescue Plan Act of 2021, P.L. No. 117-2 (March 11, 2021). 
17 This waiver is an 1135 waiver, which, when granted by CMS, does not have the effect of waiving State or local licensure 
requirements or any requirement specified by the State or a local government as a condition for waiving its licensure 
requirements.  Those requirements would continue to apply unless waived by the State.  Therefore, in order for the physician 
or non-physician practitioner to avail him- or herself of this specific waiver, the State also would have to waive its licensure 
requirements, either individually or categorically, for the type of practice for which the physician or non-physician practitioner 
is licensed in his or her home State.  CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, 
updated on February 19, 2021.  Accessed at https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-
waivers.pdf on March 22, 2021. 
18 Jiaye Liu et al., Community Transmission of Severe Acute Respiratory Syndrome Coronavirus 2, Shenzhen, China, 2020, 
Emerging Infectious Diseases, June 2020.  Accessed at https://wwwnc.cdc.gov/eid/article/26/6/20-0239_article on February 24, 
2021.  
19 CDC, COVID-19, Risk for COVID-19 Infection, Hospitalization, and Death by Age Group.  Accessed at 
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-age.html on 
February 24, 2021. 
20 CDC, COVID-19, Symptoms of Coronavirus.  Accessed at https://www.cdc.gov/coronavirus/2019-ncov/symptoms-
testing/symptoms.html on February 24, 2021.   
21 Susie Neilson and Aylin Woodward, A comprehensive timeline of the coronavirus pandemic at 1 year, from Chinas first case 
to present, Business Insider, December 24, 2020.  Accessed at https://www.businessinsider.com/coronavirus-pandemic-
timeline-history-major-events-2020-3 on February 24, 2021.  
22 CDC, media statement, CDC Confirms Possible Instance of Community Spread of COVID-19 in U.S., February 26, 2020.  
Accessed at https://www.cdc.gov/media/releases/2020/s0226-Covid-19-spread.html on February 24, 2021.  
23 WHO, WHO Director-Generals opening remarks at the media briefing on COVID-1911 March 2020, March 11, 2020.  
Accessed at https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-
briefing-on-covid-19---11-march-2020 on February 24, 2021.  
 
Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care 
OEI-09-21-00140  Endnotes | 48 
   
 
24 CDC, COVID Data Tracker, United States COVID-19 Cases and Deaths by State.  Accessed at https://covid.cdc.gov/covid-
data-tracker/?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-updates%2Fcases-in-
us.html#cases_casesper100klast7days on March 19, 2021.  
25 CDC, COVID-19, About Variants of the Virus that Causes COVID-19.  Accessed at https://www.cdc.gov/coronavirus/2019-
ncov/transmission/variant.html on February 24, 2021.  
26 CDC, COVID-19, Science Brief: Emerging SARS-CoV-2 Variants.  Accessed at https://www.cdc.gov/coronavirus/2019-
ncov/more/science-and-research/scientific-brief-emerging-variants.html#print on March 8, 2021. 
27 OIG, Hospital Experiences Responding to COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020 (OEI-06-
20-00330), April 2020.   
28 American Hospital Association, Fact Sheet: Financial Challenges Facing Hospitals and Health Systems as a Result of COVID-
19, April 2020.  Accessed at https://www.aha.org/fact-sheets/2020-04-24-fact-sheet-financial-challenges-facing-hospitals-
and-health-systems-result on March 8, 2021.  
29 75 Fed. Reg. 35035, 35035-36, (June 21, 2010).  
30 ASPR, 20172022 Health Care Preparedness and Response Capabilities, November 2016.  Accessed at 
https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/2017-2022-health care-pr-capablities.pdf on 
February 24, 2021.   
31 FEMA, Emergency Support Function #8Public Health and Medical Services Annex, June 2016.  Accessed at 
https://www.fema.gov/sites/default/files/2020-07/fema_ESF_8_Public-Health-Medical.pdf on February 24, 2021. 
32 HHS, Emergency Support Functions.  Accessed at https://www.phe.gov/Preparedness/support/esf8/Pages/default.aspx on 
March 8, 2021. 
33 FDA, testimony, COVID-19: An Update on the Federal Response, September 23, 2020.  Accessed at 
https://www.fda.gov/news-events/congressional-testimony/covid-19-update-federal-response-09232020 on March 3, 2021.   
34 HHS, Surgeon General Priority: Emerging Public Health Threats.  Accessed at 
https://www.hhs.gov/surgeongeneral/priorities/emerging-public-health-threats/index.html on March 3, 2021. 
35 ASPR, ASPR 2020 Year in Review.  Accessed at https://www.phe.gov/about/review-2020/Pages/default.aspx on February 24, 
2021. 
36 HHS, press release, Trump Administration Announces Framework and Leadership for 'Operation Warp Speed, May 15, 
2020.  Accessed at https://www.hhs.gov/about/news/2020/05/15/trump-administration-announces-framework-and-
leadership-for-operation-warp-speed.html on March 1, 2021.  
37 HHS, Emergency Support Functions, op. cit.  
38 HHS, HHS Concept of Operations for ESF #8.  Accessed at 
https://www.phe.gov/Preparedness/planning/mscc/handbook/chapter7/Pages/hhsconcept.aspx on March 11, 2021. 
39 HHS, HHS Office of the Assistant Secretary for Preparedness and Response (About ASPR Webpage).  Accessed at 
https://www.phe.gov/about/aspr/Pages/default.aspx on March 11, 2021. 
40 42 U.S.C.  247d-6b.   
41 ASPR, ASPR 2020 Year in Review, op. cit. 
42 ASPR designated 9 Special Pathogen Centers in 2015 and added an additional in 2016 for a total of 10.  HHS, press release 
HHS selects regional Ebola treatment center for southwestern U.S., June 14, 2016.  Accessed at https://wayback.archive-
 
Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care 
OEI-09-21-00140  Endnotes | 49 
   
 
it.org/3926/20170128012936/https://www.hhs.gov/about/news/2016/06/14/hhs-selects-regional-ebola-treatment-center-
southwestern-us.html on March 8, 2021. 
43 ASPR, Regional Treatment Network for Ebola and Other Special Pathogens, page 4, November 2017.  Accessed at 
https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/RETN-Ebola-Report-508.pdf on February 24, 2021.  
44 ASPR, Public Health Emergency, COVID-19 Supplemental Funding Overview.  Accessed at 
https://www.phe.gov/emergency/events/COVID19/HPP/Pages/overview.aspx on March 1, 2021. 
45 Ibid.   
46 CDC, Mission, Role, and Pledge.  Accessed at https://www.cdc.gov/about/organization/mission.htm on February 24, 2020.  
47 CDC, Guidance for COVID-19.  Accessed at https://www.cdc.gov/coronavirus/2019-ncov/communication/guidance.html on 
March 16, 2021. 
48 CDC, COVID-19: CDC's Response.  Accessed at https://www.cdc.gov/coronavirus/2019-ncov/cdcresponse/index.html on 
March 11, 2021. 
49 CDC, Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus (2019-nCoV), CDCHAN-00427.  Accessed at 
https://emergency.cdc.gov/han/HAN00427.asp on March 3, 2021.   
50 CDC, Interim Infection Prevention and Control Recommendations for Health Care Personnel During the Coronavirus Disease 
2019 (COVID-19) Pandemic, February 23, 2021.  Accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-
control-recommendations.html on March 3, 2021.   
51 CDC, Summary for Healthcare Facilities: Strategies for Optimizing the Supply of PPE during Shortages.  Accessed at 
https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/strategies-optimize-ppe-shortages.html on March 16, 2021. 
52 42 CFR pt. 482.  
53 Social Security Act,  1861(e); 42 U.S.C.  1395x(e); 42 CFR  488.3(a). 
54 42 U.S.C.  1320b-5. 
55 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, February 19, 2020.  Accessed at  
https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf on February 25, 2021.  This 
document was last updated on December 1, 2020. 
56 CMS, Medicare COVID-19 Vaccine Shot Payment.  Accessed at https://www.cms.gov/medicare/covid-19/medicare-covid-19-
vaccine-shot-payment on March 16, 2021.   
57 CMS, press release, Biden-Harris Administration Increases Medicare Payment for Life-Saving COVID-19 Vaccine, March 15, 
2021.  Accessed at https://www.cms.gov/newsroom/press-releases/biden-harris-administration-increases-medicare-payment-
life-saving-covid-19-vaccine on March 16, 2021.   
58 FDA, What We Do.  Accessed at https://www.fda.gov/about-fda/what-we-do on February 24, 2021.  
59 FDA, COVID-19 Frequently Asked Questions.  Accessed at  https://www.fda.gov/emergency-preparedness-and-
response/coronavirus-disease-2019-covid-19/covid-19-frequently-asked-questions on February 24, 2021.  
60 FDA, news release, Coronavirus (COVID-19) Update: Daily Roundup, March 25, 2020.  Accessed at  
https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-daily-roundup-march-25-2020 on 
February 24, 2021.   
 
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OEI-09-21-00140  Endnotes | 50 
   
 
61 FDA, news release, Coronavirus (COVID-19) Update: FDA Authorizes Monoclonal Antibodies for Treatment of COVID-19, 
February 9, 2021.  Accessed at https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-
authorizes-monoclonal-antibodies-treatment-covid-19-0 on February 24, 2021.  
62 NIAID, NIAID Role in Research.  Accessed at https://www.niaid.nih.gov/research/role on March 1, 2021. 
63 NIAID, COVID-19 Clinical Research.  Accessed at https://www.niaid.nih.gov/diseases-conditions/covid-19-clinical-research on 
March 1, 2021. 
64 HHS, Public Health Offices.  Accessed at https://www.hhs.gov/ash/public-health-offices/index.html on March 8, 2021. 
65 HHS, About the Office of the Assistant Secretary for Health (OASH).  Accessed at https://www.hhs.gov/ash/about-
ash/index.html on March 3, 2021. 
66 U.S. Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, 
Testimony, Review of Coronavirus Response Efforts, September 16, 2020.  Accessed at 
https://www.appropriations.senate.gov/imo/media/doc/09.16.2020--HHS%20Covid%20Relief%20Efforts%20Testimony1.pdf on 
March 3, 2021. 
67 FDA, Testimony, COVID-19: An Update on the Federal Response, op. cit.  
68 HHS, About the Office of the Surgeon General.  Accessed at https://www.hhs.gov/surgeongeneral/about/index.html on 
March 3, 2021. 
69 HHS, The Surgeon Generals Priorities.  Accessed at https://www.hhs.gov/surgeongeneral/priorities/index.html on March 3, 
2021. 
70 HHS, Office of the Surgeon General, Surgeon General Priority: Emerging Public Health Threats.  Accessed at 
https://www.hhs.gov/surgeongeneral/priorities/emerging-public-health-threats/index.html on March 8, 2021.  
71 HHS, Office of the Surgeon General, Reports and Publications.  Accessed at https://www.hhs.gov/surgeongeneral/reports-
and-publications/index.html on March 8, 2021. 
72 HHS, press release, Statement: U.S. Surgeon General Calls for COVID-19 Survivors to Donate Plasma, December 21, 2020.  
Accessed at https://www.hhs.gov/about/news/2020/12/21/statement-us-surgeon-general-calls-for-covid-19-survivors-to-
donate-plasma.html on March 3, 2021. 
73 CMS, press release, Trump Administration Provides Financial Relief for Medicare Providers, March 28, 2020.  Accessed at 
https://www.cms.gov/newsroom/press-releases/trump-administration-provides-financial-relief-medicare-providers on 
March 2, 2021. 
74 The Coronavirus Aid, Relief, and Economic Security (CARES) Act, P.L. 116-136 (March 27, 2020). 
75 Moss, K., et al., The Coronavirus Aid, Relief, and Economic Security Act: Summary of Key Health Provisions, Kaiser Family 
Foundation, April 9, 2020.  Accessed at https://www.kff.org/coronavirus-covid-19/issue-brief/the-coronavirus-aid-relief-and-
economic-security-act-summary-of-key-health-provisions/ on March 16, 2021. 
76 CMS, press release, Trump Administration Provides Financial Relief for Medicare Providers, op. cit.  
77 Congressional Research Service, Medicare Accelerated and Advance Payments and COVID-19: Frequently Asked Questions, 
March 1, 2021.  Accessed at https://crsreports.congress.gov/product/pdf/R/R46698 on March 8, 2021. 
78 Ibid.  
 
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79 HHS, CARES Act Provider Relief Fund: For Providers.  Accessed at https://www.hhs.gov/coronavirus/cares-act-provider-relief-
fund/for-providers/index.html on March 2, 2021. 
80 Congressional Research Service, The COVID-19 Health Care Provider Relief Fund, November 2, 2020.  Accessed at 
https://crsreports.congress.gov/product/pdf/IN/IN11438 on March 8, 2021. 
81 Congressional Research Service, CARES Act Assistance for Employers and EmployeesThe Paycheck Protection Program, 
Employee Retention Tax Credit, and Unemployment Insurance Benefits: Overview (Part 1), April 21, 2020.  Accessed at 
https://crsreports.congress.gov/product/pdf/IN/IN11324 on March 9, 2021. 
82 Small Business Administration (SBA), PPP Loan Forgiveness: Borrowers may be eligible for loan forgiveness.  Accessed at 
https://www.sba.gov/funding-programs/loans/coronavirus-relief-options/paycheck-protection-program/ppp-loan-forgiveness 
on March 9, 2021. 
83 Juliette Cubanski, et al., Medicare Accelerated and Advance Payments for COVID-19 Revenue Loss: More Time to Repay, 
Kaiser Family Foundation, October 8, 2020.  Accessed at https://www.kff.org/medicare/issue-brief/medicare-accelerated-and-
advance-payments-for-covid-19-revenue-loss-more-time-to-repay/ on March 2, 2021.  
84 American Rescue Plan Act of 2021, P.L. No. 117-2 (March 11, 2021).  
85 Ibid,  2303.   
86 Ibid,  2601.  Of the $7.6 billion, not less than $20 million shall be for grants or contracts to Papa Ola Lokahi and to qualified 
entities under specified sections of the Native Hawaiian Health Care Improvement Act. 
87 Ibid,  9911.   
88 Ibid,  2501.  
89 Ibid,  2603; 42 U.S.C.  297n(a).  
90 Ibid,  2703.  
91 Ibid,  2704, 2705.  
92 Department of Defense, Coronavirus: Operation Warp Speed.  Accessed at 
https://www.defense.gov/Explore/Spotlight/Coronavirus/Operation-Warp-Speed/ on March 22, 2021. 
93 HHS, press release, Trump Administration Announces Framework and Leadership for 'Operation Warp Speed op. cit. 
94  We calculated the approximate total investment figure of $19.1 billion by summing the contract values of vaccine 
candidates supported by Federal Government and Operation Warp Speed contract awards for ancillary vaccine supplies.  
Congressional Research Service, Operation Warp Speed Contracts for COVID-19 Vaccines and Ancillary Vaccination Materials, 
Table 1 and Table 2, March 1, 2021.  Accessed at https://crsreports.congress.gov/product/pdf/IN/IN11560 on March 8, 2021. 
95 Matthew Herper, FDA grants authorization to Modernas Covid-19 vaccine, the second in the U.S., STAT, December 18, 
2020.  Accessed at https://www.statnews.com/2020/12/18/fda-eua-moderna-vaccine-covid19/ on December 21, 2020. 
96 FDA, FDA Issues Emergency Use Authorization for Third COVID-19 Vaccine, February 27, 2021.  Accessed at 
http://www.fda.gov/news-events/press-announcements/fda-issues-emergency-use-authorization-third-covid-19-
vaccine#:~:text=Today%2C%20the%20U.S.%20Food%20and,SARS-CoV-2 on March 11, 2021. 
97 CDC, COVID-19 Vaccinations in the United States.  Accessed at https://covid.cdc.gov/covid-data-tracker/#vaccinations on 
March 19, 2021. 
 
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98 CDC, Vaccine Rollout Recommendations, updated February 19, 2021.  Accessed at https://www.cdc.gov/coronavirus/2019-
ncov/vaccines/recommendations.html on February 24, 2021. 
99 Jennifer Kates et al., The COVID-19 Vaccination Line: An Update on State Prioritization Plans, Kaiser Family Foundation, 
January 11, 2021.  Accessed at https://www.kff.org/coronavirus-covid-19/issue-brief/the-covid-19-vaccination-line-an-update-
on-state-prioritization-plans/ on February 24, 2021. 
100 CDC, COVID-19 Vaccination Program Operational Guidance.  Accessed at https://www.cdc.gov/vaccines/covid-19/covid19-
vaccination-guidance.html on March 12, 2021.  
101 Kaiser Family Foundation, State COVID-19 Vaccine Priority Populations.  Accessed at https://www.kff.org/other/state-
indicator/state-covid-19-vaccine-priority-populations/?currentTimeframe=0&selectedDistributions=phase-1a-
prioritization&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D on March 8, 2021. 
102 Ibid. 
103 Lena H. Sun, First 6.4 million doses of Pfizers coronavirus vaccine could go out in mid-December, Washington Post, 
November 24, 2020.  Accessed at https://www.washingtonpost.com/health/2020/11/24/vaccine-plan-first-doses/ on March 16, 
2021. 
104 Shelby Livingston and Allana Akhtar, 'This is game time': Hospitals across the country are gearing up to give the first 
COVID-19 shots to millions of healthcare workers, Business Insider, March 11, 2021.  Accessed at 
https://www.businessinsider.com/hospitals-gear-up-give-first-covid-19-vaccines-healthcare-staff-2020-12 on March 11, 2021. 
105 Shelby Livingston and Allana Akhtar, 'This is game time': Hospitals across the country are gearing up to give the first 
COVID-19 shots to millions of health care workers, Business Insider, March 11, 2021.  Accessed at 
https://www.businessinsider.com/hospitals-gear-up-give-first-covid-19-vaccines-health care-staff-2020-12 on March 11, 2021.  
106 Park, A., et al., How the First COVID-19 Vaccinations Rolled Out at Hospitals Across the U.S., TIME, December 14, 2020.  
Accessed at https://time.com/5921608/covid-19-vaccine-rollout-hospitals/ on March 11, 2021. 
107 OIG, Hospital Experiences Responding to COVID-19 Pandemic: Results of a National Pulse Survey March 2327, 2020 (OEI-06-
20-00330), April 2020.   
108 OIG, Toolkit: Insights for Health Care Facilities From OIG's Historical Work on Emergency Response (OEI-06-20-00470), 
August 2020.   
109 OIG, Toolkit: Insights for Communities From OIG's Historical Work on Emergency Response (OEI-06-20-00470), August 2020.   
110 PRAC, data report, Federal COVID-19 Testing Report: Data Insights from Six Federal Health Care Programs, January 14, 
2021.  Accessed at https://www.oversight.gov/sites/default/files/oig-reports/PRAC/Federal-COVID-19-Testing-Report.pdf on 
March 12, 2021.  
111 Substance Abuse and Mental Health Services Administration, Behavioral Health Integration, Accessed at 
https://www.samhsa.gov/sites/default/files/samhsa-behavioral-health-integration.pdf on March 13, 2021.  
112 CDC, media statement, CDC Confirms Possible Instance of Community Spread of COVID-19 in U.S., February 26, 2020.  
Accessed at https://www.cdc.gov/media/releases/2020/s0226-Covid-19-spread.html on March 2, 2021.  
113 CDC, COVID-19, Symptoms of Coronavirus, op. cit.  
114 FDA, Emergency Use Authorization for Vaccines Explained.  Accessed at https://www.fda.gov/vaccines-blood-
biologics/vaccines/emergency-use-authorization-vaccines-explained on March 2, 2021.  
115 Internal email from HHS official, August 26, 2020.   
 
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116 HHS, press release, HHS Protect: Frequently Asked Questions, July 20, 2020.  Accessed at 
https://www.hhs.gov/about/news/2020/07/20/hhs-protect-frequently-asked-questions.html on February 24, 2021.  
117 HHS, COVID-19 Guidance for Hospital Reporting and FAQs For Hospitals, Hospital Laboratory, and Acute Care Facility Data 
Reporting, March 19, 2021.  Accessed at https://www.hhs.gov/sites/default/files/covid-19-faqs-hospitals-hospital-laboratory-
acute-care-facility-data-reporting.pdf on February 24, 2021.  This HHS guidance document was initially released on July 15, 
2020, and has been updated several times, with the most recent update occurring on March 19, 2021.   
118 HHS, HHS Protect: Frequently Asked Questions, op. cit. 
119 FDA, What are Medical Countermeasures?  Accessed at https://www.fda.gov/emergency-preparedness-and-
response/about-mcmi/what-are-medical-countermeasures on March 2, 2021.   
120 CRS, Medicare Accelerated and Advance Payments and COVID-19: Frequently Asked Questions, op. cit.  
121 CDC, Mental Health Basics, Accessed at https://www.cdc.gov/mentalhealth/learn/index.htm on March 13, 2021. 
122 HHS, press release, HHS Awards $319 Million To Support Health Workforce Providers Caring for the Underserved, 
October 23, 2019.  Accessed at https://public3.pagefreezer.com/browse/HHS.gov/31-12-
2020T08:51/https://www.hhs.gov/about/news/2019/10/23/hhs-awards-319-million-support-health-workforce-providers-
caring-underserved.html  on March 9, 2021.  
123 HRSA, NHSC Service Commitments: COVID-19.  Accessed at https://nhsc.hrsa.gov/coronavirus on March 22, 2021. 
124 Congressional Research Service, CARES Act Assistance for Employers and EmployeesThe Paycheck Protection Program, 
Employee Retention Tax Credit, and Unemployment Insurance Benefits: Overview (Part 1), April 21, 2020.  Accessed at 
https://crsreports.congress.gov/product/pdf/IN/IN11324 on March 3, 2021.   
125 SBA, Paycheck Protection Program.  Accessed at https://www.sba.gov/funding-programs/loans/coronavirus-relief-
options/paycheck-protection-program on March 3, 2021.   
126 SBA, PPP Loan Forgiveness.  Accessed at https://www.sba.gov/funding-programs/loans/coronavirus-relief-
options/paycheck-protection-program/ppp-loan-forgiveness on March 3, 2021.   
127 The Center for Racial Justice Innovation, Race Reporting Guide, 2015, page 30.  Accessed at 
https://www.raceforward.org/sites/default/files/Race%20Reporting%20Guide%20by%20Race%20Forward_V1.1.pdf on March 1, 
2021. 
128 CRS, The COVID-19 Health Care Provider Relief Fund, November 2, 2020.  Accessed at 
https://crsreports.congress.gov/product/pdf/IN/IN11438 on March 3, 2021.   
129 CDC, Agency for Toxic Substances and Disease Registry, CDC Social Vulnerability Index.  Accessed at 
https://www.atsdr.cdc.gov/placeandhealth/svi/index.html on March 2, 2021.   
130 HRSA, Federal Office of Rural Health Policy, Small Rural Hospital Improvement Program (SHIP), Notice of Funding 
Opportunity, October 24, 2018.  Accessed at 
https://grants.hrsa.gov/2010/Web2External/Interface/Common/EHBDisplayAttachment.aspx?dm_rtc=16&dm_attid=889565fa-
5bd4-4214-b4b7-11c31030882e on March 2, 2021.   
131 Agency for Health Care Research and Quality, AHRQ Releases Standardized Hospital Bed Definitions, September 2005.  
Accessed at https://archive.ahrq.gov/research/havbed/definitions.htm on March 9, 2021.  
132 Texas Department of State Health Services, 2016 Hospital Nurse Staffing Study Operational Definitions.  Accessed at 
https://www.dshs.texas.gov/chs/cnws/2016_HNSS_Operational-Definitions.pdf on March 11, 2021.  Texas DSHS paraphrases 
their definition of contract/traveling nurses from the following: Committee on the Work Environment for Nurses and Patient 
 
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OEI-09-21-00140  Endnotes | 54 
   
 
Safety, Board of Health Care Services, Keeping Patients Safe: Transforming the Work Environment of Nurses, National 
Academies Press, 2004.  Accessed at https://www.ncbi.nlm.nih.gov/books/NBK216190/pdf/Bookshelf_NBK216190.pdf on 
March 11, 2021.    
133 OIG, Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak (OEI-06-15-00230), 
October 2018.   
134 We also calculated the percentage of adult inpatients and adult ICU patients with confirmed or suspected cases of 
COVID-19, for each hospital. 
 
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