The effects of the COVID-19 pandemic on urban hotspots and sparsely rural areas may be dramatically different, but both environments face harsh realities that require immediate responses that will have long-term impacts.

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The Marshfield Clinic Health System, an AMA Health System Program Partner, cares for some 1 million people over a 40,000-square-mile, mostly rural, area that covers the northern two thirds of the state of Wisconsin. Marshfield has not seen the volume of patients experienced by urban health systems, but the impact of the pandemic has still been brutal.

“We are really in a survival mode right now,” said Marshfield CEO Susan Turney, MD, during a panel discussion hosted by AMA Chief Experience Officer Todd Unger that was part the AMA’s daily COVID-19 video update series.



In addition to being a major health care provider, the system is also the region’s largest employer. “We are really critical to the ecosystem in Wisconsin,” Dr. Turney said. “People depend on us for their care, but we also support the businesses in our communities.”

During the pandemic, Marshfield has eliminated all elective procedures and closed its doors to non-urgent care.

Though telehealth services have helped make up for some of the lost revenue, Dr. Turney said the system’s operating income is down by $70 million and the financial assistance Marshfield received through the $2.2 trillion federal coronavirus relief bill “was appreciated, but the reality is that it didn’t cover half of our payroll.”

Service cuts included closing down regional clinics and dental centers except in cases of emergency.

Emergency departments, urgent care centers, and cancer care facilities remain open. Emergency department visits, however, are down 40% which Dr. Turney suspects may be patients deferring care as they observe the state’s “Safer at Home” order.

“We also have had to make some really tough choices around our workforce,” Dr. Turney said. “We have had to furlough or lay off some of our staff, and our providers and our senior administrators have all taken big salary cuts.”

The decision to suspend these services and close facilities was not made lightly and was done to protect the safety of patients, staff and communities, she said. While Marshfield is the area’s largest health care provider and employer, the system was determined not be a major contributor to the spread of COVID-19.

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“It was critical to us to set the example for our communities of what responsible action looks like during a public health crisis,” Dr. Turney said in a follow-up interview after the panel discussion.

“We, of course, also did not want our system to be a vector for spreading this virus, so shutting down much of our system was necessary,” she added. “We also don’t want to expose our critical health care workforce to any unnecessary risk of infection.”

The threat to patients is very real. Marshfield cares for an aging population. Many of its patients have a chronic illness and their median income is $8,000 less than the state average.

The system is exercising a high degree of caution at its facilities that remain open. “We are screening every person—staff or patient—who comes through our doors,” Dr. Turney said. “We’ve pivoted heavily to telehealth appointments, but that also has been a process to ramp up to the capacity we need to be at.”

Another issue facing Marshfield and other rural health systems and practices is that, even though they haven’t seen an influx of COVID-19 patients, they have had to prepare for the worst-case scenario and that preparation carries a huge cost.

“We have not experienced a surge like harder hit areas of the country, and we don’t forecast an extreme uptick in cases in at least the next several weeks,” Dr. Turney said. “However, we are all in uncharted territory, and modeling for rural health care is particularly challenging.”

There has been at least one rewarding aspect to the challenge. As it became clear that “nobody is coming to bail us out,” Dr. Turney said that it also became clear that pulling together as a team is what will get Marshfield though the crisis—and the staff has risen to the occasion.

“We have to work together to get through this and recover,” she said, adding that, what has “amazed” her is that, when there were tough decisions to be made and hard work to be done, “not one person has said ‘No.’”

“Everyone has raised their hand,” Dr. Turney said. “That is very refreshing, as the leader of a health system, to understand how committed people are to the patients and to the community that we serve.”

Wisconsin Gov. Tony Evers has released his plan for reopening state businesses. Called the “Badger Bounce Back Plan,” it includes a goal of testing 85,000 residents a week with an average of 12,000 a day.

The plan then calls for expanding contact tracing and “aggressively” tracking the spread by interviewing any Wisconsinite who tests positive within 24 hours of receiving their results and interviewing their contacts within 48 hours.

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The plan also calls for “pursuing every avenue” to grow the state’s supply of personal protective equipment for health care and public safety entities, and to bolster health system capacity “where patients can be treated without crisis care.”

The desire to return things to normal must be balanced with safety concerns, Dr. Turney said.

“When it is time to reopen, we have to do so thoughtfully and deliberately,” she said. “If we don’t, not only do we risk people getting sick and a deeper outbreak of this virus, but an even more devastating impact on our economy.”

A major barrier to reopening businesses is an inability to test as widely as is needed, Dr. Turney said. “Our health system developed the ability to test quickly, but it’s the lack of supply of swabs and other basic materials that is causing us not to be able to test as widely as we want,” she explained. “This is true across the country and world as global supply chains were unprepared for this crisis.”

When businesses, clinics, schools and other institutions “return to normal,” Dr. Turney predicts that some changes will remain in place.

One is the acceptance of telehealth by patients, payers and physicians.

“I think the genie may be out of the bottle on telehealth,” she said. “Hopefully, that is a good thing in terms of people getting familiar with receiving care in this way, more providers embracing it, and legislation moving forward that helps digitally connect rural America and makes reimbursement for telehealth services standard in the long term.”

Dr. Turney also hopes that the lessons learned during this crisis are not quickly forgotten.

“This crisis has humbled the country and the world, and I think we would be wise to carry that humility forward with us after this ends,” she said. We don’t have all the answers, we don’t have total control of our environment. That’s a truth people don’t like hearing, but one we have to grapple with.”

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