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Building resilience during the COVID-19 pandemic and beyond

How health care CFOs are navigating with an eye on the future

Wendy Gerhardt
Maulesh Shukla

From immediate financial impact and strategy shifts to a greater focus on consumers and virtual, explore how health care chief financial officers see ways to navigate the challenges of the pandemic while still driving their organisations’ long-term success.

Executive summary

MANY stereotype the health care industry as slow to change and adapt compared to other industries.1 But the COVID-19 pandemic has created and is still creating an unprecedented crisis for the health care industry that has also triggered rapid and significant change. Investments and experience from today are likely to influence the industry for years to come. How are health care finance executives changing their strategies due to the pandemic? Which of these changes do they expect will endure from the pandemic?

The Deloitte Center for Health Solutions surveyed 60 chief financial officers (CFOs) from health systems and health plans and interviewed another seven to learn how health care CFOs are navigating the challenges of the pandemic while trying to drive the long-term success of their organisations. They said that the pandemic resulted in:

Unprecedented long-lasting challenges: CFOs predict that the financial impact of the pandemic will be long and significant for the industry.

  • The median expectation for hospitals to recover financially from the pandemic is 12 months, with a range of 3–24 months.
  • Forty-seven per cent of health system CFOs and 53% of health plan CFOs say that financial viability and planning are their biggest concerns (the top response).

Even greater focus on consumers and virtual health: CFOs are rethinking how they engage consumers, conduct work and deliver care.

  • Fifty-five per cent say that consumer trust is the top driver of strategic changes in the short term (the top response).
  • Eighty-three per cent say that consumer engagement is an increased priority for their organisation after the pandemic.
  • Eighty-five per cent say that virtual health technologies are an increased priority postpandemic.

Future-focussed investments: Many have shifted capital spending towards supporting virtual capabilities versus brick-and-mortar buildings compared to last year.

  • Seventy-eight per cent expect to increase their capital spending on digital technologies.
  • Fifty-three per cent expect to reduce capital spending on new building assets.

Balancing an organisation’s financial sustainability during a crisis and steering towards future success is no small task. CFOs must not lose sight of the future while responding and recovering from today’s challenges. Financial scenario planning, nimble decision-making, prioritising investments in virtual and digital technologies, focussing on consumers, shifting to value-based care and exploring collaboration and partnership opportunities should be a key part of every health care CFO’s playbook.


The COVID-19 pandemic has created an unprecedented crisis for the health care industry. The country’s hospitals, health systems and health plans have taken extraordinary steps to respond to the pandemic. Hospitals and health systems quickly added bed capacity, created modular ICU units, sourced personal protective equipment (PPE), devised safety protocols and treated hundreds of thousands.2 Health plans waived out-of-pocket expenses, relaxed prior authorisation requirements, expanded access to virtual health and supported vulnerable communities with food and shelter.3

The crisis also created financial vulnerabilities for health care organisations. The American Hospital Association estimated the financial impact of COVID-19 on hospitals at US$202.6 billion between March and June 2020.4 This includes income loss due to cancelled elective procedures and additional costs from COVID-19 hospitalisations, PPE and workforce support programmes.

Health plans have benefitted from the lower cost trend during this period. However, many expect some negative impacts from the medical loss ratios (MLR) requirements to pay rebates and the expected shift in enrolment from employer-sponsored coverage to Medicaid, individual insurance exchanges and uninsured due to the recession.5 Health plans also face considerable uncertainty in setting premiums for 2021, not knowing how the pandemic will unfold.

As health care organisations respond to the crisis, their CFOs have one of the toughest challenges at hand—ensuring financial sustainability while planning for their organisation’s future. To learn more, we surveyed 60 health care CFOs and further interviewed seven health system CFOs (see sidebar, “Research methodology”).

Research methodology

The Deloitte Center for Health Solutions surveyed CFOs of 60 large health care organisations with a focus on understanding their strategic priorities, investments and top challenges. The respondents included:

• 30 from health systems, all with income more than US$1 billion

• 30 health plans, 80% with enrolment more than US$1 million

We also interviewed CFOs of seven diverse, large health systems—integrated delivery networks, for-profit, nonprofit and faith-based organisations.

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Research findings

The financial impact of the pandemic has driven many health care organisations to quickly change their strategies.

Since the onset of the pandemic, the financial performance of two sectors—health systems and health plans—have been like mirror images; one part of the industry’s loss of income has been the other part’s loss of cost. While health systems struggled financially, fewer claims largely benefitted health plans’ margins. Despite these differences, the surveyed CFOs for both health systems and health plans were unanimous in naming financial viability and planning as their biggest concern today (figure 1).

"The biggest unknown—and I shared this concern with my peers—what will be the new normal. A lot of my time goes into scenario planning."

—CFO, large integrated health system

The different finance and liquidity initiatives of health systems and health plans provide insights into their top concerns:

  • For health system CFOs, managing receivables to maximise income and working with finance partners to leverage and access debt are the top financial initiatives. Many interviewed CFOs discussed how they immediately drew upon lines of credit to cushion against future financial challenges when accessing debt could be more difficult.
  • For health plan CFOs, financial scenario planning is a top priority; for example, to understand different scenarios on MLR rebates and shifts in payer mix and line of business.

Two in three surveyed CFOs reported changing their organisational strategy due to the pandemic. While financial performance is a top-of-mind concern, when asked about the biggest drivers of change in organisational strategy, consumer trust and safety topped the list (figure 2). The CFOs we interviewed were working on best practises for reengaging consumers. In particular, several short-term changes in their strategy focussed on measures to ensure their patients felt safe, such as frequent facility sanitization and app-based no-contact cheque-ins.

When will the hospital industry recover financially from the pandemic? It’s complicated, according to CFOs.

It was striking how wide the predictions were for financial recovery. When asked about the time it will take for the hospital industry to reach the financial levels of the previous year, responses from the CFOs of both health systems and health plans ranged from three months to two years. The median response was 12 months.

Factors influencing this prediction include:

  • Volume. Several interviewed CFOs said volume may not return to pre-COVID-19 levels given consumers’ concerns and the safety protocols in place. The task at hand today is to estimate new-normal volume levels.
  • Payer mix. While a majority of the health system CFOs haven’t yet witnessed a significant change in payer mix, they predict a shift towards more Medicare in the near future (due to the disproportionate impact of COVID-19 cases on seniors) and towards Medicaid and uninsured patients (due to unemployment levels).
  • Case mix. Some CFOs reported a higher proportion of high-acuity patients (mainly driven by COVID-19 patients), which drove a higher case mix and thus higher payments for those patients.
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Rethinking industry norms and shifting towards the future

As CFOs retool their strategies in response to the pandemic, their areas of focus and investment priorities look to shatter some long-standing assumptions about the health care business and position them towards the future of health.

Virtual care and virtual work are table stakes

The pandemic demonstrated the value of virtual care and virtual work much faster and in ways we could not have imagined had the industry waited for longer-term trends to play out. Before the pandemic, the discussion on virtual health or virtual work remained limited for health care organisations, showing great promise but with low adoption.

Of the surveyed CFOs, 85% said virtual health technologies are an increased priority for their organisation today compared to the beginning of the year (figure 4). Many interviewed CFOs told us that both consumers and physicians were supportive of virtual visits due to ease of use, supportive access and payment regulations, and better outcomes. They expect the trend to continue and even become the default option for routine care and postoperative follow-up visits, consistent with our previous research on the future of virtual health.6

"The growth in (virtual health) volume is phenomenal and we are already investing a lot. Our goal is never to go back. Both physicians and patients are loving it. Physicians found new productivity tools and for the patients, it is a huge convenience factor."

—CFO, large not-for-profit health system

Workforce engagement emerged as another area of increased priority (figure 4). This was a concern for both health systems—supporting staff during an unprecedented crisis—and health plans—engaging a newly remote workforce. To address workforce safety and burnout, several interviewed CFOs reported working on short- and long-term virtual work strategies and new financial programmes to benefit frontline staff. Many CFOs said they hoped virtual work would endure for many functions, such as finance, information technology and income cycle.

Consumer is front and centre instead of an afterthought

For health care organisations, keeping consumers engaged is an even higher priority than it was at the beginning of the year (figure 4) because the nature of their relationship is changing. They no longer see many consumers in person due to the pandemic and industry trends are shifting towards greater consumer involvement in decision-making. The interviewed CFOs pointed to consumer trust and safety concerns as a top priority and discussed how they needed new communication channels to teach consumers about their safety initiatives. Many interviewed CFOs also said that this is the best time to engage with consumers beyond their care and treatment needs. Some are using virtual visits to discuss well-being, access and drivers of health, which they hope will make consumers value their relationship in the longer term and help build a more loyal consumer base. In fact, when asked about the long-term industry trends that will accelerate due to the pandemic, the surveyed CFOs pointed to cost-sharing, consumer assertiveness and focus on well-being (figure 5). Each of these is likely to shift the industry towards even greater consumer influence on decisions.

"We have some ambulatory locations that are old and dingy. They won’t be acceptable to consumers anymore. People just didn’t notice earlier, but now they are hyper-sensitive. So, we need to make changes to workflows, which will be permanently different."

—CFO, large regional health system

Proliferation of digital technologies

Nearly four in five CFOs reported increasing their capital spending on digital technologies, including artificial intelligence (AI), robotic process automation (RPA) and cloud (figure 6). With virtualisation of care and processes and the proliferation of data, the CFOs said they are increasing their focus on intelligent use of this data, supported by interoperability, AI and automation. The uses are manifold—they expect these technologies to enable care delivery, improve access, reduce costs by automating tasks and more importantly, improve consumer experience through convenient, user-friendly tools such as those that enable online scheduling and communications.

Nimble decision-making

Survey responses of health care CFOs on which of the changes from the pandemic they hoped would endure pointed towards rapid decision-making at the organisation, operations and finance levels. Interviewed CFOs provided some context for this response. They acknowledged that historically, health care organisations have been slow to make decisions due to size, structure and resources. However, as frontline organisations in responding to COVID-19, they could not delay decision-making. Several interviewed CFOs reported creating executive command centres, gaining consensus on ownership and governance structures, and quickly assigning decision-making powers. As a result, organisations were able to take quick actions on the organisation’s finance, technology, operations and human capital.

"We found we can move quickly as we did in this crisis to adjust. We created an incident command centre. We were really able to standardise quicker and got buy-in rapidly. Those were good learnings as management team and I hope these endure."

—CFO, large, national faith-based health system

With these changes come new strategic decisions

Key decisions both the health system and health plan CFOs face include industry partnerships and value-based care and payment models. In addition, health system CFOs also weighed in investments in virtual vs. brick-and-mortar.

Virtual vs. buildings

Many interviewed CFOs discussed how they paused capital investments during the pandemic, particularly in buildings and bed towers. They saw the acceleration of virtual health and virtual work resulting in less demand for business and clinical space. Some hope that their virtual trends continue. Now, many face the decision of what to do with assets.

Fifty-three per cent of surveyed CFOs said that they are reducing spending on new building assets compared to the beginning of the year (figure 4). Interviewed CFOs discussed pausing planned capital projects until they had reassessed demand and understood their longer-term financial position. Many said that they were rethinking hospital bed towers that were expansions vs. upgrades, with priority given to projects that would improve the consumer experience through integrated digital technologies in physical spaces and better ergonomics. Some recognised the possibility of needing fewer beds in the longer term.

Both health systems and health plans have office space that they may no longer need due to virtual work. Some interviewed CFOs said that they are rethinking their leased space. Reducing these leases could save money but most have long-term leases and landlords to contend with before they can act. Others said they are considering reconfiguring their clinics to include space for clinicians to conduct virtual visits.

"Given we are doing more video visits, does that mean we change our (real estate) strategy? The answer is yes. We will have a more conservative approach to the buildings. We are trying to build flexibility for the future."

—CFO, large integrated health system

Partnerships and collaborations vs. mergers and acquisitions

CFOs discussed the growing desire for partnerships—both as opportunities for growth as well as to collaborate to improve care delivery, costs and outcomes for their patients, members and communities. Both health systems and health plans identified collaborations and partnerships among themselves and with each other as a preferred route for inorganic growth in the short term.

When asked about consolidation, interviewed CFOs agreed that the pandemic would likely accelerate M&A among hospitals and with physicians, but they think M&A may now be more complex and require more time as organisations gain a better understanding of the long-term financial impact of COVID-19. Compared to the beginning of the year, more than 60% of health systems reported increased priority for partnerships and collaborations compared to just 23% listing M&A as a priority. Similarly, when asked about initiatives in response to the pandemic, two of the top three initiatives included collaborations with other health plans (53%) and with health systems (43%), with M&A as the least important initiative (13%). However, M&A activity can be hard to plan for and the current dynamic environment will create an increasing need for CFOs to react quickly to marketplace opportunities and threats.

Many interviewed CFOs said they had seen a great deal of collaboration with new organisations—other health systems, other health plans, employers, vendors and community organisations. Many hope that these relationships will endure and improve the industry.

"Financial resilience has come to the fore. As a strategy, we are working on strong partnerships to depend on and grow as an organisation. From an M&A perspective, it’s expensive to go through the process."

—CFO, large for-profit health system

Value-based care vs. volume

As health system CFOs worried about the return of volume to pre-COVID-19 levels, they acknowledged that value-based and capitated contracts help insulate many from the financial challenges of those still heavily involved in fee-for-service. They agree that there will be more interest in these types of contracts to help mitigate future pandemic and volume worries. Besides, they expressed confidence that more health plans are on board with capitated and other forms of risk-based contracts, with a desire to move away from fee-for-service sooner.

In the short term, there were concerns for those participating in Medicare and commercially advanced payment models over skewed benchmarks for payment calculations as a result of the pandemic. However, health system CFOs noted that won't deter them from accelerating towards value-based care arrangements in the longer term.

"Pursuing value and taking on more risk—this is going to continue. [Health systems] will pursue it even more as there is more consolidation. As they get larger, it allows them to take on more risk."

—CFO, large faith-based health system

Resilient finance leaders show the way

Amid widespread financial uncertainty and unprecedented challenges, the CFOs of some health care organisations are setting an example of resilient leadership. For instance, one of our CFO interviewees from a large health system located in a COVID-19 hotspot in the United States demonstrated the art of resilient leadership in three distinct ways.

  • Respond decisively. Decisive action—with courage—is essential. At the onset of the pandemic, the health system quickly stopped discretionary spending, created dynamic financial scenario planning models and planned for potential lines of credit, including debt.
  • Recover and learn. After initial response planning, leaders quickly adopted a nimble review plan to assess all the finance and business continuity initiatives, identify pitfalls that can be avoided during a potential second wave and share best practices to learn from competitors and other health systems.
  • Thrive in the next normal. Even as they worked on their day-to-day strategies, the leaders charted their long-term plan, including reprioritizing their strategies based on new-normal financial planning scenarios. They prioritised their investments in digital and virtual technologies, initiated dynamic instead of static budgeting and stress-tested current and potential future capital structures.
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While the pandemic has created a significant crisis for the health care industry, many CFOs see positive changes. While they still face significant financial challenges today and in the coming months, many see the opportunity to use the momentum to position their organisations for future success.

As CFOs navigate the pandemic and steer their organisations towards the future, they should consider seven critical dimensions.

  • Consumer: Consumer sentiment and trust will likely drive the speed at which demand for services and health care spending return. Health systems will need to reearn consumer trust through communication and demonstration of enhanced protocols, particularly for in-person visits. Health plans will need to develop and support consumer-friendly tools that support network decisions and improve understanding of out-of-pocket costs.
  • Clinical: The prioritisation of services will be critical and likely require a thoughtful balancing of urgency and health equity. As more research emerges about the long-term effects of COVID-19, health care organisations will need to ensure that their care models and services are agile to address patient and member needs in the context of potential additional waves of outbreaks.
  • Financial: Health care organisations should continue challenging traditional financial decision-making to seek income recovery and growth opportunities. They should prepare for rapidly evolving reimbursement models as COVID-19 forces realignment of needs and value. Both health systems and health plans should continue to shift their organisations towards more cost- and risk-sharing to drive finances focussed on value. In addition, the competitive landscape may evolve quickly, impacting capital planning and volume assumptions.
  • Technology: The acceleration of virtual and digital adoption requires investment in technology to manage increased demand as well as defence against cyber risk. Health care organisations should strive for seamless synchronisation between in-person and virtual services. They should consider leveraging cloud technologies and ensure appropriate security strategies and remote access controls to support virtual health innovations.
  • Work: A healthy, dynamic, protected and informed health care workforce (whether in front of a consumer or at a computer and desk) can help support a smoother transition when ramping up operations. Health care organisations will likely want to establish dynamic staffing models to account for variable demand to mitigate the effects of potential future waves and support workforce safety. For those functions where it makes sense, organisations should continue remote work. In addition, organisations should invest in providing emotional and well-being support to staff.
  • Community: Health care organisations will need to responsibly engage their communities within parameters defined by local, state and federal guidelines. Community collaboration around data and protocols will likely be critical not only to minimise the spread of infection, but for further research and innovation. When prioritising services, organisations should maintain focus on their mission and how to bring value to their communities. Health systems and health plans should consider how they can continue to work together even more closely beyond payment mechanisms.
  • Supply chain: To help mitigate the impact of potential future waves, health care organisations will want to balance resource availability with the need to design new processes to manage and deliver services. A revamp of infrastructure may be required to support a shift in service mix and delivery modalities. Establishing a dynamic and resilient supply chain will be critical for both PPE and other standard supplies.

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Project team: Madhushree Wagh helped with survey analysis and charting.

The authors would like to thank David Betts, David Biel, Jimmy Peterson, Jeff Bowman, Ellen Gartner-Phillips, Vicky Wu, Sarah Thomas, Ramani Moses, Laura DeSimio, and the many others who contributed to the success of this project.

This study would not have been possible without our research participants who graciously agreed to participate in the survey and interviews. They were generous with their time and insights.

  1. The George Washington University, “How we can expect the healthcare industry to change in the future,” 6 July 2020. 

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  2. American Hospital Association, “Hospitals and health systems face unprecedented financial pressures due to COVID-19,” May 2020; Robert King, “More hospitals turn to in-house tests to handle surge of COVID-19 patients,” Fierce Healthcare, 29 March 2020. 

    View in Article
  3. America's Health Insurance Plans, “Answering the call: Health insurance providers act swiftly as part of the COVID-19 solution,” August 2020. 

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  4. American Hospital Association, “Hospitals and health systems face unprecedented financial pressures due to COVID-19

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  5. Elise Reuter, “For insurers, rising unemployment a more pressing concern than Covid-19 costs,” MedCity News, 3 May 2020; Cynthia Cox et al., “How health costs might change with COVID-19,” Peterson Center on Healthcare and Kaiser Family Foundation, 15 April 2020. 

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  6. Bill Fera, Casey Korba, and Maulesh Shukla, The future of virtual health: Executives see industrywide investments on the horizon, Deloitte Insights, 30 April 2020. 

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