Introduction

The COVID-19 pandemic has increased the burden of illness and mortality but has also had an enormous economic impact on both healthcare systems and the community.

The SARS-CoV-2 virus has spread rapidly in Europe and other continents since February 2020, and at the first surge, approximately 10% of infected patients developed pulmonary infection and required hospitalization; among them, the case fatality rate was more than 10% [1].

At the end of 2020, mRNA vaccines became available, and massive population vaccination programs were started [2]. During the first few years, most countries aimed at active surveillance used nucleic acid amplification (NAAT)-based diagnostic testing and contact tracing [3]. All these efforts increased health care costs. In addition, the COVID-19 outbreak cancelled elective operations in hospitals and even temporarily closed down some less critical care pathways in many countries [4,5]. This lead to increased care debt and morbidity for outpatients, causing further outpatient health care usage. The mental burden increased, and medical workers were stressed. Finally, the secondary effects of social distancing, such as the lockdown of international travel to prevent transmission, have had a historical effect on the world economy [6,7].

In Finland, the national COVID-19 prevention strategy was based on testing, isolation, contact tracing and transmission prevention [4,8]. After the whole population was offered three doses of vaccination by March 2022, any preventive societal restrictions, including universal masking recommendations, were largely abandoned [8]. However, at that time, along with the increase in Omicron virus variants, the patient numbers and hospitalizations clearly increased, but the disease was milder [9]. Subsequently, new waves of the epidemic have occurred with novel virus variants.

In Finland, the healthcare system is mostly public, making individuals less vulnerable to direct health-related costs. In 2022, 96% of all hospital care and 77% of all health care were financed by the government [10]. COVID-19 was determined to be a generally hazardous communicable disease in Finland by the Communicable Diseases Act until 30^th June 2023. During that time, neither the patients nor their home municipalities paid much from the pocket for COVID-19 care, but the government paid reimbursement for hospitals.

In this study, we aimed to describe the disease burden and costs of the COVID-19 pandemic from a large tertiary care hospital point of view to determine how it affected the hospital economy during the first three years of the COVID-19 pandemic, 2020–2022. We also wanted to determine the alternative costs that were lost for this infection.

Materials and Methods

We conducted a retrospective analysis of the costs and effects of the COVID-19 pandemic at Turku University Hospital (TUH), a 950-bed tertiary care hospital in Southwestern Finland. The hospital serves a catchment area with a population of 489 210, constituting 8.8% of the entire country.

Results

Hospital costs

Ward and ICU care of patients hospitalized for COVID-19 infection.

There were a total of 9925 hospital days due to COVID-19 infection (Table 1). The median length of hospital stay was 5 days, varying from 6 in 2020 and 2021–4 in 2022. The proportions of all hospital days spent in the ICU was 17% (1659/9925), with a median of 4 days (Table 2). However, the proportion decreased from 28% in 2020 to 4% in 2022.

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Table 1. Yearly numbers of patients and their hospital days with COVID-19 as the primary reason for tertiary care hospitalization.

https://doi.org/10.1371/journal.pone.0323200.t001

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Table 2. Yearly numbers of patients and days in the ICU due to COVID-19.

https://doi.org/10.1371/journal.pone.0323200.t002

The total billing costs of hospitalization for patients with COVID-19 were 14 492 399 €, the median cost being 4 137 €, and the mean cost being 10 149 € per patient (Table 3). The median and mean costs per patient and per day were the lowest in 2022.

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Table 3. Total billing costs of patients hospitalized due to COVID-19.

https://doi.org/10.1371/journal.pone.0323200.t003

Almost half (47%) of the billing costs were due to intensive care (6 748 535 €, 4 068 €/day) (Table 4). This proportion decreased from 69% in 2020 to 22% in 2022. Laboratory and imaging costs were only 4.8% and 1.9%, respectively, of all billing costs (Table 4). The costs of medication (remdesivir, ritonavir-nirmatrelvir or immunological treatments) were included in the billing costs.

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Table 4. Yearly ICU, laboratory and imaging costs of patients hospitalized for COVID-19 and their proportion of the total billing costs.

https://doi.org/10.1371/journal.pone.0323200.t004

Among the different medical specialties, infectious diseases and pulmonology had the highest total costs, 8 382 324 € (1 663 €/day) and 4 586 812 € (1226 €/day), respectively. Other medical specialties covered 1 523 263 € (1 332 €/day) of the costs.

Costs of COVID-19 patients discharged from the emergency department.

In addition, 2 819 patients visited the emergency department (ED) due to COVID-19 infection between 2020 and 2022 but were discharged. The total ED cost of these patients was 2 409 308 €. During the years 2020, 2021 and 2022, these numbers were 167 587 € (855 €/patient), 677 428 € (923 €/patient) and 1 564 293 € (828 €/patient), respectively. These visits included the cost of SARS-CoV-2-NAAT.

Covid-19-related costs of patients hospitalized primarily for other reasons.

There were 1 106 patients (yearly 11, 46 and 1054) hospitalized with COVID-19 for 6 341 days. The number of isolation days for these patients was 5 206. Of these 1 106 patients, 59, 167, 149, 122, 106, 117, 68 and 318 patients were hospitalized for 1, 2, 3, 4, 5, 6, 7 or more than 7 days, respectively. The total COVID-19-associated costs for these patients were estimated to be 424 131 € (Table 5). A total of 95% of these expenses were spent in 2022. The COVID-19 test was included in the laboratory costs only if the diagnosis had not been confirmed at an outpatient clinic before hospital admission.

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Table 5. Estimated isolation costs of the 1106 patients hospitalized with COVID-19 (other diseases as a primary reason for hospitalization).

https://doi.org/10.1371/journal.pone.0323200.t005

COVID-19 testing according to the university hospital infection prevention guidelines (i.e., universal screening at admission) incurred extra costs even when the test results were negative. The cost of 64 890 negative test results for hospitalized or discharged patients was 6 172 370 €.

Other hospital costs of COVID-19 care and prevention of hospital transmission.

According to the specific financial account of the costs of the COVID-19 pandemic in hospitals, there were

7 561 090 € extra costs related to COVID-19, which were not budgeted to be covered by the hospital billing costs and were thus added to total costs. This included extra personnel (doctors, nurses, laboratory workers and administrative personnel) dedicated to COVID-19 work at a cost of 2 120 503 €. There were also costs of doctors, nurses and administrative persons working extra hours, for a total of 855 879 €. Extra IT costs and text messages (COVID-19 test results were sent by SMS) and post services due to COVID-19 cost 419 914 €. Extra cleaning services and renovation of hospital premises for COVID-19 care cost 572 626 €. Other material cost related to COVID-19 care was 2 350 148 €. Other indirect costs, including the purchase or hire of technical equipment on premises, cargo, storage and security related to COVID-19 care were 1 242 030 €.

The total estimated additional costs of the COVID-19 pandemic over 3 years in our tertiary care hospital were thus 28 899 298 €, including care costs of COVID-19 patients 14 492 399 €, ED costs for discharged COVID-19 patients 2 409 308 €, isolation costs of COVID-19 positive patients hospitalized for other reasons 424 131 €, negative screening results 6 172 370 € and other hospital costs 7 561 090 €

Losses of income and opportunity costs.

According to the interviews of the hospital leaders, no intended ward closures were implemented, but some elective surgeries were cancelled in the hospital during the pandemic. However, at the hospital level, the number of ward days was lower during the pandemic years than during the previous comparative years 2018–2019. Between 2019 and 2020, the number of ward days decreased by 7%, then increased by 4% from 2020 to 2021 and decreased by 5% again until 2022 (S4 Table). The reasons for these fluctuations were multifactorial, i.e., lack of nursing staff and not directly associated with COVID-19.

Between 2019 and 2020, operative specialities reduced the number of elective operations, leading to a reduction in income of 2 016 539 €. These findings varied between surgical specialties (Table 6). Most reductions took place in April-June 2020, during the first months of the pandemic. The change in the income was affected by both the number and type of operations.

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Table 6. Reduction in the number of elective surgeries and the related loss or increase of income between 2019 and 2020.

https://doi.org/10.1371/journal.pone.0323200.t006

COVID-19 also caused substantial other opportunity costs. Specialists and physicians attended numerous areal and national meetings on steering, vaccination and patient care (at least 3000 working hours as counted on meeting minutes) and spent time in planning new care processes for COVID-19 and guidelines. This work replaced other work including developmental activities and scientific projects which potentially lowered the care quality in the future.

Discussion

The first three years of the COVID-19 pandemic in Southwestern Finland resulted in approximately 112 000 COVID-19 patients and 2555 patients hospitalized either due to the COVID-19 infection or with COVID-19 as a co-finding. The estimated total cost of COVID-19 patient care and COVID-19-related costs during 2020–2022 in a 950-bed tertiary care hospital were 29 M€. In addition, the losses of income due to postponed operations were approximately two million euros.

The direct hospital mean and median costs of a patient hospitalized at a tertiary care hospital due to COVID-19 between 2020 and 2022 was 10 149 € and 4 137 €, respectively, which were within the range of earlier reports from different continents, although mainly from the first year of the pandemic. These costs varied from the mean of USD 6 557 USD (6 250 €) in a Mexican secondary care hospital [11], to 6 818 I$ (520 €) in a Brazilian tertiary care hospital [12], to 10 196 € in a Spanish tertiary care hospital [13], to 13 476 USD (12 860 €) in Saudi-Arabian tertiary care centers [14] and to the median of 11 695 USD (11 616 €) in academic hospitals and 10 942 USD (10 442 €) in community hospitals in the USA [15]. The differences between countries may partly reflect variations in income brackets, disparities in the intensity of required medical care, standards of care, and heterogeneous cost structures in the published studies. In a review article, the total medical costs of ICU patients with COVID-19 ranged 15 fold as the costs were adjusted into Purchasing Power parity (PPP) 2020 [16].

The greatest disease burden in the hospital was faced in 2022 during the emergence of rapidly spreading Omicron variants and the removal of community restrictions. However, due to good vaccine availability, the disease was milder, and fewer patients required ICU treatment than during the previous years. Of the total numbers during the three years, 60% of patients were treated and 46% of the hospital costs were derived from the year 2022.

The intensive care cost was a significant cost driver, with a total of 6.7 M€ during the study years. During the first two years of the pandemic, ICU costs constituted two-thirds of hospital billing costs, although the number of ICU days covered only one-fourth of all hospital days. In 2022, the proportions decreased to 22% and 4%, respectively.

The number of patients who visited the hospital ER due to COVID-19 but were discharged during the three years was double the number of patients treated in the hospital during the same period, with a total expenditure of 2.4 M€ during the three years. However, the cost of an ER visit due to COVID-19 was almost half the cost of one day of hospitalization.

The estimated isolation costs of those SARS-CoV2 positive patients who were hospitalized primarily due to other reasons were low, 64 € per day. Of this, material costs were the minority, and two-thirds consisted of work, i.e., cleaning or donning and doffing personal protective equipment.

In our study, the proportion of laboratory and imaging costs of total hospital billing costs was also low. This further highlights the fact that, in terms of hospital costs, personnel and the hospital infra are the most expensive cost drivers. The hospital financial account for COVID-19 costs revealed another 3 M€ cost for extra health care personnel and extra hours. Torres-Toledano et al reported that 95% of the costs of hospital stay were due to infrastructure, personnel and direct medical costs for COVID-19 care [11].

The COVID-19 pandemic has also caused considerable burden in hospitals by replacing other work, e.g., when hospital’s lead spent time in organizing meetings and staff were moved to give vaccinations. Many scientific and developmental projects, which cannot be easily assessed financially, had to be postponed.

The presented cost analysis covers COVID-19-related costs incurred at the hospital. Outpatient SARS-CoV-2 NAATs were not included. The latter covered 90% of the entire 55 M€ spent on diagnostic TUH microbiology laboratories. Neither outpatient care costs nor the costs of communal primary care hospitals or vaccination programs for the population were included, as these costs further increase the total costs from the whole health care point of view. The strength of this work is that we were able to describe the costs according to true clinical course of hospitalized COVID-19 patients with the comprehensive surveillance registry data at the hospital. Thus, we were able to exclude care costs unrelated to COVID-19 in patients hospitalized due to other reasons. We were also able to gather patient level costs from hospital billing sources through patient identity code linkage. Similar reports have not been published from other Finnish hospitals. However, showing the costs publicly should increase efforts for prevention in the future pandemics.

Apart from the cancellation of some elective surgeries, there were no known ward closures due to the pandemic at TUH, which is the opposite of many other hospitals in the country. However, cohorting patients and making single-bed room arrangements may have led to closure of the other bed in some two-bed rooms, which we could not detect, however. The number of total hospital days at TUH decreased from 2018 to 2019 but then decreased further until 2020, and this fluctuation may have been a sign of this. The lowest number in 2022 was, however, also due to an increasing shortage of nursing staff closing available beds in several wards.

There are some limitations in the study. First, we describe only hospitals costs, but not the outpatient costs nor the total healthcare costs. We describe the costs only from one hospital point of view and the results are best extrapolated in similar university hospital settings. The abundance and details in economic and clinical data may vary between hospitals and this may affect the variety of cost factors in different hospitals. Thus a uniform computational model should be used to make results fully comparable between hospitals. In addition, as we were retrospectively analyzing the administrative data, we could not inspect whether all sectors in our hospital had reported their COVID-19-related costs uniformly, but we consider this as a minor confounder. Thirdly, the billing costs we used, cover the direct medical costs of examinations, procedures and expensive medications but only a fixed average day fee for the personnel costs. Moreover, billing costs represent hospital charging, and from the hospital point of view, they are also income for the hospital. During COVID-19 pandemic, the government reimbursed 2/3 of the total costs for hospitals and the municipalities paid the rest with the taxpayers’ money. Patients were not directly charged for COVID-19 care. And finally, without the COVID-19 pandemic, the hospital would have treated other patients with other diseases instead with the same expenditure. Thus from the hospital point of view, the COVID-19 pandemic caused mainly societal loss by causing care debt and queues. However, extra expenditures of the COVID-19 pandemic were not left without extra need for savings during the following years in all hospitals in the country. Compared to the previous typical annual number of hospital days (> 250 000 annually) and total costs (781.4 M€ in 2022) at TUH, the annual financial burden of COVID-19 was far less than 5% of the total hospital days and expenses. However, these enormous 29 M€ total costs underline the need for financial preparedness for possible future pandemics. In the broader context, the Finnish medical authorities and government adopted a “test and isolate” strategy in response to the pandemic. Consequently, these costs could be considered unavoidable. A reduction in testing could have saved costs but could have led to a higher number of clinical infections, thereby modulating the cost drivers. In the future, hospital preventive strategies should be carefully redefined based on evidence regarding the transmission routes of the causative agent and the effectiveness of available preventive measures, including masks, vaccinations, and pharmaceuticals. For instance, AI-driven decision support systems could optimize the balance between targeted testing and isolation versus universal masking and symptom-based treatment, ensuring both cost-effectiveness and improved health outcomes.

Supporting information