- Hospitals are losing revenue from delaying elective procedures to make room for coronavirus patients, and further delays might mean serious medical complications.
- Starting in early May, patients in about 20 states are getting rebooked for non-emergency procedures like hip and knee replacements, tumor removals and organ transplants.
- But social distancing and telemedicine will be part of the experience moving forward.
Things may never return to the way they were before the Covid-19 crisis. But eventually, the world will come back online.
We asked experts in various fields for their best predictions on what the world will look like when the coronavirus pandemic finally recedes. In this segment of our series, "The Next Normal," we look at what experts are saying about when regular medical care might return.
After months of delays, hospitals are starting to schedule patients for their medical procedures. Starting in early May, patients in about 20 states are getting rebooked for non-emergency procedures like hip and knee replacements, tumor removals and organ transplants, which had been delayed until further notice.
Back in March, the Centers for Disease Control and Prevention (CDC), the U.S. Surgeon General and some of the largest medical specialty groups had advised hospitals to postpone planned procedures to ensure sufficient supplies would be available for Covid-19 patients and those treating them. "The reality is clear and the stakes are high: we need to preserve personal protective equipment for those on the front lines of this fight," said CMS Administrator Seema Verma.
But many of these procedures can only be delayed for weeks, and not months, without impacting patient health outcomes or their quality of life, and hospitals are desperately missing the lost revenue. So hospitals are looking for ways to re-open their doors to patients in a way that limits their risk of exposure.
There's a huge financial incentive to rebook elective procedures, which might prompt some hospitals to move quickly. The American Hospital Association is now reporting that hospitals are bleeding more than $50 billion per month, and the chairman of the Department of Medicine at UC San Francisco, Dr. Bob Wachter, recently told CNBC that his hospitals lost more than $5 million per day in April alone.
"What's amazing is how much we are dependent financially on these high cost elective procedures," said Dr. Esther Choo, an emergency room physician and health researcher at Oregon's Health & Science University. "That's the foundation of any hospital."
But in many cases, resuming care is also necessary to prevent further complications. A surgery might be referred to as "elective" in medical terminology, but that doesn't mean they're optional, just not immediate emergencies -- for instance, cataract surgery, hip and knee replacements, mastectomies and even organ donations can be classified as elective.
"If you delay these procedures, that itself can lead to problems and complications," noted the American College of Surgeons in a recent statement. "If cancer surgery is postponed indefinitely, for example, there is the potential risk that the disease will become more advanced."
For many hospitals, there's already a huge backlog of patients that need care. Doctors on staff will need to determine the cases that should be seen first. They'll likely defer to the categories -- and even a new scoring system -- outlined by the leading surgical associations to help doctors determine the level of urgency and risk. Naturally, there are some grey areas. "It really depends on symptoms," said Dr. Jeffrey Swisher, chairman of the department of anesthesiology at California Pacific Medical Center.
"If you have a torn meniscus, for example, it could be extremely elective -- but it could also turn into something painful, which would bump it up to a higher category."
Medical experts weigh the following questions when deciding whether it makes sense to deliver care now or hold off:
- How urgently is the procedure needed?
- Is the patient in pain?
- Are they able to maintain their quality of life?
- How virulent is the virus in the local community?
That last question means there may be big differences in different locations.
A joint statement from the American College of Surgeons, the American Society of Anesthesiologists, the Association of PeriOperative Registered Nurses and the American Hospital Association, warns that hospitals should not resume rescheduling elective procedures until they see "sustained reduction in the rate of new COVID-19 cases in the relevant geographic area for at least 14 days."
The associations also advise administrators that the facility should have an appropriate number of beds, and that medical workers should have access to personal protective equipment and ventilators.
Some states will meet the thresholds as they reopen, but others will not. And even when they reopen, patients might not show up.
"If I had an elective procedure and I was in California, I personally wouldn't wait any longer," suggests UCSF's Wachter."But if I were in New York or Michigan, I probably would because there's a lot more virus around."
Ultimately, medical experts say, doctors will need to be upfront with their patients about the risks. Otherwise, they might not seek care that they need.
"Medical groups and hospitals need to be educating patients on what they can expect, being honest with them on the urgency behind their procedures and making it a very high-touch experience to enter their facilities while they continue to care for COVID-19 patients," said Tom Cassels, president of research and investment firm Rock Health. "Like the economy, hospitals don't just turn on and off like a faucet, and it will be a lot harder to re-open than it was to delay procedures."
"It comes down to that relationship between patient and provider," said Dr. Jonathan Gleason, who is the executive vice president of clinical advancement and safety at Jefferson Health in the Greater Philadelphia Region. "If you have questions about whether it's safe to go in now or wait, talk to a doctor you trust."
Patients who do get medical care in the coming months will find that the experience is vastly different than what they're used to.
Wachter said he currently feels "safer than I do at the Safeway" because of all the protections in place at the hospitals he oversees. That includes social distancing measures in waiting rooms and Covid-19 testing for all patients ahead of their procedures. The hospital also offers tests to any medical personnel who are experiencing symptoms.
At other primary care clinics and other health facilities, medical experts think that it will become routine for patients and staff to wear a mask. Patients will also be spaced out in beds, and visitors will sit apart from each other. "I wouldn't be surprised if every other chair will have a piece of tape on it," said Swisher. "And I suspect that all these measures will be in place for a while."
Many hospitals are planning to take in a lower volume of patients. Oregon's Health & Science University started rebooking elective procedures as of May 1, said Choo. The hospital is taking in patients at a much lower capacity -- around 30 to 40 percent of the usual volumes -- to ensure that social distancing measures can be maintained.
"We're hoping that it'll be okay (to reopen) in Oregon because we have adequate protective equipment for the most part and as long as we can keep testing up," she said. "But across the country, many hospitals are ramping up elective procedures and states are reopening without case rates going down, so...deep breaths."
Meanwhile, use of telemedicine or virtual doctors' visits has skyrocketed during the pandemic, and some clinics may continue to push patients that way.
At UC San Francisco, virtual medicine visits have skyrocketed from about 2 percent to now more than 60 percent. At Kaiser Permanente, which has 12.2 million members in 8 states, about 80 percent of the visits are now online, up from less than 20 percent prior to the pandemic. And Cleveland Clinic reported completing about 60,000 telemedicine visits for the month of March compared with its prior average of about 3,400 visits per month.
It's not possible to swap out telemedicine for in-person care altogether, as many exams will still need to be done in person. But health systems are recommending that patients who aren't feeling seriously ill or don't have an underlying medical condition give online care a shot before seeing a provider in person. Prices typically hover around $40 per visit for those paying cash, but many insurers will foot the bill entirely.
"We can do a whole lot of stuff via telemedicine we didn't think we could," said Wachter from UC San Francisco.