Decisions pit a vital revenue stream for hospitals against a
greater infection risk
By Melanie Evans and Russell Gold
This article is being republished as part of our daily
reproduction of WSJ.com articles that also appeared in the U.S.
print edition of The Wall Street Journal (April 23, 2020).
Hospitals, clinics and surgery centers are moving tentatively to
resume surgeries and other procedures that were halted when the
coronavirus pandemic reached the U.S., a shift that could help
stanch the sector's financial losses but presents new risks to
infection control and public health.
Tenet Healthcare Corp. is preparing to restart some surgeries in
Texas, said people familiar with the hospital and surgery-center
company's plans. HCA Healthcare Inc., a national hospital chain,
said on an investor call Tuesday it expects to reopen across its 43
markets by the end of June. California Gov. Gavin Newsom said
Wednesday that the state is working with health-care providers to
resume postponed procedures.
One independent rural Missouri hospital is already advertising
for patients to return. "If you stub your toe at 3 a.m. and think
you broke it, yes, come in even if it's not life-threatening," said
Randy Tobler, chief executive of Scotland County Hospital in
Memphis, Mo., who went on a local radio show to announce the news.
"We're open for business."
Opening up surgery will be welcomed by anxious patients who
waited weeks for procedures that were important, such as some
diagnostic imaging and gallbladder surgeries, but could be
temporarily delayed. And for hospitals, outpatient procedures are a
growing source of revenue and typically more profitable than
treating critically ill, hospitalized patients. Shutting down
elective surgeries led to layoffs, furloughs and pay cuts across
the health-care sector. After weeks of delays, hospitals and
surgery centers face mounting financial pressure and a backlog of
patients.
Now, health care is joining other sectors of the U.S. economy
making an uncertain -- but urgent -- push to resume business.
California's governor said the state's health-care system was
working to reintroduce capacity to resume postponed procedures,
without which patients' problems could grow more acute. But Mr.
Newsom also said the state would closely monitor results for
capacity to handle another wave of Covid-19 patients. "We will not
overload the system at peril of not being able to maintain our
surge capacity," he said.
California ordered hospitals to prioritize medical care and
resources for the sickest patients, but didn't directly suspend
electives. It also said residents ought to postpone elective
procedures, urging them to contact their doctors to find out what
services would be provided.
Guidance from medical-specialty societies and federal health
officials on how best to proceed points to heavy reliance on
critical protective equipment, such as masks, and testing for the
virus to limit further contagion.
But supplies of both are limited, raising questions about how
quickly the industry can move, say health-care and
infectious-disease experts.
"Testing would be ideal, if it was available and consistently
accurate," said David Hoyt, executive director of the American
College of Surgeons. He urged a slow ramp-up in procedures, with
close monitoring of community infection rates. "We would not
recommend anyone would start like flipping a switch on."
Experts agree that restarting surgical procedures will be
difficult. "There is no easy answer to restarting routine health
care in hospitals, " said Eric Toner, a senior scholar with the
Johns Hopkins Center for Health Security. "It's got to happen. We
have to find a way to make it as safe as possible, but it's not
going to be completely safe."
As the pandemic took off across the U.S. in mid-March,
health-care providers began to delay hip surgeries, routine
colonoscopies and other procedures that weren't urgent, in an
effort to prevent infection and conserve space and equipment for a
potential surge of patients with Covid-19, the disease caused by
the coronavirus. Some states urged hospitals to do so voluntarily.
Elsewhere, governors and health departments mandated a stop.
The result was a patchwork of policies that threatened fines for
violators in some states and left hospitals and doctors to make
their own calls in others.
"Surgery is saving our bacon," said Jennifer Riley, operating
chief of Memorial Regional Health in Craig, Colo., which didn't
suspend surgery. The struggling rural hospital closed its obstetric
services at the end of 2019 and she said it couldn't afford the
additional loss of business.
"People are thinking we are doing this just for the money," she
said. "They're not wrong. We are doing this to remain economically
viable."
Many hospitals and surgery centers did halt surgeries. The
financial shock has been severe, marked by the sector's largest
one-month job loss in 30 years of published Labor Department data.
Nashville-based HCA Healthcare Tuesday reported its hospital-based
outpatient surgery dropped 70% so far this month compared with
April 2019.
Now, the Trump administration, some states and some hospitals
are moving to restart surgeries postponed by the pandemic, also
with varying criteria for how to go forward. The White House
suggested Friday those procedures could go ahead where the number
of infections appears to be tapering off, when hospitals have
adequate capacity and robust testing for high-risk workers.
Federal health officials followed Sunday with recommendations
for reopening operating rooms, while urging hospitals to keep up
efforts to conserve protective gear. The Centers for Medicare and
Medicaid Services also said patients should be tested before
treatment as soon as hospitals can do so. Until then, hospitals
should screen patients by symptoms, CMS said.
Protective equipment and testing capacity remain limited in many
U.S. communities, said Lisa Bielamowicz, president of consultants
Gist Healthcare. "In most places, both of those things are very
uncertain," said Dr. Bielamowicz.
Eight surgery centers affiliated with Cedars-Sinai in Los
Angeles have enough testing capacity for a slow, initial ramp up,
said Carole Guinane, executive director of the surgery-center
operations. The centers are making plans to reopen as California
eases its restrictions, she said.
Limited stocks of protective equipment and testing as well as
anxiety among doctors, nurses and hospital staff will slow the
ramp-up at Children's Mercy Kansas City in Kansas City, said Shawn
St. Peter, the chief of surgery.
Children's Mercy, which postponed nonessential surgery in
mid-March, began in April to test all remaining patients. That
greatly eased staff concerns, he said. No patient has tested
positive, he said, but it is unlikely the hospital would resume
surgery without more capacity to continue testing all patients.
Under an executive order from the Texas governor, hospitals can
resume all elective procedures Wednesday -- but only after they
pledge not to ask later for protective gear from local, state or
federal emergency stockpiles. Texas hospitals must also promise to
hold one-quarter of their capacity for coronavirus patients, in
case the pandemic brings another wave of critical illnesses.
The state in mid-March announced it received protective gear
from the Strategic National Stockpile, the federal emergency
reserve that was quickly depleted by the pandemic.
Baylor Scott & White Health, a Dallas-based nonprofit with
52 hospitals, is ready to reopen under those terms, it said in a
statement.
"We are confident we can safely care for patients who meet the
criteria set forth in the executive order -- patients who need
biopsies for potential cancer diagnoses, for example -- as soon as
Wednesday, while maintaining an adequate supply of personal
protective equipment," the statement said.
Tenet is also taking steps to certify with Texas health
officials that it can meet state criteria to restart, said people
familiar with the company's plans.
Eastland Memorial Hospital, a small hospital located about an
hour's drive from Abilene, Texas, scheduled four procedures this
week it couldn't do under the governor's original cessation order,
said its chief of nursing, Brandi Riley.
That was a sharp rise from recent weeks, when the hospital
required two doctors to approve any surgery to avoid running afoul
of the state's edict, she said, noting that "We might have done
three in the last month."
Eastland Memorial has protective gear for its workers, but a
local Covid-19 surge could deplete stores, Ms. Riley said. The
hospital continues to hunt for more supply.
Yet it can't wait to restart surgeries as operating losses
mount, hospital officials said. "Basically we're going to be
walking a gray line," Ms. Riley said. "We're going to be opening
our services because we need to. We're not through this
pandemic."
In states like Missouri, hospitals can move ahead as they see
fit. The state didn't order a halt to medical care.
Scotland County Hospital voluntarily shut down more than four
weeks ago. Decisions about what was essential were left to
individual clinicians, said Dr. Tobler, but the hospital's
self-imposed policy went too far. "Our abundance of caution turned
into self-exclusion," he said.
By the second week of April, Dr. Tobler was starting to
reconsider. "If we don't pay attention to our finances, we are not
going to be here to take care of people whether it is the rest of
the first wave [of the virus] or the second wave," he said. "You
need to be appropriately liberal with the provision of
services."
Corrections & Amplifications Children's Mercy Kansas City is
in Kansas City, Mo. An earlier version of this article incorrectly
said that Children's Mercy Kansas City was in St. Louis. (Corrected
on April 22, 2020.)
Write to Melanie Evans at Melanie.Evans@wsj.com and Russell Gold
at russell.gold@wsj.com
(END) Dow Jones Newswires
April 23, 2020 02:47 ET (06:47 GMT)
Copyright (c) 2020 Dow Jones & Company, Inc.
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