HCA Healthcare
April 24, 2020


SOURCE: Wall Street Journal
AUTHOR: Melanie Evans and Russell Gold

Decisions pit vital revenue stream against infection risk; patchwork of state rules means uneven revival

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. THC 0.86% is preparing to restart some surgeries in Texas, said people familiar with the hospital and surgery-center company’s plans. HCA Healthcare Inc., HCA 0.21% 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.”