Hospital Volumes Slashed by More Than Half During Pandemic

Ken Terry

May 11, 2020

As US hospitals begin to reopen for elective procedures, a new report outlines the damage that the COVID-19 pandemic has done to the facilities' patient volumes and revenues.

The study, by Strata Decision Technology, a Chicago-based financial analytics firm, suggests that across all service lines and in every region of the country, there was an average decrease of 54.5% in the number of unique patients who sought care in a hospital setting during a 2-week period in March and April.

The findings suggest how much pent-up demand will hit hospitals when they start to admit non–COVID-19 patients who need procedures that have been prohibited by temporary state bans on nonurgent hospital admissions.

Strata researchers mined the company's database to compare patient encounters during those two weeks to the comparable period last year. The analysis of over 2 million patient visits and encounters from 228 hospitals in 40 states provides a detailed view of the level of reduction in patients accessing healthcare.

Patients with life-threatening illnesses were among those who could not access care because of COVID-19 restrictions. In the context of clinical service lines, there was a 57% drop in cardiology volume, a 55% decline in breast health volume, and a 37% decline in cancer care.

Other high-volume procedural service lines experienced even larger declines: Ophthalmology fell by 81%; spine, 76%; gynecology, 75%; orthopedics, 74%; ENT, 72%; endocrine, 68%; dermatology, 67%; gastroenterology, 67%; rheumatology, 66%; neurosciences, 66%; urology, 62%; vascular, 59%; and hepatology, 58%.

Most of the top 10 hospital procedures also took major hits, the report found. These included primary knee replacement (-99%), lumbar/thoracic spinal fusion (-81%), primary hip replacement (-79%), diagnostic catheterization (-65%), other diagnostic procedures (-60%), percutaneous coronary intervention (-44%), and fracture repair (-38%).

The number of regular births and cesarean births, on the other hand, increased by 1% and 2%, respectively. And, not surprisingly, the use of mechanical ventilation jumped by 24%.

The report noted that inpatient procedures and surgeries account for the majority of hospital revenues, and that the top 10 procedures generate over 50% of the total payments made to hospitals.

The Strata analysis also found significant reductions in patient encounters, both inpatient and outpatient. These included telehealth encounters, according to Strata spokesman Todd Stein. The data did not show how much of the reduced access to care resulted from the inability of patients to secure appointments and how much of it was related to their fear of seeking care in emergency departments and physician offices, he said.

There was a significant decline in access to care for patients with life-threatening conditions, including congestive heart failure (-55%), heart attacks (-57%), and stroke (-56%). Access to care also fell for patients with chronic conditions such as hypertension (-37%) and diabetes (-67%). The high-volume patient visits and procedures that dropped the most were for cataracts (-97%), sleep apnea (-91%), osteoarthritis (-88%), and glaucoma (-88%).  Preventive wellness visits and procedures such as colonoscopies had volume drops of over 75%.

All of these massive decreases in procedures and encounters, of course, mean big financial losses for hospitals. The Strata report estimated that the 51 health systems in the study lost $1.35 billion during the 2-week study period, compared with the prior year. If all hospitals nationwide lost an equivalent amount, on average, they would have seen a revenue decline of $60.1 billion during the study period, the report said.

By implication, this estimate more than doubles the recent estimate of the American Hospital Association, which predicted that hospitals would lose $202.6 billion from March 1 to June 30 of this year because of the pandemic.

Reopening Carefully

As this financial Armageddon unfolds, hospitals across the country are starting to resume elective surgeries and other nonurgent care, pursuant to the public health policies of their states and cities.

Most of the state directives banning elective procedures remain in place, the American Medical Association noted in a fact sheet. However, Alaska, Colorado, Illinois, Indiana, Kentucky, Louisiana, Oklahoma, Texas, and West Virginia have relaxed their prohibitions, and several other states are said to be moving in the same direction.

Illinois' elective surgery ban lapsed today, Denise Chamberlain, chief financial officer of Edward-Elmhurst Health in Naperville, Illinois, told Medscape Medical News. "We're gearing up," she said, adding that "much of what was elective 2 months ago is no longer elective."

Many non–COVID-19 patients are already receiving urgently needed procedures at the system's two acute-care hospitals. Edward Hospital in Naperville has 406 beds, of which 220 (54.2%) are occupied, Chamberlain said. Just 51 of these patients have COVID-19.

At Elmhurst Hospital in Elmhurst, Illinois, 220 of the 284 beds (77.4%) are occupied. Only 66 patients have COVID-19. (The system's third inpatient facility is for behavioral healthcare.)

The big question now, Chamberlain said, is how many more non–COVID-19 cases can the two hospitals handle going forward? The biggest challenge is ensuring they have enough staff, she noted. The staffing ratio in ICUs, where many COVID-19 patients are treated, is two patients per nurse, much higher than the 3:1 to 6:1 ratio on other units. That, plus the absences of nurses who have been exposed to or are sick from the virus, makes it difficult to guarantee there will be enough staff to care for all patients as the health system opens up.

The data in the Strata report reflect the population's unmet medical needs, which could result in a big wave of admissions. Anecdotal evidence points in the same direction, Chamberlain said. "Based on what we've been hearing from patients and doctors, there's a lot of pent-up demand."

At the same time, she noted, her hospitals have to make sure they leave enough unused capacity to handle a spike in COVID-19 cases as people start going out again. Above all, she said, the system doesn't want to be in a position where it can't care for everyone who needs care.

Still, the new revenue from the ramp-up of elective procedures will be very welcome going forward. The advance payments from the Medicare Accelerated Payment Program have helped Edward Elmhurst keep its head above water, she noted, and the system was also in good financial shape before the pandemic.

"In the short term, we're fine," Chamberlain said. "But 1-2 years out, it's a hole that we have to dig out of."

Elective Surgery Math

Many hospitals are trying to balance the need to bring in more revenue against the need to maintain surge capacity, said Christopher Kerns, vice president, executive insights, for the Advisory Board Co, a Washington, DC, healthcare consulting firm, in an interview with Medscape Medical News.

What Kerns and his colleagues recommend is that, when the elective procedure bans expire, hospitals reopen 20% of their capacity every 2 weeks. Even as their occupancy rate increases, however, hospitals won't be full anytime in the near future, he predicted.

"It's just going to take a long time for patients to feel comfortable coming back into the hospital setting. Most providers will be lucky to get to 80% of the demand they were expecting."

When the occupancy rate of a hospital reaches the mid-70s, Kerns pointed out, its ability to withstand a major surge in COVID-19 drops substantially. "If you want to be able to handle a modest surge, you should keep your occupancy rate below 60%. No one is anywhere near that point now — except for those places experiencing surges."

Asked about the high percentage of non–COVID-19 admissions at Edward-Elmhurst Health and the rising demand for deferred procedures, Kerns said it's unclear what impact the dropping of state bans will have on total admissions.

"But it's likely that the severity of those admissions will be higher," he said, because if some cases are deferred for too long, they're no longer elective. "For example, you can delay cancer surgery by a few weeks, not a few months."

Those cases may be balanced, however, by scheduled elective procedures that will not take place because patients prefer nonsurgical alternatives to going to the hospital, where they might catch COVID-19.

"There are other options for treating hip and knee pain, like physical therapy," he observed. "It takes longer and is not as effective in some cases; it's a more difficult road, but it's possible."

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