Philadelphia-area hospitals may have to cut back on elective surgeries under state order

Main Line Health has more than 100 surgeries scheduled for next week that will require a hospital stay — the sort of cases that could be curtailed under a new state order designed to ensure that hospitals don’t run out of beds for COVID-19 patients.

Since Nov. 1, the number of COVID-19 patients hospitalized in Southeastern Pennsylvania has soared to 1,322 from 358, according to state data released Wednesday.

Jack Lynch, Main Line’s chief executive, said this week that the system’s finances will be greatly affected by whether it can perform elective or nonurgent surgeries in the coming months. In any event, he expects Main Line to act on its own ahead of a state Department of Health order requiring hospitals to reduce the number of elective procedures done in hospitals.

“We’re looking at the projections of the COVID cases,” Lynch said, “and our staffing capability and saying, ‘do we need to do something with those 100 cases because of either bed availability, which has not yet been a problem for us, or because of staffing.’”

The decision has significant financial implications for Main Line, which had a $67 million operating loss in the year ended June 30, largely because of a statewide ban on elective procedures from March through April. Elective procedures, including many outpatient surgeries, generate most of the profits for health systems.

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Main Line’s finances have improved since then. “I almost broke even in October, so I whack out 100 elective cases, there goes my breaking even in December,” Lynch said.

Main Line Health, with four general hospitals in well off areas of Philadelphia’s western suburbs, has the financial strength to withstand the turbulence caused by the coronavirus pandemic. But for some health care systems, the blanket ban on nonurgent procedures was devastating. Thomas Jefferson University lost nearly $300 million even with substantial federal support. The loss at Tower Health was $439 million.

It’s not clear if Secretary of Health Rachel Levine’s order, which takes effect Monday, will deliver the same financial hit to health systems as the one in March. Significantly, the order covers only procedures done in hospitals. That means systems like the University of Pennsylvania Health System, with a large network of outpatient centers, could be less impacted than it was in the spring.

The new order would not implement a statewide ban but covers hospitals by region, such as the area including Bucks, Chester, Delaware, Montgomery, and Philadelphia Counties. It set three triggers for reducing elective procedures in hospitals by 50% for seven days.

The triggers are: a third of the hospitals in a region anticipate a staffing shortage within the next week, there’s a more than 50% increase in COVID-19 admissions in the past two days, and more than 90 percent of staffed beds, not including those in the intensive care unit, are expected to be occupied during the next three days.

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If at least two of the three criteria are met, hospitals will have to reduce elective procedures. Four major health systems in the region, Penn, Jefferson, Temple and Main Line, performed an average of 2,800 outpatient surgeries a week during the three months ended September 30. That’s twice as many as the four systems did in the three months ended June 30, according to an Inquirer analysis of financial reports.

Health systems are much better equipped to handle a COVID-19 surge now than they were in the spring, Lynch and other executives said. They have ample supplies of personal protective equipment and much more testing capacity, preventing patients from occupying a bed while waiting for test results. Plus, clinicians know so much more about how to treat the disease, executives said.

This week Philadelphia-area doctors and health-care executives were parsing the new order, trying to understand exactly how it will work. They support the goal, ensuring that hospitals continue to have enough room for COVID-19 patients, but cautioned that reducing the number of elective procedures may not free up much hospital capacity because so many of them are done on an outpatient basis.

Among the questions on executives’ minds was what constitutes a staffing shortage that needs to be reported to the state health department, said James Brexler, chief executive of Doylestown Health and a member of the board of the Hospital and Healthsystem Association of Pennsylvania.

It’s also not completely obvious what counts as an elective procedure. “No one elects to go have someone cut on them,” Brexler said. Defining that should be done in an office in Harrisburg, he said. “That’s got to be done in a judgment between the clinician and the patient.”

The health department’s regional approach is much different than in the spring, when there was a blanket shutdown of elective procedures — spurred in part to stretch short supplies of personal protective equipment that was desperately needed in hospitals.

“What we saw in the spring is that some parts of the state had big heavy numbers and in other parts of the state hospitals were empty. I think doing it this way makes much more sense,” said Tony Reed, chief medical officer at Temple University Health System.

Reed said hospitals have to be thinking about which procedures could be postponed that would otherwise use precious hospital resources. Not all elective procedures do so. An endoscopy looking for an ulcer, for example, does not use hospital resources, he said.

“That’s an outpatient procedure done with an outpatient physician and outpatient nurses in an outpatient setting and the patient goes home at night,” Reed said. “Physicians, nurses, pharmacists, others, they’re not interchangeable widgets.”

On the other hand, a heart procedure like a catheterization, requires staff that could work with COVID-19 patients, he said. “If there’s a shortage of cardiac certified nurses, why do the catheterization this week,” Reed said, “why not put off until next week?” if the patient can safely wait?