By JEFF GOLDSMITH  (6)

By the end of April, the scope of COVID-19 damage to the US hospital system is becoming clearer, measured in tens of billions in lost revenues per month.    While governments can issue an “all clear” order in areas minimally impacted by COVID, restoration of normal clinical operations depends crucially on patient acceptance of the safety of the health system.  Hospitals’ path to operational recovery is fraught with complexity, and will require a disciplined, systematic approach.   

While new COVID cases and deaths seem to be levelling off nationwide,  the disappearance of hospital activity is unprecedented- 40-50% reductions in hospital admissions, surgical cases and, most unexpected of all, emergency department volumes, even for cardiac cases.  Even before state and federal officials recommended cancelling “elective” procedures, hospital executives acted in an abundance of caution, and urged patients to delay care if possible, in order to prepare for a flood of COVID cases that has thusfar failed to materialize in many places.

Given that re-opening the economy has, sadly,  become politicized, and that the public remains skeptical about the adequacy of COVID testing, it is not safe to assume that patients will come thundering back once a governmental “all clear” has been sounded.  Patients and their families still have the deciding vote and caution is likely to be the watchword.  Given these uncertainties. how should hospital and health system leaders approach restoration of their business?

Widen the Circle of Trust

The essential task is to assure the community, both directly and through clinicians, that the hospital is a safe and infection- free place for medical care.  To do this, front line clinical staff, not only in emergency departments and ICUs, but also imaging, laboratory, and regular inpatient units, as well as their supporting cast in housekeeping and food service, must feel safe and protected coming to work.  This feeling of safety presupposes the hospital’s supply of PPE meets or exceeds demand, and  that it maintains a robust and aggressive testing regime that finds both symptomatic and asymptomatic COVID cases among the workforce for isolation and treatment.  

Hospitals and health systems are frequently the largest employers in their communities.   If caregivers and support staff feel safe coming to work, and believe threat of infection has been contained, they will communicate that feeling of safety to their friends and neighbors, both by word of mouth and social media posts.     This widening circle of trust is a far more powerful force for restoration of normal operations than press releases, public service announcements, news broadcasts or paid commercial messages.  

Actively Engage Physicians

Practicing physicians, whether employed by the health system or in independent practice,  still control the decision about when to resume normal clinical activity. Physicians are anxious to return to work, but will need to communicate with patients that may have delayed receiving care, and confirm that they want to move ahead.

To make sure that the resources they need to practice are available to them when they need them, re-opening operating suites, catheterization laboratories, imaging and other services must be tightly coordinated with physicians to assure that the health system can staff and manage the renewed volume.  This complex task will be complicated by the ease with which furloughed or laid off workers can be reclaimed from unemployment and return to their supporting roles.  Particularly for lower paid healthcare workers, it may be financially stressful to return to work before unemployment coverage expires.  Availability of child care will also be a constraint, as will the work schedules of spouses or domestic partners.  

For these reasons, practicing clinicians must be closely consulted and actively participate in the phased resumption of clinical operations.   To simply fling open the doors fully staffed for normal operations and assume patients will show up is not prudent planning.  

Anticipate Patient Financial Hardship Will be a Concern 

Fear of COVID might not be the only constraining factor in resuming normal clinical operations.
Tens of millions of Americans lost work suddenly during the month of March, levels of job loss not seen in the US since the Great Depression of the 1930’s.   Many lost health coverage along with those jobs, and may or not be eligible for or enrolled in Medicaid.   Those that did not have been spending savings or incurring debt just to meet their day to day expenses.  

In the wake of this “flash depression”, millions of patients that might otherwise seeking hospital care will delay because they fear they cannot pay their share of the cost.  Rising “insured” patient bad debts were a major contributor to hospitals’ earnings slump from 2015 to 2017, during the good times.  Financial stress affects tens of millions more families now that COVID has effectively shuttered much of the US economy. 

Both physician practices and hospitals must anticipate that concerns over affordability will further slow the return to normal operations.  To cope with this threat, hospitals should be prepared to offer payment plans and rate concessions  geared to the family’s financial resources.  Employers and health insurers must be encouraged, both by their provider networks and by political leaders,  to review and revise their cost sharing policies in the post-COVID environment, and not just for COVID patients. 

Families are under intense financial stress all across the country as a result of the COVID-related financial crisis.  Even as they return to work, many families will struggle to pay their bills.

Unless care providers acknowledge these stresses, and make humane and thoughtful provision for them, the “return to normalcy” may take many months.

Author thanks Dr. Steven Motew of INOVA, Terry Shaw and Daryl Tol of Advent Health, Rich Liekweg of BJC Healthcare  and Kerry Shannon of Virginia Mason Medical Center for their comments and input into this essay.