Doctors can go back to business, but how much?
Gov. Greg Abbott has started to reopen parts of the Texas economy, and on Wednesday health care providers once again could perform elective surgery and select procedures — a month after he had ordered them to suspend such work.
That’s good news for thousands of patients who had to postpone care, and for many doctors whose practices have been walloped by deep declines in revenue.
“We’re good to go, and we’re starting to work through the rescheduling of surgeries,” said Dr. David Hassinger, an orthopedic surgeon and founder of Direct Orthopedic Care, which has five locations in North Texas.
During the pandemic, his company has primarily provided emergency care for broken limbs. Now it will start resuming hip and knee replacements, rotator cuff surgeries, ligament reconstruction and the like.
“Many people have been living with these painful conditions and they’re ready to get ‘em fixed,” Hassinger said.
But other providers, especially large hospital systems, are moving forward more tentatively. They’ve been on high alert for weeks, preparing for a potential disaster and trying to ensure the safety of front-line workers and patients.
When asked how they were getting back to business after Abbott’s order, they emphasized the need to proceed cautiously. That makes sense, an expert said, because opening too much too soon could prompt a spike in COVID-19 cases and undermine the gains made during the lockdown.
“No one wants to be the first so they’re taking baby steps,” said Britt Berrett, a longtime hospital executive who teaches at the University of Texas at Dallas. “Everyone is walking gingerly down this road.”
Dallas County Judge Clay Jenkins urged “continued caution” as providers return to elective surgery and other procedures. Leading medical associations have created a road map to resume such work, and he said providers should adopt the recommendations.
“Such a carefully planned and phased approach will best ensure patient, provider and public safety,” Jenkins said in a statement.
Baylor Scott & White Health, the largest nonprofit hospital system in the state, said it’s started contacting patients to reschedule procedures for as soon as this week. But it’s balancing that pent-up demand with the bigger risks from the virus.
“We must, of course, remain prepared for influxes of COVID-19 patients,” spokeswoman Julie Smith wrote in an email.
At UT Southwestern, officials are evaluating each non-urgent procedure to determine when and how to start seeing patients who need that help, said spokesman Russell Rian. Officials are also considering many other factors, including the availability of COVID testing and personal protective equipment, contact tracing, infection risk and the number of COVID cases in Dallas-Fort Worth.
“We want to be exceedingly careful,” Rian wrote in an email.
Texas Health Resources, which operates one of the largest hospital chains in Dallas-Fort Worth, is still working with clinicians and patients as it considers how to make the transition to the next phase. It’s not rushing into anything.
“We are committed to a safe and measured return to providing non-emergent care,” spokesman Steve O’Brien wrote in an email.
Methodist Health System in Dallas plans a phased approach, starting with testing patients for COVID-19 before they’re cleared for elective surgery.
“The phased approach will allow us to ensure we have the appropriate number of tests, as well as the correct amount of PPE, to mitigate as much risk as possible for our patients, physicians and staff,” spokesman Ryan Owens wrote in an email.
A month ago, Abbott suspended non-urgent procedures to help preserve bed capacity and equipment for a potential surge in coronavirus patients. While COVID-19 infections and deaths have been rising, the results in Texas have not been as bad as some predicted, and Abbott said there’s plenty of bed capacity and supplies.
Abbott’s new executive order, which took effect Wednesday, opens the door for many procedures but comes with some strict conditions. A facility must certify that it will keep at least 25% of bed space available for COVID-19 patients, and must agree to not ask for PPE from any government agency — federal, state or local — “for the duration of the COVID-19 disaster.”
A shortage of PPE has been a major issue in New York City, the epicenter of the coronavirus outbreak, and in other states where the number of cases has climbed rapidly.
Hassinger, who also has orthopedic centers in Austin and Oklahoma City, said his practice has plenty of PPE today.
“Very early in the crisis, we had supply chain issues, but there have been extraordinary efforts over the last 10 to 14 days,” he said.
Medical City Healthcare, which has hospitals throughout North Texas, said it’s also begun rescheduling patients for elective surgery.
On Tuesday, parent company HCA Healthcare said traffic in its hospitals nationwide has continued to fall. Because of canceled procedures, hospital-based outpatient surgery was down 70% in April compared with last year, an executive said.
In North Texas, the company said it was adhering to state and local requirements on resuming elective surgery. “At all times, the supply of PPE, hospital and intensive care unit beds, and ventilators will be taken into consideration, even in areas that are not currently managing COVID-19 infections,” Medical City said in a statement.
Specialty surgeries are major sources of revenue for hospitals and some medical practices, and canceling that work has contributed to many furloughs and layoffs during the public health crisis.
Neurosurgeons, orthopedic surgeons and cardiovascular surgeons each generate an average of more than $3.3 million per year for hospitals, according to a survey conducted by consulting firm Merritt Hawkins.
Mark Armstrong, a health care lawyer with Polsinelli in Houston, said hospitals that reserve enough capacity for COVID-19 patients and agree not to ask for PPE from public sources may “theoretically” perform any medical procedure. That doesn’t mean they will.
“Some hospitals are contemplating whether or not they want to do it,” he said.
Hospitals are worried about having enough capacity if COVID cases surge. But in rural parts of Texas, where infection rates are low, Abbott’s revised rule may allow some hospitals to “more or less get back to normal,” Armstrong said.
Individual physicians will generally determine whether their patients qualify for an elective procedure under Abbott’s order, which requires “a serious medical condition.”
“It certainly leaves a lot within the physician’s discretion,” Armstrong said. “It is a case-by-case evaluation by a physician to determine … whether or not that surgery would meet the heightened criteria.”
For example, if not having a knee replaced could result in serious medical consequences, then a doctor would probably go ahead and schedule it, he said.
Armstrong said ambiguity remains in Abbott’s revised order, but he expects additional guidance from the governor’s office soon.
The Centers for Medicare & Medicaid Services has recommended that medical facilities resuming elective surgeries screen all patients for COVID-19 symptoms, including taking temperature checks. Staff should also be routinely screened, CMS said. And when adequate testing is available, patients and staff should be tested regularly for the disease, the agency said.
Kristin S. Held, a San Antonio ophthalmologist and president of the Association of American Physicians and Surgeons, said Abbott’s revised order was a “step in the right direction.” But it was written in a confusing way, she added.
She called the original order restricting elective surgeries an “overreach,” even though she worries about having enough N95 masks and other PPE.
“This is a better approach,” Held said.
She said she’s resuming surgeries at her facility on Thursday, and she’s aware of colleagues across the state who plan to do the same.
The last time she operated was March 19, and her patients are anxious to have their procedures done.
“I’m ready to go back and operate,” Held said.