Prior to the COVID-19 pandemic, primary care physicians and specialists at Metro Health-University of Michigan Health typically saw about 2,250 patients each day.
Patients and visits dropped dramatically during the pandemic, as Metro Health and other health care providers were forced to postpone or cancel non-essential surgeries, procedures, diagnostic tests and patient visits because of state orders, and as they deployed staff and resources toward handling the pandemic.
By late May, as hospitals were allowed to resume non-essential care, patient visits had recovered somewhat and Metro Health doctors were seeing about 1,800 patients a day at their offices, which had been closed for weeks from the pandemic.
Dr. Rakesh Pai, medical group president and chief population health officer at Metro Health, expects that getting back to pre-COVID-19 volumes will take months as the pandemic and patient concerns linger.
“It’s just a reality that we’re not going to be able to recapture all of the volume that we were doing in February overnight. It’s going to be a slog,” said Pai, acknowledging that some people “are very nervous about going into a health care environment.”
“There’s a group that you’re not going to be able to convince until you get a vaccine or they know for sure there’s a treatment that can cure them or make their COVID-19 less bad if they get it, so that’s a hard group to reach,” he said.
All hospitals face the same reality today as they get back to performing elective procedures and surgeries and their physicians again see patients for routine office visits. They have to deal with people’s comfort level in going to see their doctors, having a needed diagnostic test performed at the hospital, or venturing into an ER for emergency care.
At Spectrum Health, returning patient volumes vary among different types of care, from surgeries to primary care office visits to tests such as medical imaging, President and CEO Tina Freese Decker told MiBiz. On some days, volume “in a couple areas” has gotten back to 90 percent, “and there are days where it’s lower,” Freese Decker said. The health system has experienced some patients expressing lingering concerns when they are called to reschedule postponed care.
“What we’re finding is between 75 percent and 85 percent of people are saying that they will come in for a visit or a surgery, and 15 to 25 percent of people are saying, ‘No thank you, I’d rather wait’ or ‘I don’t want the procedure anymore’ or ‘I did something else,’” Freese Decker said. “When we call patients for rescheduling, it varies by what we’re calling to schedule for and their response about what they want to do. In many cases, they’re saying, ‘Yes, I’m ready to come back,’ and in some cases they’re saying, ‘give me another month.’”
In scheduling alone, Spectrum Health is back to 100 percent in some areas. Getting fully back to pre-COVID volumes comes down to “addressing patients’ concerns and fears,” Freese Decker said.
“We do expect that volumes will be less than planned, but I do think that people will gradually feel more comfortable getting their care,” she said. “In health care, we have always been focused on infection prevention. It is something we do every single day to keep people healthy, so we are taking the best practices that we’ve done for years and we’re making sure that they are known and practiced in every way and bolstered on top of that.”
Since March, hospitals have reported declines in ER visits even for emergencies such as heart attacks and strokes, as people stayed away despite the obvious risk. Metro Health’s ER traffic declined “fairly significantly” in the pandemic, from a normal of 170 daily visits, Pai said. As of late May, it had rebounded to about 126 visits a day, he said.
“We do think that’s a consequence of people being afraid to come in,” said Pai, who called the tendency for some people to avoid care even for emergencies or chronic illnesses “super concerning.”
“Strokes don’t stop because COVID’s around. Heart attacks don’t stop because COVID’s around,” he said.
A study the U.S. Centers for Disease Control and Prevention released last week showed that ER visits to U.S. hospitals declined 42 percent from March 25 to April 29. ER visits nationally since the low point in mid-April have increased somewhat, but were still down 36 percent for the last week in May versus the prior year, according to the CDC.
Deferring care for chronic conditions such as diabetes, COPD and heart disease “that require a regular tune up” may lead to patients becoming sicker, Pai said.
How quickly hospitals are able to get back to pre-COVID-19 patient volumes depends on “how people in the community view the urgency around getting their health care-related services, versus the safety of it,” said Dr. Hyung Tai Kim, president of Mercy Health Saint Mary’s in Grand Rapids.
As they resume regular operations, hospitals and health systems need to emphasize both the safety protocols they’ve put in place to minimize risks and for people to seek the care they need, especially for an emergency or chronic medical condition, said Dr. Ken Berkovitz, CEO of Ascension Michigan.
“There is some concern and hesitancy to coming back,” Berkovitz said. “Our messaging needs to include that it’s safer to come in to see us than to stay home with some of these life-threatening conditions.”
Ascension Michigan consists of 16 hospitals across the state, including Ascension Borgess Hospital in Kalamazoo, plus AscensionBorgess Lee Hospital in Dowagiac, AscensionBorgess Pipp Hospital in Plainwell, and Borgess Allegan.
As of last week, Ascension Michigan was back to nearly 70 percent of the volume of procedures, surgeries and diagnostic tests from pre-COVID volumes, and 50 percent for ER visits.
The medical group for Ascension Michigan reopened May 18, and in West Michigan, “We hope to be back to our normal in-person rates probably by early July,” Berkovitz said.
Hospitals have put numerous safety protocols in place to prevent infections, some of them mandated by the state. Measures such as enhancing cleaning and sanitizing, social distancing, screening people for COVID-19 symptoms and checking their temperature when they come into the hospital, and requiring them to wear masks will likely remain in place for some time, and perhaps permanently, administrators said.
Similar safety protocols have also been put into place for physician offices and ambulatory care sites. Changes also have been made to how they manage patient flow to minimize risks.
At Metro Health, for example, patients visiting their doctors wait in their cars and receive a message when it’s their turn, Pai said. They must wear a mask and are escorted by a medical assistant through the office to the exam room. Once their visit is done, they are checked out in the exam room.
“They don’t have to linger or stop anywhere at the front desk or anything like that. It’s all done relatively seamlessly,” Pai said.
Hospitals looking to get back to business also have another obstacle in addition to reassuring people their facilities are safe: a surge in unemployment from the economic downturn the pandemic triggered. Higher unemployment results in many people losing their employer-sponsored health insurance, potentially causing some to opt not to seek care for a medical condition because they can no longer afford it.
“We’re trying to help people understand that it’s both safe and smart to get needed medical care. That’s still definitely true and we still have a need for them to understand that more and more. On top of that has been the economic difficulties that are caused by coronavirus and the closings and everything. The personal economic element comes in,” Kim said. “People are trying to decide, as they did in 2008, whether just from an economic standpoint, ‘Can this wait because I have other bills that I need to pay?’”
The Kaiser Family Foundation estimates that 26.8 million people nationwide could lose their health coverage as of May because of a job loss from the pandemic.
As some job losses become permanent in the weeks and months ahead, Pai expects Metro Health to see an uptick in patient volumes from people seeking to address a medical issue before their health benefits run out.
“When you lose your job, you lose your ability to pay, but we do think these 90 days here this summer will be really important to accommodate (as many) people as we can before there’s material change to their health benefits,” Pai said. “We think there’s a window this summer where people still have benefits, need to get stuff done and we need to be able to accommodate those patients because they may not have those benefits for much longer.”
The inability to perform non-essential procedures and surgeries and the reduced physician visits led to mounting losses for hospitals from lost revenue, which was on top of the higher spending to build inventories of personal protection equipment for staff, testing for the coronavirus and COVID-19, setting up temporary test locations and preparing added bed capacity.
A month ago, the American Hospital Association issued a paper that estimated hospitals and health systems across the U.S. would lose a collective $202.6 billion between March 1 and June 30. The estimate includes $161.4 billion in revenue lost over four months from not performing elective surgeries and procedures because of stay-at-home orders in several states, and people deferring care during the pandemic or not seeking emergency care when needed. The estimate also takes into account the cost to treat COVID-19 patients, add temporary capacity and locations to test people, and a $2.4 billion price tag for personal protection equipment for staff.
West Michigan hospitals have seen the financial hit from the pandemic as well.
At one point early in the pandemic, patient volumes at Mercy Health Saint Mary’s “were less than 50 percent of what they usually are,” Kim said. Surgical volumes that are “especially important to the financial sustainability of the health system” were “well below 20 percent of the norm,” he said.
“Financially, it’s been extraordinarily difficult. We’ve been affected in ways that everyone else has because (as) our volumes have gone down, our revenues have really plummeted and we’ve added additional expense to make sure we were prepared” for the coronavirus, Kim said.
The support of parent corporation Trinity Health’s financial reserves has enabled Mercy Health Saint Mary’s to remain financially stable, “and we’re confident that we’re going to be able to serve the community’s needs going forward,” he said.
Prior to the COVID-19 pandemic, Metro Health-University of Michigan Health was on track to record $480 million to $485 million in revenue for the fiscal year that runs through the end of this month. Now, after the business lost during the last three months of the pandemic, the health system expects to record about $430 million in revenue for the fiscal year, and that’s based on “moderate assumptions,” Pai said.
Metro Health CEO Peter Hahn earlier indicated to MiBiz it was projecting a $40 million net loss for the 2020 fiscal year.
Grand Rapids-based Spectrum Health, which routinely posts quarterly financial reports online, recorded a $22.8 million operating loss for the first quarter on revenue of $802.5 million across its West Michigan hospitals. The health system had been budgeted for operating income of $31.5 million.
Spectrum Health Lakeland in St. Joseph, which operates as a separate division, recorded a $4.7 million operating loss on $137.2 million in operating revenue. Lakeland was budgeted for $5.3 million in operating income for the first quarter.
“It wasn’t the quarter we had planned for,” Freese Decker said. “We’re in consistent company across the country. It’s going to be a much different year than expected, and that’s true for most businesses.”
Freese Decker hopes April was “the lower point” for volume declines from the pandemic and “as we’re doing more necessary procedures and helping people with their health needs for the month of May and now into June, that our finances will improve as we go forward and every month, I’m hoping, is a better month.”
Spectrum Health’s cash on hand during the first quarter declined by 5.7 days to 224.5 days as of March 30, according to the quarterly financial statement.
In response to the losses, Spectrum Health, Metro Health, Mercy Health in Grand Rapids and Muskegon, Bronson Healthcare in Kalamazoo, and other health systems implemented staff furloughs and moved to cut costs that included reducing executive pay and halting retirement plan contributions for employees.
Ascension Michigan was able to avoid furloughs by “dipping” into reserve funds and with the support of the parent corporation, St. Louis, Mo.-based Ascension Health, although “like every health care organization, we are very challenged,” Berkovitz said.
The operating losses and higher spending during the pandemic was somewhat offset by aid from the federal CARES Act that Congress enacted early in the pandemic.
Spectrum Health Hospitals received $43.9 million, the largest single amount for any health system in the region, according to a U.S. Department of Health and Human Services online database. Bronson Healthcare in Kalamazoo received $10.8 million for Bronson Methodist Hospital, plus $5 million for LakeView Hospital in Paw Paw, $3.9 million for Bronson Battle Creek and $4.4 million at Bronson South Haven.
Federal aid totaling $9.6 million went to Ascension Borgess Hospital in Kalamazoo and Borgess Lee received $441,948.
The aid “certainly helped, but in no way did it make us whole,” Berkovitz said. “Our economic losses are significant.”
Metro Health got $8.8 million from the federal government. Holland Hospital received $4.6 million, according to the HHS database.
Mercy Health in West Michigan got about $23 million in HHS grants as part of the CARES Act. The money still will not cover losses from the first two months of the pandemic, when patient revenues were down by about $75 million, according to a spokesperson.