Some patients are returning to hospitals to finally get that knee replacement, others remain wary of elective surgeries.

Alice Smith tore her rotator cuff years ago but didn’t consider fixing it until she tweaked it recently while cleaning, causing searing pain.

Maryland had just lifted its pandemic-related stay-at-home order, and hospitals were again allowed to perform so-called elective procedures after a two-month break designed to keep space and staff available for COVID-19 patients. But that didn’t mean Smith could see a doctor.

“The pain was unbearable,” said Smith, a retired Baltimore nurse. “And I couldn’t get an appointment.”

Hospitals cautiously resumed serving patients beginning in May, but the return to normal has been more of a jog than a sprint. Few offered every procedure immediately because they needed time to set up new safety measures for staff and patients.

And many like Smith found the line for an appointment was long because so many patients couldn’t, or wouldn’t, seek care while there were so many coronavirus cases.

The drop in preventive care, surgeries and even treatments normally handled in emergency rooms has been severe, alarming the medical field who fear more—and sicker—patients are looming. The subsequent diminishing of revenue has strained the finances of the state and national health system.

Further, hospitals must remain prepared to halt such procedures again should Maryland see another surge in COVID-19 infections, like those now being reported in many other states.

Smith was going to have to wait months for surgery, but another patient canceled and left an opening at Johns Hopkins Hospital.

Hopkins staff are now working six days a week to safely clear a backlog of elective procedures. It’s a major shift for a hospital that cared for many of the state’s sickest coronavirus patients. Despite a recent uptick in the number of Marylanders testing positive for the virus, statewide the number hospitalized with COVID-19 has been below 450 for about three weeks. That’s down significantly from late April, when more than 1,500 were hospitalized.

After many procedures were off-limits for weeks, “we now have large numbers of people who require semi-urgent and elective care,” said Dr. Robert Higgins, Hopkins’ surgeon-in-chief. “Scheduling them has been our challenge.”

Hopkins was performing about 120 daily surgical procedures before the pandemic, and Higgins said the hospital is operating at about 80% with normal levels expected in coming weeks. Cases are prioritized, with suspicious growths or painful conditions, for example, outweighing routine colonoscopies or knee replacements.

Treatment for traumas, heart problems and other emergencies never stopped, though data shows even those dropped during the pandemic.

“We don’t want folks to delay care they think is essential,” Higgins said.

Hopkins and all other hospitals, along with doctors’ offices and surgical centers, have instituted new measures, such as limiting visitors and spacing chairs in waiting areas. In-person consultations are avoided if telemedicine appointments will do. Facilities sanitize surfaces regularly, require masks and test patients for COVID-19 before surgery.

Smith, who goes by Betsy, found all the extra measures comforting during a pre-surgery MRI at a Hopkins office at Greenspring Station in Lutherville and during the procedure in a Hopkins center in White Marsh.

“They were very careful,” she said. “I remained in my car until my MRI appointment and went in when I was called. Masks were mandatory. They asked me to sanitize my hands. I was tested for COVID. On every little thing, they were playing it safe.”

State officials continue to monitor hospital space and staff should coronavirus infections flare. About a fifth of hospital beds, including ICU beds, are now available. More are ready, though unstaffed.

All the steps hospitals have taken, however, come with costs, said Bob Atlas, president and CEO of the Maryland Hospital Association.

The ban on electives devastated hospital finances, and there continue to be costs for things such as protective gear. Supply chains remain “unsteady” and prices are “extremely high,” Atlas said.

The association estimated that the state’s hospitals would lose about $1 billion in revenue for April through June, or about a quarter of their normal revenue. Some of the money has been recouped through temporary rate increases allowed by state regulators, and other funding has come from federal grants, but hospitals also have cut salaries and furloughed staff.

“We still see a gap,” Atlas said. “Hospitals have made serious adjustments to deal with loss of income from core parts of their business along with the heavy impact of added costs.”

The steep drop in elective care was surprising to many in the health care field, said Jonathan Weiner, health policy expert at the Johns Hopkins Bloomberg School of Public Health. So, too, was the financial fragility of the U.S. health care system.

“The elective care drop has led to the biggest financial threat to health care provider solvency in recent history,” Weiner said.

There may be some positive aspects, however. Many experts believe a third or more of elective surgeries are unneeded, and the hiatus could help show which patients do well with less care, Weiner said. He also said public and private health insurers that are saving billions could lower premiums or put funds toward public health initiatives during the pandemic.

Still, the number of patients who did not get needed care—the “COVID collateral damage”—is certain to be considerable, Weiner said.

A report from the American Hospital Association found the number of patients getting treatment was expected to remain well below pre-pandemic levels for the rest of the year. Hospital losses from the pandemic nationwide are expected to top $323 billion in 2020.

The association said hospitals have had nearly a 20% drop in inpatient volume and almost a 35% drop in outpatient volume from 2019 levels. Some hospitals remain focused on COVID-19 patients, and the number could increase.

The 13-hospital University of Maryland Medical System, which released its 1,000th COVID-19 patient in late June, said it still has to maintain capacity for the pandemic. It is, however, “carefully increasing patient access to a broader range of urgent and time-sensitive cases,” said spokesman Michael Schawarzberg.

Some hospitals in Maryland have found that not all patients are ready to return.

A survey of 300 people by Greater Baltimore Medical Center in May found just over half didn’t feel safe getting care at a hospital. Some said they were worried that people around them wouldn’t be following public health guidance or that hospitals lacked protective gear. Others mistrusted the government’s pandemic response.

Dr. Terry Fairbanks, vice president for quality and safety for MedStar Health, among the state’s largest health care systems, said doctors’ offices have been calling patients to reschedule but are not getting everyone booked.

“I believe patients are still hesitating to seek care,” Fairbanks said. “We’re worried about that. Some are hesitant even if they have something painful, like kidney stones. We try and explain that we’ve created a very safe environment for patients.”

Medstar’s backlog was so large that the system, which includes seven hospitals in Maryland and three in Washington, is approaching normal service levels, he said.

LifeBridge Health said its four hospitals gradually opened space, and doctors have been prioritizing patients with nonemergency needs, said Dr. Matthew Poffenroth, the system’s chief clinical officer. At Sinai Hospital in Baltimore, for example, surgeons now can reserve as much operating time as they did before the pandemic.

“There is an almost daily or weekly review with all the surgical chiefs,” Poffenroth said. “They review the caseloads and prioritize them based on urgency.”

LifeBridge made another change that may appeal to patients. Officials began allowing the patients to bring a family member or other adult visitor into the hospitals. The system appears to be the state’s first hospital system to make this change since the pandemic led all hospitals to curb visitors. The policy also includes end-of-life COVID-19 patients.

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