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Hospital Volumes Start to Fall Again, Even as COVID-19 Soars

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Editor’s note: Find the latest COVID-19 news and guidance in Medscape’s Coronavirus Resource Center.

Hospital volumes, which had largely recovered in September after crashing last spring, are dropping again, according to new data from Strata Decision Technologies, a Chicago-based analytics firm.

For the 2 weeks that ended November 28, inpatient admissions were 6.2% below what they’d been on November 14 and 2.1% below what they’d been on October 28. Compared with the same intervals in 2019, admissions were off 4.4% for the 14-day period and 3.7% for the 30-day period.

Although those aren’t large percentages, Strata’s report, based on data from about 275 client hospitals, notes that what kept the volumes up was the increasing number of COVID-19 cases. If COVID-19 cases are not considered, admissions would have been down “double digits,” said Steve Lefar, executive director of StrataDataScience, a division of Strata Decision Technologies, in an interview with Medscape Medical News.

“Hip and knee replacements, cardiac procedures, and other procedures are significantly down year over year. Infectious disease cases, in contrast, have skyrocketed,” Lefar said. “Many things went way down that hadn’t fully recovered. It’s COVID-19 that really brought the volume back up.”

Observation and emergency department (ED) visits also dropped from already low levels. For the 2 weeks that ended November 28, observation visits were off 8.4%; for the previous month, 10.1%. Compared with 2019, they were down 22.3% and 18.6%, respectively.

ED visits fell 3.7% for the 2-week period, 0.6% for the month. They dropped 21% and 18.7%, respectively, compared with those periods from the previous year.

What these data reflect, Lefar said, is that people have avoided EDs and are staying away from them more than ever because of COVID-19 fears. This behavior could be problematic for people who have concerning symptoms, such as chest pains, that should be evaluated by an ED physician, he noted.

Daily outpatient visits were down 18.4% for the 14-day period and 9.3% for the 30-day period. But, compared with 2019, ambulatory visits increased 5.8% for the 2-week period and 4.7% for the previous month.

Long-term Trends

The outpatient visit data should be viewed in the context of the overall trend since the pandemic began. Strata broke down service lines for the period between March 20 and November 7. The analysis shows that evaluation and management (E/M) encounters, the largest outpatient visit category, fell 58% during this period compared with the same interval in 2019. Visits for diabetes, hypertension, and minor acute infections and injuries were also way down.

Lefar observed that the E/M visit category was only for in-person visits, which many patients have ditched in favor of telehealth encounters. At the same time, he noted, “people are going in less for chronic disease visits. So there’s an interplay between less in-person visits, more telehealth, and maybe people going to other sites that aren’t on the hospital campus. But people are going less [to outpatient clinics].”

In the year-to-year comparison, volume was down substantially in other service lines, including cancer (-9.2%), cardiology (-20%), dermatology (-31%), endocrine (-18.8%), ENT (-42.5%), gastroenterology (-24.3%), nephrology (-15%), obstetrics (-15.6%), orthopedics (-28.2%), and general surgery (-22.2%). Major procedures decreased by 21.8%.

In contrast, the infectious disease category jumped 86% over 2019, and “other infectious and parasitic diseases” — ie, COVID-19 — soared 222%.

There was a much bigger crash in admissions, observation visits, and ED visits last spring than in November, the report shows. “What happened nationally last spring is that everyone shut down,” Lefar explained. “All the electives were canceled. Even cancer surgery was shut down, along with many other procedures. That’s what drove that crash. But the provider community quickly learned that this is going to be a long haul, and we’re going to have to reopen. We’re going to do it safely, but we’re going to make sure people get the necessary care. We can’t put off cancer care or colonoscopies and other screenings that save lives.”

System Starts to Break Down

The current wave of COVID-19, however, is beginning to change the definition of necessary care, he said. “Hospitals are reaching the breaking point between staff exhaustion and hospital capacity reaching its limit. In Texas, hospitals are starting to shut down certain essential non-COVID care. They’re turning away some nonurgent cases — the electives that were starting to come back.”

How about nonurgent COVID cases? Lefar said there’s evidence that some of those patients are also being diverted. “Some experts speculate that the turn-away rate of people with confirmed COVID is starting to go up, and hospitals are sending them home with oxygen or an oxygen meter and saying, ‘If it gets worse, come back.’ They just don’t have the critical care capacity — and that should scare the heck out of everybody.”

Strata doesn’t yet have the data to confirm this, he said, “but it appears that some people are being sent home. This may be partly because providers are better at telling which patients are acute, and there are better things they can send them home with. It’s not necessarily worse care, but we don’t know. But we’re definitely seeing a higher send-home rate of patients showing up with COVID.”

Hospital profit margins are cratering again, because the COVID-19 cases aren’t generating nearly as much profit as the lucrative procedures that, in many cases, have been put off, Lefar said. “Even though CMS is paying 20% more for verified COVID-19 patients, we know that the costs on these patients are much higher than expected, so they’re not making much money on these cases.”

For about a third of hospitals, margins are currently negative, he said. That is about the same percentage as in September. In April, 60% of health systems were losing money, he added. “The CARES Act saved some of them,” he noted.

But right now, Congress is debating a much smaller rescue package that includes only $35 billion for healthcare providers. Even that bill may not pass or even be voted on.

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