Game Planning Your Return to Elective Surgeries

By Victor Collymore, MD, FACP

The recent moratorium on elective surgeries due to the COVID-19 pandemic has been brutal on hospitals, providers, and provider organizations—especially since those surgeries are often the bread and butter of provider revenue.

According to the Medical Group Management Association, 97% of medical group practices have experienced a negative financial impact directly or indirectly related to COVID-19. On average, these practices report a 55% decrease in revenue and a 60% decrease in patient volume since the start of the COVID-19 public health emergency. Additionally, the American Hospital Association estimates that between March 1 and June 30, 2020, U.S. hospitals and health systems experienced $202.6 billion in losses, or an average loss of $50.7 billion per month for each of those four months.

Now that surgery restrictions are being lifted in some areas of the country, providers face a new dilemma—how to restart what was once a well-oiled machine. The operational requirements alone will be challenging. Restarting surgeries will not be like flipping a switch—especially with COVID-19 risks still lurking.

Since there is such a backlog of patients who are candidates for elective surgery, another major challenge will be determining which patients to target first. One logical place to start is where patient need is greatest or most urgent—those at the highest risk of an adverse event or a precipitous deterioration in their condition if surgery is delayed. This prioritization makes sense in situations where patients are in great pain (especially if they are unable to work), or where providers have a significant percentage of their revenue tied to long-term, value-based payments.

Identify the right patients

Yet, this may not be the right strategy for every provider or health system. For example, some providers may prefer to ease back into elective surgeries with simple, low-risk/high-volume procedures that can help them generate revenue quickly as they rebuild a rhythm in the operating room. Others may want to break traditional geographic barriers and direct some patients to their hospitals or clinics in neighboring counties to reduce costs, spread the workload, or take advantage of a concentration of a particular type of expertise, especially early in the process.

Whatever strategy they land on, providers will then need to identify the patients who fit the target profile and are likely to agree to surgery. Providers should also calculate the estimated savings that will come by solving patients’ core issues through surgery rather than prolonging the current course of treatment to determine whether surgery is financially beneficial to all parties. This is where providers can benefit from advanced predictive and prescriptive analytics.

A good starting point is to obtain publicly available data showing the impact of COVID-19 by county. Those counties that have the highest prevalence of the virus as well as the highest fatality rates are also the ones most likely to have the largest backlogs of elective surgeries. Digging down further, the analytics can show which surgeries traditionally have the highest volumes in those counties and compare the 2020 rate to the 2019 historic rate to determine if there has been a significant decline year-over-year. If so, the provider can focus on those surgeries that fit its preferred profile and offer enough volume to deliver a sufficient boost in revenue.

Once the most appropriate surgeries are identified, providers can use the analytics to identify specific patients to target for outreach. Patients can then be prioritized based on risk scores that include variables such as age and gender, preexisting conditions, and recently administered treatments/procedures. When compiling the patient list, social determinants of health as well as demographic and psychographic data should be factored in to help predict the patients who will be most receptive to surgery and engaged in their own recovery. Those with the highest scores should rise to the top of the list.

Analyze data to set surgery schedules  

The next step is to begin planning and scheduling the surgeries. While patient proximity to the facility is a natural parameter to take into account, it is not the only factor that should be considered while planning, especially as the pandemic continues to ebb and flow. Data on the availability of surgeons and beds, ratio of patients to surgeons, and the particular surgery’s success rate and cost to perform (both facility and individual surgeon costs) should also be included in the analytics.

The surgeons should also have input on which patients should be prioritized based on patients’ needs and desires to have the surgery. They should have the opportunity to review the preliminary list and make recommendations on who should be contacted first.

Once the list of recommendations is finalized, surgical managers (physicians and nurses) can then go through it to ensure the load is balanced, enabling much higher throughput (and better patient service) than would be possible when making decisions based on geography alone.

With this information in hand, providers can begin the final step—outreach to patients to set the actual schedule. As patients agree to their surgeries, outreach programs should deliver preparation and educational materials to ensure there are no delays. For example, if a patient needs to lose 20 pounds or bring her diabetes under control before back surgery can be performed, it is important that care managers work with that patient to ensure these critical requirements are met. Otherwise, the surgery must be delayed, all that careful planning is wasted, and the provider does not accrue the revenue that elective surgery would have brought in—at which point everyone loses, including the patient.

The loss of elective surgeries due to COVID-19 has resulted in significant revenue decreases for practices, hospitals, and health systems in 2020. While the ability to perform those surgeries has now been restored in most states, there is still a risk that they could be paused or reduced again, as has already happened in Texas and Florida. The result is an urgency to get elective surgeries up and running as quickly and efficiently as possible. Predictive and prescriptive analytics can help healthcare organizations identify the areas and patients where the need and revenue opportunity are greatest and help them put together a plan to recover at least some, if not all, of that lost revenue.

Victor Collymore is vice president and chief medical officer at EXL Service, a multinational company. There he oversees utilization management, coordinates disease and care management, and liaisons with pharmacy, sales and marketing, data and predictive modeling departments, and life sciences.