As the nation moves towards recovery and reopening, one emerging reality in the aftermath of the coronavirus outbreak is that the American health care system will see its own new normal in the coming weeks and months, according to experts and doctors.
Strapped for cash and some protective equipment, and forced to re-write protocols to better fortify against the contagious spread of COVID-19, doctors’ offices and hospitals across the country are beginning to rethink their approach to personal care -- from an increase in telemedicine and widespread coronavirus testing for patients, to the complex math about which procedures should go ahead and how.
“This is an opportunity to ask, what do we really need to do and what do we need to not do,” Robert McLean, former president of the American College of Physicians, told ABC News. The pandemic “has gotten us back to doctoring. We need to take advantage of that and critically look at the utilization of lot of things we have done.”
While virus patients flooded into some hospitals, elective and other non-emergency surgeries came grinding to a halt, causing drastic financial strain on facilities big and small. Now, as with the rest of the country, doctors have cautiously started to resume those procedures.
As of this report, at least 30 states have reportedly relaxed mitigation strategies related to surgery, and it appears more are on their way.
University of Michigan Health System has reopened its elective surgeries, but officials there said they are unsure how long it will take for the hospital to be ready for the old pace of activity.
Dr. Andrew Ibrahim, a general surgeon at University of Michigan, said physicians there are weighing the benefits of each surgical procedure against the risk of COVID-19 and the resources available. The resumption of procedures so far has been gradual.
“We've brought back surgery slowly based on their time-sensitivity in line with [Michigan] Gov. [Gretchen] Whitmer's orders,” he said.
Ibrahim said the hospital created a central committee to prioritize which cases need more urgent attention, relying on specialists to help triage the cases.
In Nebraska and Kentucky, hospital administrators and physicians like Dr. Prakash Pandalai, a surgeon at University of Kentucky, said they started by prioritizing cancer operations, surgeries needed to prevent loss of a limb, and procedures needed to prevent further acceleration of disease.
"But we need to be careful about ensuring that there is enough protective equipment for providers and patients as we come back online, Pandalai said.
'Watching PPE supplies and flow very carefully'
As Pandalai indicated, beyond the urgency of the procedures for patients, one limiting factor is the supply of personal protective equipment, better known as PPE, that became such a focal point as the coronavirus spread.
PPE is not necessarily the same for various surgeries as it would be to treat COVID-19 patients, but there is enough of an overlap in basic protective equipment that health care officials told ABC News they're taking careful note when considering the amount of PPE that would be expended for a particular operation and how much PPE they might need if a resurgence of COVID-19 strikes.
Jeffrey Tieman, President and Chief Executive Officer at the Vermont Association of Hospitals and Health Systems, said that if hospitals "don't feel confidant in PPE supply, you need to think about whether you can continue to offer those elective procedures."
Dr. Kat McGraw, physician and chief medical officer at Brattleboro Memorial Hospital in Vermont, said that since the state has allowed outpatient surgeries to resume, the hospital has been "tasked with that responsibility of being able to self supply surge PPE if we want to be able to go forward with elective procedures."
McGraw said the hospital has developed its own stockpile of PPE for an emergency, which she compared to a blood bank.
"We have been purchasing not through our usual streams, but trying to find creative ways to get augmented amount of PPE, but thats not necessarily sustainable," she said. "The trick to moving forward with surgery is making sure it doesn't impeded with our ability to have everything in place for our ability to manage a surge for COVID-19."
Dr. Brandon Mauldin, the Chief Medical Officers of the Tulane Health System in Louisiana, referred to this dilemma as a "balancing act."
"Because we have initiated and started back on elective surgeries as [COVID-19] patients have declined, the balancing of it is a lot easier to do," Mauldin told ABC News. "So we feel more comfortable that we have sufficient PPE."
Others are not as confident. Dr. Sharmila Makhija, chair of OBYGN at Montefiore Medical Center in the Bronx, said she and other colleagues "across the country" are "worried about whether we have enough personal protective equipment to do elective surgeries."
Somewhere in the middle is Providence Health, which serves urban and rural communities from Alaska to Southern California. The chief value officer there, Dr. Joanne Roberts, told ABC News they are "watching PPE supplies and flow very carefully as we resume non-emergent procedures."
Remote screenings and coronavirus tests as pre-op
One strategy to save on PPE, as well as improve general safety amid the coronavirus spread, is the increasing use of telemedicine -- what one doctor said may become a pre-operation "new normal."
Dr. Aleaf Worku, at CareMore Health, said it will be more likely that patient assessment -- the initial practice of seeing what kind of care a patient needs -- could be done remotely, sparing the patient a visit to the hospital and sparing medical professionals from coming in physical contact with the patient.
“This is why telemedicine may be the way we do pre-op screening in the new normal,” Aleaf said.
Another potential new normal for pre-op? COVID-19 testing.
That's the strategy McGraw said her Virginia hospital has adopted. Patients coming in for surgery are tested 72 to 96 hours in advance of the procedure and are required to self-isolate during that time.
She said patients should think of this as part of the new standard "pre-op" steps that so many have come to know before going in for any sort of procedure, which often include precautions such as refraining from eating or drinking for 12 hours.
"Now, everybody needs their [coronavirus] test," McGraw said.
Doctors at hospitals in California, Texas, and Louisiana said they are doing universal testing for patients scheduled for surgeries.
The testing "gives reassurance to both patients and providers, even beyond just doctors nurses, that we are doing all we can to create a COVID-safe environment," said Dr. Loren Robinson, who practices at Christus Health in Texas.
But protocols are not the same, even within the states. Dr. Quyen Chu at Oschner LSU Health in Shreveport, La., said the hospital is doing universal testing for patients undergoing elective procedures, but Mauldin at Tulane said his hospital system in Louisiana hasn't quite gone that far.
Patients and doctors there are working together to determine if testing is necessary on a case by case bases, Mauldin said. The hospital has taken other precautions, including universal masking and staggered patient appointments.
As hospitals feel financial pinch, COVID-19 sparks larger questions
Beyond the staggering human suffering, another casualty of the coronavirus' spread is the financial stability of hospitals and other health care facilities at a time when many are needed most.
Some hospitals are in dire trouble, despite billions of financial support to the industry from the federal government.
“One sad reality is that smaller or stand-alone hospitals may have lost too much revenue the last two months to remain viable,” said Ibrahim.
Physicians interviewed by ABC News predicted a wave of hospital closures could strike this summer.
"How is it possible for hospitals to be so vital at the same time they're so vulnerable and what is the solution in the new normal?" asked Deb Gordon, a consumer health advocate.
For those that survive, like many belonging to larger systems that have multiple hospital locations, health care officials said COVID-19 may be the catalyst for asking and answering bigger, long-term questions related to what's called value-based care, a philosophy that seeks to change how much is spent on health care as a nation and improve outcomes. The approach prioritizes keeping people healthy rather than having to deliver and pay for avoidable and unnecessary care that is inefficient and may not improve health.
For example, in the aftermath of the coronavirus, health systems may be more willing to reorganize care so it meets patients where they are at in their health journey and keep them safer, such as ambulatory surgery centers and improved care at home.
While the moves can also make sense from a financial perspective, experts warned they will need to be balanced against potential safety concerns.
Value-based care also prioritizes chronic disease management, a significant issue that has been exposed during the pandemic. Those with chronic diseases are more likely to have worse outcomes if they contract the coronavirus.
Telemedicine and remote patient monitoring could allow for better management of chronic diseases earlier and prevent patients from showing up in a healthcare setting that can potentially expose them to the virus.
"It is a fascinating time. The opportunities are huge," Providence Health's Roberts said.
But for all the changes hospitals could make, much is going to depend on whether patients feel comfortable enough to come in at all. ABC News has reported that people are foregoing in-person consultations of even potentially serious conditions for fear of COVID-19.
"We did just complete a patient sample survey of 12,000 volunteers, and the biggest barrier does seem to be their fear of getting COVID in our facilities. Only 18% say they feel safe going back to clinics, [emergency rooms], or hospitals," Roberts told ABC News.
With the new safety measures, hospitals and doctors across the country hope to change that.
Jay Bhatt, a practicing internist and Aspen Health Innovators Fellow, is an ABC News contributor.