Trinity Health Michigan, Henry Ford Health System and Beaumont Health in southeast Michigan are a few of the healthcare organizations that have begun to perform more of the surgeries and other procedures they delayed the past six weeks because of the COVID-19 crisis.
While Gov. Gretchen Whitmer didn't lift any of the earlier restrictions she placed on nonessential surgeries and procedures, she urged residents on Friday to start scheduling them.
"We are encouraging anyone who has been holding off on surgery that really needs to be done to get that scheduled and to proceed," Whitmer said Friday at a news conference.
The governor's March 21 order halting elective procedures came at a time when southeast Michigan hospitals were bracing for a surge in COVID-19 patients and a dwindling supply of N95 masks, gloves, shields and other personal protective equipment for nurses and doctors.
"Now we've been able to build up enough that we can proceed with these other procedures and we're encouraging hospital systems to move forward with that," said Whitmer, who later added that oncology and knee surgeries "should be scheduled."
Whitmer's executive order prohibited cosmetic, bariatric and total joint replacement surgeries, and other "nonessential" procedures.
But the order was vague, healthcare attorneys and administrators say, and allowed doctors to decide to proceed if postponing surgeries or procedures would jeopardize patient health or worsen a condition.
Rob Casalou, CEO of Trinity Health Michigan, said the eight-hospital system restricted more healthcare services than Whitmer's order called for because there was a shortage of personal protective equipment such as special masks and gowns.
"We didn't do as much as we could have (the past month). We scaled back further because of PPE," Casalou said. "We are getting ready to open up. We will slowly ramp up, little this week, more next week. We need to do surgeries that need to get done."
Casalou said Trinity doctors will conduct more general surgery for cancer patients, open heart surgeries and cardiac procedures such as valve replacements and interventional cardiology services.
Over the past week, Casalou said Trinity doctors have been contacting patients who were scheduled and postponed. However, only about 10% of patients contacted have agreed to come in, he said.
"They are afraid of coming in because of the virus. We have a huge consumer confidence problem," Casalou said. "We are ready for them and it is safe. We have COVID-19 areas and non-COVID-19 areas" to keep patients separated.
That consumer confidence issue was evident this week in Detroit's hospitals, which had more than 800 vacant adult hospital beds, Mayor Mike Duggan said Friday.
Duggan this week began publicly calling for Whitmer to loosen restrictions on healthcare systems.
"The hospital beds in this city continue to be empty at a rate I've never seen in my life," Duggan said Friday at a news conference. "The healthcare systems have got to respond. … Our hospitals know exactly how to care for people while separating the infectious from the non-infectious."
Duggan, former CEO of the Detroit Medical Center, acknowledged hospitals were overrun for about a month, but said the situation has calmed.
"I'm hoping next week we really start to see some messaging coming out of our healthcare systems," he said.
Over the past two weeks, Dr. Adnan Munkarah, Henry Ford's chief clinical officer, said the system's doctors also have been calling back patients who had surgeries or procedures postponed.
But about 20%-40 % of patients, depending on where they live, have asked to wait another two weeks before coming in for their postponed procedure, Munkarah said.
"They want more of a comfort zone. They are asking, 'Am I OK to come into the hospital?' " Munkarah said. "We continue to take care of non-COVID patients. We've been doing it all along. We have to educate them" that it is safe to come to hospitals.
Munkarah said his greatest fear is that people with moderate yet treatable conditions are staying at home and allowing their conditions to become worse.
"We are seeing patients virtually (with online telemedicine consultations) and we are identifying problems," Munkarah said. "The numbers of patients wanting to come in are getting higher the past few day as people hear news (the COVID-19 case load and deaths are) slowing down, and things are getting better."
Munkarah said Henry Ford has been conducting surgeries and procedures such as breast cancer treatment that either can be conducted on an outpatient basis or only require overnight stays.
"We are doing more cancer surgeries or kidney blockages or obstructions where (someone) would lose kidney," he said. "We have a handful spine surgery cases where there are neurological symptoms."
Despite the postponements, Munkarah said he hasn't heard any anecdotes that delays have resulted in poorer outcomes for patients.
"The public believes all elective surgeries (have been halted)," he said. "The reality is urgent, emergent procedures have continued to be conducted. The numbers were smaller. But they have continued to be safely done in the hospital."
At Beaumont, spokesman Mark Geary said in an email that the health system is working within Whitmer's order and allowing physicians to offer "time-sensitive medical services and care to patients with non-COVID-19 related medical conditions."
Beaumont also launched a website to help educate patients about what kinds of safe care is available:
"If your surgery, medical procedure or exam was delayed due to COVID-19, contact your doctor to reschedule," according to Beaumont's website. "Appointments are available now. Your surgery could be rescheduled sooner than you might expect."
Detroit Medical Center spokesman Brian Taylor said in an email that the health system continues to abide by Whitmer's directives, including limits on nonessential procedures.
"We recognize that patients continue to require medical attention for conditions other than those due to COVID-19. We trust the clinical judgment of our medical staff, and we offer all medically necessary, time-sensitive procedures to meet the needs of our patients," he wrote.
"If a patient needs a procedure or surgery which their physician believes would risk their health or safety to delay, our hospitals are safe for this care. This includes our emergency departments, imaging departments, cardiac labs and operating rooms."
Michigan Medicine spokesperson Mary Masson said Ann Arbor-based University Hospitals has been doing essential cancer surgeries throughout the pandemic.
"We've been able to gently increase our surgery volumes for time-sensitive procedures, even now, for patients for whom further delay would create harm," Masson said in an email to Crain's late Friday.
"We're in the active planning stages of expanding the surgeries and procedures we can provide to those patients who are at greatest risk for the progression of their disease," Masson said.
"As always, we would protect our patients from any infectious disease with careful procedures that are always in place," she said. "Throughout this pandemic, safety has been a top priority and we have taken many steps to minimize the spread of disease."
When should Whitmer reopen nonessential services? Casalou and Munkarah said their health systems would be ready to further expand nonessential surgeries and procedures between May 8 and 15.
Munkarah said he consults regularly with other chief clinical officers at hospitals across the state. "We recently discussed when we can get back to doing more of these services (that were restricted)," he said.
"Over the next two weeks, if we continue to see a decline in COVID cases, we may be able to do total joint replacements cases."
Casalou said he didn't expect Whitmer to rescind or issue new nonessential surgery instructions until May 15, when her stay-at-home order expires.
"We are going to honor the order. None of us should be saying, 'Hey, come back,' but there is wiggle room (in the order). If it is in the patient's best interest for health, we will do the surgery, the procedure," Casalou said.
To reopen May 15, Casalou said Whitmer needs to hear two things from hospitals: Do they have adequate supplies of PPE? And do they have enough bed and staff capacity to handle a second possible surge of COVID-19 in the fall?
"I can only speak for Trinity and we are prepared for that. The answer is 'yes,' we believe we have enough starting next week," Casalou said.
Right now, however, Casalou and Munkarah said there is a tremendous shortage of disposable gowns. Other PPE, including masks, gloves and face shields, appear to be in sufficient supply, they said.
"The disposable gowns are made in Wuhan (China) right now," Casalou said. "We are manufacturing reusable gowns (in Michigan and elsewhere). We should have enough in a week or so."
On staffing, Casalou and Munkarah said doctors, nurses and others working in intensive-care units caring for COVID-19 patients will be redeployed back to their original service or outpatient areas as the numbers of inpatients has declined the past two weeks.
"We've done 1,500 video visits per day and doctors are bringing patients in for testing and emergent surgeries" as symptoms warrant, Casalou said.
JJ Hodshire, chief operating officer at Hillsdale (Mich.) Hospital, sent a letter this week to Whitmer, asking her to lift restrictions on many elective procedures, including orthopedic and bariatric surgeries, at the 47-bed hospital.
"We are following the letter of the order" to halt nonessential surgeries and "we are down 37% in net revenue" comparing April 2019 with April 2020, Hodshire said. "We are projecting a $10 million loss. … Our orthopedic practice is tremendous portion of revenue generation. We are putting our hospital at risk" by halting these surgeries.
Hodshire said Whitmer should consider reopening elective surgeries based on geography and whether COVID-19 cases are low and not increasing.
"The purpose of my letter was to ask the governor as you are making these decisions, the environment is different in Hillsdale than for Detroit," Hodshire said, adding that the upward trend of cases in Hillsdale County has been declining since April 3.
"There has been 118 positives in the county and 14 deaths, but well over 50% of the cases and 65% of the cases came from one nursing home," Hodshire said.
Beaumont, which was hit the hardest of any health system in terms of total cases and deaths and has arguably experienced the greatest revenue loss, created a new website solely intended to allay patients' fears about returning to its hospitals.
"Surgical patients will be screened for symptoms via phone prior to surgery. If admission is required, non-COVID-19 patients will be admitted to a room on a unit away from COVID-19 patients," Beaumont said.
Beaumont also answered the question of safety that is on most patients' minds.
"You are safe coming to Beaumont for care. Beaumont is still the safe and clean health system with the same compassionate people and high-quality services and care you have always relied upon," according to Beaumont.
Like other hospitals that treated high numbers of COVID-19 patients, Beaumont said "our doctors and caregivers have created a safe and secure environment where COVID-19 patients are treated in separate areas and great care is taken to prevent the spread of infection."
Beaumont also issued advice that many doctors have tried to pass along to their patients.
"We are highly trained in how to protect our patients, families and each other when caring for patients. Don't delay your medical needs or ignore symptoms that you would typically visit an emergency center or call your doctor about. As always, early detection and treatment improves our ability to provide the most comprehensive and effective care for you."
Crain's Detroit Business Reporter Annalise Frank and Senior Editor Chad Livengood contributed to this report.
This article first appeared in Crain's Detroit Business.