Status of ASC operations, staff of concern during COVID-19 pandemic

During this time of significant concern regarding transmission of the novel coronavirus and a recent warning from South Korea regarding the possibility of the virus recurring in patients with minimal COVID-19 symptoms who tested positive, it is difficult to navigate issues related to ASC management, staffing and surgical caseload. In this Healio Orthopedics Round Table, orthopedic surgeons discuss the dilemmas they face concerning ownership and overseeing their ASC facilities and how they are coping with current restrictions.

- Jack M. Bert, MD

Moderator

Jack M. Bert, MD: Has your ASC stayed open thus far during the COVID-19 pandemic? If so, what types of cases are you doing? Why?

Richard K.N. Ryu, MD: We have remained open and are handling emergent and urgent cases. We have generated a list of indications to include tendon ruptures, fractures, unstable osteochondral fragments, locked knees with or without ACL injuries, etc. We fully understand that orthopedic injuries requiring prompt intervention will continue in our community and we are prepared to provide the best level of care possible given the circumstances.

We are very conscious of our responsibility to the local community to avoid any spread of the COVID-19 virus and have taken extraordinary precautions to protect our patients, staff and physicians. We have also offered our facility to the local hospital as a non-COVID overflow option, if needed.

We have created a four-person committee that decides whether or not a submitted case can be considered urgent or emergent. The committee has the final say on whether the procedure can take place in the center.

James W. Stone, MD, FAAOS: I will address the perspective of the physician-owned hospital rather than the surgery center.

Our orthopedic hospital has stayed open during the COVID-19 pandemic. However, on March 19, all elective surgeries were suspended and only emergency and approved urgent cases have been allowed. Our facility is a “hospital within a hospital,” occupying one floor of a five-floor building which houses an inpatient med/surg unit along with an ICU and emergency room facilities. The ortho hospital has 16 inpatient beds (including two negative pressure rooms), six operating rooms and two procedure rooms. The caseload has been very low. Obviously, emergent cases, such as fractures, can be scheduled. Urgent cases must be approved by the chief of staff of the hospital.

Louis F. McIntyre, MD: Our ASC is closed and we are not doing any elective cases. This is a system-wide directive to devote as many resources as possible to treating pandemic infection cases. Hospitals are doing only emergent cases: fractures, infections and spine with neuro deficit.

Eric M. Stiefel, MD: On March 18, the local hospital made the decision to stop preforming elective surgery. Our ASC followed suit. We have remained partially open, but have limited the surgical days to twice a week. The type of cases we are doing include basic fracture care and acute injury (ACL, distal biceps rupture, etc.).

In the ASC setting, it can be challenging to differentiate between non-urgent and elective procedures. One of the major factors we are considering is whether or not delay in treatment may adversely affect the long-term outcome or complicate the surgical procedure. We also look at the individual’s risk factors and are careful to consider the patient’s desire to proceed or delay surgery, with special consideration to the ongoing COVID crisis.

The decision to proceed with surgery is still, very much, a shared decision-making process. I spend a great deal of time discussing the impact that surgical timing has on outcomes. This way patients can make a decision that is best for them. Since canceling elective procedures, the ASC’s case volume has decreased by more than 60%, but we are still performing necessary surgeries. I think we’re doing our part to protect patients and conserve personal protective equipment (PPE) without compromising care for the individual.

 

Bert: How many of your ASC staff are furloughed at this time? What percent of your overall staff is that? 

Ryu: We have six staff that we are paying a minimum of 25 hours per week. So, they are partially furloughed in the weeks we cannot support them for more hours. We fully furloughed about another six to eight individuals, but not all those are full-time. A good estimate is we furloughed more than half of our staff.

Stone: At this point, we have not furloughed any staff. The hospital is part owned by physicians and part owned by a large health care system. The staff are leased from the health care system and, as such, can be made available for work in other parts of the hospital. Staff is in the process of either being cross-trained to fulfill needed services in the main hospital or already working in other areas. In addition, we have opened our inpatient beds to non-COVID patients as necessary for overflow as we approach an anticipated surge of patients during the next couple of weeks. Our local community has not seen the very rapid community spread as in places like New York City, with our case-doubling times in the metro area at approximately 6 to 8 days. In the worst case scenario, our ORs could also be utilized as intensive care rooms.

McIntyre: None of our staff are furloughed, but many of them have been reassigned to other positions in which they are dealing with the pandemic.

Stiefel: All our staff remains employed, but we have had to cut hours in response to decreased surgical cases. We have also decreased the pay for salaried employees. We will be closely monitoring our volume and collections and are expecting to see our case numbers rebound in the coming weeks, especially given our growing backlog of elective procedures.

 

Bert: Are your furloughed staff being paid by you, the ASC owners or your health care system, or are they receiving unemployment benefits or is there another scheme for their compensation?

Ryu: We are paying the health benefits of the furloughed and they are getting unemployment at the higher rate for 4 months (ie, with the stimulus addition, it is about $1,000 per week for many of them).

Stiefel: Since this crisis began, all our staff is still employed by our company, but we have decreased hours and cut salaries. Our human resources department is helping those eligible to apply for unemployment benefits; however, some of our workers are not eligible given the state’s income restrictions.

I am hopeful the Small Business Administration (SBA) loan program will allow us to increase payroll over the short term (about 8 weeks). If we do not see the expected rebound in the next few months, the next step is to apply for an advance through the Medicare Accelerated and Advance Payment Program. Based on our projections, these two programs could help to maintain cashflow and avoid layoffs for a 4-month time period. By then, I would expect to see a strong recovery.

 

Bert: Have you or will you be applying for governmental financial relief for employee wage loss at each of your centers?

Ryu: Yes, we applied for the Paycheck Protection Plan SBA loan through a local lending institution. This loan will be forgiven if we can staff back-up using that money. We are hopeful that case volume in May will justify this, so we can get the full forgiveness. That said, the SBA has not given great direction on the forgiveness calculation, so we are a bit in a holding pattern on decision-making as that information rolls out.

Stone: With our leased employee arrangement, we are probably not able to apply for the Paycheck Protection Program loan. However, as anyone has seen as the Paycheck Protection Program process evolved over recent weeks, rules are frequently being clarified and if it becomes clear that we are able to do so, we will. The more our employees can be redeployed to work in other parts of the system, the less urgent is the need to cover payroll to the remaining staff who must be available for surgery and inpatient needs.

McIntyre: We have a large system with 61,000 employees. It is too large to be eligible for the Paycheck Protection Program. We do not know if we are doing the Medicare Accelerated and Advance Payment Program.

Stiefel: We submitted our application for the Paycheck Protection Program SBA-sponsored loan on April 3. Our loan is currently under consideration. We plan to use this money to increase payroll while our surgical volume recovers.

 

Bert: What are the essential factors that will determine when you will reopen any closed ASCs?

Ryu: We will follow the recommendations of federal, state and local government, as well those espoused by the various governing specialty societies, eg, anesthesia. When we return to a full schedule will depend primarily on the conditions in our community and any potential risk to the greater good.

Stone: We anticipate returning to an elective surgery schedule when our federal and state governments lift any “shelter-in-place” orders, and then, only when the burden of COVID-19 patients will clearly be on the significant downswing. We anticipate the ramp up will be slow and may be limited by the amount of COVID-19 testing that is available at that time, the availability of adequate personal protective equipment including N95 masks, which may be required for surgical procedures, and by other inefficiencies which may be required by continued personal distancing and other changes, such as whether terminal cleaning may be required between all cases.

McIntyre: We will reopen when directed to by our health care system. Most likely, this will be some time in mid-May, but it is a moving target.

Stiefel: The plan is to stay in-step with our local hospital and follow the recommendations from appropriate state and local agencies. We plan to stay partially open and are prepared to ramp-up as demand increases. Now, more than ever, surgery centers can play an important role, by offering patients an option for surgical care outside of the hospital setting.

For more information:

Jack M. Bert, MD, can be reached at Minnesota Bone & Joint Specialists Ltd., 2025 Woodlane Dr., Woodbury, MN 55129; email: bertx0001@gmail.com.

Louis F. McIntyre, MD, can be reached at Northwell Health Phelps Hospital, 755 N. Broadway, Suite 530, Sleepy Hollow, NY 10591; email: lfm@woapc.com.

Richard K.N. Ryu, MD, can be reached at The Ryu Hurwitz Orthopedic Clinic, 2936 De La Vina St., Santa Barbara, CA 93105; email: rknrmd@gmail.com.

Eric M. Stiefel, MD, can be reached at South Georgia Medical Center, 250 N. Patterson St., Valdosta, GA 31602; email: eric.stiefelmd@yahoo.com.

James W. Stone, MD, FAAOS, can be reached at Aurora Advanced Healthcare, 2901 W. Kinnickinnic River Pkwy., Suite 102, Milwaukee, WI 53215; email: jamesstonemd@gmail.com.

 

Disclosures: McIntyre reports he is chief quality officer for United States Orthopedic Partners. Ryu reports he is a paid consultant for MedBridge, which builds and manages outpatient surgery centers. Stiefel reports he is the owner of an ASC. Stone reports he is a physician owner of the Midwest Orthopedic Specialty Hospital and serves on the hospital’s board of directors. Bert reports no relevant financial disclosures.