key: cord-0721175-ry7zbp3m authors: O’Connor, Casey M.; Anoushiravani, Afshin A.; DiCaprio, Matthew R.; Healy, William L.; Iorio, Richard title: Economic Recovery Following the COVID-19 Pandemic: Resuming Elective Orthopaedic Surgery and Total Joint Arthroplasty date: 2020-04-18 journal: J Arthroplasty DOI: 10.1016/j.arth.2020.04.038 sha: c897eaa413f4a1efc8955949ad880c83adb0253c doc_id: 721175 cord_uid: ry7zbp3m BACKGROUND: The economic effects of the COVID-19 crisis are not like anything the U.S. health care system has ever experienced. METHODS: As we begin to emerge from the peak of the COVID-19 pandemic, we need to plan the sustainable resumption of elective procedures. We must first ensure the safety of our patients and surgical staff. It must be a priority to monitor the availability of supplies for the continued care of patients suffering from COVID-19. As we resume elective orthopedic surgery and total joint arthroplasty, we must begin to reduce expenses by renegotiating vendor contracts, use ambulatory surgery centers and hospital outpatient departments in a safe and effective manner, adhere to strict evidence-based and COVID-19–adjusted practices, and incorporate telemedicine and other technology platforms when feasible for health care systems and orthopedic groups to survive economically. RESULTS: The return to normalcy will be slow and may be different than what we are accustomed to, but we must work together to plan a transition to a more sustainable health care reality which accommodates a COVID-19 world. CONCLUSION: Our goal should be using these lessons to achieve a healthy and successful 2021 fiscal year. care beds. Other healthcare institutions are not under the same volume pressure, but have 25 financial issues due to the moratorium on elective surgical procedures. In an attempt to conserve 26 resources and slow the spread of disease the Centers for Medicare and Medicaid Services 27 (CMS) [9] , the Surgeon General, and The American College of Surgeons (ACS) [10] 28 recommended against elective surgeries. As the allocation of resources became more difficult, 35 29 states placed moratoriums on elective procedures [11] . The moratorium on elective procedures 30 jeopardizes the financial integrity of healthcare systems that are disproportionately reliant on 31 elective procedures as a revenue source. In response, the United States Congress passed the 32 Coronavirus Aid, Relief, and Economic Security Act (CARES), a $2.2 trillion bill with $100 33 billion designated to hospitals and $350 billion designated to small businesses including private 34 orthopaedic practices [12] [13] [14] . Although these relief programs may alleviate some of the 35 economic burden, the legislation is not comprehensive, and it will not resolve all financial losses 36 accrued by healthcare systems and orthopaedic practices. Without the revenue from elective 37 procedures, many orthopaedic practices have had to furlough employees and withhold surgeon 38 salaries [15, 16] . Mayo Clinic has announced a projected $900 million shortfall, with employee 39 pay adjustments and furloughs [17] . 40 41 New York City has dealt with one third of the COVID-19 cases in the United States and has 42 become the epicenter of the US COVID-19 outbreak. However, the number of new 43 hospitalizations in New York has begun to decrease, giving hope that the peak of the pandemic is 44 near. As we reach this critical point, it is crucial that we begin to plan for a return to a more 45 normal healthcare reality. Healthcare and orthopaedic surgery will be an important component of 46 the economic recovery. The healthcare sector in America represents 18% of the United States 47 Gross Domestic Product (GDP) [18] . As orthopaedic surgeons we should help develop 48 sustainable institutional protocols allowing for the safe return of elective surgery and economic 49 profitability to healthcare institutions and orthopaedic practices. Total joint arthroplasty (TJA) 50 represents a large portion of orthopaedic revenue production due to high volume and high 51 margins. As we begin to make this transition, we need to understand that it will not be realistic 52 to conduct the same case volume as we were prior to the COVID-19 outbreak. We should assess 53 patient demand for elective TJA operations following the pandemic. Economic recovery will 54 require a safe and comprehensive approach for the sustainable resumption of elective 55 orthopaedic practice. We must also critically assess the economic impact of the COVID-19 crisis 56 so that we may adjust institutional protocols in a manner enabling an efficient response to future 57 pandemics. During the COVID-19 crisis, TJA has been deemed a non-essential procedure to help conserve 91 resources for COVID-19 patients. Loss of revenue from elective procedures for several months 92 of the fiscal year will guarantee that statements of operations for 2020 will record unfavorable 93 losses. Resuming TJA will be essential for economic recovery in healthcare. Lower extremity 94 TJA is one of the most effective, quality of life improving procedures available to patients [21] . 95 Resuming TJA will also be essential to improve the well-being of our patients, however, it must 96 be done in a safe and sustainable manner. Here we present Six Pillars required for the sustainable 97 resumption of elective TJA ( Figure 1 ). If properly implemented, we anticipate a return to a new 98 normal level of elective TJA by fiscal year 2021. 99 100 I. In order to plan the orthopaedic economic recovery from the COVID-19 pandemic, it will be 102 necessary to understand patient demand for elective TJA operations. Following the Great 103 Recession of 2008, demand for elective surgery was decreased because patients had to work, 104 they could not afford time to schedule hip and knee procedures, and many patients lost health 105 insurance. Following the COVID-19 crisis, patients will have the same economic, employment, 106 and insurance concerns, but patients may also be concerned about the risk of entering a 107 healthcare facility. It is likely that the demand surge we anticipate may be lower than expected. 108 Older patients may be reluctant to undergo procedures while the pandemic simmers and their risk 109 of infection is high. Younger patients may not be able to delay work for long periods of time to 110 recover or may have insurance issues. 111 112 It may be prudent for orthopaedic practices to assess patient demand by asking patients who 113 were cancelled for elective TJA operations if they want to reschedule immediately, cancel, or 114 wait 3 to 6 months. When orthopaedic practices understand demand for elective TJA services, 115 they can plan for efficient utilization of surgical facilities, which will be critical to economic 116 recovery and sustainability. 117 118 II. Medical Optimization in a COVID-19 World with Evidence-Based Practices 119 As we begin to resume elective orthopaedic surgery cases, surgeons may be anxious to return to 120 the operating theatre. It will be imperative that orthopaedic surgeons adhere to evidence-based 121 medical optimization practices, which include local and federal recommendations regarding 122 testing elective TJA patients for COVID-19 exposure or immunity. TJA candidates with 123 substantial risk factors prior to surgery need to be optimized to ensure high-quality outcomes 124 Surgeons may be anxious to return to operating and will want block availability as soon as 132 possible. It is our recommendation that operating room availability be designated by division 133 instead of by surgeon, with urgent procedures prioritized. Hospital systems may want to consider 134 shifting elective orthopaedic surgery procedures to non-COVID or COVID-light facilities for 135 patient comfort, safety and peace of mind. Operating room staff will also need to be tested and 136 protected to provide a safe environment for the patients. 137 138 III. Early Discharge and Outpatient Total Joint Arthroplasty 139 As orthopaedic surgeons restart their elective practices we anticipate an increase in early 140 discharge and outpatient TJA. The psychological barriers (e.g. pain and ambulation) preventing 141 eligible TJA candidates from considering early discharge and outpatient TJA will likely be less 142 relevant as patients attempt to distance themselves from exposure to COVID-19. It will be the 143 orthopaedic surgeon's responsibility to ensure that strict patient selection and screening be 144 performed prior to surgery at hospital outpatient departments (HOPD) and ambulatory surgery 145 centers (ASC). Patients not meeting the selection criteria for early discharge can instead be 146 enrolled in rapid recovery programs at a regional hospital with minimal COVID-19 exposure. 147 Adherence to strict patient selection protocols will allow high quality clinical outcomes, while The economic effects of the COVID-19 crisis are not like anything the United States healthcare 225 system has ever experienced. As we begin to emerge from the peak of the COVID-19 pandemic, 226 we need to plan the sustainable resumption of elective procedures. We must first ensure the 227 safety of our patients and surgical staff. It must be a priority to monitor the availability of 228 supplies for the continued care of patients suffering from COVID-19. As we resume elective 229 orthopaedic surgery and TJA, we must begin to reduce expenses by renegotiating vendor 230 contracts, use ASCs and HOPD's in a safe and effective manner, adhere to strict evidence-based 231 and COVID-19 adjusted practices, and incorporate telemedicine and other technology platforms 232 when feasible in order for healthcare systems and orthopaedic groups to survive economically. 233 The return to normalcy will be slow and may be different than what we are accustomed to, but 234 we must work together to plan a transition to a more sustainable healthcare reality which 235 accommodates a COVID-19 world. Our goal should be employing these lessons to achieve a 236 Table 1 . The projected 25% reduction in overhead costs can be achieved with the implementation of Pillar V, via the renegotiation for essential disposables (e.g. implants), office space, and imaging equipment, while temporarily eliminating non-essentials (e.g. robotics, navigation systems, custom implants, radiofrequency sealant devices). How Does the 2020 Stock Market Crash Compare With Others World Health Organization. WHO Director-General ' s remarks at the media briefing on How the current stock market collapse compares with others in history. 256 USA Today Newsom Orders All Californians to Stay Home About 95% of Americans have been ordered to stay at home. This map 262 shows which cities and states are under lockdown Fed's Bullard says US economy not in 'free fall' despite 32% 266 unemployment projection US weekly jobless claims double to 6.6 million Great Recession, great recovery? Trends from the Current Population 272 Survey CMS adult elective surgery and procedures 274 recommendations: limit all non-essential planned surgeries and procedures COVID-19: Guidance for Triage of Non-Emergent Surgical 278 Procedures. Am Coll Surg 2020 Association ASC. State Guidance on Elective Surgeries Congress 116th. S.3548 -CARES Act 2020 Small Business Guidance & Loan 286 Resources 2020 Crisis An Orthopaedic Perspective Rothman surgeons drop pay to avoid employee layoffs, shift to telemedicine: 4 292 details New England Orthopedic Surgeons furloughs half its workforce Mayo Clinic projects $900M shortfall, implements cost-cutting measures National Health Expenditure Data Impact of the 306 economic downturn on adult reconstruction surgery. A survey of the american association 307 of hip and knee surgeons Infographic: How the Recession Hurt Hospitals' Inpatient Margins Quality-Adjusted Life Years After Hip The Joint 316 Utilization Management Program-Implementation of a Bundle Payment Model and 317 Comparison Between Year 1 and 2 Results Outpatient Total Joint Arthroplasty Orthopedic Surgery Post COVID-19: An 322 Opportunity for Innovation and Transformation GlobalMed Simplifies Telehealth Costs for Clinicians with its New Cost Simplified 325 Solution Variation in the Cost of Care for Different Types of Joint Arthroplasty Determining the True Cost to 332 Deliver Total Hip and Knee Arthroplasty Over the Full Cycle of Care: Preparing for 333 Bundling and Reference-Based Pricing 336 Patterns of costs and spending among orthopedic surgeons across the United States: a 337 national survey February Projected Gross Profit with Fixed and Adjusted Overhead Fixed Overhead Gross Profit Adjusted Overhead Gross Profit