A silver lining to COVID-19: Fewer low-value elective procedures

By Judith Garber | April 20, 2020

Most U.S. hospitals have halted elective surgeries as they treat (or prepare to treat) the surge of COVID-19 patients who require intensive care. Despite reluctance on the part of some hospitals, it is clear that pausing elective surgeries is a good move for preventing the spread of the virus and freeing up space and protective equipment for treating incoming COVID-19 patients.

It’s also a good idea for another reason: many of these elective procedures were never needed in the first place, and they expose patients to unnecessary harm. In a recent article in The Conversation, University of Sydney Professor Adam Elshaug and director of the Grattan Institute health program Steven Duckett pointed out that COVID-19 could be an opportunity to significantly reduce low-value care.

Low-value care, also known as overuse, refers to medical services for which the harms outweigh the benefits for patients. Not all elective surgeries are low-value, nor are all low-value services elective. However, many elective procedures–such as spinal fusion, vertebroplasty for osteoperosis, knee arthroscopy for osetoarthritis, stents for stable heart disease, just to name a few–have proven to be no more effective than a placebo. Even more procedures reside in a gray area in which little is known about the true benefit to patients, because not enough research has been done.

Low-value procedures are not only ineffective, they expose patients to the risk of hospital-acquired complications. In a 2019 study in JAMA Internal Medicine, out of 9000 patients who received a low-value procedure in the hospital, 1.5% had a hospital-acquired complication. Seven percent of patients who underwent spinal fusion, carotid endarterectomy, or renal artery stents had a complication.

Why have hospitals continued to perform low-value elective procedures? “For most hospitals, elective surgery is where the money is,” said Shannon Brownlee, Senior Vice President of the Lown Institute. Most hospitals are paid fee-for-service, and elective surgeries are typically high-margin procedures that drive much of hospital revenue.

“For most hospitals, elective surgery is where the money is.”
Shannon Brownlee

In our health care system that rewards doing more (and more complex procedures), hospitals have to perform elective surgeries to survive financially. Now that hospitals cannot perform elective procedures, many are hemorrhaging money. Some are even furloughing health care workers because they cannot afford to pay them. We have created a system in which hospital financial stability is in some ways dependent on low-value care.

COVID-19 should be a wake-up call to policymakers and hospital administrators that our current hospital payment system is broken. But the pandemic gives us an unprecedented opportunity for change. As Elshaug and Duckett explain, the pandemic has swiftly reoriented hospital supplies and staff away from elective procedures and toward helping people who need it now–something policymakers have struggled to do for years. Although hospitals are itching to get back to doing elective surgeries–hospital groups have already released guidelines for returning to the status quo– we should not just go “back to normal” once the virus is more contained.

Here are some things we should be doing instead:

Stop paying for low-value care. There are a great many tests and procedures that Medicare and Medicaid pay for, despite not showing evidence of benefit for certain patients. Government programs should stop reimbursing for these procedures when they are unnecessary, to reduce the incentives for clinicians to perform them.
Switch to value-based payments rather than fee-for-service. Our fee-for-service reimbursement system for hospitals feeds into our desire to do more, regardless of whether or not it makes patients healthier. But fee-for-service is not the only way to pay hospitals. In Maryland, hospitals are reimbursed per patient through their global budget system, which gives them an incentive to keep patients healthy and out of the hospital. This type of reimbursement system would encourage hospitals to do some of the innovative practices they have started during the pandemic, such as increasing telehealth visits and moving towards community-based and home-based care.
Evaluate hospitals based on overuse. Hospitals are evaluated on many quality metrics, but they are rarely evaluated for how often they provide low-value care, especially in the more well-known hospital rankings.

“Look at outcomes during this period of shutdown, and I bet you’ll see something shocking.”
Dr. Zubin Damania

Last, but not least: Take the opportunity to research health outcomes associated with fewer elective surgeries being provided nationally. “Look at outcomes during this period of shutdown, and I bet you’ll see something shocking,” said Dr. Zubin Damania, internist and founder of Turntable Health. Damania predicts a similar result as the 2018 study that examined health outcomes for people suffering heart attacks when interventional cardiologists were at conferences. They found that these patients were more likely to survive in the month after their heart attack than patients seen when all the cardiologists were present. Tracking patient outcomes during this pandemic will provide important information about the health effects of elective surgeries.

Hospitals are hoping to start up elective surgeries as soon as they can, but it is not clear whether this would benefit patients. We should take this opportunity to change how we pay for care, evaluate hospitals’ provision of low-value care, and measure the effects of reduced elective surgeries on patient health.

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