A substantial side-effect of the COVID-19 pandemic is the hard reality that many people, including those with chronic conditions, are delaying care. Diagnostics are down, routine visits are being missed, borderline elective procedures and surgeries postponed. The decreased patient volumes are already taking a financial toll on providers and what could be even worse will be the health debt consumers experience in the aftermath of the pandemic.

Not to be confused with medical debt, as in unpaid or even surprise bills that bankrupt or strain the finances of so many American families, health debt manifests from a lack of care, whether it’s medications not taken or skipping screening that could detect disease and adverse health events before they occur.

And while many executives and public health officials are publicly warning of a second wave of COVID-19 infected patients taxing hospital employees, beds, ventilators, PPE and other equipment before herd immunity is achieved, the threat posed by patients carrying health debt is real.

The scope of health debt
Diagnostic testing is down 60 percent, while rising unemployment during the pandemic has driven the number of uninsured Americans up 114 percent, according to research conducted by Strata Decision Technology. And across all service lines, 54.5 percent fewer unique patients sought care at a hospital setting as of this week.

Strata also found that overall volumes were beginning to rebound toward the end of May, but are still far short from last year at this same time, said Strata CEO Dan Michelson.

What’s more, the American College of Emergency Physicians estimates that emergency room visits are down 30 percent, while the Journal of American College of Cardiology determined that 38 percent fewer procedures to treat a specific type of heart attack are being performed.

Widespread health debt will emerge as a short- and long-term result of fewer patient encounters — and while many health officials in the public and private sectors are expecting a second wave of COVID-19 infections either as states re-open economies or in the autumn of 2020, others are anticipating that people bearing health debt will create excessive demand for care services.

“A second wave is coming and it may not consist of patients infected with COVID,” Michelson said. “If 60 percent of diagnostics volume is down, we’re going to see a spike in cases that are more complex, more traumatic from a clinical and financial perspective.”

Cecelia Health CEO Dave Weingard added: “Without question, every day we need to treat people with chronic diseases such as heart health, obesity, diabetes, those are problems that need to be addressed. We have a second wave coming where patients who are not well–controlled in their chronic conditions have a high likelihood of complications.”

According to a New York Times analysis of CDC data, more non-coronavirus deaths than normal occurred in the New York/New Jersey region between March 15 and May 2, 2020. Deaths from Alzheimer’s rose 1 percent, flu and other respiratory diseases 5 percent, heart disease and diabetes 15 percent. That’s not to downplay COVID-19, which accounts for 60 percent of excess deaths in the region, states that have seen 40 percent of the nation’s coronavirus death toll to date.

“This pandemic could accelerate health debt by years,” Weingard said. “And I think that’s going to be happening.”

Hospital financials make health debt harder to correct
Increasing health debt inevitably cut both ways: People will carry it for years into the future and possibly for the rest of their lives because there is simply no making up for an untreated heart attack or not catching stage 3 cancer early. Furthermore, the financial strain COVID-19 and health debt are placing on providers and health payers will make patient care that much more difficult.

Although the data does not yet paint a complete picture of how much costs will increase, Weingard said that anecdotally Cecelia Health is hearing from clinicians that they could experience somewhere between a 25 percent and 50 percent rise in treating people with diabetes on top of the $327 billion annual expenditure.

Diabetes is just one example. Weingard also pointed to mental health as creating another wave of its own because, with estimates that 1 in 3 Americans will have diabetes by 2030 and 40 percent of diabetic patients experience anxiety, behavioral conditions are also on the rise.

All of this is happening while hospitals are collectively operating on $60 billion a month less revenue than the organizations were earning prior to the pandemic, according to Strata’s research.

For hospitals, returning to 85 percent of revenue is an optimistic outlook and, even still, achieving that doesn’t get the organizations where they need to be when operating on 2 percent margins and having to preserve space for another influx of COVID-19 infections alongside non-COVID patients.

“More complex patients will be coming, receiving more care, and at the additional expense of treating them because of PPE provisions,” Strata’s Michelson said. “That is the direction health care is heading.”

In the last two weeks of March, the vast majority of health systems across the country cancelled or postponed “elective” procedures as a means to prepare for an anticipated surge of COVID-19 patients. Reflecting in his daily public letter to faculty and staff on the operational changes New York-Presbyterian Health System was making to confront COVID-19, wrote Craig Smith, chair of surgery, March 20:

Nothing would give me greater pleasure than to apologize profusely in a few weeks for having overestimated the threat. That would mean we never exceeded capacity, and that mortalities and morbidities rarely seen in non-pandemic circumstances were avoided. The next month or two is a horror to imagine if we’re underestimating the threat. So what can we do? Load the sled, check the traces, feed Balto, and mush on.

Although the nation’s decision to cancel electives was effective in preventing the type of mass casualty event that was feared — where bed supply would fall short of projected demand — the cost to U.S. health systems has been cataclysmic. New research suggests that U.S. health systems, which operated on a 2.1% average margin in pre-COVID-19 times, are losing $60 billion per month during the COVID-19 crisis due to volume reductions.

Yet the impact of the cancelation of electives extends far beyond hospitals’ finances: It cuts to the health of our nation.

The true impact of the hiatus from elective procedures

To appreciate the gravity and scope of health system leaders’ efforts to revitalize their organizations, we must first objectively understand the clinical and financial dimensions of this crisis. An analysis of procedure volumes at 51 health systems representing 228 hospitals across 40 states found that the number of unique patients who sought care in hospitals during a two-week period between March and April 2020 dropped 54.5 % compared with the same period in the prior year.[a]

If we look at only the top 10 inpatient procedures and surgeries — those encounters that drive over 50% of health system revenue annually — the crisis becomes even more stark. The exhibit below shows that three of the highest contribution margin procedures for hospitals — the “hips, knees and spines” trifecta — all saw declines of between 79% and 99%.

Volume changes for top 10 inpatient surgeries and procedures

Primary knee replacement


Lumbar.thoracic spinal fusion -81%
Primary hip replacement -79%
Diagnostic catheterization -65%
Diagnostics -60%
Percutaneous coronary intervention -44%
Fracture repar -38%
C-section   2%
Regular delivery   1%
Mechanical ventilation   24%
Source: Strata Decision Technology, May 2020. Data current as of May 11, 2020
Percentages represent changes year-over-year from a two-week period in 2019 (March 24 to April 6) to the corresponding two-week period in 2020 (March 22 to April 4). Care family definition per Sg2 Care Grouper™

These volume decreases accompanied changes to payer mix, following the rise in the national unemployment rate. In the cohort of hospitals studied, the percentage of encounters involving patients who lacked insurance grew from 5% in January to 8% in May (preliminary results), a 62% increase.

Percentage of self-pay encounters by month

Source: Strata Decision Technology, May 2020. Data current as of May 11, 2020

Combining a precipitous decline in procedures with a material shift in payer mix complicates an already challenging reforecasting exercise. As leaders project the time frame by which their organizations will break even on operations, they must overlay a higher allowance for uncollectable accounts onto forecasts of reduced procedures.

The burden of avoided care

Even more than posing a financial challenge for hospitals, the sharp reduction in patients accessing care bears grave clinical implications for patients. If we examine the decrease in access to care by procedure category, we see huge declines in access both for life-threatening illnesses such as congestive heart failure (-55%), heart attacks (-57%) and stroke (-56%) and for chronic diseases such as hypertension (-37%) and diabetes (-67%).

Change in inpatient and outpatient encounters by clinical care family

Cataracts -97%
Sleep apnea (often a harbinger of cardiac disorders -91%
Glaucoma -88%
Osteoarthritis -88%
Coronary heart disease -75%
Chronic otitis media and sinusitis (ear/sinus infection) -75%
Hypertension -74%
Hyperlipidemia -74%
Neuro pain and neuropathy -71%
Care for diabetes -67%
Asthma -62%
Ischemic stroke -56%
Congestive heart failure -55%
Chest pain (non-cardiac) -44%
Prostate cancer -44%
Source: Strata Decision Technology, May 2020. Data current as of May 11, 2020
Percentages represent changes year-over-year from a two-week period in 2019 (March 24 to April 6) to the corresponding two-week period in 2020 (March 22 to April 4). Care family definition per Sg2 Care Grouper™

Furthermore, the screening and prevention category, recognized as important but not sufficiently emergent to be permitted under most elective procedure freezes, suffered a steep volume loss: Breast health, gynecologic wellness and gastroenterology screenings all declined by more than 75%.

Such an environment, where procedures surrounding critical illnesses are canceled and patients are actively avoiding emergency care for fear of contracting COVID-19, exhibits all the hallmarks of a public health crisis. So far, most of the data indicating the deleterious effects of COVID-19-driven care avoidance has been anecdotal — such as surgeons at Northwell Health citing amputations on patients that might have been avoided had the patients been treated sooner. But the care gaps created by COVID-19 will almost certainly become a dominating narrative in the months to come.

Recommendations from the field

So where do we go from here? How do leaders plot a path to financial viability, while remaining vigilant against current and future COVID-19 outbreaks? How do executives integrate the wartime innovations they produced during the pandemic into their operations moving forward? Here are some strategies gleaned from our conversations with health system leaders.

Amplify care teams through remote patient monitoring. As emergency departments (EDs) in hotspot markets became flooded with COVID-19 patients, executives were confronted by a number of critical challenges around capacity and supplies, including:

  • Preserving inpatient beds for those most in need
  • Securing adequate staff coverage amid an insufficient supply of caregivers
  • Sequestering COVID-19 patients from those in the hospital for other ailments

In response, several health systems quickly leveraged remote patient monitoring (RPM) solutions, whereby COVID-19-positive or presumptive positive patients are discharged with a set of Bluetooth-connected devices. From their own beds, each patient’s oxygen saturation and temperature are continuously transmitted to a telehealth nurse, who is thus equipped to determine whether a patient’s clinical conditions merit inpatient observation.

As health systems experienced the dramatic improvement in nurse-patient staffing ratios that was achieved through the use of RPM (one system citing an improvement in the ratio of nurses to patients from 1:15 to 1:65), many have started aggressively rolling out RPM across their broader clinical enterprise, viewing it as an inextricable part of their care delivery strategy moving forward.

Christiana Care based in Newark, Delaware, offers a noteworthy example: The health system leveraged its versatile RPM platform to expand its care team’s ability to support COVID-19 patients at home and for virtual care management. “We rapidly scaled our virtual operations, and now that same platform is being used to support care teams working to restart elective surgeries and procedures,” Randall Gaboriault, chief digital and information officer, told us. “This model did not just change the way we work; it changed the work.”

Re-envisioning the digital front door. In early March, health system call centers became inundated with patient requests. Queries ranged from checks on symptoms to proactive efforts to schedule previously postponed care to requests for information on COVID-19. Health systems best poised to communicate with their patients at scale had already made substantial investments in their digital front doors, having integrated an array of self-service functions, including scheduling, asynchronous messaging, personalized content and automated check-ins.

Aaron Martin, executive vice president and chief digital and innovation officer at Providence St. Joseph Health, said: “As the pandemic accelerated, the digital front door became the central entry point by which patients interact with their systems. COVID-19 demonstrated in stark terms for health systems the problems with the off-line, fee-for-service business model in which they have limited digital engagement with their patients between episodes of care. The digital front door is now critical as health systems will need to create an engaged digital health experience with their patients, which will drive growth, efficient care delivery, new revenue streams, and make managing population health and capitation at scale possible.”

Recouping lost volumes through virtual care. Supported by expanded funding and the relaxation of certain privacy regulations, the COVID-19-driven explosion of telemedicine is well-documented. Yet the range of virtual care use cases extend far beyond conventional definitions. Before elective procedures began to be canceled due to COVID-19, providers were recouping critical revenues by providing virtual post-surgical checkups for procedures. These practices laid the foundation for a vigorous elective phase-in by offering pre-surgical consultations during the months of April and May and helped launch proactive virtual prevention and wellness campaigns to keep clinicians productive.

“CommonSpirit Health has expanded access to care and provides more than 10,000 virtual visits a day in a range of clinical areas,” said Rich Roth, chief strategic innovation officer at CommonSpirit Health, Chicago. “We have also launched automated tools (chat bots, screening tools), which are being used by thousands of additional individuals, each working to educate and triage community members to effective care settings and helping to safeguard caregivers in our communities.”

Pinpointing interventions for the most vulnerable through targeted analytics. In the past two years, no digital health subsector has had more meteoric expectations assigned to it than clinical artificial intelligence. With the onset of COVID-19, many healthcare organizations have found concrete use cases for these technologies in identifying those greatest at risk of experiencing severe COVID-19 outcomes, determining which interventions are most likely to work for which patient populations and informing the redeployment of clinical resources to where they are most urgently needed.

“Leveraging a predictive analytics product, we’ve been able to proactively reach out to those patients in our population who are most vulnerable to COVID-19, while offering our employer clients the ability to mitigate the impacts of this disease on their population,” said Vickie Rice, vice president of strategic analytics at CareATC in Chicago.

Radical cost reduction through administrative process automation. Despite recent data suggesting encounters are rising, most health system leaders do not expect volumes to meet pre-COVID-19 levels in the near-term. In this context, many executive teams have modified their business models to do more with less. Given the need to maintain a robust clinical workforce, healthcare leaders have looked more closely at their administrative structures to find cost- optimization opportunities.

“Our health system has been automating transactions around our consumer self-service strategy for years,” said Chad Brisendine, CIO of St. Luke’s University Health Network, headquartered in Bethlehem, Pennsylvania. “With the onset of COVID-19, the need to further automate has never been more important. St. Luke’s has expanded its automation work to include virtual care processes.”

Safeguarding the lifeblood of the organization by optimizing payments. For many health systems, the COVID-19 crisis has been characterized by a major shift in procedure mix, an increase in the proportion of self-pay patients and a change in clinical site-of-service from in-person to virtual. These changes have introduced major revenue cycle challenges for health systems at a time when maximizing revenue is critical to survival. As leaders prepare for a transformed healthcare delivery landscape, they must realize that the payments reality has changed as well. Administrators may emerge from this crisis to find that many of the traditional billing and collection practices that served them well previously are outmoded. As systems chart their courses back to profitable operations, they will find it beneficial to invest in a secure and scalable payments infrastructure that includes text-to-pay functionality, point-to-point encryption and optimized mobile and online payments experiences.

Moving forward with demonstrated successes

As elected officials and healthcare leaders across the nation observed a European health system stretched beyond capacity by COVID-19, they acted, almost in unison, to cancel elective procedures. This decision helped U.S. health systems avoid the nightmarish scenario observed elsewhere in which physicians were forced to make the harrowing choice of who would receive an available bed and who would not.

Yet this decision also dealt a crushing financial blow to our delivery system and severely curtailed access for patients in need of care. As executives begin to phase back in scheduled procedures, while preparing for a second potential wave of COVID-19 in the Fall, they would be well served to incorporate best practices gleaned from leaders in virtual care, remote patient monitoring, payments, digital front door, and predictive analytics.


[a] This article draws upon data from Strata Decision Technology’s National Patient and Procedure Volume Tracker, which has been updated weekly between May 11 and May 26. Future iterations will incorporate forthcoming updates.

About the Authors

Ezra Mehlman, MBA, is managing partner at Health Enterprise Partners, New York ([email protected]).

Steve Lefar is executive director of StrataDataScience, the analytics group within Strata Decision Technology (part of Roper), Chicago ([email protected]).

In the history of America’s healthcare system, there has perhaps been no bigger disruptor to hospital finances than COVID-19, which has strained resources and shut down service lines. Telehealth reimbursement waivers have provided a fiscal lifeline for struggling organizations, but for some, more is needed. That’s where examining and re-thinking labor costs come into play.

In a way, looking at labor costs is an obvious consideration for hospitals, as such costs typically represent the largest category of health system expense. But with labor cost information generally siloed from an organization’s other data, a modern solution requires some form of automation technology to truly give hospitals and health systems a sense of how they can shift resources in an effective and efficient manner. If the goal is to avoid furloughing or laying off workers, these capabilities are essential.

Nebraska Medical Center realized this. Leadership knew it wanted budget, cost accounting and patient data all in one place, and got the ball rolling in January with new data capabilities and some training and education to get physicians, nurses and hospital leadership on board. As the worst of the coronavirus’ first wave has played out, the hospital has yet to furlough an employee, and hopes to keep it that way.

“When we were in pandemic mode here, we thought, ‘Let’s not panic and furlough people, because we’re going to need them back,'” said Kristi Atkinson, budget and cost accounting manager at Nebraska Medical. “Let’s use the data so we’re not playing favorites, and we can look at the data and say, ‘Whose productivity is down because they don’t see patients anymore? Whose productivity is too high?’ We used it as a way to determine where we have resources, who’s up and who’s down.”

In that way, Nebraska medical was able to shift around some staff to maximize their available resources. Clinicians who are otherwise unoccupied are helping in the access department, assisting overwhelmed staff in performing check-in processes. Surgical nurses who find themselves in limbo after the cancellation of elective surgeries are plugging in those gaps and escorting patients to various spots in the facility during check-in, taking some of the pressure off regular access department employees.

At the same time, management created a flex pool so managers could see where there’s a need for more bodies and who’s available to help. The hospital pays these employees based on flex codes.

Some hospital employees had trepidation about shifting their roles, but a thorough training program convinced them that shifting resources, and stepping out of their comfort zones, was the best move for the stability of the business.

Liz Kirk, senior vice president of strategic services at Strata Decision Technology, Nebraska Medical’s tech partner, said the move is a preferred alternative to paying out overtime to overworked employees. It’s all about challenging conventional wisdom, she said.

“Challenging conventional wisdom is sometimes hard to do,” said Kirk. “But in this time, when there’s such a need for financial recovery after COVID, as well as the level of attention organizations have from senior leaders, and the mountains people have moved over the last couple of months, this is the time to challenge that conventional wisdom.”


Typically, the data Nebraska Medical needs would exist in two different systems: The billing and cost accounting systems. Now, all of the data is in one place and staff can easily blend together payroll data, volume data, and statistics on cost, revenue and margin. With all of this information in one central repository, various teams across the hospital can get a full picture and understand the financial impact of each move they make.

“If we didn’t have productivity set up on a daily basis, and hadn’t validated the data and gotten statistics in there, we would be pulling from multiple systems on the fly,” said Atkinson. Now, the team can drill down by cost center and be more nimble when deciding which staff members can fill a need in another department. It’s quicker and more user-friendly than using the payroll system.

In addition to allowing for a better handle on its financials, the hospital noticed that the move has mitigated feelings of stress and burnout among clinicians — which has been a growing problem in healthcare for years, only made worse by the pandemic.

With the reduction in surgeries, Nebraska Medical was able to shift some of its pulmonary and sleep study staff to more active departments, for example. And with respiratory capabilities set up in the anesthesiology department, anesthesiologists can now be tapped to help out with respiratory aid for COVID patients.

“With elective surgeries resumed, we’re in the crunch and bringing on some contracted labor,” said Atkinson. “But our COVID patients are higher now than they’ve ever been. Nursing leaders are trying to make sure we get the right people on the right units, and adjusting the ratios a little bit. Same with the emergency department — we can’t be as efficient as we used to be, but we have nursing leaders looking into that.”

The results have been dramatic: By the second week of May, Nebraska Medical saw an 80% drop in overtime pay. That’s ticking back up slightly at the moment due to a challenging market, but the hospital still hasn’t furloughed any staff, which is a top consideration given that a main goal is to prevent people from losing their jobs.

“The difference between organizations that can predictably improve costs and margins and those that can’t is having strong governance and accountability processes in place,” said Atkinson. “To do that well you have to be able to keep track of all these different initiatives. For recovery, health systems will be doing hundreds of initiatives, but to keep track of them and keep track of the financial benefits of that, the only way you can do that is through automation. Organizations will drive themselves crazy trying to do it in Excel.”

  • Study finds cardiology visits down 57%; breast health visits fall 55%
  • Elective procedures plunge; uninsured hospital patients increase

U.S. hospitals are losing an estimated $60.1 billion a month and facing a 113% increase in uninsured patients during the Covid-19 pandemic, according to a new study.

The heavy losses reflect a 54% drop in patient visits due mainly to the cancellation of non-emergency and elective procedures, according to data from 2 million patient encounters across 40 states compiled by Strata Decision Technology, which provides financial analytics for the health-care industry.

The data, derived from a two-week period between March and April, saw revenue for 51 health systems fall by an estimated $1.35 billion when compared with the same period in 2019. Projecting the findings nationwide suggests an overall revenue loss of $60.1 billion per month for the nation’s hospitals.

The losses occurred as the share of uninsured patients rose from 7% in January to 15% in early May as millions of Americans lost job-based coverage.

The findings released Monday are the latest to show the financial impact of the Covid-19 health emergency on the nation’s hospitals. On May 5 the American Hospital Association released a report that estimates hospitals will see $202 billion in losses between March and June of this year. That averages out to more than $50 billion in monthly losses.

At Yale New Haven Hospital in Connecticut, revenue is down roughly $1.5 million a week, Keith Churchwell, the facility’s executive vice president and chief operating officer, said in an interiew.

The 1,541-bed hospital is likely to receive some stimulus funding, but Churchwell, who’s a cardiologist, doesn’t know when or how much.

Whatever the amount, it “will not make up for our overall deficit by the end of our business year,” Churchwell said. “We’re in the hundreds of millions of dollars in terms of our overall deficit.”

In the Strata study, clinical service lines that saw sharp declines over the two-week study period included cardiology encounters, down 57%; breast health visits, a decline of 55%; and cancer encounters, down 37%. Patient volume also fell for cataract care, down 97%; coronary heart disease, down 75%; hypertension, down 74%; and diabetes, down 67%.

Those canceled visits helped fuel the loss of 1.4 million health-care jobs lost last month “simply because the patients aren’t coming though,” said Dan Michelson, CEO of Strata Decision Technology.

Ten inpatient procedures account for about 50% of hospital revenue, Michelson said.

“So when hip and knee surgeries go down by 79 and 99%, when spinal fusions are down by 80%, when stents are down by 44%, that has an enormous impact” on hospital employment and revenue, Michelson said in an interview.

Even if hospitals restored half of their lost volume over the next six months, the industry would still require hundreds of billions in additional government funding to bring them back to pre-pandemic levels, Michelson said. “The ability to weather this storm is super challenging,” he said.

‘A Wave of Demand’

As the Covid-19 threat lessens and more facilities resume elective procedures, millions of patients who put off non-emergency care will likely “flood hospitals and physician offices seeking care,” the study said. “Many facilities will likely be hard-pressed to handle the surge while simultaneously maintaining capacity for Covid-19 patients.”

“You’ve got a wave of demand that hasn’t been taken care of,” Steve Lefar, executive director of the data science division at Strata Decision Technology, said in an interview.

“You’re seeing urgent care and important care being delayed and it’s being called ‘elective,’” Lefar said. But “it’s not really elective once it gets out two or three months from when that stuff was scheduled.”

Churchwell said he’s concerned that patients who put off care during the pandemic, “in many cases, went through their acute medical issues at home, leading to significant adverse events,” including possible deaths.


The COVID-19 pandemic has had an unprecedented impact on hospital visits, driving volumes to record lows. But patient volumes could be on the upswing as elective procedures resume, TransUnion Healthcare recently reported.

An analysis of over 500 hospitals across the nation found that hospital visit volumes further declined between the weeks of March 1st through the 7th and April 12th through the 18th. Volumes fell between 33 and 62 percent after already sliding throughout the month of March. TransUnion Healthcare previously reported that hospital visit volumes fell between 32 and 60 percent in March alone.

The updated analysis showed that hospital visits may have reached their lowest levels, but recent trends also indicated early signs of improvements.

For example, the analysis showed that outpatient hospital visits saw a record one-week 64 percent decline during the week of April 5th, as compared to pre-coronavirus volumes. However, outpatient hospital visit volumes started to rise by about 4 percent between the weeks of April 5th and April 12th, marking the first increase in hospital visit volumes since COVID-19 was deemed a pandemic, TransUnion Healthcare reported.

“Our research suggests that as hospital providers look to re-engage patients and resume elective procedures, the slight rise in outpatient visits may indicate very early stages of patient volume recovery,” said David Wojczynski, president of TransUnion Healthcare.

More than half the states have started to reopen according to the Trump administration’s plan for bolstering the economy, The New York Times reported Saturday.

The plan requires states, among other criteria, to have a 14.day decline in either documented COVID-19 cases or positive tests. But the number of coronavirus patients continues to rise nationwide, with over 4 million confirmed cases in the US, data from Johns Hopkins University showed at the time of publication.

The growing number of confirmed COVID-19 cases prompted lawmakers and healthcare providers to stop elective procedures and other non-emergent services to reduce exposure to the highly contagious virus. That number also prevented patients from seeking hospital services.

About 55 percent fewer Americans sought hospital care in March and April due to COVID-19, a new report from Strata Decision found.

The sharpest declines were services for life-threatening illnesses, such as a 57 percent decrease in cardiology, and a 55 percent decrease in breast health with a 37 percent decline in cancer care overall. Inpatient procedures and surgeries that normally drive hospital revenue – accounting for over 50 percent of total payments made to hospitals – also fell dramatically, with significant decreases in hip (-79 percent) and knee (-99 percent) replacement surgeries, as well as in spinal fusions (-81 percent) and repair of fractures (-38 percent).

“Hospitals across the country are eager to open their doors to elective procedures so they can serve their community, care for their patients, and survive economically but how they get there is literally a hundred-billion-dollar question,” said Dan Michelson, CEO of Strata Decision Technology. “Many facilities will likely be hard-pressed to handle the surge while simultaneously maintaining capacity for COVID-19 patients.”

Re-engagement of patients will be key to handling increasing hospital visit volumes, stated Jonathan Wiik, principal of healthcare strategy at TransUnion Healthcare.

“As providers approach patients, one consideration will be to check-in with those who may have delayed necessary care the most, then engage those who would like to reschedule as soon as possible,” Wiik explained.

Younger patients were also more eager to reschedule delayed or canceled services, TransUnion Healthcare found in a separate survey. Meanwhile, older patients part of the Baby Boomer and Silent Generation groups demonstrated the largest declines in hospital visits by nearly 60 percent each, the recent analysis found.

Having visibility into patient volumes across service lines to critical to the re-engagement strategy, Michelson added. Tracking hospital visit volume will allow organizations to “safely engage patients while balancing the clinical, operational and financial complexity and pressures imposed by COVID-19,” he said.

Across all service lines, COVID-19 pushed the number of unique patients who sought hospital care down by an average of 54.5 percent, according to a year-over-year analysis from Strata Decision Technology.

For the analysis, data scientists examined more than 2 million patient visits and procedures from 51 healthcare delivery systems in 40 states. The 228 hospitals represented in the study had varying rates of COVID-19 cases.

Here are the estimated volume losses for 30 service lines for a two-week period in late March-April 2020 compared to the same period a year prior:

Ophthalmology: 81 percent
Spine: 76 percent
Gynecology: 75 percent
Orthopedics: 74 percent
Ear, nose and throat: 72 percent
Endocrine: 68 percent
Dermatology: 67 percent
Gastroenterology: 67 percent
Rheumatology: 66 percent
Neurosciences: 66 percent
General medicine: 64 percent
Urology: 62 percent
Genetics: 60 percent
Vascular: 59 percent
Hepatology: 58 percent
Cardiology: 57 percent
Pulmonology: 56 percent
Breast health: 55 percent
General surgery: 54 percent
Nephrology: 52 percent
Hematology: 49 percent
Allergy and immunology: 48 percent
Behavioral health: 45 percent
Burns and wounds: 44 percent
Cancer: 37 percent
Obstetrics: 30 percent
Infectious disease: 23 percent
Neonatology: 20 percent
Not assigned: 4 percent
Normal newborn: 2 percent

View the full report here.

More than 3,000 surgeries have been put off at Yale New Haven Health since mid-March, which accounts for about 80% of its total surgeries.

That scenario mirrors health systems across the country that have had to delay procedures deemed less urgent as they focus on the COVID-19 pandemic. At Yale, overall outpatient services have declined by about 50%, said Dr. Keith Churchwell, the system’s chief operating officer.

“The numbers are staggering,” he said, noting that the 3,000 doesn’t factor in diagnostics and imaging. “The impact has been significant and going forward, we have to plan how to restart that.”

Restarting deferred surgeries pose a series of series of hurdles related to operations, finances, testing, staffing, supplies and patient safety, among others. One of them is how treatment will be prioritized.

The significant drop off in the number of patients receiving emergency care related to heart attacks and stroke is a major concern, Churchwell said.

“This patient population hasn’t gone away,” said Churchwell, adding that fear has likely kept them at home. “We are concerned that there has been a missed opportunity to give appropriate care and that we will be seeing patients down the road who will be sicker and more complicated, unfortunately.”

Nearly 55% fewer Americans sought hospital care over the past two months, resulting in a $60.1 billion average monthly revenue loss across all U.S. hospitals, according to a new Strata Decision Technology analysis of more than 2 million visits from 228 hospitals. Those losses represent about a fifth of the healthcare industry’s monthly output.

A decrease in procedures for life-threatening illnesses was particularly alarming, researchers said, noting a 57% decrease in services related to cardiology, 55% decline to breast health and 37% decrease to oncology.

“When you see things like heart attacks down 50% to 60% and the number of necessary procedures like stenting down 45%, it is really remarkable,” said Steve Lefar, executive director of Strata Decision Technology’s StrataSphere line of business. “This tells the story of the secondary implications of all this care deferral.”

About 40% of inpatient admissions at Edward-Elmhurst Health are non-urgent procedures. The health system in the west Chicago suburbs saw significant declines in cardiology, orthopedics and cancer care, said Denise Chamberlain, chief financial officer at Edward-Elmhurst.

“Procedures that were considered elective have now become urgent,” she said.

Treatment related to chronic conditions like hypertension and diabetes fell 37% and 67%, respectively, according to Strata data. Preventive wellness visits, gynecologic wellness and screenings, and gastrointestinal benign neoplasms and polyps all saw volumes drop by more than 75%.

That pent-up demand threatens to overwhelm providers. Edward-Elmhurst continues to reconfigure its workforce, ramp up testing, reorganize its facilities to improve social distancing and add to its personal protective equipment supply, which has been one of the biggest obstacles, Chamberlain said.

Eisenhower Health has had a similar problem, said Ken Wheat, chief financial officer at the Palm Springs, Calif.-based system.

“The biggest challenge from the planning and prioritization standpoint is PPE,” said Wheat, adding that the organization incrementally restarted elective surgeries about a week and a half ago. “But we are a long way from having enough PPE to open up the gates.”

As for the financial impacts, inpatient surgeries and procedures typically account for the majority of hospitals’ revenue. Some of the biggest impacts stemmed from a 99% decline in knee replacement surgeries, 81% decline in spinal infusions, 79% drop in hip replacements and 38% decrease in fracture repairs.

Meanwhile, the number of self-pay patients has increased by 114% in just 90 days as millions have lost their employer-sponsored insurance. In January, 7% of all patients lacked health insurance. By April that figure had risen to 11%, and early results from May indicate 15% of all patients are uninsured, Strata found.

“This is the equivalent of the banking crisis of 2008,” said Dan Michelson, CEO of Strata Decision Technology. “We’re on the verge of a financial collapse in healthcare.”

The $3.6 trillion healthcare economy makes up around 18% of the country’s gross domestic product, he noted.

Going forward, relying on the fee-for-service system is not sustainable, Chamberlain said.

“We have to get off the model where we get paid the most for patients being in the hospital—I don’t think that model works in the future,” said Chamberlain, expecting more of a capitated model. But that will require convincing self-insured employers that approach will lower costs and improve outcomes, Chamberlain said.

“I don’t think healthcare will go back to the way it was.”