june 2020, Volume XXXIV, Number 3

cover story One

When elective procedures aren’t elective

Planning for future emergencies

innesota has always set a high bar for innovation, quality outcomes, and delivery of health care, consistently ranking high among all the other states. Even so, the COVID-19 pandemic has provided policy leaders, public health officials, and the medical community with an opportunity to do better.

On March 19, 2020, Minnesota Gov. Tim Walz signed Executive Order 20-09, which directed the delay of inpatient and outpatient elective surgery and procedural cases. Guidance was provided and included this language:

A non-essential surgery or procedure is a surgery or procedure that can be delayed without undue risk to the current or future health of a patient. Examples of criteria to consider in making this determination include:

  1. Threat to the patient’s life if surgery or procedure is not performed.
  2. Threat of permanent dysfunction of an extremity or organ system, including teeth and jaws.
  3. Risk of metastasis or progression of staging.

While the guidance was helpful for triaging in the short term, several significant matters were not considered, and delays in necessary care developed as the duration of the executive order continued.

We owe it to patients to establish clinically based definitions on what is urgent/emergent versus elective.

Physicians clearly understood the need for an immediate shutdown to evaluate the crisis and be in “survival” mode, making assessments and recommendations for reducing the spread of the virus, response capacity, personal protective equipment (PPE) supply levels, etc. But there needed to be a next step after that. Deferring care for one to two weeks for some patients was acceptable but was ultimately harmful when those same patients had to be deferred for four weeks or more. Additionally, Minnesota failed to seize upon the opportunity to recognize that free-standing ambulatory surgery centers (ASCs) play a critical role in the overall health care system. Safe outpatient care is not a “nice to have” option, but rather a significant part in providing continued services and allowing hospitals and the rest of our health care system to focus on other emerging priorities.

Defining elective

Surgery is defined under Minnesota Statute 144.7063, subdivision 5z as follows: “Surgery means the treatment of disease, injury, or deformity by manual or operative methods. Surgery includes endoscopies and other invasive procedures.”

While there are mentions of “elective outpatient surgery” under Minnesota statute, that term or related terms are not defined. That undoubtedly presented a problem when the Governor and public health officials were considering the executive order. In fact, when Executive Order 20-09 was issued, the supporting documents made it clear that Minnesota does not have its own definition of “elective surgery or procedure.” The Minnesota Department of Health attempted to clarify the issue with its “FAQ: Executive Order Delaying Elective Medical Procedures” (https://tinyurl.com/mp-mdh-faq). That document explained the reasoning behind the order and provided direction from professional and academic organizations, but did not reflect a Minnesota perspective. It is unfortunate that conversations about what constitutes “elective” have never taken place, but now we have that opportunity.

Additionally, it would be nearly impossible to determine when and where the term “elective” first took hold and became a catch-all for any procedure or surgery that wasn’t performed as the result of an emergency, but it is terminology that needs a fresh look. The term may have become commonplace for the purposes of reimbursements, insurance, and coverage. We can’t turn back the clock, but we owe it to patients to establish clinically based definitions on what is urgent/emergent versus elective with medical necessity versus purely elective for screening or cosmetic reasons. In Minnesota, we can do better. Now is the time to focus on what “elective” means for the higher purpose of patient health and providing care.

Not all elective procedures are the same

By general definition, “elective” means chosen by the patient rather than urgently necessary; one that it is open for choice, is optional, voluntary, discretionary, and not required. However, while the patient might have some flexibility or control in scheduling that procedure, the actual procedure is often not discretionary or a matter of choice in terms of their health.

Additionally, not all procedures are the same in their immediacy, and deferment can mean different things for different patients. Without a proper understanding of how different procedures affect a patient’s current or future health, it isn’t possible to make well-informed decisions that are included in a broad executive order.

Three scenarios demonstrating the various interpretations of “elective” with regard to medical urgency:

  1. Patient A has a positive stool hemoccult as a screening test for colorectal cancer. Patient B has occasional gross blood in his stool and a 5-pound weight loss. Both are not emergencies, and delays in care can have long-term consequences, but Patient B should be assessed with colonoscopy as soon as possible.
  2. Patient A can no longer play tennis and needs a right knee replacement. She has gained 10 pounds while not being able to exercise. Patient B has significant right knee arthritis and can no longer walk up a flight of stairs. She lives in a two-story home. Again, neither case is an emergency, both need knee replacements, and Patient B should be minimally delayed from surgery.
  3. Patient A cracks a crown on his second molar which needs dental repair. Patient B bites into an apple and cracks off a crown on his front tooth. He works as a television anchorman. Both can still eat, neither has a medical emergency, yet there are different degrees of urgency for their respective dental care.

Free-standing surgery centers do not pose a threat to  inpatient care or ICU beds.

A better solution for Minnesota

While I am not advocating for every term to be defined in Minnesota statute, it has become increasingly clear that before there is another surge or the next health pandemic strikes, there should be meaningful discussions between those who govern and those who provide direct patient care.

Ultimately, the goal would be a mutually accepted and agreed-upon process for leaders and physicians to follow when executive orders are issued in the future.

Here is my prescription for those leadership discussions and a roadmap for the future:

  • Work to acknowledge the value of ASCs and the critical role they can play in an overwhelmed health care system. Free-standing surgery centers do not pose a threat to inpatient care or ICU beds and provide an important method to deliver high-quality care that does not require an overnight stay in a hospital. Safe outpatient care is not a “nice to have” option, but rather a significant part of the overall solution.
  • Work to establish clinically based and mutually accepted definitions of “elective,” acknowledging there are differences between what is urgent or emergent versus elective with medical necessity versus purely elective for screening or cosmetic reasons. Come to an understanding that “elective” refers to timing and scheduling of a procedure, but it does not mean the procedure isn’t needed. There could also be conversation about PPE use for various procedures, so hospital supplies do not feel unnecessarily threatened in time of crisis.
  • Work to identify interim steps between “survival” shutdown mode and “all clear” that can be activated during future executive orders. Interim steps would recognize that there are dangers to postponing all procedures within a broad category. Deferring care for one to two weeks might be acceptable for some patients, but a continued postponement can ultimately be harmful when those same patients are deferred for four weeks or more. While there is an obligation to public health, there is also a need to focus on the needs of patients. Identifying steps would allow for some elective procedures to resume following an immediate shutdown.

Conclusion

COVID-19 has presented Minnesota with an opportunity to do better for patient care, especially in times of crisis. Now is the time to have discussions that will lead to better solutions for the future.

Scott R. Ketover, MD, AGAF, FASGE, is a practicing gastroenterologist and President and CEO of MNGI Digestive Health (previously Minnesota Gastroenterology), one of the largest independent gastroenterology practices in the country. He completed his medical degree, residency, and GI Fellowship at the University of Minnesota. Dr. Ketover also serves as the Chairman of the 3,000-physician member Allina Integrated Medical Network, a Minnesota Accountable Care Organization (ACO). He is a Fellow of the AGA and the ASGE. 

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Scott R. Ketover, MD, AGAF, FASGE, is a practicing gastroenterologist and President and CEO of MNGI Digestive Health (previously Minnesota Gastroenterology), one of the largest independent gastroenterology practices in the country. He completed his medical degree, residency, and GI Fellowship at the University of Minnesota. Dr. Ketover also serves as the Chairman of the 3,000-physician member Allina Integrated Medical Network, a Minnesota Accountable Care Organization (ACO). He is a Fellow of the AGA and the ASGE.