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Some hospitals are performing elective medical procedures contrary to recommendations from the federal government as the COVID-19 coronavirus surges, threatening to overwhelm the healthcare system.

On March 18, the Centers for Medicare & Medicaid Services (CMS) and sent out a . The most essential care includes treating patients with severe COVID-19 symptoms and other services in which a lack of in-person treatment would result in patient harm. The lowest tier, which should be evaluated using telehealth, includes primary or preventive care, according to CMS recommendations.

The American College of Surgeons (ACS) also issued guidance on , stating electively scheduled operations, endoscopies, or other invasive treatments should be minimized, postponed, or cancelled "until we have passed the predicted inflection point in the exposure graph."

But on the ground, providers are responsible for making the call, and with the economic toll of the pandemic already reaching hospitals, there may be financial incentives tangled up in an already difficult decision-making process.

Interpretation Varies by Facility, State

As of April 9, officials in 35 states and the District of Columbia to limit elective procedures, according to the Ambulatory Surgery Center Association.

In Minnesota, directing the delay of elective surgery and procedural cases, effective March 21.

This led Sanford Health, which operates 44 medical centers throughout the Midwest, to postpone all non-essential surgeries in their Minnesota facilities, according to a statement provided to 麻豆传媒.

But Sanford Health is continuing with procedures in states like South Dakota and North Dakota, which have less restrictive or no such policies in place.

In states where procedures are still being done, decisions are made by providers and patients "based on patient symptoms, resources available and the clinical justification to proceed," said Sanford Health Vice President and Medical Officer Douglas Griffin, MD, in a statement.

"We are striving to ensure that all patients who need urgent medical care continue to receive it without delay while also preparing to care for those affected by COVID-19," Griffin stated. "Balancing the health care needs of our patients with the anticipated needs of COVID-19 positive patients requires constant evaluation and a measured approach."

As of April 8, North Dakota had with 34 coronavirus-related hospitalizations and 4 deaths.

For areas with a higher concentration of disease, the decision to continue with elective procedures is being met with backlash.

On March 21, a group of 291 physicians and healthcare providers at the University of Pittsburgh Medical Center (UPMC) citing concerns that their facilities had "not yet moved to cancel routine clinic visits and elective procedures, unnecessarily increasing risk of exposure and spread."

There have been in the five counties in and neighboring Pittsburgh. But, the UPMC providers argued, the relatively low numbers don't mean it's OK to continue with elective cases.

"The current limitation on testing patients means we do not truly understand the burden of disease, and therefore cannot appropriately triage and treat our patients," they wrote. "Using this logic to justify continuing with elective cases is therefore poorly-based."

UPMC recommends elective procedures for higher risk patients and these are being triaged in a way that meets the CMS guidelines, according to a statement provided to 麻豆传媒.

"We appreciate, understand and embrace the concerns and the potential solutions offered by all at UPMC," they said in a statement. "Balancing our patients' ongoing clinical needs with the avoidance of unnecessary exposure requires a nuanced approach -- not an across-the-board cancelling of clinics and procedures."

Keeping the Lights On

Financial incentives may also be involved in the decision-making process as hospitals begin to feel the economic impact of the pandemic.

Surgical admissions bring in and hospitals earn about than on patients admitted through the emergency department, according to an analysis of Medicare data.

For example, Bon Secours Mercy Health in Cincinnati, Ohio, for each month that the pandemic continues. After cancelling elective procedures and other services unrelated to COVID-19, the hospital system furloughed all nonessential employees last week.

Although UPMC reported the system that have decreased through the years, even slipping into the negative.

"The financial implications of not being able to do elective procedures are vast and there are unfortunately going to be hospitals that may have a hard time even keeping the lights on," said Alyssa Burgart, MD, of the Stanford Center for Biomedical Ethics. "Those incentives are real and for hospitals that want to be able to continue to provide care in their community, this is a hard call."

However, hospitals that continue to provide elective care may miss out on vital preparedness as the height of the pandemic unfolds, Burgart said.

"We'll have no one to take care of sick people who really need and deserve quality care if we can't keep our hospitals open," she said. "Whenever it is we are able to start performing these procedures again, anesthesiologists, surgeons, surgical techs, and nurses are going to have plenty of work to do, and having these centers survive this time will be crucial."

Ultimately, patient health is the primary consideration and providers must balance the potential harms of delaying a procedure with the potential harm of performing it, including the risk of intensive care unit (ICU) admission, Burgart added.

"Surgeons are deeply committed to their patients," she said. "What's challenging is putting this in the context of a public health crisis, how can we help support surgeons to make a decision that makes sense for the goals we have now in terms of conserving PPE, not exposing healthcare workers to increased risk that will prevent them from caring for critically ill patients, and also protecting patients from undue exposure during the pandemic."

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