SIOUX FALLS, S.D. — Hospitals that weathered the initial arrival of COVID-19 in the Upper Midwest are now looking for another, more hidden surge: people who put off needed health care.

As the pandemic struck the region over the past few months, many hospitals limited the procedures they offered, following the direction of state officials. Many people who otherwise would have gotten immunizations, cancer screenings or care for chronic conditions stayed home.

Health systems are now taking stock of the toll on those who didn't get needed medical care during the pandemic's arrival. And while it's hard to say exactly how much health care was missed or delayed, the initial assessment doesn't look good.

Most evident are the most trackable things, said chief medical officers from two large regional health systems. People missed scheduled immunizations and regular appointments for care of chronic conditions such as diabetes. The number of screenings for things such as breast cancer plummeted year over year. In line with national observations, so did reported heart attacks. And not because there were fewer heart attacks.

"People were staying at home, having their heart attack, and not coming in," said Dr. Richard Vetter, chief medical officer of Essential Health, based in Duluth, Minnesota, which has 14 hospitals and 69 clinics and serves patients in Minnesota, North Dakota and Wisconsin.

A Kaiser Family Foundation poll in mid-May found nearly half of Americans say they or a family member missed medical care due to the pandemic, and 11% said that person's condition worsened as a result. Nearly seven in 10 people polled said they expected to get care in the following three months.

But the question for medical professionals is, what will be the health cost of that missing three months of care?

What kept people home

Essentia limited most nonessential procedures for more than a month starting in mid-March as it marshalled resources for an expected surge of COVID-19 patients.

Predictably, visits slumped, even as the health system unveiled what became a popular platform for virtual visits. In response, health system leaders laid off hundreds of workers, cut some operations and throttled executive pay.

“We were making those hard choices to make sure we would be viable for the long term," Vetter said.

Essentia Health's Fargo campus at 3000 32nd Ave. S. Forum file photo
Essentia Health's Fargo campus at 3000 32nd Ave. S. Forum file photo

Health systems continue to grapple with how many people avoided care due to the arrival of the pandemic — part of the full public health toll of COVID-19.

A spokesman for Altru Health System, which serves about 200,000 people in Minnesota and North Dakota, said staff there was still too soon to say if delayed care was an issue for its patients. And Altru isn't alone.

“I don’t know that we have the full impact of what’s been delayed," said Dr. Allison Suttle, chief medical officer of Sanford Health, based in Sioux Falls. "We’re just digging into it now."

Sanford, which has 44 medical centers and some 480 clinics, largely serving patients in South Dakota, North Dakota and Minnesota, never fully halted elective procedures across its network and didn't announce any pandemic-related layoffs.

Sanford Health leaders kept a weather eye on COVID-19 cases, and estimated the rise of the virus in rural areas, home to many of the health system's patients, wouldn't be as dramatic as that seen in more densely populated urban areas. For the most part, they were right.

Sanford Medical Center in southwest Fargo. (Forum file photo)
Sanford Medical Center in southwest Fargo. (Forum file photo)

Still, patients stayed home as they absorbed the drumbeat of lockdowns and limitations instituted across the nation and worried about potential exposure to COVID-19.

Even with its facilities open for business, planned vaccinations at Sanford Health slumped 64 percent. And the system's health care providers worried about those with chronic conditions who refused to come in for care.

“We have, particularly in rural America, a lot of individuals with chronic medical conditions. Those chronic medical conditions, people live with every day, and their behavior impacts their chronic disease," Suttle said. "But when they get the message, 'stay home, stay home, stay home,' they put medical care aside, and that can have long-term consequences for these individuals.”

Gauging the full human cost

Both Sanford Health and Essentia Health are better prepared for a wave of COVID-19 patients, with predictive modeling in place, close tracking of supplies and plans for rapid expansion of needed hospital beds as needed.

Now, leaders are closely watching to see if patients are growing more comfortable with the new normal. Their marketing departments are working hard on messaging and advertising insisting it's safe — and important — to return to health care facilities. And both health systems report business has rebounded.

At Essentia, screenings for cancer and lab testing for cholesterol are nearing usual numbers, Vetter said.

“Those have almost come back, I would say, to 100 percent of before, which is great,” he said. “People are taking that a little more serious, which is good.”

At Sanford, a hoped-for rebound in vaccinations has been bittersweet, Suttle said. Missed vaccines could contribute to outbreaks of illnesses, such as measles, usually squelched by immunizations.

"I think more will become apparent as we get back into school and we see more gaps in care," she said. "So it's going to be a catch-up game for, I think, a number of years."