There was less outpatient care than expected in a pandemic


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Outpatient care utilization fell below expected levels during the pandemic, according to an analysis of national claims data from January 1, 2019 to October 31, 2020.

“The COVID-19 pandemic has severely disrupted access to U.S. outpatient care, endangering the health of the population,” John N. Mafi, MD, of the University of California, Los Angeles, said in a presentation at the annual meeting of the Society of General Internal Medicine.

Mafi and colleagues conducted the analysis, which included 20 monthly cohorts, and measured the rates of external visits per 100 members during the 20 months of study. The researchers used a “difference-in-difference study design” and compared changes in outpatient care visit rates between January-February 2019 to September-October 2019 with the same 2020 periods.

They found that global utilization fell to 68.9% of projected rates. This figure increased to 82.6% of the rates forecast for May-June 2020 and to 87.7% of the rates forecast for July-August 2020.

To examine the impact of COVID-19 on U.S. outpatient care patterns, researchers identified 10.4 million people 18 years of age or older using the MedInsight research claims database. This database included Medicaid patients, commercial, eligible for both (receiving both Medicare and Medicaid benefits), Medicare Advantage (MA), and Medicare pay-per-service (FFS) patients. The mean age of the individuals studied was 52 years and 55% of the population were women. The researchers measured outpatient visit rates per 100 beneficiaries for various types of outpatient visits: emergency, urgent care, office, physical exams, prevention, alcohol / drugs, and psychiatric care.

The researchers verified the parallel trends in visits between 2018 and 2019 to establish a historical benchmark and divided the patient population into three groups based on insurance enrollment (continuously enrolled, not continuously enrolled). and fully enrolled) to take into account new members adding insurance and discontinued coverage caused by job losses or other factors. Trends in the use of outpatient care were similar across group cohorts.

The rebound observed in the summer of 2020 showed variations when broken down by type of insurance: 94.0% for Medicare FFS; 88.9% for commercial insurance; 86.3% for Medicare Advantage; 83.6% for double eligible people; and 78.0% for Medicaid.

“The big picture is that utilization looks similar in all three groups and has not reached pre-pandemic levels,” Mafi said.

When results were broken down by service type, utilization rates remained below expected rates, while needs remain similar for preventive screening services recommended by the U.S. Preventive Services Task Force, Mafi pointed out. Demand for psychiatric services and substance use has increased, but usage rates are lower than expected. In addition, the use of avoidable and unavoidable ED remained below expected rates.

Face-to-face visits are reduced to all insurance groups, but virtual visits are soaring, to all insurance groups, Mafi added. However, virtual care visits have not fully offset the decline in face-to-face visits, especially among members of dual-entitlement insurance and Medicaid.

The takeaway for policymakers includes the fact that while some reductions in unnecessary care, such as preventable ED visits, may be beneficial, the “USPSTF-recommended cancer reduction and other types Evidence-based disease prevention can worsen health outcomes, especially for Medicaid beneficiaries, “he said.

Dissemination and results

The study is important because “understanding the patterns of outpatient care during the pandemic can highlight the vulnerabilities and opportunities of our health care system,” Mafi said in an interview.

“While the COVID-19 pandemic has severely altered access to U.S. outpatient care, most studies have focused on the early months of the pandemic,” he noted.

Mafi said he was not surprised that the use of outpatient care has not risen among Medicaid beneficiaries relative to other insurance groups.

“Medicaid beneficiaries are resource-poor individuals who are disproportionately ethnic and racial minorities and have historically had difficulty accessing care. Our data suggest that the COVID-19 pandemic may be widening these pre-existing inequalities in access to ‘outpatient care,’ he noted.

The results of the study were limited by the use of the MedInsight research dataset, which is a sample of convenience; and therefore the results may not be generalizable nationally, Mafi said. “However, it includes beneficiaries of all major types of insurance in the 50 U.S. states. In addition, our analysis was completed at the population level rather than at the patient level, so we were unable to consider the characteristics of the patient, such as clinical complexity. “, he explained.

“The message that doctors can take home is that our Medicaid-insured patients may need additional efforts to overcome barriers to accessing outpatient care, such as creating robust telemedicine programs,” Mafi said. . “Policy makers should also consider providing additional support and resources to safety net health systems that disproportionately serve Medicaid beneficiaries, such as higher reimbursements for both face-to-face visits and telemedicine.”

More research is needed, he stressed. “We need urgent research on the impact of this persistently deferred use of outpatient care on health-important outcomes, such as preventable death / disability and quality of care.”

COVID Consequences Challenge Care Ambulatory

“These results from the study reflect what we are seeing in primary care settings,” said Maureen Lyons, MD, of the University of Washington. St. Louis, he said in an interview. “With the pandemic, there are many additional barriers for patients accessing care and these barriers have disproportionately affected those who are already disadvantaged.

“From clinical experience, there are barriers directly related to COVID-19, such as the risk of infection or discomfort in a clinical setting with other people. However, there are also barriers related to changing financial situation or insurance related to changes or loss of employment, ”he said.

“In addition, many patients need to take on more responsibilities in other areas of their lives, such as caring for a sick family member or the responsibility of the children’s virtual school,” he said. These new responsibilities may lead people to omit or postpone outpatient visits.

“Loss of outpatient care is likely to lead to an increase in preventable diseases with lasting effects,” Lyons noted. “Studying this robustly, as Mafi and his colleagues have done, is a critical step in understanding and addressing this urgent need.”

Mafi noted that the data he presented is preliminary and that he and his team hope to publish definitive estimates of outpatient use rates in an upcoming scientific paper.

The study was a collaboration between UCLA and Millman MedInsight, an actuarial health analytics firm. Several co-authors are Millman employees. Mafi and the other investigators had no other relevant financial conflict to reveal. Lyon had no financial conflicts to reveal.

This article originally appeared on, which is part of the Medscape professional network.

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