Less Ambulatory Care Occurred Than Expected in Pandemic

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

"The COVID-19 pandemic has seriously disrupted access to U.S. ambulatory care, endangering population health," said John N. Mafi, MD, of the University of California, Los Angeles, 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 outpatient visit rates per 100 members across all 20 study months. The researchers used a "difference-in-differences study design" and compared changes in rates of ambulatory care visits in January-February 2019 through September-October 2019 with the same periods in 2020.

They found that overall utilization fell to 68.9% of expected rates. This number increased to 82.6% of expected rates by May-June 2020 and to 87.7% of expected rates by July-August 2020.

To examine the impact of COVID-19 on U.S. ambulatory care patterns, the researchers identified 10.4 million individuals aged 18 years and older using the MedInsight research claims database. This database included Medicaid, commercial, dual eligible (receiving both Medicare and Medicaid benefits), Medicare Advantage (MA), and Medicare fee-for-service (FFS) patients. The average 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 several types of ambulatory care visits: emergency, urgent care, office, physical exams, preventive, alcohol/drug, and psychiatric care.

The researchers verified 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 account for new members adding insurance and disrupted coverage caused by job losses or other factors. The trends in ambulatory care utilization were similar between cohorts across the groups.

The rebound seen by the summer of 2020 showed variation when broken out by insurance type: 94.0% for Medicare FFS; 88.9% for commercial insurance; 86.3% for Medicare Advantage; 83.6% for dual eligible; and 78.0% for Medicaid.

"The big picture is that utilization looks similar across the three groups and has not attained prepandemic levels," Mafi said.

When the results were divided by service type, utilization rates remained below expected rates while needs remain similar for U.S. Preventive Services Task Force–recommended preventive screening services, Mafi noted. The demand for psychiatric and substance use services has increased, but use rates are below expected rates. In addition, both avoidable and nonavoidable ED utilization both remained below expected rates.

In-person visits are down across insurance groups, but virtual visits are skyrocketing, across all insurance groups, Mafi added. However, virtual care visits have not completely compensated for declines in in-person visits, notably among dual-eligible and Medicaid insurance members.

Takeaways for policy makers include the fact that, while some reductions in unnecessary care, such as avoidable ED visits, may be beneficial, the "reduced USPSTF-recommended cancer and other evidence-based disease prevention may worsen health outcomes, particularly for Medicaid beneficiaries," he said.

Outreach and Outcomes

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

"While the COVID-19 pandemic has seriously disrupted access to U.S. ambulatory care, most studies have focused on the early months of the pandemic," he noted.

Mafi said he was not surprised that ambulatory care utilization has not rebounded among Medicaid beneficiaries relative to other insurance groups.

"Medicaid beneficiaries are underresourced individuals who are disproportionately racial/ethnic minorities, and they historically have had difficulties accessing care. Our data suggest that the COVID-19 pandemic may be widening these preexisting inequities in access to ambulatory care," he observed.

The study findings were limited by the use of the MedInsight research dataset, which is a convenience sample; and, therefore, the results might not be generalizable nationally, Mafi said. "However, it does include beneficiaries from all major insurance types across all 50 U.S. states. Additionally, our analysis was completed at the population level rather than the patient level, and so we were unable to account for patient-level characteristics such as clinical complexity," he explained.

"The take-home message for clinicians is that our patients with Medicaid insurance may need additional efforts to overcome barriers to accessing ambulatory care, such as creating robust telemedicine outreach programs," said Mafi. "Policy makers should also consider providing additional support and resources to safety net health systems who disproportionately care for Medicaid beneficiaries, such as higher reimbursements for both in-person and telemedicine visits."

More research is needed, he emphasized. "We urgently need further inquiry into the impact of this persistently deferred ambulatory care utilization on important health outcomes such as preventable death/disability and quality of care."

COVID Consequences Challenge Ambulatory Care

"These study findings mirror what we are seeing in primary care settings," Maureen Lyons, MD, of Washington University. St. Louis, said in an interview. "With the pandemic, there are many additional barriers for patients accessing care, and these barriers have disproportionately impacted those who are already disadvantaged.

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

"Additionally, many patients have needed to take on increased responsibilities in other areas of their lives, such as caring for an ill family member or being responsible for children's virtual school," she said. These new responsibilities can lead people to skip or postpone ambulatory care visits.

"Loss of ambulatory care is likely to lead to increases in preventable illnesses with long-lasting effects," Lyons noted. "Studying this in a robust fashion, as Mafi and 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 finalized estimates of ambulatory utilization rates in a forthcoming scientific paper.

The study was a collaboration between UCLA and Millman MedInsight, an actuarial health analytics company. Several coauthors are Millman employees. Mafi and the other researchers had no other relevant financial conflicts to disclose. Lyons had no financial conflicts to disclose.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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