Pandemic Shock Threatens to Undermine Outpatient Care
Updated since original publication on April 23, 2020.
In March, the coronavirus outbreak caused an unprecedented disruption in the usual sources of care for patients in the United States.
Early in the crisis, the policy response focused on bolstering hospital capacity. But outpatient care was also disrupted, as office visits with physicians and nurse practitioners plummeted. Fee-for-service revenue fell precipitously, prompting furloughs, layoffs, and even closures at many practices.
Outpatient offices faced a perfect storm of stay-at-home orders, infection risks, and severe financial stress — all while still trying to deliver desperately needed clinical care. Clinicians and patients fell back on a century-old technology — the telephone — and started to use newer telemedicine platforms like videoconferencing and text chats.
In April, the Commonwealth Fund collaborated with researchers at Harvard University and Phreesia, a health care technology company, to publish a real-time snapshot of the dramatic changes occurring in outpatient practice. The team has now updated that picture based on three months of data from a large and diverse set of outpatient practices in all 50 states. These practices use the Phreesia technology platform to manage several aspects of daily workflow, including registration, insurance verification, patient questionnaires, patient-reported outcomes, and payments.
After an initial decline in outpatient visits of nearly 60 percent from pre-crisis levels — affecting all regions of the U.S., all ambulatory care specialties, and patients of all ages — the updated report through May 15 shows an emerging rebound. The rebound appears to be mostly due to increasing in-person visits.
An initial uptick in the use of telemedicine has plateaued, and telemedicine still accounts for a small fraction of the lost ambulatory visits. Even so, outpatient visits are still about 30 percent lower than before. The rebound seems evenly distributed among regions, specialties, and patients of different ages. In an added chart, the report shows a similar pattern of decline and rebound across organizations of different sizes.
What are the implications for U.S. health care?
- The health of Americans is still at risk. Loss of access to health care services can have a negative impact on health, especially for people with acute and chronic conditions. Subtle symptoms that may indicate serious health problems like heart attack, stroke, or pneumonia may go unrecognized, and a lack of timely lab testing and adjustments to medications can lead to deterioration of chronic conditions. Prior to the pandemic, not all outpatient visits were necessary, but many were. Unchecked, the erosion of outpatient capacity will undermine needed care.
- All regions are still affected. Disruptions in care do not appear limited to areas of the country that were facing serious outbreaks or had stay-at-home orders in place.
- To meet patient needs, telemedicine may still have to expand. Telemedicine volume has grown too modestly to make up for lost in-person visits. Moreover, clinicians may still be learning how to use telemedicine effectively. Tracking its growth and use among specialties over time will be important. At the same time, telemedicine cannot replace all types of visits: in-person visits will still be needed to diagnose and test certain complex conditions.
- Most outpatient practices still face substantial financial risk. Most practices rely on fee-for-service payments, meaning the decline in visits is causing a direct hit to revenue. Even with the recent rebound and boost to telemedicine payments, practices faced with large revenue losses will struggle to continue delivering care. Many will have no choice but to cut back on staff and operations just when services are most needed. Those that serve traditionally underserved patient populations may be especially at risk.
These findings show that outpatient care continues to be threatened by this national emergency. While the results are from a sample of practices accounting for approximately 5 percent of ambulatory visits in the U.S., it seems likely that other practices are facing similar challenges. Additional funding will almost certainly be needed to allow outpatient practices to remain intact and functioning; to halt further staff layoffs; to expand telemedicine capacity; and to invest in the kind of modifications, like personal protective equipment, that can allow practices to offer in-person services and procedures safely. Any further erosion of capacity during this first wave of the pandemic will leave Americans ill-prepared to receive the ambulatory care they need now and in the future.
During this unprecedented public health and economic crisis, practices, policymakers, and patients will have an ongoing need for timely information on the status of outpatient care and its potential to recover. We expect additional analyses will shed needed light for policymakers and others making decisions that may profoundly affect the future of outpatient care in the U.S.