Affordable, quality health care. For everyone.

The Impact of the COVID-19 Pandemic on Outpatient Visits: Changing Patterns of Care in the Newest COVID-19 Hot Spots

A new report, which describes visit trends through October 10, 2020, is available here.

 

The COVID-19 pandemic has brought dramatic changes to the delivery of outpatient care. To decrease the risk of transmitting the novel coronavirus to patients or health care workers, health care practices have deferred elective visits, modified their practices to safely accommodate in-person visits, and increased their use of telemedicine.

In late April, we published findings demonstrating that, early in the pandemic, the number of visits to ambulatory care practices had declined by nearly 60 percent. We issued an update in mid-May showing a substantial rebound in office visits and an update in late June showing the beginning of a plateau in this rebound. In this, our fourth report, we describe visit trends through August 1.  

During late May and much of June, local and state officials were lifting many of the restrictions placed on travel and nonessential services. Stores and other businesses began to reopen. By late June, however, several “hot spots” had emerged, with new COVID-19 cases surging in early-opening states like Arizona, Florida, and Texas while other areas of the country, most notably the Northeast, saw declining or low rates of new cases.

In all areas of the United States, outpatient practices and patients face a changing incidence of COVID-19 in their community, shifting local public health recommendations, and the ongoing challenges of revenue shortfalls and keeping patients and providers safe.

By tracking trends in outpatient office visits, we hope to shed light on several persistent questions:

  • What is the clinical impact of the pandemic? Are people getting the care they need from their providers?
  • Are new policies encouraging greater use of telemedicine?
  • What is the financial impact of the pandemic on health care practices?

Researchers at Harvard University, Phreesia (a health care technology company), and the Commonwealth Fund analyzed data on changes in visit volume for the more than 50,000 providers that are Phreesia clients. The following charts illustrate how declines in visits vary by patient age, geographic area, clinical specialty, and insurer. Details on data sources, analyses, and study limitations are available at the bottom of this post.

The number of visits to ambulatory practices fell nearly 60 percent by early April before rebounding through mid-June. From then through the end of July, weekly visits plateaued at 10 percent below the prepandemic baseline. The cumulative number of lost visits since mid-March remains substantial and continues to grow.

Several states with surging COVID-19 cases during June and July (Arizona, Florida, and Texas) have seen a decline in provider office visits, although it’s been a small one compared to early in the pandemic. Visit volumes in other states with surging new cases have held steady. Visit rates in the Northeast continue to lag most of the nation, even with relatively low weekly new case counts.

Initially, as in-person visits dropped, telemedicine visits rose rapidly.  Since that peak in mid-April, telemedicine use declined and now appears to have plateaued at a substantially higher rate than prior to the pandemic. We show telemedicine use in three ways in the following graphs.

In the hot spot states of Arizona, Florida, and Texas, there has been a surge in telemedicine use corresponding in time to the surge in new COVID-19 cases. This is one example of how practices have adapted to changing circumstances in their community. Practices in these states appear to have maintained most of their visit volume by increasing telemedicine visits and creating new safety protocols for in-person visits.

Most recently, visits to some specialties, such as dermatology, ophthalmology, and adult primary care, have returned to or exceeded their baseline rates. Visits to other specialties, such as pediatrics and pulmonology, remain substantially below baseline.

There have been striking differences in speciality visit trends throughout the pandemic. Dermatology had one of the largest initial declines in visits but then rebounded above baseline. Behavioral health, which had one of the smallest initial declines, has only modestly rebounded, with visits plateauing at 15 percent to 20 percent below baseline.

The rebound in visits has varied by type of insurance: visits by Medicare patients have been robust while those by Medicaid patients have lagged.

The fraction of all visits per week for self-pay patients (those lacking insurance) has increased over the course of the pandemic. This could be because the number of people becoming uninsured is increasing or more uninsured patients are becoming ill and seeking care.

There continues to be a striking difference in visit patterns between adults and children. Visit rates for children remain substantially lower than for adults.

The rebound in visits to Federally Qualified Health Centers (FQHCs) has been smaller than the rebound seen in other types of practices. This could partly reflect the fact that FQHCs care for more children than other practices do.

FQHCs are now providing more of their care via telemedicine compared to other practices. This could be partly driven by their patient populations and by their greater likelihood of providing behavioral health services.

Data and Analyses

Phreesia is a health care technology company that helps ambulatory practices with the patient intake process, including registration, insurance verification, patient questionnaires, patient-reported outcomes, and payments. The data reported here come from Phreesia’s clients, which include more than 1,600 provider organizations representing more than 50,000 providers across all 50 states. In a typical year, these provider organizations have more than 50 million outpatient visits, or more than 1 million visits a week.

The provider organizations include independent single-provider practices, multispecialty groups, Federally Qualified Health Centers, and large health systems. Of all visits in a typical week before the pandemic, 47 percent are with primary care physicians (adult and pediatric) and the other 54 percent of visits are spread across more than 25 specialties. Visits with nurse practitioners and physician assistants are included under these 25 other specialties.

The data come from several sources at the practices: 1) practice management/scheduling software; 2) check-in information submitted via patients on the Phreesia platform (e.g., age); and 3) selected data from the electronic health record, such as problem lists.

Visits were captured from February 1 through August 1, 2020. A visit was counted if it was in the practice’s scheduling software and the patient was “checked in.” A visit is considered checked in when either the patient or someone at the practice (such as a nursing assistant) filled in the necessary information using the Phreesia platform and the patient was ready to see the provider. Telemedicine visits were identified in the scheduling software based on the appointment type or location. Telemedicine includes both telephone and video visits. The data exclude any new Phreesia clients who joined after February 15, 2020.

All data were analyzed by Phreesia staff in consultation with Harvard University researchers. Results were calculated and shared with Harvard researchers in aggregate form as percentage drops from baseline. The baseline for visits was defined as the week of March 1 to 7; a representative week among the practices prior to effects of the pandemic. Visits on holidays (President’s Day, February 17, Good Friday, April 10, Memorial Day, May 25, and the Fourth of July — as well as Friday, July 3) were excluded.

The data have limitations. As with any convenience sample of practices, the patterns we observe may not be representative of all practices nationally or regionally. Unscheduled same-day and walk-in visits are typically captured in the scheduling software, but it is possible some unscheduled telephone encounters may not be captured if they were not recorded in the software. Workflow and documentation practices have likely shifted during the pandemic. In addition, early in the pandemic, providers were still creating processes to designate telemedicine visit types in their scheduling software. As a result, the fraction of all visits identified as telemedicine may be underestimated.

Publication Details

Publication Date: August 13, 2020
Contact: Ateev Mehrotra, Associate Professor of Health Care Policy and Medicine, Harvard Medical School
Citation:

Ateev Mehrotra et al., The Impact of the COVID-19 Pandemic on Outpatient Visits: Changing Patterns of Care in the Newest COVID-19 Hot Spots (Commonwealth Fund, Aug. 2020). https://doi.org/10.26099/yaqe-q550

Experts

Ateev Mehrotra
Associate Professor of Health Care Policy and Medicine, Harvard Medical School
Michael Chernew
Leonard D. Schaeffer Professor of Health Care Policy, Harvard Medical School
David Linetsky
Senior Vice President, Life Sciences, Phreesia
Hilary Hatch
Vice President, Clinical Engagement, Phreesia
David Cutler
Otto Eckstein Professor of Applied Economics, Kennedy School of Government, Harvard University
Eric C. Schneider, M.D.
Senior Vice President for Policy and Research, The Commonwealth Fund