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The Impact of the COVID-19 Pandemic on Outpatient Visits: Practices Are Adapting to the New Normal

A new report, which describes visit trends through August 1, 2020, is available here.

 

The COVID-19 pandemic has dramatically changed how outpatient care is delivered in health care practices. To decrease the risk of transmitting the virus to either patients or health care workers within their practice, providers had been deferring elective visits when possible. They also are converting in-person visits to telemedicine visits.

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. In mid-May, we issued an update that indicated the beginning of a rebound in visits. In our third report, we describe visit trends through June 20.

Many local and state restrictions on travel and nonessential services have now been lifted. Stores and other businesses have begun to reopen. At the same time, we have seen a surge of cases in new areas of the country. Outpatient practices have been adapting to this new reality, developing new ways of delivering care both in person at their practices and via telemedicine.

But while visit numbers have rebounded, they are still substantially lower than before the U.S. pandemic began. Over the past three months, forgone visits have created “cumulative deficits” in both patient treatment and practice revenue.

Knowing the impact COVID-19 is having on office visits helps us to address several ongoing 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 economic impact of the pandemic on health care practices?

Researchers at Harvard University and Phreesia, a health care technology company, 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 type, geographic area, clinical specialty, insurer, and size of provider organization. Details on data sources, analyses, and study limitations are available at the bottom of this page.

 

To view commentary on the findings, see our accompanying To the Point post. Also see our related feature, which describes practices that have not returned to the precrisis normal.

Overall visit counts for the week of June 14 are still substantively lower than baseline. The “cumulative deficit” in visits over the last three months (March 15–June 20) is nearly 40 percent.

The number of visits to ambulatory practices had declined nearly 60 percent by early April. Since that time, the numbers have rebounded substantially, though the rebound may be beginning to plateau.

The rebound in visits is occurring across the U.S. The initial decrease in visits was most evident in the New England, Mid-Atlantic, and Pacific regions.

The decline in visits was greatest in those states that had an early surge in COVID-19 cases. Visits remain more depressed in these states.

Initially, as in-person visits dropped, telemedicine visits increased rapidly. Since that peak in mid-April, telemedicine use has begun to decline, though it remains substantially higher than prior to the pandemic.

In the past week, visits to some clinical specialties, such as dermatology and rheumatology, have returned to their baseline rates.

Since the nadir of visits in late March, there has been a substantial rebound in visits among people covered by Medicare. The rebound among people covered by Medicaid has lagged.

There is a striking difference between adults and children in how visits have rebounded.

Among smaller practices — one to five clinicians — both the initial decline in visits in early March and the subsequent rebound in visits were smaller.

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 June 20, 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 15th, 2020.

All data were analyzed by Phreesia staff in consultation with Harvard 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, and Good Friday, April 10) were excluded.

Provider organization size is based on the number of independent clinicians and includes physicians, nurse practitioners, psychologists, physician assistants, and social workers. The organization is the financial entity that contracts with Phreesia. It can be a single clinic or be a large health care system that includes numerous clinical sites.

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 scheduling 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: June 25, 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: Practices Are Adapting to the New Normal (Commonwealth Fund, June 2020). https://doi.org/10.26099/2v5t-9y63

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