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Improving Health Care Quality

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The Impact of COVID-19 on Outpatient Visits in 2020: Visits Remained Stable, Despite a Late Surge in Cases

Octoclean worker Erick Borjas uses electrostatic disinfectant (ESD) to clean and rid a waiting room of COVID-19 during the coronavirus pandemic at a medical facility on April 15, 2020 in Riverside County, California.

The COVID-19 pandemic dramatically altered the delivery of outpatient care in 2020. Beginning in March, health care practices began deferring elective visits, modifying their practices to safely accommodate in-person visits, and increasing the use of telemedicine.

Since the start of the pandemic, we have issued a series of reports tracking weekly outpatient visit volume. In April, we reported that the number of visits to ambulatory care providers had declined by nearly 60 percent. By May, visits had rebounded, though they were still below the prepandemic baseline. In our August update, we described modest drops in visits in some of the COVID-19 hot-spot states. By October, office visit volumes had essentially returned to baseline, and telemedicine use showed signs of declining.

In this, our sixth report, we describe visits through the end of 2020. Over November and December, the nation witnessed an unprecedented rise in COVID-19 cases. Coming on the heels of the holiday season, this COVID-19 surge affected nearly all states, exacerbating several challenges already facing care providers: treating patients exposed to the virus or infected by it; managing patients with non-COVID-19-related illnesses; keeping providers and staff healthy; and ensuring the financial viability of their practices.

The charts that follow point to the resiliency of outpatient practices in the face of these challenges, as the number of weekly outpatient visits overall remained stable. However, there were several notable changes in November and December, including a modest shift back to telemedicine and a substantial drop in visits among children. Furthermore, while visit volumes mostly remained stable, they were below the levels for early winter seen in prior years — a time when visit volumes typically rise.

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

  • What is the clinical impact of the pandemic, and how accessible has outpatient care been during the pandemic?
  • Are new policies encouraging greater use of telemedicine?
  • What has been the financial impact of the pandemic on health care providers?

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. To better understand the impact of the pandemic on visit volumes, we also present outpatient visit volumes averaged over the prior four years. Comparing weekly visits during 2020 to weekly visits during prior years helps us better understand whether changes we have observed are unusual or reflect annual seasonal changes.

In addition, we refined the sample of practices we included in the analyses to ensure that changes in practice composition are not driving the shifts in visit volume. Details on these changes, data sources, analyses, and study limitations are available at the bottom of this post.

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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. 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.

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

Visits were captured from January 1, 2016, to December 31, 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.

We made several modest changes in this most recent report. We included all Phreesia clients that were part of the data as of January 1 of a given year. New Phreesia clients that joined after January 1 were not included in the data for that year. During the year, existing clients may introduce Phreesia to new clinical sites. For example, an organization might buy a new practice site or begin to use Phreesia services at existing clinical sites that had not been previously counted in our data. To avoid bias in our estimates of changes of visit patterns, we excluded organizations that displayed very high levels of such expansion. This change had a very small impact on our overall visit counts, but readers will note that this change did have a substantive change in dermatology results from our October 2020 report.

Phreesia staff, in consultation with Harvard University researchers, analyzed all data. They calculated results and shared them with the 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 organizations prior to effects of the pandemic. Visits on holidays were excluded, and, during holiday weeks, we adjusted visit counts to account for the fewer days during the week.

The data have limitations. As with any convenience sample of providers, the patterns we observe may not be representative of all organizations nationally or regionally. While we have tried to address situations in which organizations added or dropped practice sites, changes in the organizations (e.g., expansion of providers at a single site) could be driving some of the results described. Unscheduled same-day and walk-in visits are typically captured in the scheduling software, but it is possible some unscheduled telephone encounters were not captured if the software did not record them. Workflow and documentation practices have likely shifted during the pandemic as well. Finally, the fraction of all visits identified as telemedicine may be underestimated, since, early in the pandemic, providers were still creating processes to designate telemedicine visit types in their scheduling software.

Publication Details

Date

Contact

Ateev Mehrotra, Associate Professor of Health Care Policy and Medicine, Harvard Medical School

[email protected]

Citation

Ateev Mehrotra et al., The Impact of COVID-19 on Outpatient Visits in 2020: Visits Remained Stable, Despite a Late Surge in Cases (Commonwealth Fund, Feb. 2021). https://doi.org/10.26099/bvhf-e411