While Sick Visits to Pediatric Practices Decline, Mental Health Visits Rise

Despite surges of COVID-19 cases during November and December, ambulatory care visits by U.S. adults were just 5 percent to 6 percent below the typical level by year-end, according to the latest analysis of trends in outpatient office visits conducted by researchers from the Commonwealth Fund, Harvard University, and the health care technology company Phreesia. Pediatrics practices, however, have not seen the same rebound. Among children ages 3 to 17, weekly visit volumes fell after October and ended the year substantially lower (24%) than what would normally be expected.

We reached out to leaders of six diverse pediatric practices that use the Phreesia platform for patient check-ins to understand what accounts for the sustained reduction in office visits among younger patients, particularly those under 5. We asked about the challenges they’re facing and their concerns for patients and families during the pandemic.

Sick Visits Down, But So Too Are Well Visits

Part of the drop in pediatric visits can be attributed to declines in sick visits. In January, these visits were down more than 40 percent at a D.C.-area practice, Capital Area Pediatrics, and down 50 percent at a small Texas practice, Piga Primary Care. Mask use and less socializing have meant that children across the country have experienced fewer cases of strep, respiratory syncytial virus, and flu over the winter, leading to fewer office visits. “It’s been a very light sick season,” says Stewart Samuel, M.D., a pediatrician with Allied Physicians Group, which operates 35 pediatric practices in the New York City area, many on Long Island. Allied Physicians’ sick visits in January 2021 were 30 percent lower than last year. “It’s not a great business model, but our goal is to keep everyone out of the office,” Samuel says.

More worrisome, some pediatricians saw steep drop-offs in well visits. Children receive time-sensitive immunizations and developmental screenings during well visits. These visits also give pediatricians opportunities to detect rare but serious childhood illnesses like leukemia and screen for problems like maternal depression or child abuse. Anecdotal reports from emergency departments (EDs) suggest child abuse has increased during quarantine periods, and teachers worry red flags are being missed with kids out of classrooms.

Across the board, the pediatricians we talked to have doubled down in their efforts to encourage families to come into the office by emphasizing the safety measures they’ve taken. These include segregating sick and well-child visits, limiting the number of visitors, and offering drive-through vaccination clinics. Most have been able to get well-child visits to 90 percent of expected visits or higher.

Still, some face challenges. For example, at the University of North Texas Health Science Center Pediatric Clinic in Fort Worth, Texas, well-child visits were down 38 percent from March through December 2020 compared with the prior March to December, partly because the clinic stopped double- and triple-booking appointments. To ensure children receive vaccinations, the clinic stationed a mobile unit in a parking lot to deliver well-child immunizations. The practice has been able to weather the loss of revenue from the steep decline in visits because of a financial cushion built over the past several years and from funding — the health system secured $500,000 in support through the CARES Act and Payroll Protection Program, says Priya Bui, D.O., one of the practice’s five pediatricians.

Blue Ridge Pediatric and Adolescent Medicine, in Boone, N.C., also has sought to make vaccination easier for both parents and children. Last year, the practice offered outdoor influenza vaccination clinics and partnered with a local pharmacy to offer parents the vaccine at the same time.

Naomi Piga, M.D., runs Piga Primary Care in Frisco, Texas, a pediatric and internal medicine practice, with her brother and sister-in-law. Piga has used Facebook to highlight the safety measures they’ve taken, including installing new ventilation equipment and air purifiers, and recently held a Zoom town hall about the COVID-19 vaccines. It helps that the practice is well stocked on masks, gowns, and other personal protective equipment, which Piga acquired in January 2020 while worrying about her parents who were travelling in Asia. The stockpile allowed her to keep the practice open while others closed their doors. “When a lot of my colleagues said they were down to one box of masks, I had 20,” she says.

Increase in Mental Health Problems

Leaders of these pediatric practices also report dramatic increases in depression and anxiety among children and at younger ages than is typical. School administrators in Las Vegas pointed to school closures as a factor in a spate of student suicides. Before the pandemic, suicides among youth had already been rising, becoming the second-leading cause of death among adolescents in 2019.

“Mental health issues have gone through the roof and the acuity has gone up,” says Elizabeth Watts, M.D., CEO and medical director of Capital Area Pediatrics, with offices in cities and suburbs skirting D.C. The medical group has a nurse navigator dedicated to helping youth and adolescents, some suicidal, find therapists and inpatient care. Watts is particularly concerned about children and teens who before the pandemic turned to school and friends as a respite from conflict at home, and teens who identify as LGBTQ and find their peers at school. “Those are the kids I’m checking in with every three months and saying, ‘How is it going?’”

Gregory Adams, M.D., a pediatrician at Blue Ridge Pediatric and Adolescent Medicine, has been taken aback by the number of children and teens exhibiting mental distress. “Anxiety levels have never been higher — at all ages. One afternoon was nothing but new-onset anxiety. Every patient,” he says. It’s hard for Adams to refer children and teens to therapists because providers aren’t seeing patients in person or don’t accept Medicaid. Adams has been prescribing medications and offering reassurance, giving his cell phone number to those who are depressed or suicidal. “Just knowing they have my number gives them peace of mind,” he says.

Piga has seen a similar trend of children manifesting anxiety and depression at younger ages. “I’ve actually done more prescribing in the last year than I have in the previous 14 years — and for younger children,” she says.

Part of the problem is that during the pandemic children and teens have been deprived of opportunities to engage in extracurricular activities that gave their lives meaning. “You realize for many kids, their piece of happiness is some type of activity. They pass their classes so they can play basketball or participate in band and that got taken away. We definitely see that having a huge impact on behavioral health, motivation, mood, all of it,” Bui of University of North Texas Health Science Center Pediatric Clinic says.

Offering Supports Beyond the Office

With fewer office visits, the pediatric practices have been working to offer additional support to families during the pandemic.

Bui and a medical student came up with the idea of having third- and fourth-year medical students reach out to families to check on their mental health and connect them with providers or other sources of support. Through the “Pediatric Mental Health Calls” program, volunteer medical students reached out to high-risk groups: teenagers who may be struggling and new mothers who may be experiencing postpartum depression. After Bui heard reports from local EDs about a spike in child abuse cases, they began calling families with toddlers, a group that accounts for a disproportionate share of child abuse cases. Following a script that involves taking psychosocial histories and screening for problems, medical students made more than 3,500 calls from March to November 2020. One of five families asked for some type of support for issues ranging from maternal depression to food insecurity. Nearly one of five teens (17%) asked to schedule a mental health visit with a provider.

Child & Family Development, a North Carolina family therapy practice that provides diagnostic and therapeutic services for children, teens, and young adults with mental health needs or developmental conditions, also has increased outreach to parents who may be experiencing strain managing developmental problems at home. It set up virtual parenting sessions for parents of children with autism. The practice has seen an increase in the numbers of parents reaching out for help with children who struggle to learn; with virtual school, parents are seeing firsthand the challenges. “Parents are saying I just didn’t know what a big struggle it was,” says Gretchen Hunter, Ph.D., clinical neuropsychologist and clinical supervisor.

Hunter worries about other children whose parents are putting off visits out of fear of the virus or wishful thinking that problems will vanish with the pandemic’s end. The practice has begun hosting Zoom webinars to offer guidance on remote schooling and to drive home the message that with developmental delays, “the risk of not contracting the virus doesn’t outweigh the reward of addressing a problem early when there is a secure, safe environment to get assessment and diagnosis,” says Pam Jones, M.B.A., president of the practice.

Policy Implications

It has become clear that shuttered schools, missed soccer games, and the consequences of other social-distancing restrictions, as well as the economic fallout of the pandemic, are putting strain on children and teens. The pediatricians we spoke with are spending less time treating flu and other seasonal ailments, and more time helping kids struggling with anxiety and depression, as well as checking in with families — some applying for food support and other benefits for the first time. Based on our conversations, the following policies would support their work during the pandemic and beyond.

Help with pandemic-related costs and adequate payment for testing. Pediatricians have worked hard to encourage families to feel safe in their offices. They are spending more on personal protective equipment (PPE) and other cleaning supplies while at the same time billing for fewer visits. Last year, the American Medical Association established a code to bill for the costs of PPE and other safety provisions, but many insurers are not reimbursing for it. And many pediatricians say insurers are not reimbursing anywhere near their costs for coronavirus testing.

The American Rescue Plan Act of 2021 may help some pediatricians; it includes $8.5 billion in direct support for rural providers that demonstrate lost revenue and additional expenses related to the pandemic, as well as funds for vaccines, treatment, personal protective equipment, testing, contact tracing, and public health workforce development.

At the same time, some of the pediatricians we spoke with are dismayed they haven’t been tapped to help in the coronavirus vaccination campaign; historically, pediatricians along with pharmacists have done the lion’s share of all vaccinations. “We do flu vaccines for kids and their parents in two to three months,” says Watts of Capital Area Pediatrics. “We have that infrastructure and we’re used to reporting. It’s already hardwired for us.”

Support to help pediatricians treat the growing number of kids with mental health problems. Pediatricians are seeing the high toll the pandemic is taking on kids’ well-being. They are struggling to help them in their own practices or find therapists and psychiatrists to refer them to.

Many of the families in Piga’s Texas practice cannot find affordable therapists or psychiatrists; many providers don’t accept insurance. Piga has access to the state’s Child Psychiatry Access Network, which enables pediatricians to receive same-day consults from pediatric psychologists or psychiatrists about mental health assessments, symptoms, and medications as well as help with referrals; many other states and American Indian tribes have similar programs. “This helps pediatricians become comfortable with prescribing psychiatric medicines for simpler cases and frees up the child psychiatrists for the difficult cases,” Piga says. The American Rescue Plan Act provides an additional $80 million to support such approaches through the Pediatric Mental Health Care Access program.

Capital Area Pediatrics’ providers have benefitted from REACH (Resource in Advancing Children’s Health) Institute training, in which they learn from child psychologists and psychiatrists about ways to use structured screening tools, manage psychiatric medications, and look for red flags indicating kids may need specialty support. The training is paid for through a grant from the Virginia chapter of the American Academy of Pediatrics. To build the practice’s in-house capacity, Watts has been trying to hire a therapist, but has struggled because of workforce shortages and low reimbursements for therapeutic services. Changing the rules to allow therapists working toward licensure requirements to bill for their services would help, she says.

Hunter of the family therapy practice Child & Family Development says billing codes need to be adjusted to allow behavioral health specialists like her to provide short-term and consultative services to pediatricians. “We would be able to provide more targeted interventions and consultation to pediatricians with more flexibility,” she says.

Support for families beyond the office. The pandemic has prompted pediatricians to reach out in new ways: proactively calling their patients, using video to connect with them in their homes, and tapping social media to offer information and guidance. Pediatricians we spoke with noted the importance of sustaining these connections beyond the pandemic; this will require payers to continue to reimburse for telehealth visits on par with in-person services.

Responding to families’ need for food, housing, and other social supports is a common challenge. Pediatricians in North Carolina have access to NCCare360, a statewide platform that enables health care providers to easily connect to human services agencies and nonprofits through a network of on-call navigators, a shared resource repository, and electronic referrals. But many pediatricians rely on ad hoc networks of resources, or hand patients lists of places to call themselves.

Looking Ahead

One year into the pandemic, pediatricians and other primary care providers are still grappling with the evolving public health crisis that places high demands on them — from extra time spent counseling patients to protecting the physical and mental health of staff and strategizing to make up for revenue shortfalls that one study estimates at an average of nearly $68,000 per provider.

We interviewed just a handful. Their experiences indicate the last year has had some silver linings. For instance, declines in sick visits suggest that public health interventions including masks work. In addition, practices found new ways of leveraging the enthusiasm of medical students and developed nimble responses to promoting vaccinations that offer lessons for this pandemic and future infectious disease outbreaks.

It will be important for policymakers and payers to recognize what has worked well during the pandemic and bolster pediatricians’ efforts to support families for the long term.