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May 29, 2020

As Outpatient Visits Rebound, COVID-19 Pandemic’s Threat to Outpatient Care Remains

Author Affiliations
  • 1Consulting Editor, JAMA Health Forum and JAMA
JAMA Health Forum. 2020;1(5):e200685. doi:10.1001/jamahealthforum.2020.0685

After a precipitous decline in outpatient visits to clinicians early in the coronavirus disease 2019 (COVID-19) pandemic, there are signs of an emerging rebound, according to new data published on May 19 by the Commonwealth Fund. However, the rebound falls well short of prepandemic levels, and outpatient care continues to be threatened by the pandemic’s effects.

During the study period (mid-February to mid-May 2020), there were about 12 million outpatient visits. The number declined nearly 60% between baseline levels in mid-February and the end of March, according to the researchers, who are at Harvard University, University of Michigan, and Phreesia, a health information technology firm. Since then, visits have rebounded somewhat across all specialties, but as of mid-May, the overall number of visits remained about 30% less than baseline levels.

The analysis is based on a snapshot of the number of outpatient visits from mid-February to mid-May for more than 50 000 clinicians at more than 1600 organizations (Phreesia’s clients), which included independent single-practitioner practices, multispecialty groups, federally qualified health centers, and large health systems. These practices use Phreesia’s platform to manage such aspects of workflow as registration, insurance verification, patient questionnaires, and payments.

The researchers noted that the decline in visits reflects clinician efforts to decrease the risk of COVID-19 transmission to either patients or health care workers within a practice by deferring elective and preventive visits, such as annual physical examinations. Many patients are also avoiding visits because they are concerned about risking exposure to severe acute respiratory syndrome coronavirus 2. A national survey of approximately 2200 US adults conducted on behalf of the American College of Emergency Physicians in mid-April found that 80% of those surveyed worried about contracting COVID-19 if they needed to receive medical care and nearly 30% had actively delayed or avoided seeking medical care because of such concerns.

When possible, the researchers noted, clinicians are providing care via telehealth sessions rather than in-person visits. “But the increase in telehealth visits only partially offset the drop in in-person visits,” they wrote.

Slightly less than half of all visits in a typical week before the pandemic were with adult and pediatric primary care physicians; 25 specialties (including visits with nurse practitioners and physician assistants) accounted for about 54% of visits. All specialties experienced declines in visits, but the magnitude of the decline varied substantially by specialty, with larger declines among surgical and procedural specialties and pediatrics and a much smaller decline for behavioral health.

Similarly, although all specialties experienced a rebound in visits, the extent of the recovery varied by specialty. For example, in the week starting May 10, declines relative to prepandemic levels remained larger among surgical and procedural specialties and pediatrics and smaller for areas such as adult primary care, oncology, and behavioral health.

Recovery also varied by patient age group. Outpatient visits for adults 65 years and older rebounded from the low point in early April (less than 40% of prepandemic visits) to about 70% of the level of prepandemic visits 5 weeks later, whereas the rebound was much smaller for school-aged children.

The findings also show that all areas of the country experienced a downturn in outpatient visits—although declines were greatest in the mid-Atlantic and New England regions. And all regions are still affected by a reduced level of outpatient care.

The large decline in outpatient care and the tepid rebound in outpatient visits have important implications for US health care, including for the health of patients and the financial future of outpatient practices, noted Eric C. Schneider, MD, MSc, senior vice president for policy and research at the Commonwealth Fund, and Tanya Shah, MBA, MPH, vice president in the delivery system reform program, in an accompanying commentary. “Loss of access to health care services can have a negative impact on health, especially for people with acute and chronic conditions,” they wrote. “Unchecked, the erosion of outpatient capacity will undermine needed care.”

Schneider and Shah also noted that because most practices rely on fee-for-service payments, the substantial decrease in patient visits is causing “a direct hit to revenue.” This means that this financial risk to practices poses a threat to the recovery of US outpatient care. “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,” they wrote.

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