Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic | Cancer Screening, Prevention, Control | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic, 2019-2021

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Were there differences in returns to expected rates of US ambulatory care use between more vs less socioeconomically disadvantaged patients in the first year of the COVID-19 pandemic?

Findings  In this retrospective cohort study that included more than 14.5 million patients, there was an overall increase in the return to expected rates of use of 6 ambulatory care services between March 2020 and February 2021. This increase was significantly lower for patients with Medicaid or those with Medicaid-Medicare dual eligibility than for those with commercial, Medicare Advantage, or Medicare fee-for-service.

Meaning  As the pandemic progressed through early 2021, there remained significant differences by insurance type in the return to expected rates in the use of 6 ambulatory services.

Abstract

Importance  Following reductions in US ambulatory care early in the pandemic, it remains unclear whether care consistently returned to expected rates across insurance types and services.

Objective  To assess whether patients with Medicaid or Medicare-Medicaid dual eligibility had significantly lower than expected return to use of ambulatory care rates than patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance.

Design, Setting, and Participants  In this retrospective cohort study examining ambulatory care service patterns from January 1, 2019, through February 28, 2021, claims data from multiple US payers were combined using the Milliman MedInsight research database. Using a difference-in-differences design, the extent to which utilization during the pandemic differed from expected rates had the pandemic not occurred was estimated. Changes in utilization rates between January and February 2020 and each subsequent 2-month time frame during the pandemic were compared with the changes in the corresponding months from the year prior. Age- and sex-adjusted Poisson regression models of monthly utilization counts were used, offsetting for total patient-months and stratifying by service and insurance type.

Exposures  Patients with Medicaid or Medicare-Medicaid dual eligibility compared with patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance, respectively.

Main Outcomes and Measures  Utilization rates per 100 people for 6 services: emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening.

Results  More than 14.5 million US adults were included (mean age, 52.7 years; 54.9% women). In the March-April 2020 time frame, the combined use of 6 ambulatory services declined to 67.0% (95% CI, 66.9%-67.1%) of expected rates, but returned to 96.7% (95% CI, 96.6%-96.8%) of expected rates by the November-December 2020 time frame. During the second COVID-19 wave in the January-February 2021 time frame, overall utilization again declined to 86.2% (95% CI, 86.1%-86.3%) of expected rates, with colonoscopy remaining at 65.0% (95% CI, 64.1%-65.9%) and mammography at 79.2% (95% CI, 78.5%-79.8%) of expected rates. By the January-February 2021 time frame, overall utilization returned to expected rates as follows: patients with Medicaid at 78.4% (95% CI, 78.2%-78.7%), Medicare-Medicaid dual eligibility at 73.3% (95% CI, 72.8%-73.8%), commercial at 90.7% (95% CI, 90.5%-90.9%), Medicare Advantage at 83.2% (95% CI, 81.7%-82.2%), and Medicare fee-for-service at 82.0% (95% CI, 81.7%-82.2%; P < .001; comparing return to expected utilization rates among patients with Medicaid and Medicare-Medicaid dual eligibility, respectively, with each of the other insurance types).

Conclusions and Relevance  Between March 2020 and February 2021, aggregate use of 6 ambulatory care services increased after the preceding decrease in utilization that followed the onset of the COVID-19 pandemic. However, the rate of increase in use of these ambulatory care services was significantly lower for participants with Medicaid or Medicare-Medicaid dual eligibility than for those insured by commercial, Medicare Advantage, or Medicare fee-for-service.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: John N. Mafi, MD, MPH, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, 1100 Glendon Ave, No. 908, Los Angeles, CA 90024 (jmafi@mednet.ucla.edu).

Correction: This article was corrected on January 24, 2022, to adjust the number of ambulatory services and the percentages of office and urgent care visits and contraception counseling or HIV screenings delivered from January 1, 2019, through February 28, 2021.

Accepted for Publication: December 19, 2021.

Author Contributions: Dr Mafi had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Mafi, Craff, Nelson, Sarkisian, Kahn.

Acquisition, analysis, or interpretation of data: Mafi, Craff, Vangala, Pu, Skinner, Tabatabai-Yazdi, Nelson, Reid, Agniel, Tseng, Damberg, Kahn.

Drafting of the manuscript: Mafi, Craff, Pu.

Critical revision of the manuscript for important intellectual content: Mafi, Craff, Vangala, Skinner, Tabatabai-Yazdi, Nelson, Reid, Agniel, Tseng, Sarkisian, Damberg, Kahn.

Statistical analysis: Mafi, Vangala, Tabatabai-Yazdi, Agniel, Tseng, Damberg.

Obtained funding: Mafi.

Administrative, technical, or material support: Mafi, Craff, Pu, Skinner, Nelson, Reid, Kahn.

Supervision: Mafi, Craff, Skinner, Sarkisian, Kahn.

Conflict of Interest Disclosures: Dr Mafi reported receiving grants from National Institute on Aging and Arnold Ventures and nonfinancial support from Milliman. Dr Craff reported being an employee of Milliman. Dr Pu reported being an employee of Milliman. Dr Skinner reported being an employee of Milliman. Dr Tabatabai-Yazdi reported receiving consulting fees from UCLA. Dr Nelson reported being an employee of Milliman. Dr Reid reported receiving support from the Centers for Medicare & Medicaid Services, the American Academy of Physicians, the Department of Health and Human Services, the California Health Care Foundation, and the Milbank Memorial Fund and grants from the Agency for Health Care Research and Quality and the National Institutes of Health (NIH). Dr Sarkisian reported receiving grants from NIH during the conduct of the study. No other disclosures were reported.

Funding/Support: This work was supported by the National Institute on Aging K76 Career Development Award. UCLA paid Milliman to provide the data and perform descriptive cohort analyses provided by Drs Craff and Nelson and Messrs Pu and Skinner. UCLA also paid Mr Tabatabai-Yazdi to perform data analysis and data visualization. All statistical analyses were completed at UCLA.

Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Carol Bazell, MD, MPH (Milliman) received specific compensation to critically review earlier versions of this manuscript. We also thank Michelle Rockwell, PhD (Virginia Tech) for her critical review of earlier versions of this manuscript, for which she received no compensation. In addition, we thank Sara Delgado, BA (UCLA) for her administrative support and Julia Arbanas, BA (UCLA) for her administrative support, proofreading, and editing of this paper, neither of whom received compensation beyond their regular salaries.

Additional Information: This paper is dedicated to the loving memory of Dr. Charles Dillon Woody, Emeritus Professor of Psychiatry and Biobehavioral Sciences and Neurobiology at the David Geffen School of Medicine at UCLA.

References
1.
CMS releases recommendations on adult elective surgeries, non-essential medical, surgical, and dental procedures during COVID-19 response. centers for Medicare and Medicaid services. News release. March 18, 2020. Accessed June 21, 2021. https://www.cms.gov/newsroom/press-releases/cms-releases-recommendations-adult-elective-surgeries-non-essential-medical-surgical-and-dental
2.
Mehrotra  A , Chernew  M , Linetsky  D , Hatch  H , Cutler  D . What impact has COVID-19 had on outpatient visits? Commonwealth Fund. Posted February 22, 2021. Accessed April 18, 2021. https://www.commonwealthfund.org/publications/2021/feb/impact-covid-19-outpatient-visits-2020-visits-stable-despite-late-surge
3.
Czeisler  MÉ , Marynak  K , Clarke  KEN ,  et al.  Delay or avoidance of medical care because of COVID-19–related concerns—United States, June 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(36):1250-1257. doi:10.15585/mmwr.mm6936a4PubMedGoogle ScholarCrossref
4.
Findling  MG , Blendon  RJ , Benson  JM .  Delayed care with harmful health consequences—reported experiences from national surveys during coronavirus disease 2019.   JAMA Health Forum. 2020;1(12):e201463-e201463. doi:10.1001/jamahealthforum.2020.1463Google ScholarCrossref
5.
Woolf  SH , Chapman  DA , Sabo  RT , Weinberger  DM , Hill  L .  Excess deaths from COVID-19 and other causes, March-April 2020.   JAMA. 2020;324(5):510-513. doi:10.1001/jama.2020.11787 PubMedGoogle ScholarCrossref
6.
Schmidt  AL , Bakouny  Z , Bhalla  S ,  et al.  Cancer care disparities during the COVID-19 pandemic.   Cancer Cell. 2020;38(6):769-770. doi:10.1016/j.ccell.2020.10.023 PubMedGoogle ScholarCrossref
7.
Whaley  CM , Pera  MF , Cantor  J ,  et al.  Changes in health services use among commercially insured US populations during the COVID-19 pandemic.   JAMA Netw Open. 2020;3(11):e2024984. doi:10.1001/jamanetworkopen.2020.24984 PubMedGoogle Scholar
8.
Patel  SY , Mehrotra  A , Huskamp  HA , Uscher-Pines  L , Ganguli  I , Barnett  ML .  Trends in outpatient care delivery and telemedicine during the COVID-19 pandemic in the US.   JAMA Intern Med. 2020.PubMedGoogle Scholar
9.
Uscher-Pines  L , Sousa  J , Jones  M ,  et al.  Telehealth use among safety-net organizations in California during the COVID-19 pandemic.   JAMA. 2021;325(11):1106-1107. doi:10.1001/jama.2021.0282 PubMedGoogle ScholarCrossref
10.
Rodriguez  JA , Betancourt  JR , Sequist  TD , Ganguli  I .  Differences in the use of telephone and video telemedicine visits during the COVID-19 pandemic.   Am J Manag Care. 2021;27(1):21-26. doi:10.37765/ajmc.2021.88573 PubMedGoogle Scholar
11.
Martin  K , Kurowski  D , Given  P , Kennedy  K , Clayton  E. The impact of COVID-19 on the use of preventive health care. Health Care Costs Institute. Published April 16, 2021. Accessed November 17, 2021. https://healthcostinstitute.org/hcci-research/the-impact-of-covid-19-on-the-use-of-preventive-health-care
12.
Hartnett  KP , Kite-Powell  A , DeVies  J ,  et al; National Syndromic Surveillance Program Community of Practice.  Impact of the COVID-19 pandemic on emergency department visits—United States, January 1, 2019-May 30, 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(23):699-704. doi:10.15585/mmwr.mm6923e1 PubMedGoogle ScholarCrossref
13.
Cox  C , Amin  K , Kamal  R . How have health spending and utilization changed during the coronavirus pandemic? Kaiser Family Foundation. Posted March 21, 2021. Accessed January 19, 2021. https://www.healthsystemtracker.org/chart-collection/how-have-healthcare-utilization-and-spending-changed-so-far-during-the-coronavirus-pandemic/#item-start
14.
Mehrotra  A , Wang  B , Snyder  G , Telemedicine: what should the post-pandemic regulatory and payment landscape look like? Commonwealth Fund. Posted August 5, 2020. Accessed April 19, 2021. https://www.commonwealthfund.org/publications/issue-briefs/2020/aug/telemedicine-post-pandemic-regulation
15.
Joynt Maddox  KE , Reidhead  M , Qi  AC , Nerenz  DR .  Association of stratification by dual enrollment status with financial penalties in the hospital readmissions reduction program.   JAMA Intern Med. 2019;179(6):769-776. doi:10.1001/jamainternmed.2019.0117 PubMedGoogle ScholarCrossref
16.
American Community Survey. United States Census Bureau. Accessed May 27, 2019. https://www.census.gov/programs-surveys/acs
17.
The who, what, when, why & how of NPI. Centers for Medicare & Medicaid Services. Published August 2006. Accessed November 13, 2021. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/enrollmentsheet_wwwwh.pdf
18.
Milliman MedInsight White Paper. Frameworks and considerations for COVID-19 related analyses. Accessed July 20, 2021. https://us.milliman.com/-/media/milliman/pdfs/articles/frameworks-considerations-covid-19-related-analyses.ashx
19.
US Preventive Services Task Force. Grade A and B recommended services. Accessed 04/16/2021.https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations
20.
Health Resources and Services Administration. Women’s preventive services guidelines. Published 2021. Accessed July 26, 2021. https://www.hrsa.gov/womens-guidelines/index.html#guidelines%20concerning
21.
Medicare telemedicine health care provider fact sheet. Centers for Medicare & Medicaid Services. Posted May 17, 2020. Accessed April 16, 2021. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
23.
Telemedicine. Medicaid. Accessed April 16, 2021. https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html
24.
Overview of Medicare and Medicaid state telehealth policies. Center for Connected Health Policy. Accessed December 30, 2021. https://www.cchpca.org/topic/overview
25.
Benjamini  Y , Hochberg  Y .  Controlling the false discovery rate.   J R Stat Soc B. 1995;57(1):289-300. doi:10.1111/j.2517-6161.1995.tb02031.xGoogle Scholar
26.
Fronstin  P , Woodbury  SA . How many Americans have lost jobs with employer health coverage during the pandemic? The Commonwealth Fund. Posted October 7, 2020. Accessed April 18, 2021. https://www.commonwealthfund.org/publications/issue-briefs/2020/oct/how-many-lost-jobs-employer-coverage-pandemic
27.
Khorrami  P , Sommers  BD .  Changes in US Medicaid enrollment during the COVID-19 pandemic.   JAMA Netw Open. 2021;4(5):e219463. doi:10.1001/jamanetworkopen.2021.9463 PubMedGoogle Scholar
28.
Nolen  LST , Beckman  AL , Sandoe  E . How foundational moments in Medicaid’s history reinforced rather than eliminated racial health disparities. Health Affairs. Posted September 1, 2020. Accessed April 18, 2021. https://www.healthaffairs.org/do/10.1377/forefront.20200828.661111/full
29.
Parikh-Patel  A , Morris  CR , Kizer  KW .  Disparities in quality of cancer care: the role of health insurance and population demographics.   Medicine (Baltimore). 2017;96(50):e9125-e9125. doi:10.1097/MD.0000000000009125 PubMedGoogle ScholarCrossref
30.
Saloner  B , Sabik  L , Sommers  BD .  Pinching the poor?   N Engl J Med. 2014;370(13):1177-1180. doi:10.1056/NEJMp1316370 PubMedGoogle ScholarCrossref
31.
Coronavirus in the US: latest map and case count. New York Times. Updated December 28, 2021. Accessed December 30, 2021. https://www.nytimes.com/interactive/2021/us/covid-cases.html
32.
Yabroff  KR , Reeder-Hayes  K , Zhao  J ,  et al.  Health insurance coverage disruptions and cancer care and outcomes.   J Natl Cancer Inst. 2020;112(7):671-687. doi:10.1093/jnci/djaa048 PubMedGoogle ScholarCrossref
33.
Woolf  SH , Chapman  DA , Sabo  RT , Zimmerman  EB .  Excess deaths from COVID-19 and other causes in the US, March 1, 2020, to January 2, 2021.   JAMA. 2021;325(17):1786-1789. doi:10.1001/jama.2021.5199 PubMedGoogle ScholarCrossref
34.
Bray  MJC , Daneshvari  NO , Radhakrishnan  I ,  et al.  Racial differences in statewide suicide mortality trends in Maryland during the coronavirus disease 2019 (COVID-19) pandemic.   JAMA Psychiatry. 2021;78(4):444-447. doi:10.1001/jamapsychiatry.2020.3938 PubMedGoogle ScholarCrossref
35.
Maringe  C , Spicer  J , Morris  M ,  et al.  The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK.   Lancet Oncol. 2020;21(8):1023-1034. doi:10.1016/S1470-2045(20)30388-0 PubMedGoogle ScholarCrossref
36.
Yang  J , Landrum  MB , Zhou  L , Busch  AB .  Disparities in outpatient visits for mental health and/or substance use disorders during the COVID surge and partial reopening in Massachusetts.   Gen Hosp Psychiatry. 2020;67:100-106. doi:10.1016/j.genhosppsych.2020.09.004 PubMedGoogle ScholarCrossref
37.
Becker  NV , Moniz  MH , Tipirneni  R , Dalton  VK , Ayanian  JZ .  Utilization of Women’s Preventive Health Services During the COVID-19 Pandemic.   JAMA Health Forum. 2021;2(7):e211408-e211408. doi:10.1001/jamahealthforum.2021.1408Google ScholarCrossref
38.
Godwin  J , Arnold  DR , Fulton  BD , Scheffler  RM .  The Association between hospital-physician vertical integration and outpatient physician prices paid by commercial insurers.   Inquiry. 2021;58:46958021991276-46958021991276.PubMedGoogle Scholar
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close