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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?
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.
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.
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.
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.
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.
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.
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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.
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 (firstname.lastname@example.org).
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.
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