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Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic, 2019-2021John N Mafi et al. JAMA. 2022.
. 2022 Jan 18;327(3):237-247. doi: 10.1001/jama.2021.24294. Authors John N Mafi 1 2 , Melody Craff 3 , Sitaram Vangala 1 , Thomas Pu 3 , Dale Skinner 3 , Cyrus Tabatabai-Yazdi 4 , Anikia Nelson 3 , Rachel Reid 2 5 , Denis Agniel 2 , Chi-Hong Tseng 1 , Catherine Sarkisian 1 , Cheryl L Damberg 2 , Katherine L Kahn 1 2 AffiliationsItem in Clipboard
AbstractImportance: 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.
Conflict of interest statementConflict 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.
FiguresFigure 1.. Unadjusted Overall Utilization per 100…
Figure 1.. Unadjusted Overall Utilization per 100 Patients
The primary analysis cohort consisted of 26…
Figure 1.. Unadjusted Overall Utilization per 100 PatientsThe primary analysis cohort consisted of 26 cross-sectional cohorts with 1 cross-section per month, each cross-section requiring at least 12 prior months of continuous enrollment. For example, the January 2019 primary analysis cohort included patients continuously enrolled for at least 12 months prior to January 2019. The noncontinuously enrolled cohort included individuals with disruptions in insurance coverage and was restricted to individuals who did not meet criteria for inclusion in the primary analysis cohort. A fully enrolled cohort included patients continuously enrolled from January 2019 through February 2021 but did not allow new patients after January 2019. Individuals not in the fully or continuously enrolled cohorts but included in 1 of the groups contributing data to the research database are included in the noncontinuously enrolled cohort, many of whom experienced periods with no health insurance. This is consistent with the graph demonstrating their utilization rates are at a level lower than for the fully and continuously enrolled cohorts. WHO indicates World Health Organization.
Figure 2.. Ratio of Rate Ratios of…
Figure 2.. Ratio of Rate Ratios of Service Types Among 14 505 945 Patients in…
Figure 2.. Ratio of Rate Ratios of Service Types Among 14 505 945 Patients in the Primary Analysis CohortSee the Methods section for an explanation of the difference-in-differences design for determining utilization rate differences from before the pandemic to during the pandemic, using age- and sex-adjusted Poisson regression models. Utilization effects of the pandemic were summarized in terms of the ratio of rate ratios, derived from difference-in-differences estimated on the log-utilization rate. This metric was interpretable as the proportion of expected pandemic-associated utilization rates that were actually observed, assuming that pandemic-associated utilization trends would have paralleled prepandemic trends in the absence of the pandemic. Although the y-axes numerical labels are the actual ratio of rate ratios, they are plotted on a log scale. The dotted line indicates a reference point for the ratio of rate ratios, consistent with situations in which observed utilization, matches the expected levels had the pandemic not occurred; error bars, 95% CIs.
Figure 3.. Ratio of Rate Ratios of…
Figure 3.. Ratio of Rate Ratios of Overall Utilization of Telemedicine and Overall Services (Telemedicine…
Figure 3.. Ratio of Rate Ratios of Overall Utilization of Telemedicine and Overall Services (Telemedicine Plus In-Person Services) Among 14 505 945 Patients in the Primary AnalysisSee the Figure 2 legend for a general explanation. Dual indicates Medicare-Medicaid dual eligibility.
Figure 4.. Ratio of Rate Ratios of…
Figure 4.. Ratio of Rate Ratios of Utilization of Office and Urgent Care, Emergency Department,…
Figure 4.. Ratio of Rate Ratios of Utilization of Office and Urgent Care, Emergency Department, and Behavioral Health Services Among 14 505 945 Patients in the Primary Analysis CohortFigure 5.. Screening-Based Services Among 14 505…
Figure 5.. Screening-Based Services Among 14 505 945 Patients in the Primary Analysis Cohort
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