Ambulatory care practices are beginning to rebound from the staggering 58% drop in patient visits in late March but new data shows that things are far from normal.
Visit numbers have rebounded in May and early June but are still substantially lower than before the U.S. pandemic began, according to an analysis by researchers at Harvard University and health tech company Phreesia.
Researchers analyzed visit volumes for 50,000 providers and found that patient trips to ambulatory practices during the week of June 14 are still down 11% compared to baseline.
The cumulative deficit in visits from March 15 to June 20 is nearly 40%, the analysis shows. The cumulative deficit is the fraction of all visits during this roughly three-month time period that did not occur, researchers said.
While that represents an emerging rebound from the 60% drop in patient visits seen in mid-March, the data indicates that practices still have a long road ahead as they adapt to an evolving pandemic.
After several months of lost visits and revenue, practices are still recovering from closed sites, staff layoffs, and furloughs while trying to assist patients to obtain care that had been delayed.
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In March and April, many practices expanded their use of telemedicine from a very low baseline of less than 1% of visits to double digits. Since a peak in mid-April, telemedicine use has begun to decline, though it remains substantially higher than before the pandemic.
By early June, the growth of telemedicine plateaued and accounts for a relatively minor fraction of all ambulatory visits, the analysis shows. This suggests that practices and patients may be reluctant or may still be learning how best to use the technology, researchers said.
In the past week, some clinical specialties, such as dermatology and rheumatology, have seen patient visits return to pre-pandemic levels.
The cumulative decline in visits from the start of the pandemic is greatest among pediatricians, pulmonologists, and several surgical specialties, the analysis showed.
Visits to pediatric practices remain 34% below pre-crisis levels and pulmonology practices are still seeing a 29% decline in patient volume as of June 14.
The analysis found a striking difference between adults and children in how visits have rebounded. In the last week, visits by adults age 75 and older are only depressed 3% from baseline. But among children ages 3 to 5, visits remain depressed 43% from baseline.
According to researchers, the health of Americans is at risk because of reduced access to services. Childhood vaccines have been delayed and patients with chronic conditions may have missed out on timely diagnoses, lab testing and adjustments to medications that prevent worsening health.
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"We worry some patients who are delaying surgery and in severe pain might start taking prescription opioids, or self-medicating with alcohol, cannabis or other means,” said Charles Peterson, M.D., an orthopedic surgeon with Proliance Surgeons, according to an accompanying article the researchers wrote.
Proliance Surgeons’ decision to curtail elective surgeries, days before a state moratorium, cost the organization about $1 million per day over the eight-week shutdown.
"We’re going to be digging our way out of a financial hole for quite some time,” Peterson says.
That said, visits for elderly patients and Medicare beneficiaries—traditionally the population with greatest health needs—appear to have rebounded more than for other patients. Medicare patient visits to ambulatory practices are down only 5% compared to pre-crisis levels, according to the study.
Ambulatory practices adapting
The COVID-19 pandemic has dramatically changed how outpatient care is delivered in health care practices, according to researchers.
"Most are adapting to new safety protocols and workflows to protect both patients and staff from infection. They also are spending more time educating patients about COVID-19, managing fear and anxiety, and helping them to cope with the emotional stresses of lost livelihoods, restricted social activities and isolation," the researchers wrote.
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The COVID-19 pandemic has necessitated changes in office procedures to protect patients and staff at the same time clinicians scramble to make up deferred care, help patients cope with the fear and uncertainty triggered by a new disease and adjust to staff furloughs and lost revenue that some may never recoup, according to researchers.
The Harvard researchers spoke to medical practices across the country about how they are adapting to the "new normal."
"The physicians we spoke to are working harder but at a slower pace, as once straightforward procedures like pulmonary function and stress tests now require more steps to mitigate the risk of viral transmission," researchers said.
Many practices are sequencing visits in new ways to reassure patients it’s safe to return: One provider was offering treatment, including lab work, to high-risk patients in their cars while another has been asking patients to remain in the parking lot until their appointment time.
“I don’t know what we’re going to do in the winter,” said Gregory Adams, M.D., a pediatrician at Blue Ridge Pediatrics and Adolescent Medicine in Boone, North Carolina, where 40% of families are covered by Medicaid. “Some of our families don’t have cars.”