Q&A: Use of ambulatory care rebounds, but at a lower rate for Medicaid beneficiaries

Between March 2020 and February 2021, the combined utilization of six ambulatory care services among U.S. adults fell, then came close to reaching expected rates, data show.

However, the return-to-expected rates were lower for people with Medicaid or Medicaid-Medicare dual eligibility, according to John N. Mafi, MD, MPH, an associate professor of medicine in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA, and colleagues.

The researchers looked at the rates of use for six ambulatory care services between January and February 2020. They then compared those rates with each 2-month timeframe that followed, comparing the changes in the corresponding months from the year before until Feb. 28, 2021. The data were from more than 14.5 million U.S. adults (mean age, 52.7 years; 54.9% women) who received 162,533,375 ambulatory services, including ED care (7.1%), office and urgent care (67.2%), behavioral health services (12%), screening colonoscopies (0.96%), screening mammograms (3.2%) and contraception counseling or HIV screening (9.5%).

In the March to April 2020 timeframe, the analysis indicated that the use of all six ambulatory services fell to 67% (95% CI, 66.9-67.1) of the expected rate. However, by the November to December 2020 timeframe, the overall rate had returned to 96.7% (95% CI, 96.6-96.8) of expected rates.

During the second wave of COVID-19 cases in the January to February 2021 timeframe, combined use of the six services dropped to 86.2% (95% CI, 86.1-86.3) of expected rates, with colonoscopy staying at 65% (95% CI, 64.1-65.9) and mammography at 79.2% (95% CI, 78.5-79.8) of expected rates. During this timeframe, the overall return-to-expected rates by insurance type were: 78.4% (95% CI, 78.2-78.7) for Medicaid; 73.3% (95% CI, 72.8-73.8) for Medicare-Medicaid dual eligibility; 90.7% (95% CI, 90.5-90.9) for commercial insurance; 83.2% (95% CI, 81.7-82.2) for Medicare Advantage; and 82% (95% CI, 81.7-82.2) for Medicare fee-for-service.

“These findings suggested potentially worsening access to care during the pandemic among patients with Medicaid and patients with Medicare-Medicaid dual eligibility,” the researchers wrote. “These individuals are typically socioeconomically disadvantaged.”

Healio asked Mafi to discuss the implications of the results and how the changes in health care utilization are impacting physicians and patients.

Healio: Why do you think the increase in ambulatory care services was significantly lower for participants with Medicaid or Medicare‐Medicaid dual eligibility? What are the clinical implications of this finding?  

Mafi: Our study found that care rebounded at a lower rate for patients with Medicaid or Medicare-Medicaid dual eligibility during the pandemic but does not directly answer why.

We know from multiple sources in the United States that socioeconomically disadvantaged and racial and ethnic minority individuals suffered a greater burden of morbidity and mortality during the pandemic. Loss of life or health by one’s family, friends, coworkers or neighborhood is associated with sadness and mourning. Furthermore, grieving individuals often suffer additional disruptions in the fabric of their lives as they assume additional family, community and work responsibilities. During the COVID-19 pandemic, these additional responsibilities might augment physical or emotional stresses, exposures to COVID-19 risks with imposition of isolation protocols, or financial strains, all potentially limiting opportunities for individuals to have adequate time, strength, or resources to access medical care and to complete recommended service use.

The clinical implications of this finding can be characterized at the personal or individual level or at a group or cohort level. In either case, those who miss needed medical care may suffer missed physical or mental health diagnoses that could benefit from early intervention, missed opportunities for in-office or at-home ongoing treatments that could prevent the onset of or progression of disease, and the missed support and guidance that follows continuity care with a regular health care provider.

One of our supplementary analyses suggest that delays in care were exacerbated among Medicaid patients who had disruptions in insurance coverage. This relationship between lower utilization of services and disruptions in insurance coverage has been previously recognized. Multiple data sources have documented that loss of coverage was associated with worse health outcomes, particularly among patients with Medicaid insurance. While we speculate that many of the same socioeconomic barriers afflicting disadvantaged populations long before the pandemic are still at play, further research needs to assess whether these care disparities represent characteristics of the patients, their physicians, the health system or practice where they receive care, the neighborhood in which they live, an aspect of their insurance coverage, or a combination of these and/or other factors.

Healio: The return to near‐expected rates of ambulatory care utilization were diminished following the second wave of COVID‐19 cases. How are these changes in health care utilization impacting physicians and practices?  

Mafi: Our study did not assess the financial impact of the utilization changes on physician practices during the pandemic. However, some other evidence suggests that the COVID-19 pandemic has negatively impacted the revenues of both hospitals and physician practices. Furthermore, the chaotic patterns of patients returning to care, in many cases following long absences from encounters with health care providers and from treatments, had led to increased strain on the entire health care team.

Healio: How are the disruptions in preventive services affecting the overall health of the U.S. population? Are physicians already seeing the ramifications, such as an increase in late‐stage cancer at diagnosis? 

Mafi: Our study measured changes in utilization patterns of important health services during the pandemic. We did not directly measure patient outcomes. Unfortunately, other emerging data is suggesting increases in later stage cancer diagnoses as a result of the delays in access to care and cancer prevention, which we did observe in our study.

Anecdotally, as a practicing primary care physician, I sadly have lost patients who delayed life-saving care because of their fear of contracting COVID-19 in health care facilities. Further research needs to examine the precise relationship between delays in care processes and their effects on patient health outcomes during the pandemic.

Healio: What efforts are needed to improve ambulatory care services during the pandemic?

Mafi: According to study senior author Dr. Katherine Kahn, a distinguished professor of medicine and practicing general internist at the David Geffen School of Medicine at UCLA, “policymakers, health system leaders, clinicians and patients should proactively develop rapid and effective ‘catch-up’ strategies to avoid harm that could result from missed opportunities for care during the pandemic.”

Healio: What is your take‐home message for primary care providers?  

Mafi: According to Dr. Kahn, “ongoing efforts to educate patients about timely symptom-based and preventive care, paired with expanded telemedicine outreach and community engagement programs — in the context of commitments to equity, diversity and inclusion — could make a big difference.”

Healio: Anything else to add?   

Mafi: I hope that our work will prompt policymakers, health system leaders, clinicians and patients to come together to address the problem of delayed access to vital health services during the COVID-19 pandemic. Even if care begins to reach pre-pandemic levels, U.S. health care services would need to exceed pre-pandemic levels for some time to catch up with necessary care such as evidence-based disease prevention. Unfortunately, some of the delayed care may be unrecoverable, such as delayed cancer or stroke diagnoses.

Additionally, the worsening access to care we observed among socioeconomically disadvantaged Americans is particularly concerning because it suggests that the pandemic is widening inequities in access to vital health services such as emergency care, preventive cancer screening and behavioral health services.

Reference:

Mafi JN, et al. JAMA. 2022 doi:10.1001/jama.2021.24294.