Pandemic has exacerbated disparities in care, study finds

Americans’ use of common outpatient health services fell sharply at the start of the COVID-19 pandemic, then rebounded to near-normal levels in late 2020, only to decline again in the second surge in January-February 2021, according to a new study led by UCLA.

But the resumption of care in 2020 has not been equal for all, the researchers found. Some of the most socioeconomically disadvantaged patients—those on dual Medicaid or Medicare-Medicaid coverage—were much less likely than those on other insurance plans to resume using outpatient services at lower rates. approaching normal pre-pandemic levels.

The study, published this week in the Journal of the American Medical Association and based on data on 14.5 million adults in the United States, raises concerns that patients are missing treatments for acute illnesses, delaying preventive care, and unclear when to seek help. help during the pandemic, said lead author Dr. John Mafi, associate professor. of Medicine and General Internist at the David Geffen School of Medicine at UCLA.

“The deterioration in access to care we’ve seen among socioeconomically disadvantaged Americans is particularly concerning,” Mafi said, “because it suggests the pandemic is deepening inequities in access to health services. such as emergency care, preventive cancer screening and behavioral health services”.

For the study, researchers looked at the use of six ambulatory care services: emergency department visits, doctor’s office visits (including for urgent care), behavioral health services, screenings colonoscopy, mammography screening and HIV testing or contraceptive advice. They compared the use of these services between patients with commercial insurance, Medicare Advantage, paid-for Medicare insurance and those with dual-eligibility Medicaid or Medicare-Medicaid insurance between January 1, 2019 and January 28, 2019. February 2021. (Patient data was taken from the Milliman MedInsight Emerging Experience research database and included patient data from all US states.)

They found that during the initial surge of COVID-19 in March-April 2020, the overall use of the six ambulatory care services fell to just 67% of the levels that would be expected had the pandemic not passed. not produced.

During these early months of the pandemic, the Centers for Medicare and Medicaid Services have asked hospitals and medical practices nationwide to limit certain outpatient services to preserve resources for more critical care and to minimize the transmission of COVID- 19, the researchers noted. Additionally, many patients have canceled scheduled outpatient appointments for fear of contracting the virus. As a result, many people did not receive the outpatient care they otherwise would have received.

However, in November-December 2020, use of the six outpatient services rebounded to 97% of expected rates. During the second surge, in January-February 2021, overall utilization fell again, to 86% of expected rates, and the return to expected rates varied by insurance type, with patients eligible for both Medicaid and Medicare-Medicaid having lower recovery rates:

  • Trade Assurance: 91%
  • Medicare advantage: 83%
  • Health insurance fee-for-service: 81%
  • Medical help: 78%
  • Dual Medicare-Medicaid eligible: 73%

The study authors said there remains a need to understand the reasons for persistently delayed care, particularly among socioeconomically disadvantaged patients, and to consider various approaches to address this challenge.

“Policy makers, health system leaders, clinicians and patients should proactively develop rapid and effective ‘catch-up’ strategies to avoid the harm that could result from missed opportunities for care during the pandemic,” said the lead author, Dr. Katherine Kahn, eminent professor of medicine and general internist at the Geffen School. “Patients at high risk of adverse health effects associated with missed care during the pandemic or in the period leading up to it may need extra efforts to overcome barriers to accessing outpatient care. “

Kahn emphasized that continued efforts to educate patients about timely symptom-based and preventative care, coupled with expanded telemedicine outreach and community engagement programs – in the context of equity commitments , diversity and inclusion – could make a big difference.

The researchers’ study design took into account potential changes in the study population during the pandemic and adjusted for patient characteristics by age, gender and national region. Nevertheless, the researchers noted several limitations: the results may not apply to all US healthcare organizations and patients, the study population may have changed in “undocumented” ways over the study period, In the study, adjustments for individual patient characteristics did not include patient-specific demographics or medical history, and results did not include adults who were uninsured during the study period.

The other authors are Sitaram Vangala, Cyrus Tabatabai-Yazdi, Chi-Hong Tseng and Dr. Catherine Sarkisian, all from UCLA; Dr. Melody Craff, Thomas Pu, Dale Skinner and Dr. Anikia Nelson of Millman MedInsight; Dr. Rachel Reid of Harvard University; and Denis Agniel and Cheryl Damberg of the RAND Corporation. Mafi, Reid and Kahn also hold research positions at RAND.

The research was supported by the National Institute on Aging, part of the National Institutes of Health (Award No. K76AG064392). Author disclosures are available in the study.

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