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Cited by 120COVID-19 and healthcare impactsHealthcare Policy and ManagementPrimary Care and Health Outcomes

Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic, 2019-2021

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Mafi, John N., Craff, Melody, Vangala, Sitaram, Pu, Thomas, Skinner, Dale, Tabatabai-Yazdi, Cyrus, Nelson, Anikia, Reid, Rachel +5 more·2022·JAMA
DOI 10.1001/jama.2021.24294PMC PMC8767442
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Abstract

Importance: 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.

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  • Medicare- or Medicaid-related interventions were the most common policy category among the reviewed DiD studies, with 10 studies (24%).

    “with interventions related to Medicare or Medicaid as the most popular (n = 10, 24%) [49-58].”

    From Difference-in-Differences for Health Policy and Practice: A Review of Modern Methods (2025) · cites this paper as [49]

    The Design, Setting, and Participants passage describes a difference-in-differences study comparing ambulatory care use across insurance groups, including Medicaid and Medicare. It does not identify a Medicare- or Medicaid-related policy intervention; the exposure studied is the pandemic. As one of citations [49–58], this paper also cannot establish the citing review’s aggregate count or ranking. (LLM, conf=0.82)

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Research works printed but not linked: 2

  1. [36]36. Nolen LST, Beckman AL, Sandoe E. How foundational moments in Medicaid's history reinforced rather than eliminated racial health disparities. Health Affairs. Posted September 1, 2020. Accessed April 18, 2021. https://www. healthaffairs.org/do/10.1377/forefront.20200828. 661111/full · DOI
  2. [38]38. Saloner B, Sabik L, Sommers BD. Pinching the poor? N Engl J Med. 2014;370(13):1177-1180. doi:10. 1056/NEJMp1316370 31. Coronavirus in the US: latest map and case count. New York Times. Updated December 28, 2021. Accessed December 30, 2021. https://www. nytimes.com/interactive/2021/us/covid-cases.html

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Authors
Mafi, J. N., Craff, M., Vangala, S., Pu, T., Skinner, D., Tabatabai-Yazdi, C., Nelson, A., Reid, R., Agniel, D., Tseng, C.-H., Sarkisian, C., Damberg, C. L., & Kahn, K. L.
Affiliations
  • RAND Corporation (US)
  • Milliman (United States) (US)
  • University of California, Los Angeles (US)
  • Brigham and Women's Hospital (US)
Corresponding author
Mafi, John N.
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2022-01-18
Volume
327
Issue
3
Pages
237
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2021.24294
PMC
PMC8767442
OpenAlex
W4206699338
Cited by
120
References
22
Citations by year
2026: 26 · 2025: 19 · 2024: 26 · 2023: 35 · 2022: 14
FWCI
9.83
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
National Institute on Aging (K76AG064392, K24AG047899, R01AG070017)
Topics
  • Health Sciences › Medicine › Oncology › COVID-19 and healthcare impacts
  • Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
  • Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
Keywords
COVID-19 pandemic, ambulatory care utilization, Medicaid, Medicare-Medicaid dual eligibility, private insurance, Medicare Advantage, emergency department visits, urgent care, behavioral health services, colonoscopy, mammography, contraceptive counseling, HIV screening, health care access, United States adults
MeSH terms
COVID-19, Adult, Aged, Aged, 80 and over, Ambulatory Care, Colonoscopy, Female, Medicare, Health Services Needs and Demand, Humans, Insurance, Health, Male, Mammography, Medicaid, Middle Aged, Retrospective Studies, Time Factors, United States, Databases, Factual, Telemedicine, Fee-for-Service Plans, Young Adult, Pandemics

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