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The Impact of COVID-19 on the Use of Preventive Health Care

COVID-19 has had an extraordinary impact on the US health care system since its emergence in early 2020. One of the largest and most immediate impacts has been the death toll with the pandemic having claimed more than 180,000 lives as of September 1, 2020, but the pandemic has also brought a set of (seemingly endless) new trade-offs and choices for people to make as they navigate their daily lives, and the health care system. Among them, whether, when, and how to resume their pre-pandemic health care life. How do the risks of leaving their homes and going to medical facilities stack up against the well-documented benefits of preventive care? Whether annual mammograms or other screenings or children's well-child visits and immunizations, each venture into non-emergency health care sparks a calculus of risk and reward without a clear answer.

Several studies have identified a substantial drop in health care utilization in March and April as most medical offices closed or dramatically scaled back operations, and people generally avoided interactions with the health system in the hopes of not contracting the virus, including reductions in outpatient visits, emergency department visits, and elective surgeries like lower joint replacement. However, these studies were often limited in scale and scope. Curious about the effect the pandemic is having on which health care services people receive, the Health Care Cost Institute (HCCI) looked at a sample of health claims clearinghouse records from 18 states containing 184 million claims from 30 million patients in 2019 and 94 million claims from 20 million patients for the first 6 months in 2020. Specifically, we examined women's preventative health services, select services provided during pregnancy and delivery, childhood immunizations, and other sentinel preventive medical services including colonoscopies, and prostate-specific antigen (PSA) tests. Overall, we found that the pandemic is having a significant dampening effect on the use of certain health care services.

The dashboard below compares use of the select services between 2020 and 2019 using a 7-day rolling average.

Submitted claims for most preventive services we examined, such as mammography and childhood immunizations exhibited significant declines in 2020 compared to 2019, particularly mid-March through mid-April. Even by June 2020 utilization of many preventive services appeared to be running below 2019 levels. Trends from the data as of June 2020 show:

  • Childhood immunizations were, on aggregate, down about 60 percent in mid-April in 2020 compared to 2019. This ranged from 75 percent for Meningococcal and HPV vaccines to 33 percent for Rotavirus and the diphtheria, tetanus toxoids, acellular pertussis family of vaccines.
  • Mammograms and Pap smears were down nearly 80 percent in April 2020 compared to 2019, and by June were down nearly a quarter from 2019.
  • Colonoscopies, down almost 90% at one point in mid-April 2020 compared to 2019, are as of June 2020, only down about 30% compared to last year, representing a substantial rebound in care delivered.
  • PSA tests, which are used for prostate cancer screening, while down approximately 22% for the year, have seen a strong rebound, with delivery of PSA tests reaching near 2019 levels starting in June.
  • Use of services that cannot be deferred or forgone, like childbirth, have tracked more closely to 2019 levels. All deliveries declined by about 7 percent on average from 2019 to 2020. Cesarean section deliveries declined slightly more than vaginal deliveries (10 percent and 4 percent, respectively), perhaps reflecting changes in preferences towards early elective deliveries, which tend to have longer lengths of stay than vaginal deliveries, though additional research is needed to understand what is leading to the difference in utilization.

This analysis is merely a preliminary glimpse at the impact of COVID-19 on health care utilization in 2020 and is not intended to provide definitive answers about the ways in which the pandemic is affecting people's health care. We expect HCCI's new national dataset, with more than 1 billion claims for approximately 55 million people with employer-sponsored health insurance coverage, which will be launched in later 2020, will facilitate a much more comprehensive assessment of those questions. These data suggest, though, that for now, people have chosen to forego care they would otherwise have received with potential implications for their long-term health and well-being.

Methods

Methods

Methodology

This study uses data made available by the COVID-19 Research Database, a cross-industry collaborative contributing real world, de-identified data to researchers wishing to study issues related to COVID-19. For this analysis we used a clearinghouse database which spanned 184 million claims from almost 30 million patients in 2019 and 94 million claims from nearly 20 million patients in the first 6 months in 2020. The claims were all from members who resided in a consistent set of 18 states, with roughly half living in California in both study years. Lastly, while the claims were associated with all payer types, they were predominately from the commercially insured: 86% commercial (ESI and MA), 12% Medicare, and 2% Medicaid, on average across both years.

Claims clearinghouses are responsible for scrubbing and transmitting medical claims to insurance carriers. Once a response is received from the issuer, the clearinghouse transmits the denial or acceptance of the claim back to the provider. While some clearinghouses may transmit payment information back to the provider, typically only charge data are reliably available from the clearinghouse. Additionally, accurate enrollment files may not be available since they are maintained by the issuer, which presents a limitation for this type of analysis.

We defined our services of interest from physician and other professional service charges (i.e. non-facility charges) as the count of unique claims from the charge submissions for the following HCPCS/CPT codes:

Women’s Preventative Health Services

HCPCS/CPT Codes

Diagnostic pap smear (cytopathology)

88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88155, 88164, 88165, 88166, 88167, 88174, 88175

Screening pap smear (cytopathology)

P3000, G0123, G0143, G0145, G0146, G0147, G0148

Diagnostic mammography

77055, 77056, 77066, 77065

Screening mammography

77057, 77067

Birth control, IUD

J7297, J7298

Ultrasound, pelvic (non-obstetric)

76858, 76857, 76830

Fibroid removal (myomectomy)

58140, 58145, 58146, 58545, 58546

Hysterectomy

58570, 58571, 58572, 58573, 58550, 58552, 58553, 58554, 58541, 58542, 45543, 58544, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58150, 58152, 58180, 58200, 58210, 58240               

Human papilloma virus (HPV) test

87623, 87624

Pregnancy and Delivery

HCPCS/CPT Codes

Pregnancy test

81025

Ultrasound, pregnancy

76801, 76802, 76805, 76810, 76811, 76812, 76817

Childbirth, Caesarian section

59510, 59514, 59515, 59618, 59620, 59622, 59409, 59612

Childbirth, vaginal delivery

59400, 59409, 59410, 59610, 59614

Childhood Immunizations

HCPCS/CPT Codes

Measles, mumps, rubella, varicella

90707, 90710, 90716

Hepatitis A

90633

Hepatitis B

90744

Haemophilus influenza type b (Hib)

90647, 90648

Human papilloma virus (HPV)

90651

Rotavirus

90680, 90681

Pneumococcal conjugate

90670

Meningococcal

90620, 90621, 90734

Poliovirus vaccine, inactivated (IPV)

90713

Diphtheria, tetanus toxoids, acellular pertussis (Td/DTaP/Tdap)

90700, 90714, 90715

Diphtheria, tetanus toxoids, and acellular pertussis vaccine and inactivated poliovirus vaccine (DTaP-IPV)

90696

Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza type b, and inactivated poliovirus vaccine (DTaP-IPV/Hib)

90698

Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and inactivated poliovirus vaccine (DTaP-Hep BIPV)

90723

Other Health Services

HCPCS/CPT Codes

Diagnostic colonoscopy

45379, 45380, 45381, 45382, 45383, 45384, 45385, 45386, 45387, 45388, 45389, 45390, 45391, 45392, 45393, 45394, 45395, 45396, 45397, 45398

Screening colonoscopy

45378, G0105, G0121

Diagnostic prostate-specific antigen (PSA) test

84153

Screening prostate-specific antigen (PSA) test

G0103

HIV test

86689, 86701, 86702, 86703, 87534, 57535, 87536, 87390

Influenza vaccine

90653, 90694, 90662, 90672, 90674, 90682, 90685, 90686, 90687, 90688, 90756, 90656, 90662, Q2035

The table below shows the total count of claims used for this analysis by service and by year.

Service Name

2019 Count

2020 Count

All Vaccines

2,350,562

1,691,911

All Colonoscopies

213,737

136,953

All Childbirths

79,197

73,774

All Mammograms

447,222

312,390

All Pap Smears

591,428

405,405

All PSA Tests

502,193

390,781

C-Section Delivery

33,776

30,357

Vaginal Delivery

45,421

43,417

Diagnostic Colonoscopy

134,197

87,524

Diagnostic Mammogram

90,031

77,642

Diagnostic Pap Smear

575,147

394,691

Diagnostic PSA test

484,390

376,156

DTaP-HepB-IPV Vaccine

75,593

62,761

DTaP-IPV/Hib Vaccine

127,732

108,189

Hepatitis A Vaccine

195,204

139,772

Hepatitis B Vaccine

119,284

91,015

Hemophilus Influenza B (Hib) Vaccine

160,315

124,859

HPV Test

312,699

219,289

HPV Vaccine

169,171

115,634

Hysterectomy

11,101

7,695

Poliovirus Vaccine (IPV)

78,107

49,218

Intrauterine Device

12,537

10,183

Meningococcal Vaccine

196,284

126,368

MMRV Vaccine

257,943

160,350

Pelvic Ultrasound

232,455

180,513

Pneumococcal Conjugate Vaccine

338,800

265,231

Pregnancy Test

461,261

287,262

Pregnancy Ultrasound

195,276

181,995

Rotavirus Vaccine

169,206

143,608

Screening Colonoscopy

79,540

49,429

Screening Mammogram

357,191

234,748

Screening Pap Smear

16,281

10,714

Screening PSA Test

17,803

14,625

Tdap-IPV Vaccine

64,126

42,077

Uterine Biopsy

15,958

12,105

Percent Change for each service on a given day of the year is calculated as the difference between the 2020 and 2019 values divided by the 2019 value, then multiplied by 100. That is, Percent Change = (([2020]-[2019])/[2019])×100. 

We attempted to stratify the data by gender and age, however, demographic data for claims submitted in 2020 was significantly more incomplete than the demographic information on claims from 2019. While more specificity in the demographic profile of these services is important, the preventative screenings, tests, and procedures, selected (with the exception of colonoscopies and HIV tests), are utilized primality by a single sex, and immunizations are primarily utilized by children.

Trends were calculated using a 7-day rolling average, and we include a 60-day run out window from the date of data extract to allow for sufficient claims maturity. Note that inferences made comparing 2019 utilization to 2020 utilization may be influenced by factors not related to patients delaying or foregoing care. These factors include but are not limited to claims lag beyond our 60-day window, and the possible change in the mix of providers utilizing the clearinghouse from which these data are derived or a change in the mix of the types of patients being served.

We differentiate diagnostic services from screenings using their respective HCPCS/CPT codes. There may be limitations to our results related to how payers reimburse these services as some payers may require different or additional mechanisms for documenting diagnostic or screening services other than the HCPCS/CPT code.

We also do not discuss impacts of the pandemic on the utilization of telehealth services or other service substitutions, however, with the exception of HIV testing and pregnancy testing, none of these services are customarily performed without direct care from a health professional. While we can’t fully attribute the dips in preventative care to patient’s decisions to delay/forego care (e.g. many providers may have been closed during shutdown orders), this does represent a meaningful shift in the delivery of services.

Finally, the data from these findings are overly representative of the western U.S. and not generalizable to the entire population of insured persons.

The data, technology, and services used in the generation of these research findings were generously supplied pro bono by the COVID-19 Research Database partners, who are acknowledged at https://covid19researchdatabase.org/.

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