The COVID-19 pandemic has dramatically reduced the use of health care services in the US, a trend hinted at by media reports and now showing up in electronic medical record (EMR) data. In a recent issue brief, we used a unique EMR data set to estimate the magnitude of reductions in outpatient visits, including emergency department (ED) visits, at California general acute care hospitals since the pandemic took hold. Likewise, we were able to quantify early reductions in inpatient admissions in California.

For this blog post, we provide a more robust portrait of the pandemic’s initial impact on hospital use by analyzing a larger sample of data from more than 500 hospitals in six states: California, Massachusetts, New Mexico, Oregon, Virginia, and Washington. This analysis also covers a longer period (January 1 through June 9, 2020) than our initial brief, allowing us to understand whether the significant reductions we initially found are persisting. These findings could help public health officials by providing early signs of potential COVID-19 reemergence and help inform policymakers engaged in longer-term economic planning.

Key Findings

Hospital ED visit volume in early 2020, before the pandemic took hold, matches volume in the prior year. January visits were up 3% compared to the same period in 2019 (based on a seven-day moving average). For the first two weeks of February, there was no difference from last year, but we begin to see a downward trend in the second half of February (-3%). By the second week of March, ED visits had fallen by 10% across all six states. The next week they were down by 27%. The decline in ED visits continued until reaching bottom on April 17 at 47% below the previous year. Since then, ED visit volume has started to slowly return. As of June 9, ED visits are still 29% below the same time in 2019.

We also compared trends in ED visit volume across the six states, focusing on the differences among them and changes in trend related to the timing of each state’s guidance for residents to shelter in place and for hospitals to suspend nonemergency services. Shelter-in-place orders were issued in these states (PDF) between March 19 and 30, and soft reopenings began in early May. Emergency departments in all six states experienced significant declines at least 10 days before their state public health rules took effect. In three states, the downward trend continued for at least 10 days after shelter-in-place before bottoming out, while the other three states saw continued reductions for at least 20 days after shutdown.

At their low points, hospitals in the six states were treating only about half the number of ED patients compared to pre-COVID-19 levels. ED volume started to rebound before their reopening dates. While hospitals in the six states report volumes closer to pre-COVID-19 levels within 10 days of reopening in their state, they all remain below prior year visit levels more than 38 days after reopening. In combination, these trends suggest that consumer safety concerns and factors other than state public health guidance are the primary drivers of hospital ED utilization nationwide.

The data for this analysis were supplied by Collective Medical, a care coordination software company based in Utah that is an investee of CHCF’s Innovation Fund. It is important to note that, while the data used for this study include more than 500 hospitals, it is a sample that may not be representative of all hospitals nationally or of individual states. However, the hospitals in this study provided a significant proportion of total ED visits for the six states we studied, ranging from over 40% in California to over 98% in Oregon. In addition, our estimates are consistent with results reported by the US Centers for Disease Control and Prevention from the National Syndromic Surveillance Program (NSSP), which includes ED visits from a subset of hospitals in 47 states and captures approximately 73% of ED visits nationwide.

ED Use: A Leading Economic and Public Health Indicator

Our analysis of hospital ED visit data documents the sudden and sharp reduction in hospital use and the slow rebound in patients accessing hospitals for emergency care. Hospital ED demand fell by almost 50% and has since begun to recover, but it is still about one-third below pre-COVID-19 levels. Continuing to monitor use of emergency departments through real-time EMR data sets can provide leading indicators to both policymakers and public health officials.

From an economic standpoint, EDs are the financial engine of many hospitals, generating substantial revenue by serving outpatients who are treated and released, as well as the inpatients who are admitted to hospitals through their EDs. Because EDs are so important to hospital budgets and because hospitals are major employers in many communities, real-time monitoring of trends in the demand for ED care could provide information for broader, long-term economic planning by policymakers.

Perhaps most importantly, in the absence of an effective vaccine for the novel coronavirus, public health officials worry about potential spikes in COVID-19 infections that might overwhelm hospital capacity. EMR data can provide an early warning of emerging outbreaks, a real-time test of which may be unfolding right now. The data in this analysis now go through June 9, two weeks after states began opening up during the Memorial Day holiday and the beginning of daily marches and mass gatherings throughout the country following George Floyd’s death at the hands of Minneapolis police. Monitoring real-time EMR data on known or suspected COVID-19 infections after the incubation period following these events may help officials target resources and public health interventions.

Glenn Melnick

Glenn Melnick, PhD, is an expert in health economics and finance. He joined the USC Price School of Public Policy faculty in 1996 and currently holds the Blue Cross of California Chair in Health Care Finance. Previously, he served as a faculty member of the UCLA School of Public Health, a consultant at RAND, and an expert witness for the Federal Trade Commission. He has been published in American Journal of Public Health; Health Affairs; Medical Care; Journal of Health Politics, Policy and Law; Health Policy Reform: Competition and Controls; and the Journal of Ambulatory Care Management. He has also been principal investigator for a number of funded projects in Jakarta, Indonesia, and in Taiwan.

Susan Maerki

Susan Maerki, MHSA, MAE, is an independent consultant. Previously, Maerki was a director and health policy specialist at PricewaterhouseCoopers (PwC) where her clients included state Medicaid agencies, health care foundations, health care professional organizations, commercial insurers, and state policy agencies, such as state departments of insurance and Covered California, the individual health benefit exchange.

Ben A. Zaniello

Ben A. Zaniello, MD, MPH, is the chief medical officer at Collective Medical, the nation’s largest network for care collaboration. He is a practicing Infectious Disease physician and technologist and has worked in care transformation for over a decade, most recently at Providence St. Joseph Health, the Seattle-based health system.