Inpatient health care utilization before, during and after the coronavirus pandemic: Long-term trends, short-term changes, and their drivers

Updated project title: Routinely collected health care data to monitor and evaluate effects of health services: Impact of telemedicine on nursing home residentsBackground and rationale: Telemedicine (i.e., remote audio or video consultations with a clinician at real time) has the potential to improve access to health care. It has a particularly high potential to improve the quality of health care services provided in nursing homes. Residents often have mobility restrictions, making it difficult to travel for in person visits, and rely on emergency services instead. Telemedicine use quickly expanded at the start of COVID-19 pandemic in 2020 in many countries, but it is not well known whether it remained widely used afterwards and how it changed overall patterns of nursing home residents' health care.Objectives and aims: This project studied the effects of telemedicine adoption for routine and specialist consultations in US nursing homes in 2020-2022. The project first aimed to describe the overall specialty care use in nursing home residents, and how it changes for patients moving in from previous independent or community living setting. Next, it aimed to describe the adoption of telemedicine in nursing homes and study its effect on access to health care. Finally, it identified further health care policy changes in US nursing homes in 2020-2022 and explored how they changed residents' care.Methods: I used Medicare health care claims (covering up to 50 million elderly and disabled US patients annually) and Minimum Data Set (regular survey on US nursing home residents) data to identify nursing home residents and health care services they received in 2017-2022. The three studies used descriptive statistics to count the number of total and telemedicine visits, identified by service- and place-specific codes, over time. I applied logistic regression models to identify resident, nursing home, and provider-specific characteristics of telemedicine use. Finally, I applied difference-in-differences analysis to compare health care received in high- vs low-telemedicine adopting nursing homes in clinical scenarios that often result in barriers to care in nursing homes. Results:Telemedicine was rapidly adopted for nursing home residents' care in the US in early 2020, increasing from 0.15% of all visits in February 2020 to 15-25% of visits in May 2020. Subsequently, it stabilized at a low use rate (2-8% depending on the visit type) Higher telemedicine use was associated with improved access to psychiatry visits in the nursing home, but had a smaller impact in other clinical scenarios, such as visits for residents with limited mobility or new specialist visits. Overall, the use of specialty care falls significantly after patients transition to a nursing home in the US. Among long-term care residents with previous specialty care use, the proportion of residents with visits decreased consistently in all specialties in the 12 months after the transition, ranging from a relative decrease of 14.4% for orthopedics to 67.9% for psychiatry visits. The decrease was similarly high even among residents with a diagnosis likely requiring continued specialty care. Telemedicine use in nursing homes in the US was enabled by a waiver allowing its reimbursement for Medicare beneficiaries at parity with in-person visits. Another public health emergency waiver removed the requirement that nursing home residents can receive reimbursed skilled nursing care only after a 3-day hospitalization. This project found that the introduction of this waiver increased the number of such nursing care episodes markedly, particularly in the first year of the COVID-19 pandemic. The waiver was used primarily among certain types of facilities and for long-term care residents with COVID-19, and it did not result in overall substantially higher skilled nursing care costs - all suggesting its successful implementation.Conclusions and impact:While adoption of telemedicine and relaxation of other rules on reimbursement rules in nursing homes helped to provide valuable health care services to residents during peak COVID-19 pandemic times, they did not have a lasting impact on the overall patterns of care use. The majority of nursing homes reverted to low telemedicine use, although higher than before the pandemic, from 2021. More sustained effort and further incentives will be needed for residents to benefit fully from the flexibility and increased access that telemedicine can provide in nursing homes.