Mental Health Service Utilization Rates Among Commercially Insured Adults in the US During the First Year of the COVID-19 Pandemic.

Importance: The COVID-19 pandemic has been associated with an elevated prevalence of mental health conditions and disrupted mental health care throughout the US. Objective: To examine mental health service use among US adults from January through December 2020. Design, Setting, and Participants: This cohort study used county-level service utilization data from a national US database of commercial medical claims from adults (age >18 years) from January 5 to December 21, 2020. All analyses were conducted in April and May 2021. Main Outcomes and Measures: Per-week use of mental health services per 10 000 beneficiaries was calculated for 5 psychiatric diagnostic categories: major depressive disorder (MDD), anxiety disorders, bipolar disorder, adjustment disorders, and posttraumatic stress disorder (PTSD). Changes in service utilization rates following the declaration of a national public health emergency on March 13, 2020, were examined overall and by service modality (in-person vs telehealth), diagnostic category, patient sex, and age group. Results: The study included 5 142 577 commercially insured adults. The COVID-19 pandemic was associated with more than a 50% decline in in-person mental health care service utilization rates. At baseline, there was a mean (SD) of 11.66 (118.00) weekly beneficiaries receiving services for MDD per 10 000 enrollees; this declined by 6.44 weekly beneficiaries per 10 000 enrollees (ß, -6.44; 95% CI, -8.33 to -4.54). For other disorders, these rates were as follows: anxiety disorders (mean [SD] baseline, 12.24 [129.40] beneficiaries per 10 000 enrollees; ß, -5.28; 95% CI, -7.50 to -3.05), bipolar disorder (mean [SD] baseline, 3.32 [60.39] beneficiaries per 10 000 enrollees; ß, -1.81; 95% CI, -2.75 to -0.87), adjustment disorders (mean [SD] baseline, 12.14 [129.94] beneficiaries per 10 000 enrollees; ß, -6.78; 95% CI, -8.51 to -5.04), and PTSD (mean [SD] baseline, 4.93 [114.23] beneficiaries per 10 000 enrollees; ß, -2.00; 95% CI, -3.98 to -0.02). Over the same period, there was a 16- to 20-fold increase in telehealth service utilization; the rate of increase was lowest for bipolar disorder (mean [SD] baseline, 0.13 [16.72] beneficiaries per 10 000 enrollees; ß, 1.40; 95% CI, 1.04-1.76) and highest for anxiety disorders (mean [SD] baseline, 0.20 [9.28] beneficiaries per 10 000 enrollees; ß, 9.12; 95% CI, 7.32-10.92). When combining in-person and telehealth service utilization rates, an overall increase in care for MDD, anxiety, and adjustment disorders was observed over the period. Conclusions and Relevance: In this cohort study of US adults, we found that the COVID-19 pandemic was associated with a rapid increase in telehealth services for mental health conditions, offsetting a sharp decline in in-person care and generating overall higher service utilization rates for several mental health conditions compared with prepandemic levels.

Spatial modeling of vaccine deserts as barriers to controlling SARS-CoV-2.

BACKGROUND: COVID-19 vaccine distribution is at risk of further propagating the inequities of COVID-19, which in the United States (US) has disproportionately impacted the elderly, people of color, and the medically vulnerable. We sought to measure if the disparities seen in the geographic distribution of other COVID-19 healthcare resources were also present during the initial rollout of the COVID-19 vaccine. METHODS: Using a comprehensive COVID-19 vaccine database (VaccineFinder), we built an empirically parameterized spatial model of access to essential resources that incorporated vaccine supply, time-willing-to-travel for vaccination, and previous vaccination across the US. We then identified vaccine deserts-US Census tracts with localized, geographic barriers to vaccine-associated herd immunity. We link our model results with Census data and two high-resolution surveys to understand the distribution and determinates of spatially accessibility to the COVID-19 vaccine. RESULTS: We find that in early 2021, vaccine deserts were home to over 30 million people, >10% of the US population. Vaccine deserts were concentrated in rural locations and communities with a higher percentage of medically vulnerable populations. We also find that in locations of similar urbanicity, early vaccination distribution disadvantaged neighborhoods with more people of color and older aged residents. CONCLUSION: Given sufficient vaccine supply, data-driven vaccine distribution to vaccine deserts may improve immunization rates and help control COVID-19.

COVID-19 has affected the elderly, people of color, and individuals with chronic illnesses more than the general population. Large barriers to accessing the COVID-19 vaccine could make this problem worse. We used a website called VaccineFinder, which has information on the location of most COVID-19 vaccine doses in the US, to measure vaccine accessibility in early 2021. We then identified vaccine deserts, defined as small US regions with poor access to the COVID-19 vaccine. We found that over 10% of the US lived in a vaccine desert. Overall, we found that vaccines were less available to people in rural areas, people of color, and individuals with chronic illnesses. It will be important to reverse this pattern and ensure enough vaccines are sent to these communities to help reduce the spread of COVID-19.

The impact of the COVID-19 pandemic and policy response on health care utilization: Evidence from county-level medical claims and cellphone data.

The COVID-19 pandemic has forced federal, state, and local policymakers to respond by legislating, enacting, and enforcing social distancing policies. However, the impact of these policies on healthcare utilization in the United States has been largely unexplored. We examine the impact of county-level shelter in place ordinances on healthcare utilization using two unique datasets-employer-sponsored insurance for over 6 million people in the US and cell phone location data. We find that introduction of these policies was associated with reductions in the use of preventive care, elective care, and the number of weekly visits to physician offices, hospitals and other health care-related industries. However, controlling for county-level exposure to the COVID-19 pandemic as a way to account for the endogenous nature of policy implementation reduces the impact of these policies. Our results imply that while social distancing policies do lead to reductions in healthcare utilization, much of these reductions would have occurred even in the absence of these policies.

The Impact of the COVID-19 Pandemic and Policy Response on Health Care Utilization: Evidence from County-level Medical Claims and Cellphone data

The COVID-19 pandemic has forced federal, state and local policymakers to respond by legislating, enacting, and enforcing social distancing policies. However, the impact of these policies on healthcare utilization in the United States has been largely unexplored. We examine the impact of county-level shelter in place ordinances on healthcare utilization using two unique datasets—employer-sponsored insurance for over 6 million people in the US and cell phone location data. We find that introduction of these policies was associated with reductions in the use of preventive care, elective care, and the number of weekly visits to physician offices and hospitals. However, controlling for county-level exposure to the COVID-19 pandemic reduces the impact of these policies. Our results imply that while social distancing policies do lead to reductions in healthcare utilization, much of these reductions would have occurred even in the absence of these policies.

Assessing the Association Between Social Gatherings and COVID-19 Risk Using Birthdays.

Importance: Many policies designed to stop the spread of COVID-19 address formal gatherings, such as workplaces and dining locations. Informal social gatherings are a potentially important mode of SARS-CoV-2 transmission, but studying their role in transmission is challenged by data and methodological limitations; birthdays offer an opportunity to empirically quantify the potential role of small social gatherings in COVID-19 spread. Objective: To assess the association between social gatherings and SARS-CoV-2 transmission by studying whether COVID-19 rates increase after birthdays in a household. Design, Setting, and Participants: This cross-sectional study used nationwide data from January 1 to November 8, 2020, from 2.9 million US households with private insurance to compare COVID-19 infections between households with and without a birthday in the preceding 2 weeks, stratified according to county-level COVID-19 prevalence in that week and adjusting for household size and both week- and county-specific differences. The study also compared how birthday-associated infection rates differed by type of birthday (eg, child vs adult birthday, or a milestone birthday such as a 50th birthday), county-level precipitation on the Saturday of each week (which could move gatherings indoors), political leanings in the county, and state shelter-in-place policies. Main Outcomes and Measures: Household-level COVID-19 infection. Results: Among the 2.9 million households in the study, in the top decile of counties in COVID-19 prevalence, households with a birthday in the 2 weeks prior had 8.6 more diagnoses per 10 000 individuals (95% CI, 6.6-10.7 per 10 000 individuals) compared with households without a birthday in the 2 weeks prior, a relative increase of 31% above the county-level prevalence of 27.8 cases per 10 000 individuals, vs 0.9 more diagnoses per 10 000 individuals (95% CI, 0.6-1.3 per 10 000 individuals) in the fifth decile (P < .001 for interaction). Households in the tenth decile of COVID-19 prevalence had an increase in COVID-19 diagnoses of 15.8 per 10 000 persons (95% CI, 11.7-19.9 per 10 000 persons) after a child birthday, compared with an increase of 5.8 per 10 000 persons (95% CI, 3.7-7.9 per 10 000 persons) among households with an adult birthday (P < .001 in a test of interactions). No differences were found by milestone birthdays, county political leaning, precipitation, or shelter-in-place policies. Conclusions and Relevance: This cross-sectional study suggests that birthdays, which likely correspond with social gatherings and celebrations, were associated with increased rates of diagnosed COVID-19 infection within households in counties with high COVID-19 prevalence.

Use of buprenorphine for those with employer-sponsored insurance during the initial phase of the COVID-19 pandemic.

OBJECTIVE: To quantify weekly rates of use of buprenorphine for those with employer-based insurance and whether the rate differs based on county-level measures of race, historical fatal drug overdose rate, and COVID-19 case rate. METHODS: We used 2020 pharmaceutical claims for 4.8 million adults from a privately insured population to examine changes in the use of buprenorphine to treat opioid use disorder in 2020 during the onset of the COVID-19 pandemic. We quantified variation by examining changes in use rates across counties based on their fatal drug overdose rate in 2018, number of COVID-19 cases per capita, and percent nonwhite. RESULTS: Weekly use of buprenorphine was relatively stable between the first week of January (0.6 per 10,000 enrollees, 95%CI = 0.2 to 1.1) and the last week of August (0.8 per 10,000 enrollees, 95%CI = 0.4 to 1.3). We did not find evidence of any consistent change in use of buprenorphine by county-level terciles for COVID-19 rate as of August 31, 2020, age-adjusted fatal drug overdose rate, and percent nonwhite. Use was consistently higher for counties in the highest tercile of county age-adjusted fatal drug overdose rate when compared to counties in the lowest tercile of county age-adjusted fatal drug overdose rate. DISCUSSION: Our results provide early evidence that new federal- and state-level policies may have steadied the rate of using buprenorphine for those with employer-based insurance during the pandemic.

Who Is (and Is Not) Receiving Telemedicine Care During the COVID-19 Pandemic.

INTRODUCTION: The COVID-19 pandemic has forced telehealth to be the primary means through which patients interact with their providers. There is a concern that the pandemic will exacerbate the existing disparities in overall healthcare utilization and telehealth utilization. Few national studies have examined the changes in telehealth use during the COVID-19 pandemic. METHODS: Data on 6.8 and 6.4 million employer-based health plan beneficiaries in 2020 and 2019, respectively, were collected in 2020. Unadjusted rates were compared both before and after the week of the declaration of the COVID-19 pandemic as a national emergency. Trends in weekly utilization were also examined using a difference-in-differences regression framework to quantify the changes in telemedicine and office-based care utilization while controlling for the patient's demographic and county-level sociodemographic measures. All analyses were conducted in 2020. RESULTS: More than a 20-fold increase in the incidence of telemedicine utilization after March 13, 2020 was observed. Conversely, the incidence of office-based encounters declined by almost 50% and was not fully offset by the increase in telemedicine. The increase in telemedicine was greatest among patients in counties with low poverty levels (ß=31.70, 95% CI=15.17, 48.23), among patients in metropolitan areas (ß=40.60, 95% CI=30.86, 50.34), and among adults than among children aged 0-12 years (ß=57.91, 95% CI=50.32, 65.49). CONCLUSIONS: The COVID-19 pandemic has affected telehealth utilization disproportionately on the basis of patient age and both the county-level poverty rate and urbanicity.

Changes in Health Services Use Among Commercially Insured US Populations During the COVID-19 Pandemic.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has placed unprecedented strain on patients and health care professionals and institutions, but the association of the pandemic with use of preventive, elective, and nonelective care, as well as potential disparities in use of health care, remain unknown. Objective: To examine changes in health care use during the first 2 months of the COVID-19 pandemic in March and April of 2020 relative to March and April of 2019 and 2018, and to examine whether changes in use differ by patient's zip code-level race/ethnicity or income. Design, Setting, and Participants: This cross-sectional study analyzed health insurance claims for patients from all 50 US states who receive health insurance through their employers. Changes in use of preventive services, nonelective care, elective procedures, prescription drugs, in-person office visits, and telemedicine visits were examined during the first 2 months of the COVID-19 pandemic in 2020 relative to existing trends in 2019 and 2018. Disparities in the association of the pandemic with health care use based on patient's zip code-level race and income were also examined. Results: Data from 5.6, 6.4, and 6.8 million US individuals with employer-sponsored insurance in 2018, 2019, and 2020, respectively, were analyzed. Patient demographics were similar in all 3 years (mean [SD] age, 34.3 [18.6] years in 2018, 34.3 [18.5] years in 2019, and 34.5 [18.5] years in 2020); 50.0% women in 2018, 49.5% women in 2019, and 49.5% women in 2020). In March and April 2020, regression-adjusted use rate per 10 000 persons changed by -28.2 (95% CI, -30.5 to -25.9) and -64.5 (95% CI, -66.8 to -62.2) for colonoscopies; -149.1 (95% CI, -162.0 to -16.2) and -342.1 (95% CI, -355.0 to -329.2) for mammograms; -60.0 (95% CI, -63.3 to -54.7) and -118.1 (95% CI, -112.4 to -113.9) for hemoglobin A1c tests; -300.5 (95% CI, -346.5 to -254.5) and -369.0 (95% CI, -414.7 to -323.4) for child vaccines; -4.6 (95% CI, -5.3 to -3.9) and -10.9 (95% CI, -11.6 to -10.2) for musculoskeletal surgery; -1.1 (95% CI, -1.4 to -0.7) and -3.4 (95% CI, -3.8 to -3.0) for cataract surgery; -13.4 (95% CI, -14.6 to -12.2) and -31.4 (95% CI, -32.6 to -30.2) for magnetic resonance imaging; and -581.1 (95% CI, -612.9 to -549.3) and -1465 (95% CI, -1496 to -1433) for in-person office visits. Use of telemedicine services increased by 227.9 (95% CI, 221.7 to 234.1) per 10 000 persons and 641.6 (95% CI, 635.5 to 647.8) per 10 000 persons. Patients living in zip codes with lower-income or majority racial/ethnic minority populations experienced smaller reductions in in-person visits (≥80% racial/ethnic minority zip code: 200.0 per 10 000 [95% CI, 128.9-270.1]; 79%-21% racial/ethnic minority zip code: 54.2 per 10 000 [95% CI, 33.6-74.9]) but also had lower rates of adoption of telemedicine (≥80% racial/ethnic minority zip code: -71.6 per 10 000 [95% CI, -87.6 to -55.5]; 79%-21% racial/ethnic minority zip code: -15.1 per 10 000 [95% CI, -19.8 to -10.4]). Conclusions and Relevance: In this cross-sectional study of a large US population with employer-sponsored insurance, the first 2 months of the COVID-19 pandemic were associated with dramatic reductions in the use of preventive and elective care. Use of telemedicine increased rapidly but not enough to account for reductions in in-person primary care visits. Race and income disparities at the zip code level exist in use of telemedicine.