Changes in Primary Care Visits in the 24 Weeks After COVID-19
Stay-at-Home Orders Relative to the Comparable Time Period in 2019 in
Metropolitan Chicago and Northern Illinois
Children are potentially more vulnerable to the effects of public health responses to
mitigate spread of SARS-CoV-2 - than they are to infection from
the virus itself. , Public health measures, including masking, physical distancing, and limits on
gatherings, are expected to continue to some extent until scientists find an
effective treatment or vaccine. Stay-at-home orders, enacted in Illinois on March
21, 2020, have caused children to experience loss of in-person education, group
activities, and social connections. Families have experienced loss of jobs, housing,
and food resources. In addition to the social, emotional, and nutritional impacts on
children, there have been reports of dramatic declines in vaccine
administration , and emergency department utilization. , Primary care is the mainstay of healthcare for children in the US but patterns of
primary care utilization by children after the implementation of stay-at-home orders
have not been described. The US healthcare system changed rapidly in response to
awareness of community spread of COVID-19 infection in early March 2020. Federal and
state policy makers loosened restrictions at the federal and state level on
telehealth, payers increased telehealth reimbursement, and healthcare providers
rapidly expanded telehealth services to patients and families. - In late April 2020, the lay press reported on reductions in childhood vaccine administration.
This was followed by social media campaigns to encourage families to return to care
and to call their pediatrician. , In this brief report, we
characterize primary care service utilization in metropolitan Chicago over the first
24 weeks of the COVID-19 pandemic response in relation to the comparable time period
in the year prior. 

We examined retrospective visit and billing data from 15 pediatric practices within
the Lurie Children’s Pediatric Partners (LCPP), an Accountable Care Organization
(ACO) of 252 pediatricians in 71 pediatric primary care offices throughout
metropolitan Chicago including northern Illinois and northwest Indiana. The 15
practices included in this study were selected because they share a common
electronic medical record platform (Epic EMR, Verona, WI) that supplies visit data
nightly to LCPP. Five practices were within the city of Chicago, 7 were in suburban
Cook County, and 3 were in Winnebago County. Practices were primarily small and
medium size with 4 solo practitioners, 6 practices with 3-5 providers, and 4
practices with 7-9 providers. There were 2 larger practice groups with 20 and 27
total providers and 2 offices each. The LCPP practices function independently but
are connected through the value-based contracts and quality improvement initiatives
of the ACO. This analysis of deidentified visit counts is considered Non-Human
Subjects Research by the Lurie Children’s Institutional Review Board. We examined the included practices’ total visits made by children, regardless of
payer, in one-week epochs, over the 24 weeks from March 22 through September 5, 2020
and the comparable period in 2019. In addition, we provide baseline data from the
4 weeks prior to the COVID-19 pandemic response and the comparable period in 2019.
Data were extracted on September 25, 2020 to account for delays in closure of visits
in the electronic medical record (EMR). The 2020 timeframe of this study represents 4 phases of the Illinois response to
COVID-19: (1) on March 23, 2020, the governor issued a Stay-at-Home Executive Order,
which limited healthcare visits to emergencies and COVID-19 care, closed schools to
in-person instruction, and limited daycare to groups of 10 or fewer children of
essential workers; (2) on May 11, 2020 Phase 2 began, which allowed for elective
procedures and essential gatherings of 10 or fewer people; (3) in the first week of
June 2020, Illinois entered Phase 3 of reopening, which lifted restrictions on
healthcare services, limited opening of daycare and summer camp programs, permitted
gatherings of 10 or fewer people for any reason and allowed outdoor seating at
restaurants; (4) on June 26, 2020 Phase 4 began, which expanded daycare and summer
camp programs and allowed for opening of more businesses with capacity limits.
Illinois continued in Phase 4 through September 5, 2020. In August, schools outside
of the city of Chicago opened to various hybrid, in-person, and remote learning
models. Most schools in the city of Chicago, including Chicago Public Schools,
opened to remote learning on September 8, 2020, after Labor Day and after our study
period. We identified well-child and immunization-only (WC-IO) visits based on the presence
of Current Procedural Terminology (CPT) Evaluation and Management codes for a
well-child visit, a billing line item belonging to the Immunization/Injection
grouping, or an International Classification of Diseases, Tenth Revision, Clinical
Modification (ICD-10-CM) code for Health Examination or Participation in Sport. All
other visits were categorized as Other. We used CPT codes to identify visits with a
telemedicine modifier. To characterize the types of Other visits, we applied Agency
for Healthcare Research and Quality (AHRQ) Clinical Classification Software (CSS)
version 2020.1 to the principal ICD-10-CM codes associated with these visits. We present counts and percentages for WC-IO and Other visit types for each week for
the 2 years included in the study. In addition, we present counts and percentages of
visits with a telemedicine billing modifier by age groups (younger than 2 years,
2-5 years, 6-10 years, 11-13 years, and 14 years or older) for both years. We did
not perform statistical hypothesis testing for the descriptive study results in this
brief report. 

There were 102 942 total visits (72 030 WC-IO and 30 912 Other) during the 24 weeks
in 2020 compared with 144 672 visits (80 578 WC-IO and 64 094 Other) in the
comparable timeframe in 2019. Immunization-only visits represented 9% of WC-IO
visits in both 2020 and 2019. The payer mix for the included practices was
consistent over the 2 years of study, 93% private, 6% public, and 1% other. shows the pattern of
primary care utilization over the 4 weeks before and the 4 weeks of the initial
COVID-19 Stay-at-Home Order as well as in Phase 2, 3, and 4 of Reopening. All visits
showed a dramatic decline in the two weeks prior to the Stay-at-Home Order (between
March 8 and March 22, 2020). WC-IO visits steadily increased starting in week 3 of
the Illinois Stay-at-Home Order and by the end of Phase 2 were at 90% of the 2019
baseline. In Phase 3 and 4, WC-OI visits returned to 2019 levels, with decreases
around Memorial Day and Fourth of July in both years and Labor Day in 2019. In
contrast, Other visit types have remained low since March 22, 2020 without an
increase since resumption of elective healthcare services and the phased reopening
of daycare, school, and camp programs. A telemedicine billing modifier was not
observed in the included practices before the week of March 15. In the week of March
15 a telemedicine billing modifier was present for 4% of visits. There was a rapid
increase in application of a telemedicine billing modifier peaking at 22% in the
week of April 29. From the start to end of May, a telemedicine billing modifier was
applied to 18% to 13% of visits, respectively. A telemedicine billing modifier was
applied to 5-8% of visits since June. shows the number
of visits for each age group by visit type in the study timeframe for 2020 and 2019.
During both years, the youngest children (<2 years) had the greatest number of
visits, primarily WC-IO. This age group represented 42% of all visits in 2020 and
39% of all visits in 2019. The smallest number of visits were for 11- to
13-year-olds, representing 9% of all visits in both years. There were no
telemedicine billing modifiers on visits in the 2019 timeframe for any included
practice. The percentage of visits with a telemedicine modifier varied slightly
across age groups . The top 10 primary ICD-10-CM codes associated with Other visits in 2020 included
fewer visits for upper respiratory, ear and throat infections and relatively more
visits for fever, skin disorders, and mental health conditions . The top 10
primary ICD-10-CM code diagnoses represented 22.2% of Other visits in 2020 and 33.5%
of Other visits in 2019. Rash and dermatitis ranked second and seventh overall in
2020, 2nd and 4th for visits with a telemedicine billing modifier but were not
ranked in the top 10 in 2019. Attention-deficit hyperactivity disorder was ranked
fourth for Other visits overall; third and ninth for visits with a telemedicine
billing modifier in 2020; generalized anxiety disorder was eighth among visits with
a telemedicine billing modifier but were not ranked in the top 10 in 2019. When the
primary ICD-10-CM codes were aggregated using the CCS, there was more overlap
between categories in 2019 and 2020, but the rankings differed . For example,
fever ranked first in 2020 overall and for visits with a telemedicine billing
modifier whereas fever ranked third in 2019. The CCS categories represented a
smaller proportion of Other visits in 2020 (41.7%) than in 2019 (54.2%). 

This analysis of healthcare utilization from 16 primary care practices in
metropolitan Chicago and northern Illinois, documents the dramatic decreases in
primary care visits during the early weeks of the Stay-at-Home Executive Order in
Illinois relative to the prior year. We observed a slow but steady return to 2019
levels of WC-IO visits over the study period as Chicago and Illinois faced high
rates of COVID-19 infections into June. The return of these visits occurred in the setting of active efforts to
encourage families to catch up on delayed immunizations. Each practice was given the
freedom to determine the best approach for their individual circumstances, drawing
on resources from LCPP webinars and email communications. Some practices utilized
their EMR and the LCPP population health management platform to send text and email
messages that promoted return to care. It is also possible that families sought well
child care after exposure to press coverage of declines in immunization rates and
mass media campaigns emphasizing safety measures health systems put in place to
prevent spread of infection. Although, each state and region has been impacted by
COVID-19 infections on different time courses and public health responses have
varied, our results demonstrate that WC-IO visits can return to pre-pandemic levels.
These findings can be utilized by policy makers to ensure that essential pediatric
well child and immunization visits are maintained if restrictions on healthcare
visits are reinstituted. In contrast to WC-IO visits, the number of Other visits has been persistently
suppressed, despite resumption of elective healthcare services and reopening of
daycare, school, and camp programs in the area. The top 10 ICD-10-CM code diagnoses
and CCS categories represented smaller proportions of Other visits in 2020 than
2019. This indicates a lower concentration of visits for the most common conditions
in 2020. The practices included in our analysis saw fewer children for respiratory,
ear, and throat infections since the start of the pandemic than the comparable time
period in the prior year. The predominance of fever and skin disorders in the top 10
lists from 2020 could reflect evaluation for symptoms of COVID-19 compatible illness
and concerns for skin changes associated with post-viral inflammatory
syndrome - that received
much media attention in May and June 2020. The presence of mental health concerns
including attention deficit hyperactivity disorder and anxiety in the top 10 lists
for Other visits with a telehealth modifier may be indicative of the emotional
stress of the pandemic and suggests these conditions are amenable to
telemedicine. Our results also demonstrate the role that telemedicine played during the pandemic in
a sample of pediatric primary care practices with largely privately-ensured patient
populations. These findings mirror reports of the rapid expansion of telemedicine
services at the start of the pandemic response. , The telemedicine modifier was
not observed within included practices until 1 week prior to the issuance of the
Illinois Stay-at-Home Executive Order. Prior to the pandemic, parity laws had been
passed in 29 states and the District of Columbia, but not in Illinois. Within 2
weeks after the Stay-at-Home Order, up to 20% of pediatric primary care visits in
study practices had a telemedicine modifier. As Illinois reopened, telehealth visits
dropped to less than 10% of total visits to practices included in this study. In
Phase 4, visits with a telehealth modifier stabilized around 5% (approximately 300
visits per week across the 16 practices) and have been maintained at this level
throughout Summer 2020. Policy makers in states without telemedicine parity have an
opportunity to pass legislation that expands access to this model of care. While the lack of Other visits may signal that children are gaining the benefit of
fewer infections from staying home, these findings raise concerns for the financial
viability of pediatric practices. Telemedicine reimbursement provided a financial
lifeline for practices at the start of the pandemic. With dramatic suppression of
healthcare utilization for children, now may be an opportune time for pediatric care
to shift toward value-based contracts. If reimbursement is maintained, telehealth
visits could play a bigger role in the provision of pediatric care in the future.
Providers, practices, and patients now have greater experience and comfort with the
delivery of remote care. Providers and payers have an opportunity to reshape
patterns of healthcare seeking for children as we establish a new normal in the
United States. These are important areas for program evaluation, quality
improvement, and research Our study is subject to limitations. First, our results are drawn from 16 practices
in metropolitan Chicago and northern Illinois, on a common EMR, caring primarily for
privately insured patients and may not be generalizable to other settings. There is
practice variation in the number of providers and the urban and suburban locations.
Second, we are unable to determine the cause for the return of well child and
immunization only visits because each practice had the ability to tailor their
approach to encouraging families to return to care. Third, we can only hypothesize
as to reasons why Other visit types have remained lower in 2020 than 2019 throughout
the 24 week study. We cannot determine if children are experiencing fewer infections
or their families are less likely to seek care for infectious symptoms due to
concerns about contracting COVID-19 in clinical settings. Similarly, we do not have
data on the individual patient or practice-level factors that contributed to the
resumption of WC-IO visits. Nevertheless, these results present timely baseline
estimates of the impact of COVID-19 on child healthcare utilization in a major
metropolitan area. Finally, our findings are subject to the accuracy of electronic
medical record data. 

The COVID-19 pandemic and public health response to control the spread of infections
has shaped patterns of primary care utilization for children in metropolitan Chicago
and northern Illinois. Our findings can inform future research on pediatric primary
care delivery models as areas affected by COVID-19 reopen, schools experiment with
different learning models to mitigate the spread of the virus, and we approach the
winter viral season. Our findings can also shape policy for telemedicine and
essential healthcare services to ensure that children receive recommended and
medically necessary care as the COVID-19 pandemic unfolds. 

