Among a group of primary care accountable care organizations, patients with hypertension were 50% less likely to have a blood pressure recorded in April compared with February.
In March 2020, as part of the US response to COVID-19, CMS relaxed restrictions on telehealth services.1 But how the system’s transition to virtual care1 affected certain patient populations and key preventive services, such as blood pressure (BP) monitoring, remains unclear. Before the pandemic, large disparities existed in telehealth utilization.2 We examined differences in telehealth primary care use by patient and practice characteristics and relationship to out-of-office BP monitoring.
Data come from Aledade, a health care organization that works with primary care clinics to form accountable care organizations (ACOs). We used Medicare administrative data and utilization data from outbound claims collected from practice billing systems. BP data are normalized from more than 90 practice electronic health record systems. This study was determined to be institutional review board exempt.
We assessed changes in likelihood of primary care visits (in person or virtual) and BP monitoring between February and April 2020 across patient and practice characteristics. For adjusted analyses, we estimated logistic regression models of the likelihood of any primary care visit controlling for age, sex, Medicare eligibility category, race/ethnicity, CMS Hierarchical Condition Category risk score, and practice size/type.
Between February and April 2020, across 461,362 Medicare beneficiaries in 441 primary care clinics across 38 ACOs, the proportion of patients with any in-person primary care visit dropped by almost 50% (33% to 17%) (Figure). Telehealth visits grew (0% in February to 9% of population in April), making up about half the in-person loss.
Certain patient populations experienced greater decreases in their likelihood of having any primary care visit (Table). Independent correlates of no visit included receiving care at large practices or federally qualified health centers (FQHCs), being older than 75 years, being female, and having fewer comorbidities (all P ≤ .001). Black and Hispanic patients were more likely to have a primary care visit than White patients.
Patients with hypertension were half as likely to have a BP reading recorded in April vs February (30% vs 15%). Those with uncontrolled vs controlled hypertension were no more likely to have a reading (Figure). Among patients with hypertension, those with an in-person primary care visit were more likely to have a BP measurement than those with only a telehealth visit (96% vs 32%). There were no other patient- or practice-level correlates of having a BP measurement.
Despite increasing telehealth utilization, primary care visits overall decreased among a group of ACOs. Certain populations in this sample of practices were less likely to access primary care during the COVID-19 pandemic, including the elderly and those served by FQHCs. For other characteristics such as race, primary care utilization was similar.
It is concerning that patients with hypertension were 50% less likely to have a BP recorded in April compared with February. Patients with uncontrolled vs controlled hypertension were no more likely to have a visit. These findings underscore the need to improve risk stratification and outreach for people with uncontrolled hypertension and are consistent with other work showing decreases in preventive services during the pandemic.3,4
For some primary care services, current telehealth approaches may be inadequate. Telehealth visits had a more than 3-fold lower rate of BP follow-up documentation than in-person visits. The fact that Medicare does not reimburse for home BP monitors may be contributing. Payers should consider policies to reduce financial and logistical barriers to home BP monitoring, which may be more accurate than office BPs.5
Limitations include that data are not representative of all practices nationally. Absence of racial disparities in primary care access in our study may stem from proactive population health management among these practices. Additionally, drops in BP recordings may reflect a gap in home BP measurement, documentation, or both, which all are essential for chronic hypertension management.
Adam L. Beckman, BS, and Jennifer King, PhD, contributed equally as co–first authors.
The authors first acknowledge the 441 independent primary care clinics that led the ACO efforts. They also appreciate feedback from Drs Jennifer Cohn and Thomas R. Frieden.
Author Affiliations: Harvard Medical School (ALB), Boston, MA; Aledade Inc (JK, DS, NB, FM), Bethesda, MD; Department of Health Policy & Management, Harvard T.H. Chan School of Public Health (JFF), Boston, MA; Division of General Internal Medicine, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital (JFF), Boston, MA.
Source of Funding: None.
Author Disclosures: Mr Beckman reports prior employment with Aledade and prior consulting with Aledade, unrelated to this work. Dr King, Mr Streat, Mr Bartz, and Dr Mostashari are full-time employees at Aledade and hold stock options in Aledade as part of their employee benefits package. Dr Mostashari is also a founder and board member of Aledade in his capacity as CEO. Aledade is a partner organization that shares in the risk and reward of accountable care organizations in which the practices profiled in this article are involved. Dr Figueroa has received grants from The Commonwealth Fund, Arnold Ventures, and Robert Wood Johnson Foundation related to other work.
Authorship Information: Concept and design (ALB, JK, DS, NB, JFF, FM); acquisition of data (NB); analysis and interpretation of data (ALB, JK, DS, NB, JFF, FM); drafting of the manuscript (ALB, NB); critical revision of the manuscript for important intellectual content (ALB, JK, DS, NB, JFF, FM); statistical analysis (NB); administrative, technical, or logistic support (ALB, DS, JFF); and supervision (FM).
Address Correspondence to: Adam L. Beckman, BS, Harvard Medical School, 25 Shattuck St, Boston, MA 02115. Email: email@example.com.
1. Mehrotra A, Chernew M, Linetsky D, Hatch H, Cutler D. The impact of the COVID-19 pandemic on outpatient visits: a rebound emerges. The Commonwealth Fund. May 19, 2020. Accessed June 2, 2020. https://www.commonwealthfund.org/publications/2020/apr/impact-covid-19-outpatient-visits
2. Lin CCC, Dievler A, Robbins C, Sripipatana A, Quinn M, Nair S. Telehealth in health centers: key adoption factors, barriers, and opportunities. Health Aff (Millwood). 2018;37(12):1967-1974. doi:10.1377/hlthaff.2018.05125
3. Robbins R. Routine cancer screenings have plummeted during the pandemic. STAT. May 4, 2020. Accessed June 2, 2020. https://www.statnews.com/2020/05/04/cancer-screenings-drop-coronavirus-pandemic-epic/
4. Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration — United States, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(19):591-593. doi:10.15585/mmwr.mm6919e2
5. Dolan E, Stanton A, Thijs L, et al. Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin outcome study. Hypertension. 2005;46(1):156-161. doi: 10.1161/01.HYP.0000170138.56903.7a