ED volumes slowest to begin recovery after COVID-19, analysis finds

• The largest hospital volume declines stemming from COVID-19 occurred in EDs.
• Mandatory suspensions of hospital procedures affected 45% of the U.S. population.
• Hospitals may find success in drawing patients to return by tailoring their messages based on generational differences.

As hospital volumes begin to recover from a coronavirus-related plummet that hit its nadir in mid-April, emergency department (ED) use remains the biggest laggard.

A new revenue cycle analysis by TransUnion Healthcare of more than 500 hospitals examined patient volumes in three major hospital areas and found that compared with the pre-coronavirus period, volumes for the week of May 10-16 were:

• Down 40% in EDs
• Down 31% in outpatient settings
• Down 20% in inpatient settings

“Heart attack and strokes didn’t stop; where did they go?” James Bohnsack, senior vice president and chief strategy officer with TransUnion Healthcare, said about the ED volume drop. “The fact is, they didn’t go anywhere, unfortunately. And then bad outcomes happened.”

Drops of between 20% and 40%, depending on setting, from the first week of March to the week of May 10-16 were less steep than TransUnion Healthcare had found spanning the first week of March to the week of April 12-18. Those volume declines ranged from 33% to 62%.

The volume losses will affect hospital revenues differently depending on setting, but generally inpatient services generate the largest amount of revenue, outpatient services tend to generate greater profits and ED services feed much of the inpatient volume.

The TransUnion Healthcare findings echoed those recently reported by Kaufman Hall, which found that in April, compared with April 2019:

• Operating room minutes fell 61%.
• Overall discharges fell 30%.
• Adjusted discharges fell 41%.
• Adjusted patient days fell 39%.
• ED visits fell 43%.

Compared to the first eight full weeks of the year — Jan. 5-11 through Feb. 23-29 — hospital outpatient volume declines hit 64% during the week of April 5-11. Since then, ED visits recovered 22% of volume and inpatient volumes regained 35%.

Factors that drove volume declines

Patient volumes throughout hospitals slumped as hospitals voluntarily and involuntarily suspended nonemergency services amid the COVID-19 pandemic.

Although some states recently have begun to lift restrictions, as many as half, representing nearly 45% of the U.S. population, mandated suspension of nonemergency care and elective surgeries as the scope of the pandemic grew, Moody’s Investors Service recently reported.

Although hospitals across all regions saw significant declines in operating room minutes, for example, Kaufman Hall found hospitals in the Northeast and Mid-Atlantic region were the most affected. The combined region had the highest rates of COVID-19 and has had a slow ramp-up of nonurgent procedures.

Geographic breakdowns of the decline in operating room minutes included:

• 83% year-over-year in the Northeast/Mid-Atlantic
• 49% year-over-year in the West

Regarding ED visits, hospitals in the Northeast/Mid-Atlantic had the steepest declines (46% year-over-year), compared with 34% among Great Plains hospitals.

Data increasingly indicate people have been avoiding EDs due to coronavirus concerns, sometimes with severe consequences. For instance, New York City reported in April that roughly 200 residents were dying each day away from hospitals and nursing homes, compared with about 35 per day between 2013 and 2017.

More benign drivers of ED volume drops could include increased use of urgent care clinics and improved access to primary care providers through telehealth, Bohnsack said.

Factors driving volume recovery

Bohnsack said he has seen volumes recover faster in states that opened earliest, especially among less complex services.

The ED volume lag has caught the attention of many hospital operators.

Amid worries not just about hospitals’ financial stability but also patient health, hospitals in states like Texas and California have launched campaigns to persuade people to seek ED services in emergencies.

TransUnion also sees an opportunity to tailor appeals when data indicate patients of a certain generation are more comfortable returning to a particular setting. For instance:

• Older generations are returning to EDs more quickly than millennial and Gen Z patients.
• Millennial and Gen Z outpatient visit volumes have increased more than those of other generations since the first full week of April.
• Millennials and Gen Z have driven positive trends in inpatient visit volumes.