The COVID-19 pandemic in the United States is easing, but it has not significantly accelerated the pace of people returning to routine medical care. As the pandemic enters its third year, medical experts express "deep concern" that patient visit volumes have yet to return to normal. People continue to delay important screenings and treatments, raising concerns about long-term health impacts on patients and the capacity of the national healthcare system.

According to an analysis by healthcare data firm Strata, the decline in patient visit volumes is widespread, with inpatient, outpatient, emergency, and cardiac care all below pre-pandemic levels. The firm analyzed data from more than 170 health systems across the country, covering over 1,100 hospitals, including academic medical centers, children's hospitals, and rural hospitals.

Over the past two years, even during COVID-19 outbreaks, patient visits have remained below pre-pandemic levels, highlighting the fact that large numbers of people have stayed away from hospitals and other traditional medical settings. Some had expected a significant compensatory rebound after the sharp drop in visits in 2020, but that rebound has not materialized, leaving the industry puzzled about when demand will return to normal.

"The scary part we haven't started discussing is what this means five years from now," said Sarah Alwardt, practice director of the Center for Healthcare Transformation at Avalere, a Washington, D.C.-based consulting firm.

Patient visit volumes remain in a "transitional period"

Despite the pandemic causing hundreds of thousands of hospitalizations in the U.S. and straining hospital resources, inpatient volumes have still declined significantly. Strata data shows that hospitalizations, including COVID-19 patients, fell 9.7% in 2020 and 7% in 2021; excluding COVID-19 patients, hospitalizations fell 14.9% and 14% in 2020 and 2021, respectively.

It's not just hospitalizations that have declined. Strata data shows emergency department visits fell 21% and 15.5% in 2020 and 2021, respectively. Outpatient visits (excluding testing and vaccinations) also remain below historical levels, down 16.5% in 2020 and 3.2% in 2021.

"We're seeing delays or deferrals of care, and we're very, very concerned about that," Steve Lefar, executive director of data science at Strata, said in an interview. Since the federal government declared a public health emergency in spring 2020, the virus or its threat has continued to influence patient behavior, dragging down key visit metrics.

The changes in visit volumes throughout the pandemic have been a closely watched topic for Chris Mast and his colleagues at Epic Research. They analyzed electronic health record data from millions of patients to paint a clear picture of healthcare utilization over the past two years.

The research found that many Americans missed key screenings for cervical, breast, and colon cancer. Despite repeated calls to return to "baseline"—the normal visit trends of 2019—Epic Research's analysis shows that the U.S. has neither returned to baseline nor made up for missed screenings. To close the gap, screening volumes below historical trends would need an equally large excess rebound above baseline.

Mast and his colleagues are uncertain whether a catch-up in screenings will occur, especially over time. However, he noted that patients remain responsive to messaging, with predictable increases in screenings during Breast Cancer Awareness Month each year. "That tells me the messaging is impactful," Mast said. He added that, given this, healthcare organizations should actively encourage patients to return for annual check-ups.

It's not just cancer screenings; emergency department visits have also lagged throughout the pandemic. This trend has puzzled medical experts: Where have all the health emergencies gone? Have people really had fewer heart attacks and strokes?

"It's puzzling. When we dug deeper, we found that in some cases, patients didn't really go anywhere," Mast said. Data shows that emergency department visit rates for high-acuity patients, such as those with heart attacks and strokes, are above baseline levels, while rates for low-acuity patients are below 2019 levels.

"I would describe the current state of healthcare services and care-seeking patterns as 'in a transitional period.' We're still waiting to see where these trends will ultimately settle," Mast said.

Threat to hospitals

The decline in patient demand has been so severe that the federal government has funneled billions of taxpayer dollars to hospitals nationwide to keep them financially afloat as operations were disrupted almost overnight. As people delayed care and hospitalizations fell, insurers paid out less in medical claims than historical levels, recording record profits.

But as federal relief funds dwindle and visit volumes remain sluggish, concerns are rising about the financial outlook for healthcare providers. As visit volumes shrink, hospitals are facing rising costs, especially for wages and benefits—many facilities are stretched thin on staffing. During multiple COVID-19 surges, hospitals had to pay premium rates to hire travel nurses to fill staffing gaps.

Healthcare analysts point out that these operational challenges will continue to squeeze profit margins for many hospital operators. Meanwhile, the pandemic has accelerated the shift of care to outpatient settings.

Strata data shows that inpatient orthopedic surgeries over the past two years have fallen significantly compared to 2019. Lefar said these procedures have seen a "massive shift" to outpatient facilities, and orthopedic service lines are highly profitable for many organizations. The continued migration of care from inpatient to outpatient settings will pose challenges for some operators, especially those lacking robust outpatient services.

"Dependence on inpatient services is going to be a problem, and there's no way around it," Lefar said bluntly.

As healthcare executives ponder how to move forward, experts like Avalere's Alwardt say they need to think differently about engaging with patients, especially after the rapid growth of telehealth services. "They're used to patients coming to them," Alwardt said. Now, healthcare executives need to shift their mindset to think about how to proactively maintain these patient relationships. "This will require investment in digital transformation, and I'm not sure they anticipated having to do that," he added.