JULY 2020 Issue Brief Care in the COVID-19 Era: An Analysis of California Community Clinics W hile COVID-19 has not yet created the over- in California. This issue brief uses OCHIN’s unique data whelming surge of cases feared by leaders of sources to provide new information on how the COVID- California’s health care delivery system, the 19 pandemic is impacting health and the health care pandemic is having unprecedented effects. Patients con- system in California. OCHIN’s providers are vital to tinue to put off routine and nonemergency care,1 primary underserved communities, collectively serving more than care doctors are increasingly worried about the survival 1.3 million patients throughout the state (Figure 1). Their of their practices2 and hospitals are experiencing a dra- experiences and electronic health records data can pro- matic decline in emergency and inpatient visits.3 vide new insight into how the COVID-19 pandemic has magnified existing health disparities in California, led to OCHIN is a nonprofit information technology and research sizable decreases in in-person visits, and provided new organization that serves a nationwide network of primary momentum to the shift toward care delivered by phone care practices, including 29 health care organizations or video, often referred to as telehealth. Figure 1. OCHIN’s California Network Overview 1,320,072 OCHIN Network Patients Female 56% White 71% 29 Male 44% Unknown 13% Other/Unknown 1% Black 7% Asian 7% Health Care Native American 1% Organizations 0–17 years 21% Pacific Islander 1% 18–29 years 17% 30–49 years 30% Latino 47% 50–64 years 19% Non-Latino 45% 65+ years 12% Unknown 8% Notes: Source uses AI/AN, Black/African American, and Hispanic. Demographic groups may not add to 100% due to rounding. Source: OCHIN (May 2020). COVID-19 Pandemic Reflects Deep Rapid Deployment of Telehealth Health Disparities Helped Providers Maintain Care According to the California network data as of June 26, Emerging reports show dramatic declines in patient vol- 2020, 3,770 OCHIN network patients were confirmed or ume across hospitals, clinics, and primary care practices presumed to be COVID-19 positive. Providers’ records both in California and nationally. Providers in the OCHIN show that the virus is disproportionately affecting Latino network are no different. The national data show that the patients, who represent 47% of the network’s total patient number of inpatient visits to clinics fell by more than half population in California but comprise 64% of its COVID- — from an average weekly volume of 21,101 encoun- 19-positive cases (Figure 2). This disparity has also been ters in early 2020 to 8,761 encounters in May 2020 (not well documented nationally.4 Beyond California, Latino shown). In this context, providers throughout OCHIN’s patients in the OCHIN network are twice as likely, and network have turned to telehealth — patient visits con- Black patients are 2.5 times as likely, to have a docu- ducted by phone or video — to help maintain continuity mented COVID-19 diagnosis in their electronic health of care. records data, compared with non-Latino white patients. In California, nearly half of all patient encounters on the OCHIN network are now completed virtually (Figure  3, page 3). This rise is dramatic and unprecedented. In January, just 0.5% of the nearly 219,000 patient visits to In California, Latino patients are OCHIN safety-net facilities in California were conducted by phone or video. In May, nearly 55% of more than 206,000 disproportionately experiencing the visits were virtual. OCHIN has seen similarly dramatic rises COVID-19 pandemic. in virtual behavioral health visits (Figure 4 page 3). With those telehealth encounters factored in, total behavioral health visits were up roughly 25% in April and May. Figure 2. Percentage of OCHIN’s California Patient Population vs. Patients on COVID-19-Positive Registry, by Race and Ethnicity OCHIN Population (N=1,320,072) !44D" COVID-19-Positive Patients (n=3,770) N4D" 71% 72% 64% T4D" 47% 45% L4D" 23% 25% 34D" 13% 11% 7% 7% 8% 2% 2% 1% 0% 1% 0% 4D" White Unknown Black Asian Native Pacific Latino Non-Latino Unknown American Islander RACE ETHNICITY Notes: Source uses AI/AN, Black/African American, and Hispanic. Demographic groups may not add to 100% due to rounding. Source: OCHIN, retrieved June 26, 2020. California Health Care Foundation www.chcf.org 2 Figure 3. Percentage of OCHIN’s Completed In-Person and Telehealth Encounters, California, January 2020 to June 2020 In California, telehealth encounters increased as in-person encounters declined in response to the COVID-19 pandemic. 99.5% 99.4% !44D" In-Person Telehealth 82.5% N4D" T4D" 56.4% 54.6% 52.0% 45.4% 48.0% 43.6% L4D" 17.5% 34D" 0.5% 0.6% 4D" Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 (n=218,972) (n=212,403) (n=195,882) (n=197,137) (n=206,287) (n=202,352) Figure 4. Number of OCHIN’s Completed In-Person and Telehealth BH Encounters, California, January 2019 to June 2020 OCHIN’s California network has increasingly transitioned to telehealth for behavioral health encounters in response to the COVID-19 pandemic. 20,000 18,000 Telehealth 16,000 In-Person 14,000 12,000 10,000 8,000 6,000 4,000 2,000 4" Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 FIGURES 3 and 4: Source: OCHIN, retrieved June 26, 2020. Care in the COVID-19 Era: An Analysis of California Community Clinics www.chcf.org 3 Taken together, these data show that California’s Emergency Regulations Spurred community health centers are experiencing an unprec- Telehealth Spread edented shock to their care delivery models and finances The rapid transition to telehealth has helped many provid- because of the COVID-19 crisis. To close existing gaps ers find new ways to deliver care, redeploy existing staff, and increase access to high-quality health care for every- and help offset revenue loss from the sharp decline of one, policymakers must ensure that safety-net facilities in-person visits. Across the OCHIN network, overall visit have the tools, infrastructure, and financial support nec- volume has already rebounded to around 85%–90% of essary to provide virtual and in-person care throughout pre-COVID-19 levels as telehealth visits have increased, and beyond the pandemic. but charges are still down nearly 20% (Figure 5). Policies that temporarily increased reimbursement for telehealth Average charges for behavioral health visits, particularly phone screenings and consults, have been a vital stopgap for providers, ensuring they are paid services increased while charges for for their services regardless of how they are delivered. primary care and dental service decreased Still, even with these temporary measures, gross monthly charges in OCHIN’s California network are down signifi- during the COVID-19 pandemic. cantly, particularly when it comes to dental care. Figure 5. OCHIN’s Average Monthly Gross Charges, California, by Specialty and Date March 2019 to February 2020 M4Z444644"" March 2020 to April 2020 $302,699.03 44Z444644"" $275,391.69 M4Z444644"" $237,767.67 $195,256.91 44Z444644"" M4Z444644"" $116,275.91 $106,068.45 44Z444644"" M4Z444644"" d4644"" Primary Care Dental Behavioral Health Source: OCHIN, retrieved June 26, 2020. California Health Care Foundation www.chcf.org 4 About the Author Endnotes Abby Sears is the chief executive officer at OCHIN, a non- 1.Mallory Moench, “Bay Area Doctors Worry About Patients Skipping Preventive Medical Care During Coronavirus profit health care innovation center designed to provide Pandemic,” San Francisco Chronicle, June 18, 2020. knowledge solutions that promote quality, affordable 2.Kristof Stremikis, “COVID-19 Tracking Poll: One-Third of health care to all. Learn more at ochin.org. California Primary Care Doctors Worry Their Practices Won’t Survive,” The CHCF Blog, May 15, 2020. About the Foundation 3.Glenn Melnick and Susan Maerki, The Financial Impact of The California Health Care Foundation is dedicated to COVID-19 on California Hospitals, California Health Care advancing meaningful, measurable improvements in the Foundation, June 3, 2020. way the health care delivery system provides care to the 4.Miriam Jordan and Richard A. Oppel Jr., “For Latinos and people of California, particularly those with low incomes Covid-19, Doctors Are Seeing an ‘Alarming’ Disparity,” and those whose needs are not well served by the status New York Times, May 7, 2020. quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemak- ers to create a more responsive, patient-centered health care system. For more information, visit www.chcf.org. Care in the COVID-19 Era: An Analysis of California Community Clinics www.chcf.org 5