This is part of a series on how hospitals are faring two years into the COVID-19 pandemic. Clickhereto follow the rest of the series.

The easing of the COVID-19 pandemic in the U.S. has not significantly accelerated the return of patients to regular medical care. As the pandemic enters its third year, medical experts express "high concern" that patient visit volumes have yet to return to normal. People continue to delay important screenings and treatments, raising concerns about both the long-term health of patients and the capacity of the nation's healthcare system.

According to an analysis by Strata, a healthcare data services provider, the decline in patient care demand is widespread, with visit volumes below pre-pandemic levels across inpatient care, outpatient visits, emergency departments, and even cardiac care. Strata analyzed data from more than 170 healthcare systems nationwide, encompassing over 1,100 hospitals, including academic medical centers, children's hospitals, and rural hospitals.

Over the past two years, even during surges of COVID-19, patient visits have remained below pre-pandemic levels, highlighting how many people have stayed away from hospitals and other traditional healthcare settings. Some had expected a significant compensatory rebound after the sharp drop in visits in 2020, but the rebound has not materialized to the expected degree. This leads some to wonder: when will the pendulum swing back?

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

Patient volumes still 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 by 9.7% in 2020 and 7% in 2021; excluding COVID-19 patients, hospitalizations fell by 14.9% and 14% in 2020 and 2021, respectively.

It's not just hospitalizations that have declined. Emergency department visits have also decreased, according to Strata, falling by 21% and 15.5% in 2020 and 2021, respectively. Outpatient volumes (excluding testing and vaccinations) have also been 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," said Steve Lefar, executive director of data science at Strata, in an interview. Since the federal government declared a public health emergency in the spring of 2020, the virus or its threat has continued to influence patient behavior and weigh on key visit metrics.

Chris Mast of Epic Research and his colleagues have been closely monitoring changes in visit volumes during the pandemic. They analyzed electronic health record data from millions of patients to clearly illustrate how healthcare utilization has evolved over the past two years. They found that many Americans missed key screenings for cervical, breast, and colon cancers. Despite much discussion about returning to "baseline" (i.e., the normal visit trends of 2019), Epic Research's analysis shows that the U.S. has neither returned to baseline levels nor made up for missed screenings. To close the gap, screening volumes below historical trends would need to be offset by a rebound of equal magnitude above baseline.

Mast and his colleagues are uncertain whether screenings can be caught up, especially as time goes on. However, he noted that patients are responsive to messaging, with predictable increases in screenings during Breast Cancer Awareness Month each year. "This tells me that these messages have an impact," he said, adding that, given this, healthcare organizations should actively encourage patients to return for their annual check-ups.

It's not just cancer screenings; emergency department visits have also lagged throughout the pandemic, a trend that puzzles experts. Where have all the health emergencies gone? Have people really had fewer heart attacks and strokes? Mast said, "It's puzzling. When we dig deeper, we find that in some cases they didn't actually go to the hospital." Data shows that emergency department visit rates for high-acuity patients (such as those with heart attacks and strokes) are above baseline, while rates for low-acuity patients are below 2019 levels. Mast said, "I would describe the delivery of healthcare services and people's care-seeking behavior as 'in a transitional period.' We're still waiting to see how these trends will ultimately settle."

Threat to hospitals

The decline in patient demand has been so severe that the federal government has funneled tens of billions of taxpayer dollars to hospitals nationwide to shore up their finances as operations were disrupted almost overnight. As people delayed care and hospitalizations fell, insurers paid out less in medical costs than historical levels, recording record profits. But with federal relief funds dwindling and visit volumes remaining low, concerns are rising about the financial outlook for healthcare providers.

As visit volumes shrink, hospitals are facing rising costs, especially for wages and benefits, as many struggle to find enough staff. During multiple COVID-19 surges, hospitals had to pay exorbitant rates for travel nurses to fill staffing gaps. Healthcare analysts point out that these operational challenges will continue to compress profit margins for many hospital operators.

Meanwhile, the pandemic has accelerated the shift of healthcare services to outpatient settings. Strata data shows that inpatient orthopedic surgeries over the past two years have declined significantly compared to 2019. Lefar said there has been a "massive shift" of these procedures to outpatient facilities, a service line that is highly profitable for many hospitals. The continued migration of services from inpatient to outpatient settings will pose challenges for some operators, especially those lacking strong outpatient services. Lefar said, "Reliance on inpatient services will become a problem, there's no doubt about that."

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