As outpatient treatment options continue to expand, we wanted to examine states Hospital Outpatient Department (HOPD) utilization for Medicare patients. In addition, we wanted to quantify the impact that COVID-19 had on utilization per Medicare beneficiary when comparing to 2018-19 to understand how much care behavior has changed in the growing Medicare population. To perform this analysis we used the outpatient CMS limited dataset for hospital-based care. We then summarized both the unique patients[1] and distinct encounters[2]. We focused on average encounters per patient in order to normalize the data between large and small states. This approach also highlights the care behavior trends more effectively than simply looking at distinct patients or encounters. The results highlighted some interesting regional trends that we suspect are driven by a combination of healthcare infrastructure and patient care trends.

Outpatient Medicare Utilization v2

Analysis & Results

Pre-pandemic in 2019, the states with the highest utilization of outpatient medicine per patient were Maine (10.4 encounters per patient), Vermont (9.9 encounters per patient), North Dakota (9.3 encounters per patient), South Dakota (8.8 encounters per patient), and New Hampshire (8.5 encounters per patient). When compared to the national average of 6.3 encounters per patient, those five states have between 65% (Maine) and 35% (New Hampshire) higher utilization per patient. Each of these states are predominantly rural and have a higher-than-average amount of “Willful Endurer[3]” psychographic profiles, or individuals who live in the “here and now”, in their Medicare population, making them more likely to seek care in outpatient settings compared to other patient profile types. Even so, additional research and analysis are needed to understand why utilization is higher in these states when compared to others.

Next, we wanted to understand the impact that COVID-19 had on these states in terms of utilization per patient. On average, the nation experienced a 6.1% reduction in encounters per patient from 2019 to 2020 (6.3 encounters in 2019 compared to 5.9 in 2020). For the some of the states with the highest utilization per patient, this decrease was significantly larger. The largest year-over-year decrease in utilization per patient occurred in Maine (14.6%), Vermont (12.9%), and New Hampshire (11.6%). North Dakota (6.5% decrease) and South Dakota (6.1%) experienced decreases much closer to the national average. One hypothesis for this disparity is proximity to substantial outbreaks. The New England states were impacted at the beginning of the pandemic with New York and Massachusetts, both bordering states, having significant COVID-19 spread and mortality. North and South Dakota had relatively benign spread and little interaction with the virus until the summer and fall of 2020.


Understanding the relationship between patient care behaviors and preferences in the context of availability of healthcare infrastructure is critical to meet patient needs. Hospitals have historically been an important access point, especially in more rural settings. As our analysis suggests, the decrease in utilization during the COVID-19 pandemic may reflect a lack of access to alternative sites of care in rural areas. Whether one effect of the pandemic is a fundamental change in the care behavior of historically heavy utilizers should be considered more fully, as it would have profound consequences for consumers and hospitals if true.

[1] Desy_sort_key in CMS OP LDS file

[2] Claim_no in CMS OP LDS file.

[3] WILLFUL ENDURERS live in the “here and now” and believe there are more important things to focus on than improving their health for the future. They are not necessarily unhealthy, but they do what they like, when they like, and typically, do not change their habits.