This study assesses the utilization of outpatient COVID-19 treatments among Medicare beneficiaries in 2022 and simulates the potential outcomes of reallocation based on patient risk for severe COVID-19. Key findings include: - **Utilization of Outpatient Treatments**: In 2022, 6.0% of Medicare beneficiaries received any COVID-19 outpatient treatment, with 40.5% of these treatments having no associated COVID-19 diagnosis within 10 days. - **Disparities in Treatment**: Patients at higher risk for severe COVID-19 infection received less outpatient treatment. For example, 6.4% of those aged 65 to 69 years received treatment compared to 4.9% of those 90 years and older (adjusted odds ratio [aOR], 0.64 [95% CI, 0.62-0.65]). Black patients received 3.0% of treatments compared to 6.4% of White patients (aOR, 0.56 [95% CI, 0.54-0.58]). - **Clinical Factors**: The presence of contraindications to nirmatrelvir (a common outpatient treatment) was associated with higher rates of outpatient COVID-19 treatment, not lower rates. - **Testing and Ambulatory Visits**: Groups receiving less outpatient treatment did not test or attend ambulatory visits less often. - **Geographic and Practice-Level Variation**: Adjusting for hospital referral regions or primary care practices did not significantly reduce differences in outpatient COVID-19 treatment across patient characteristics. - **Simulated Reallocation**: reallocating nirmatrelvir doses based on patient risk for severe COVID-19 could have averted 16,503 COVID-19 deaths (16.3% reduction) in the sample. The study concludes that outpatient COVID-19 treatment was disproportionately accessed by individuals at lower risk for severe infection, potentially undermining its public health benefit. This misallocation is not driven by lack of access or treatment contraindications but may be related to patient preferences, clinician prescribing practices, and structural barriers.This study assesses the utilization of outpatient COVID-19 treatments among Medicare beneficiaries in 2022 and simulates the potential outcomes of reallocation based on patient risk for severe COVID-19. Key findings include: - **Utilization of Outpatient Treatments**: In 2022, 6.0% of Medicare beneficiaries received any COVID-19 outpatient treatment, with 40.5% of these treatments having no associated COVID-19 diagnosis within 10 days. - **Disparities in Treatment**: Patients at higher risk for severe COVID-19 infection received less outpatient treatment. For example, 6.4% of those aged 65 to 69 years received treatment compared to 4.9% of those 90 years and older (adjusted odds ratio [aOR], 0.64 [95% CI, 0.62-0.65]). Black patients received 3.0% of treatments compared to 6.4% of White patients (aOR, 0.56 [95% CI, 0.54-0.58]). - **Clinical Factors**: The presence of contraindications to nirmatrelvir (a common outpatient treatment) was associated with higher rates of outpatient COVID-19 treatment, not lower rates. - **Testing and Ambulatory Visits**: Groups receiving less outpatient treatment did not test or attend ambulatory visits less often. - **Geographic and Practice-Level Variation**: Adjusting for hospital referral regions or primary care practices did not significantly reduce differences in outpatient COVID-19 treatment across patient characteristics. - **Simulated Reallocation**: reallocating nirmatrelvir doses based on patient risk for severe COVID-19 could have averted 16,503 COVID-19 deaths (16.3% reduction) in the sample. The study concludes that outpatient COVID-19 treatment was disproportionately accessed by individuals at lower risk for severe infection, potentially undermining its public health benefit. This misallocation is not driven by lack of access or treatment contraindications but may be related to patient preferences, clinician prescribing practices, and structural barriers.