Patients are now more comfortable using telehealth as the COVID-19 pandemic drove a surge in virtual visits.
According to a new RAND Corporation study published in Health Affairs Monday, use and willingness to use video telehealth rose most sharply in the past two years among Black Americans and people with less education.
The study was the last of four in a series published beginning in 2020 to mark the development of public response to telehealth during the pandemic. The new RAND study followed about 1,600 adults who participate in the RAND American Life Panel and completed surveys during February 2019, May 2020, August 2020 and March 2021 about their use and attitudes toward telehealth. Participants were asked questions regarding their willingness to use telehealth, barriers to use and modality preferences.
“Using regression, we were able to show a correlation with previous use: use increases people's willingness to use, which is reassuring,” Shira Fischer, the study’s lead author and a physician scientist at RAND, a nonprofit research organization, said in an interview. “So as people are exposed to technology, maybe some of the barriers that are very real at the beginning tend to disappear such as fear or not knowing how to use or concern about privacy or things like that. Obviously, if you don't have access, you don't have access. And there may be other reasons why people are unwilling to use and there still was a not insignificant minority who were unwilling [to use the technology]. But, there was a narrowing of the differences and who was willing to use.”
By March 2021, Black adults ages 20 to 39 and high-income adults showed the greatest willingness to use video telehealth.
Before the pandemic, non-Hispanic Black populations were the least willing to use the technology while respondents with less than a high school education were the lowest of all with 30% willingness.
By the time of the last survey, over 50% of the 1,604 surveyed respondents showed an interest in telehealth. According to the study, Back adults were less willing to use telehealth than those of other races or ethnicities before the pandemic, with only 42% reporting willingness to use telehealth in February 2019. However, a year into the pandemic, 67% of Black adults were willing to use telehealth, which was as high as or higher than any other racial or ethnic group.
“So obviously the tipping point was COVID and suddenly it was available,” Fischer said. “Once you have it available, you can really ask why people are using it or not. But if it's not even available, maybe theoretically they wouldn't use it, but in practice, once it is there, maybe they would. Having tried it out seems to be a major factor affecting willingness to use it.”
The first study in the series was released in late October 2020 and showed that between February 2019 and April 2019 only 4% of respondents had engaged with videoconferencing visits, but 49% expressed interest.
Respondents ranked patient portals, email, text messaging, e-vists and video conferencing as their preferred mode of communicating with a physician to get advice about a health issue in that order with telehealth receiving only 4.2% of responses. Of the 83% of respondents who said they had used telehealth at least once, 54.5% said it was with a physician they were previously unfamiliar with.
The second study in the series, based on survey results from May 2020, showed that once the pandemic began, the vast majority of patients using telemedicine were communicating with their own doctors. Results also showed that video was less common for physical healthcare than behavioral health care.
At the time, the authors wrote, telehealth still remained at the periphery of U.S. healthcare between mid-March and early May 2020. As regulatory changes related to reimbursements, privacy standards and licensure went into effect, telehealth use expanded.
“Our findings suggest that more Americans are becoming comfortable with telehealth and using video technology,” Fischer said. “This is important because there are concerns that lack of access to or willingness to use video telehealth may exacerbate disparities in the delivery of high-quality health care.”
The researchers emphasized the need to focus on equity of access as telehealth evolves.
“If [patients] were using video telehealth pre-pandemic, it was likely a direct-to-consumer product that got them a doctor on their phone, but it was not usually a familiar doctor—only about half of the time,” Fischer said. “One of the big shifts of the pandemic is suddenly everybody's own doctor was available via video—an overwhelming majority of video telehealth was with a familiar doctor. And that's very different if you're talking about quality or comfort with a familiar physician.”
RAND’s penultimate study in the series was published in December 2021 with survey results from March of the same year. Just over half of respondents said they would prefer an in-person appointment with a doctor.
When confronted with the possibility of high medical costs for in-person care, 23% of those who initially expressed an interest in an office visit changed their preference for virtual care.
Conversely, among those who first preferred a video visit, 61.7% switched to an in-person visit when presented with higher relative costs for video visits. Therefore, the study concluded that those who preferred telemedicine were more sensitive to paying out-of-pocket costs.
“In a lot of this research it is presented as telehealth versus in-person health: one versus the other; which should we pay for more; which should be happening more often?” Fischer said. “And I don't think that's really the question. I think the question is: which kind of care is best for who, for what kind of problem, and when. In some cases, maybe it's appropriate to meet in person sometimes and then continue virtually. Other times maybe it's a trade-off: start off in person and then meet in person and virtually, depending on the situation. You could have the benefits of not having the person have to come into the office and reduce travel time and travel costs, but still get the benefit of having the face-to-face interaction, at least on occasion.”
The final study, seen in this month’s issue of Health Affairs, showed overall substantial increases in patients' use of telehealth technology. The RAND study found that in May 2020, 12% of people had used video telehealth since the beginning of the pandemic, which was more than three times the proportion who had reported having used it when asked in February 2019.
The percentage of those who reported having video telehealth visits increased to almost 20% by August 2020 and 45% by March 2021. Those without insurance showed a rate of just over 40% interest in the technology compared to over 60% of those with insurance.
As is generally expected, telehealth skews towards younger populations with nearly 80% of respondents between 20 and 39 years of age expressing willingness to use the technology and those over 60 years of age expressing half the rate of interest.
When it comes to income, patients who make over $100,000 a year are the most likely to use telehealth.
Once patients had their first experience with video visits, they were overall more willing to attend more of such visits, the study authors wrote. The researchers propose that by using their own doctors and hybrid models of care, patients' fears or hesitation may have been quelled.
The authors also highlighted the need for carving out a more permanent place for telehealth in care delivery. Fischer used the example of the curb-cut effect. While sidewalk curbs were first cut in the 1970s to create crude ramps and reach ADA compliance, not only those using wheelchairs benefitted. Parents with strollers, kids on bikes and travelers with suitcases all now take advantage of the decreased barrier. Making something more accessible, even if for one population, can support other populations, Fischer said.
“Telehealth came into play on the American healthcare market because of COVID,” Fischer said. “That was a very important tool to reduce transmission of infectious disease, but it also solves a lot of problems for a lot of other people. For example, access to transportation, time to take off work, childcare, access to local providers, and when it comes to behavioral health or a lot of other specialties."
She added, "I hope that even as the pandemic wanes, hopefully, and reduces the need for telehealth because of infectious reasons, it stays in place to serve all of the other access issues that it has helped address if not eliminate.”