Perceptions of Telehealth Among Commercial Members Who Responded to a Patient-Experience Survey During the Onset of the Coronavirus-19 Pandemic

Introduction

Approximately 25% of population of the United States does not have a primary care provider (PCP) or have access to one, mainly in rural areas. ¹ Survey reports indicate that 81% of physicians described themselves as either overworked or at full patient capacity with no time to take on new patients. ^{1 –4} As the U.S. population continues to grow, millions become insured, and the demand for health care increases; technologies such as telehealth can offer access to care when providers are not available.

Telehealth has been defined as the use of medical information that is exchanged between a provider and patient through electronic communication to improve a patient's health, provide access to health care, and eliminate disparities. ^{5 –7} Telehealth was originally created for rural and underserved patients, but it has since emerged into a variety of health care specialties in both rural and urban settings. ⁸ The Department of Health and Human Services has estimated that >60% of health care institutions and 40–50% of hospitals use some form of telehealth. ^5,7

There is a large body of literature examining patient satisfaction with telehealth. However, to date, the knowledge about patient experiences with telehealth is limited to specific disease-related applications. ^{9 –18} There is a paucity of research that compares patient perceptions of telehealth with those of in-office visits in other settings such as primary care. In addition, most studies have findings that are either mixed, have small sample sizes, use inadequate methodology, or are not generalizable to the total U.S. population. ^{1,8,19,20,21,22,23 –25}

A 2016 study ¹ assessed patient satisfaction and preferences about telehealth services in a telehealth program implemented at CVS Minute Clinics in California and Texas. Out of 1,734 patients, 32% preferred telehealth visits to traditional in-person visits, 57% rated telehealth visits just as good as a traditional in-person visit, 1% of patients rated telehealth as worse than an in-office visit, and 10% were unsure. In addition, 99% of patients reported that they would definitely or probably use telehealth again or recommend it to someone else. However, these results may not be generalizable to the total U.S. population. This study used survey data from a small nonrandomized pilot program that appeared to be geared toward an adult population who may have difficulty accessing medical care and live in California or Texas.

In a 2019 review, ⁸ the authors examined 36 studies on patient and caregiver satisfaction with telehealth, focusing specifically on the use of videoconferencing to manage their health. Results indicated that attending an appointment in one's local community via telehealth offsets the inconvenience of traveling long distances to an urban center for the same appointment, especially for people with chronic conditions, parents with young children, and caregivers of elderly patients. However, this review also highlighted methodological problems with all 36 studies (small sample sizes and heterogeneity in terms of how satisfaction was defined and, in some cases, measured using psychometrically untested instruments).

Although some studies have shown that face-to-face interactions may be preferable under certain circumstances, ²² other research has shown that the convenience, reductions in lost work and travel time, decreased waiting times in crowded waiting rooms, and fewer missed or rescheduled appointments may outweigh some of these benefits. ^{1,19 –22,26,27} In investigating the feasibility, effectiveness, and acceptability of real-time patient encounters using videoconferencing, a 2008 study ²² found that patients thought telehealth visits were similar to face-to-face visits in terms of perceived time spent with provider, level of attention paid to the patient, ability to explain the clinical plan, and level of clinical competence.

In contrast, overall reported satisfaction with telehealth was less than that of face-to-face visits due to a lack of a hands-on personal approach to care and a belief that a physical exam was not possible. Although patients stated a preference for face-to-face visits, 84% stated that they would recommend a telehealth visit because of the ease of use, time savings, lower cost, and reduced travel time. When providers were asked about their patient encounters, they rated obtaining the patient's medical history the same between the two modes of visits. However, they reported that the quality of the exam and the overall visit was worse than traditional face-to-face visits.

With the considerable growth in the use of telehealth, technological advances, and the mixed results of prior studies of patient opinion, an improved understanding of how patients perceive telehealth options is needed to guide both policy and innovation activities in the health care delivery system. Our study can fill the gap in literature by providing added research on the overall patient perception of telehealth.

Materials and Methods

The data for this cross-sectional study were collected for a random sample of members who were enrolled in an Anthem commercial plan in any of the 14 core service areas (CA, CO, CT, GA, IN, KY, ME, MO, NH, NV, NY, OH, VA, and WI) and administered a member experience survey in July 2020. The survey included the standard Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) questions as well as six questions on telehealth perception.

The primary purpose for conducting the survey was to determine member perceptions of telehealth, including willingness to pay for it and the likelihood to access it again, among commercial members who had a telehealth visit during the onset of the coronavirus-2019 (COVID-19) pandemic. We wanted to compare different aspects of telehealth services that were available with Anthem's commercial members to gain a better understanding on how best to expand their use, particularly based on which types of providers they visited. We hypothesized that members who sought telehealth visits with their PCP or a provider within the same practice would have a more optimistic perception of telehealth than members who saw a provider out of their PCP's practice.

On the survey, patients were asked whether they had a telehealth visit in the past 6 months and reported their age, gender, highest level of attained education, self-rated health, and self-rated mental health. Patients also reported which provider they saw during their visit: their PCP (on whom the CG-CAHPS survey focused), someone else in their PCP's office, a physician not part of their PCP's office, or a medical or behavioral health specialist. Using a four-point Likert scale, members were asked to rate the likelihood that they would utilize telehealth in the future, if offered. Members were also asked to report their willingness to pay the same copayment for a telehealth visit that they pay for a regular, in-office visit. ¹⁹ Lastly, members rated telehealth visits in comparison to traditional in-office medical visits: better than a traditional visit; no different; worse; or unsure. ¹

To be eligible for the study, members had to be an adult and have had a telehealth visit with their primary care doctor between January 1, 2020 and June 30, 2020. To determine member perception of telehealth, we assigned eligible members into two groups: those who had a telehealth visit with their PCP or a provider in the same practice and those who had a telehealth visit with a provider outside of their PCP's practice. We coded a provider as outside the member's PCP's practice if a member responded that they had a telehealth visit with a medical or behavioral health specialist or a different doctor outside of their PCP's practice.

The primary outcome of the study was the member's overall telehealth rating. This rating was defined as the perception of telehealth in comparison to in-office visits and was measured as either no difference between telehealth or in-office visits, in-office visits were better, or telehealth visits were better. We also estimated the likelihood of future telehealth use as well as the willingness to pay a regular visit copay for a virtual visit as a function of our exposure category along with member-level characteristics. Items were rated on a 4-point Likert scale, ranging from “very likely” to “very unlikely” and “definitely” to “no” respectively.

The member-level characteristics were collected from the survey and included: self-rated general health, self-rated mental health, age group, education attainment, and gender. We also controlled for member urbanicity and average Area Deprivation Index (ADI), a surrogate measure for socio-economic status (SES). ²⁸ We used the member zip code to determine member urbanicity and ADI quartile. We extracted the member zip code by linking the survey data to administrative data from Anthem's data warehouse. This study was exempt from Institutional Review Board review as it was part of an internal quality improvement exercise to guide strategy around how to structure telehealth offerings to members. Surveyed members were informed that they were free to opt out of the survey, that their answers would be kept confidential, and that their responses to the survey would have no impact on their benefits or the care they would receive..

Distribution and summary statistics for member characteristics and outcome measures were calculated for both populations. Categorical variables are presented as frequencies and percentages, whereas continuous variables (including risk scores) are shown as mean (standard deviation [SD]) values.

Logistic regression and multinomial logistic regression models, controlling for member-level characteristics, were used to estimate the likelihood of using telehealth again in the future, willingness to pay a regular visit copay for a virtual visit, and overall telehealth rating.

A sensitivity analysis was also performed to examine the three outcome measures by more granular groups of members. We decomposed the study population into four categories: members who had a telehealth visit with their PCP, a provider within their PCP's practice, a medical or behavioral health specialist, and a different doctor outside of their PCP's practice.

In each of the models, members who had a virtual visit with their PCP were compared with the three other groups of members who saw a different provider, respectively. All analyses were performed by using SAS software, version 7.1 (SAS Institute, Inc., Cary, NC).

Results

Of the 1,419 members who responded to the CG-CAHPS survey, 444 (31.3%) members reported they had a virtual visit during the previous 6 months. Of the 444 members, 21.1% had a telehealth visit with a provider outside of their PCP's practice and 78.8% had a telehealth visit with their PCP or a provider in the same practice (Fig. 1). After grouping members into two categories (members who saw their PCP or a provider in the same practice and those who saw a provider outside of their PCP's practice), we found the member-level characteristics to be relatively balanced (Table 1).

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Fig. 1.

We administered a patient-experience survey to which 1,419 commercial members responded. A total of 444 (31.3%) reported that they had a virtual visit within the past 6 months. Of the 444, 21.1% had a telehealth visit with a provider outside of their PCP's practice and 78.8% had a telehealth visit with their PCP or a provider in the same practice. CG-CAHPS, Clinician and Group Consumer Assessment of Healthcare Providers and Systems; PCP, primary care provider.

Compared with those who saw a provider outside of their regular practice, members who saw their PCP or a provider in the same practice were more likely to have excellent or very good self-rated mental health (62.0% vs. 51.1%) and self-rated general health (47.7% vs. 45.7%). In addition, they were more likely to be over 55 (58.0% vs. 52.1%) and female (62.9% vs. 54.3%), and they were less likely to have a 4-year degree or higher (43.4% vs. 51.1%) compared with members who saw a provider outside of their normal practice. Members who saw their PCP or a provider in the same practice were slightly more likely to live in the most urban areas compared with members who saw a provider outside of their PCP's practice: 24.0% versus 21.3%.

Average ADI was comparable between groups, suggesting that members in this study were of a similar level of SES: 38.6 among members who saw their PCP or a provider in the same practice versus 39.6 among members who saw a provider outside of their PCP's practice (Table 1).

We found that members who saw a provider within their PCP's practice had 3.76 higher odds (confidence interval [95% CI]: 1.49–9.44) of rating in-person care as no different than virtual care versus rating in-person care as better compared with members who saw a provider outside of their regular PCP's practice, a statistically significant result. In addition, they had 0.91 odds (95% CI: 0.47–1.77) of rating virtual visits better than in-person office medical visits, but this result was not statistically significant. Further, they had 2.29 higher odds (95% CI: 1.30–4.04) of reporting that they would likely use telehealth again in the future compared with members who had their telehealth visit with a provider outside of their PCP's practice, a statistically significant result.

These same members also had 1.70 higher odds (95% CI: 0.99–2.91) of responding that they would be willing to pay a regular, in-office visit copay for a telehealth visit, compared with members who saw a provider outside of their PCP's practice (Fig. 2).

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Fig. 2.

Compared with members who saw a provider outside of their PCP's practice, members who had a virtual visit within their PCP or a provider within the same practice had 3.76 higher odds (95% CI: 1.49–9.44) of rating in-person care as no different than virtual care versus rating in-person care as better; 0.91 odds (95% CI: 0.47–1.77) of rating virtual visits better than in-person office medical visits; 2.29 higher odds (95% CI: 1.30–4.04) of reporting that they would likely use telehealth again in the future; and 1.70 higher odds (95% CI: 0.99–2.91) of responding that they would be willing to pay a regular, in-office visit copay for a telehealth visit. CI, confidence interval.

Our sensitivity analysis found that members who had a virtual visit with a provider in the same practice as their PCP had decreased odds of rating virtual care as no different than in-person care: (odds ratio [OR]: 0.77, 95% CI: 0.28–2.11); decreased odds of reporting virtual care better than in-person care: (OR: 0.47, 95% CI: 0.13–1.71); increased odds of reporting that they would be likely to use telehealth in the future (OR: 1.15, 95% CI: 0.45–2.95); and decreased odds of reporting that they would be willing to pay a regular, in-office copay for virtual care (OR: 0.79, 95% CI: 0.36–1.72) compared with members who had a virtual visit with their PCP.

In addition, we found that members who had a virtual visit with a medical or behavioral health specialist had decreased odds of rating virtual care as no different than in-person care (OR: 0.41, 95% CI: 0.16–1.06); slightly decreased odds of reporting virtual care better than in-person care: (OR: 0.98, 95% CI: 0.46–2.12); significantly decreased odds of reporting that they would be likely to use telehealth in the future (OR: 0.49, 95% CI: 0.25–0.93); and significantly decreased odds of reporting that they would be willing to pay a regular, in-office copay for virtual care (OR: 0.53, 95% CI: 0.28–0.98) compared with members who had a virtual visit with their PCP.

Further, we found that members who had a virtual visit with a different, nonspecialist provider outside of their PCP's practice had slightly increased odds of reporting virtual care better than in-person care: (OR: 1.21, 95% CI: 0.39–3.77); significantly decreased odds of reporting that they would be likely to use telehealth in the future (OR: 0.35, 95% CI: 0.13–0.91); and decreased odds of reporting that they would be willing to pay a regular, in-office copay for virtual care (OR: 0.71, 95% CI: 0.27–1.86) compared with providers who had a virtual visit with their PCP (Figs. 3 and Fig. 4). The sample size of members who had a virtual visit with a different provider outside of their PCP's practice was too small to evaluate the odds of rating telehealth no different than in-person care.

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Fig. 3.

Members who had a virtual visit with a different, nonspecialist provider outside of their PCP's practice had slightly increased odds of reporting virtual care better than in-person care: (OR: 1.21, 95% CI: 0.39–3.77); significantly decreased odds of reporting that they would be likely to use telehealth in the future (OR: 0.35, 95% CI: 0.13–0.91); and decreased odds of reporting that they would be willing to pay a regular, in-office copay for virtual care (OR: 0.71, 95% CI: 0.27–1.86) compared with providers who had a virtual visit with their PCP. The sample size of members who had a virtual visit with a different provider outside of their PCP's practice was too small to evaluate the odds of rating telehealth no different than in-person care. OR, odds ratio.

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Fig. 4.

Members who had a virtual visit with a medical or behavioral health specialist had decreased odds of rating virtual care as no different than in-person care (OR: 0.41, 95% CI: 0.16–1.06); slightly decreased odds of reporting virtual care better than in-person care: (OR: 0.98, 95% CI: 0.46–2.12); significantly decreased odds of reporting that they would be likely to use telehealth in the future (OR: 0.49, 95% CI: 0.25–0.93); and significantly decreased odds of reporting that they would be willing to pay a regular, in-office copay for virtual care (OR: 0.53, 95% CI: 0.28–0.98) compared with members who had a virtual visit with their PCP.

Discussion

To our knowledge, this is the first study to evaluate the perception of telehealth between patients who accessed care from their PCP or a provider within their practice compared with members who sought care with a provider outside of their PCP's practice.

The COVID-19 pandemic presented a unique opportunity to study perception of telehealth services, because many practices began offering virtual services by mid-2020, at the time of this survey. With more members utilizing virtual visits, we were able to study a slightly larger population than other studies that have examined telehealth in the past.

Results suggest that the member's familiarity with the practice administering virtual care impacts overall member outlook on telehealth, including their willingness to pay for it, the likelihood that they will use it again, and their general opinion of it compared with traditional, in-office visits.

Members who saw a provider within their PCP's practice had higher odds of reporting that they would likely use telehealth again in the future, higher odds of responding that they would be willing to pay a regular, in-office copay for a virtual visit, and higher odds of rating in-person care as no different than virtual care versus rating in-person care as better.

These findings are consistent with several past studies that have also rated telehealth visits just as good as traditional in-person visits as well as probably to definitely would use telehealth again in the future.

The sensitivity analyses echo the main analysis results, namely that members demonstrated a preference to telehealth with their PCP over telehealth visits with specialists or other doctors outside their PCP's practice.

The results of our secondary analysis suggest that there is no difference in member experience between telehealth visit with a member's PCP and visits with a doctor within the same practice. In addition, members who had a telehealth visit reported that they are less likely to use telehealth in the future and that they are less willing to pay a regular visit copay for it. This result is reasonable, considering how specialist care is typically more involved and usually centers around a serious medical concern or chronic condition. Further, members who had a telehealth visit with a nonspecialist provider outside of their PCP's practice reported that they were less likely to use it again in the future. These results emphasize the preference that members had for a telehealth visit with a familiar doctor.

A clear limitation of our study was that the study population consisted of only Anthem commercial members and does not include members from other private insurance plans or government-funded (Medicare or Medicaid) plans. Therefore, results may not reflect member preferences, especially willingness to pay a regular copay, among those enrolled in plans offered by other payers or other lines of business.

Conclusions

Future studies are needed to further assess the relationship between familiarity and telehealth perception to examine whether results remain consistent within other medical specialties and across other lines of business.

Ultimately, virtual care may become commonplace in commercial business, with payers opting to cover this type of care beyond the end of the COVID-19 pandemic. If that is the case, payers will want to ensure they are building appropriate networks to support telehealth and may not want to contract with third-party providers, with whom members are unfamiliar.

As payers and providers work together to build telehealth networks, considering member familiarity with the provider may be an important factor in improving member utilization and positive overall perception of telehealth.