Accessibility of Telehealth Services During the COVID-19 Pandemic

A Cross-Sectional Survey of Medicare Beneficiaries

Boon Peng Ng, PhD; Chanhyun Park, PhD

Disclosures

Prev Chronic Dis. 2021;18(7):e65 

In This Article

Abstract and Introduction

Abstract

Introduction: Telehealth plays a role in the continuum of care, especially for older adults during the COVID-19 pandemic. Our objective was to examine factors associated with the accessibility of telehealth services during the COVID-19 pandemic among older adults.

Methods: We analyzed the nationally representative Medicare Current Beneficiary Survey COVID-19 Rapid Response Supplement Questionnaire of beneficiaries aged 65 years or older. Two weighted multivariable logistic regression models were used to examine associations between usual providers who offered telehealth 1) during the COVID-19 pandemic and 2) to replace a regularly scheduled appointment. We examined factors including sociodemographic characteristics, comorbidities, and digital access and literacy.

Results: Of the beneficiaries (n = 6,172, weighted n = 32.4 million), 81.2% reported that their usual providers offered telehealth during the COVID-19 pandemic. Among those offered telehealth services, 56.8% reported that their usual providers offered telehealth to replace a regularly scheduled appointment. Disparities in accessibility of telehealth services by sex, residing area (metropolitan vs nonmetropolitan), income level, and US Census region were observed. Beneficiaries who reported having internet access (vs no access) (OR, 1.75, P < .001) and who reported ever having participated in video, voice, or conference calls over the internet before (vs not) (OR, 2.18, P < .001) were more likely to report having access to telehealth. Non-Hispanic Black beneficiaries (versus White) (OR, 1.57, P = .007) and beneficiaries with comorbidities (vs none) (eg, 2 or 3 comorbidities, OR, 1.25, 95% P = .044) were more likely to have their usual provider offer telehealth to replace a regularly scheduled appointment.

Conclusion: Although accessibility of telehealth has increased, inequities raise concern. Educational outreach and training, such as installing and launching an online web conferencing platform, should be considered for improving accessibility of telehealth to vulnerable populations beyond the COVID-19 pandemic.

Introduction

Since the first documented community spread of COVID-19 in the US on February 26, 2020, the pandemic has affected many.[1] As of February 9, 2021, the total number of COVID-19 cases in the US was approximately 27 million, with the number of deaths exceeding 460,000.[2] Within the Medicare population, as of November 2, 2020, about 1.9 million total COVID-19 cases and over 493,000 COVID-19–related hospitalizations had been reported.[3] Many studies reported higher adverse health outcomes, such as mortality and hospitalization among older adults with COVID-19.[4–6] A study reported that among recorded deaths, about 80% were adults aged 65 years or older, often with chronic conditions.[5] Furthermore, COVID-19 imposes a substantial economic burden. As of November 2, 2020, Medicare spent $7.4 billion in fee-for-service claims alone for COVID-19–related hospitalizations, with an average of $23,558 per beneficiary.[3] Research related to older adults with COVID-19, therefore, remains a high priority.

With the rapid spread of COVID-19 that has affected everyday life, preventive behaviors, such as social distancing, mask wearing, and handwashing, have been recommended by health care organizations.[7,8] At various phases of the pandemic, many US states mandated or encouraged their residents to minimize the risk and spread of COVID-19.[9] Sheltering-in-place, however, presents a dilemma for vulnerable populations, such as older adults with chronic conditions that require a regular continuum of care, because they must choose between risking COVID-19 exposure and delaying care. As a result, the Centers for Disease Control and Prevention has recommended that providers offer care via telehealth.[1,10] Telehealth is the use of 2-way telecommunication technologies to provide clinical health care through a variety of remote methods.[1] Telehealth came to recognition as a vital mode of care delivery during the pandemic, especially for older adults at high risk of adverse health outcomes from COVID-19.[11] During the early months of the pandemic, studies on the availability and use of telehealth showed a rapid increase of telehealth use.[1,12,13] These studies reported that younger patients and female patients had the most telehealth encounters,[1] and race and income disparities in the use of telehealth at the zip code level were observed.[13]

Although the availability and use of telehealth is longstanding, there have been barriers to widespread use, such as lack of infrastructure, strict regulation, and sparse reimbursement structure.[14,15] With the passing of the Coronavirus Preparedness and Response Supplemental Appropriations Act, the US Department of Health and Human Services via the Centers for Medicare and Medicaid Services (CMS) was able to authorize policy changes and regulatory waivers in March 2020. These interventions focused on Medicare-related requirements for telehealth services, thereby applying no penalties for using technologies not compliant with the Health Insurance Portability and Accountability Act, and waivers were provided for use of telehealth services for Part B beneficiaries to broaden and facilitate the use of telehealth.[15] In response to these changes, information about access to telehealth among Medicare beneficiaries is of wide interest. The objectives for our study, therefore, were 1) to examine factors (ie, sociodemographic; comorbidity; access to technology and the internet; and previous experience with video, voice, or conference calls over the internet) associated with having health care providers who offered telehealth to regular patients during the COVID-19 pandemic, and 2) to examine factors associated with providers who offered telehealth to replace a regularly scheduled appointment for Medicare beneficiaries aged 65 years or older.

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