Americans’ Awareness of Access Changes and Utilization of Telehealth During COVID-19: A Survey in the United States

Introduction

For medical treatments to be effective for patients, they must have actionable access to them. Of course, the treatments must be covered under their insurance, but, moreover, they need to be armed with a working knowledge of health care, including their access to care. Adherence is a long-standing issue in health care, and connections have been made between improved health literacy and better adherence.¹ Health literacy is complex and is broad, encompassing all things that affect a person’s “ability to find, understand, and use information and services,” and includes the access offered by one’s insurance coverage.^2,3

There is some evidence suggesting that adherence might be improved with longer prescription duration, and transportation barriers are recognized as a basic step necessary for effective access.^4,5 Access, again, is a broad concept in health care; it is more than general market availability, and is described by the Institute of Medicine as “degree to which individuals and groups are able to obtain needed services from the medical care system,” which includes elements of coverage.^6,7 Without literacy with respect to what transportation programs might support access, patients experience avoidable gaps in care.⁸

The COVID-19 pandemic’s social distancing and public concern only served to exacerbate patients’ delays or avoidance of health care. Concerns for this exacerbation and the impact such delays may have on patients’ health and health outcomes led many employers and health insurers to offer new ways for patients to access their health care benefits during the pandemic, often expanding telehealth benefits. While this information was shared, it is unclear how much people were aware of or able to utilize these expanded benefits, which we will consider as part of an expanded concept of health literacy that addresses not only their awareness of medical information but also the health system and how they can access care. Knowing about access to telehealth is crucial in a time period where, as we will show, many people had to miss or cancel in-person medical appointments.

In this article, we describe the results of a consumer survey we conducted to examine the impact COVID-19 pandemic has had on U.S. adults’ use of medical care and prescription medications. The survey also measured respondents’ awareness of the changes made by governments, private insurers, and employers to increase access to benefits such as telehealth services, well-being and mental health programs, and new prescription medication refill and delivery options.

Methods

Survey Design

The main questionnaire included four sections, covering four aspects of how U.S. adults’ access to health care and health benefits may have changed during the COVID-19 pandemic. The survey contained 26 closed-ended questions. The full questionnaire is available from the authors by request.

In the first section of the survey, we asked respondents if they or their medical providers had delayed, rescheduled, or canceled medical appointments, or if they had chosen not to make a medical appointment for a new problem or symptom. The next section focused on access to prescription medications and if, since March 1, 2020, respondents were unable or unwilling to obtain prescribed medications from the pharmacy.

We then asked if respondents had utilized any form of telehealth or telemedicine since March 1, 2020, and why, as well as if respondents’ health care plans covered telehealth appointments, what types they covered, and if their employer, health insurer, or primary care provider has promoted telehealth services since the pandemic began. Finally, we asked about potential changes to benefits made by health insurance providers or employers during the pandemic changes, and if respondents were aware of or utilized any change.

Data Collection

The survey was conducted online between September 23–29, 2020. The survey was programmed and hosted by Dynata, the largest reaching market research firm in the world, which has a reach of 62 million people worldwide.⁹ Dynata’s panel management is compliant with all privacy laws, and the authors did not have access to respondents’ personally identifiable data.¹⁰ A total of 451 respondents completed the survey and passed all quality control checks.

Sample Description

Quota sampling was used to ensure that the sample was representative of the U.S. population by gender and age. We show how the sample compares to the 2019 U.S. population census data (Table 1), as well as respondents’ employment status and insurance coverage at the time of the survey (Table 2).

Results

Delayed, Rescheduled, and Canceled in-Person Medical Appointments

Our survey found that between March 1, 2020, and mid-September 2020, just over two-thirds of respondents (69.4%) delayed, rescheduled, or canceled at least one medical appointment for reasons they attributed to the pandemic. Appointments for preventative health care (i.e., wellness visit—52.5%, annual disease screening—39.5%, and vaccinations—27.3%) were most frequently subject to delay, rescheduling, or cancellation (Table 3). Smaller, but still sizable, shares of respondents delayed, rescheduled, or canceled sick or urgent visits, or visits for new health problems or symptoms (18.2% and 22.8% of respondents, respectively).

Consistent with our findings, doctors globally have reported fewer patients showing up to emergency rooms during the pandemic, be it for appendicitis, infected gallbladders, heart attacks, or other ailments, and many who do arrive are showing late presentation, meaning their conditions have already advanced.^11–13

The Centers for Disease Control and Prevention (40.9% of U.S. adults as of June 30, 2020) and the U.S. Census Bureau (40.6% of American households from May 5 to July 21, 2020) have also estimated that substantial shares of Americans have delayed medical care during the pandemic.^14,15

Our survey expands on previous surveys in three important ways. First, we distinguished between different ways that medical care may be delayed or avoided. Specifically, we asked about “delayed appointments” (those in which the respondent delayed making an appointment, but eventually scheduled it), “rescheduled appointments” (those in which a previously scheduled appointment was rescheduled), and “canceled appointments” (those in which an appointment was canceled and not rescheduled). Second, we asked about specific types of medical appointments, such as wellness visits, specialist visits, and vaccinations.

Third, we asked why respondents delayed, rescheduled, or canceled appointments (Table 4). The most frequently cited reasons were those associated with three specific COVID-19 concerns: belief that it was more important to avoid possible exposure to COVID-19 than to get treatment, compliance with COVID-19 restrictions or a stay-at-home orders, and desire to preserve health care resources for those with COVID-19. Among respondents who delayed, rescheduled, or canceled a medical appointment, 55.6% said that such COVID-19 concerns were a factor.

A substantial share of respondents also reported that their health care provider canceled the appointment (32.9% of those who had a missed appointment). A total of 16% of respondents with missed appointments reported accessibility issues as factors that caused them to postpone their appointments. Such respondents indicated that they could not afford the visit or that they rely on public transportation and did not want to use it during the pandemic or that their normal routes were disrupted. Telemedicine can be linked to reduced use of resources, for example, one study of telemedicine visits to a VA Hospital in Vermont between 2005 and 2013 resulted in an average travel payment savings of $18,555 per year.¹⁶

Our survey revealed that the pandemic resulted in ∼24% of respondents deciding not to make a medical appointment for a new problem or new symptoms. When added to the cancellation of appointments without rescheduling, this heightens concerns that patients may be putting themselves at greater risk of health complications by avoiding care as a consequence of COVID-19.

Access to Prescription Medication

Because our survey was conducted among the general adult population, not all the respondents had been prescribed medication before the pandemic. However, prescription drug use is common among Americans, with recent estimates around 50%.^17,18 Of the 451 respondents we surveyed, 66.1% reported that they regularly take prescription medication. Moreover, almost one-quarter of respondents (23.7%) reported having “been prescribed any new medication to take on a regular basis” since March 1, 2020. Overall, 11.8% of respondents reported that they needed prescription medication, but were unable to get it during the pandemic.

Among those who reported getting a prescription for a new medication, almost half (43.0%) reported being unable to get their medication during the pandemic. Among respondents who took prescription medication on a regular basis, but did not get a prescription for a new medication since March 1, only 3.6% had this same problem. Attempting to make it easier for people to access their prescriptions, many private health insurers have expanded prescription drug benefits during the pandemic.^19–24 Government legislative and agency changes also improved access conditions for patients.^25–28

Overall, these changes are directionally correct to have a positive effect on access and outcomes for patients. However, patients’ awareness of access conditions could still be an issue. Even if Centers for Medicare & Medicaid Services (CMS), health insurers, and employers work to make access conditions more favorable, patients must have an updated understanding of these new easier access conditions under their insurance for them to be fully effective in promoting appropriate use. Therefore, we looked at respondents’ awareness and usage of these benefits intended to increase prescription medication accessibility, that is, their health literacy with respect to access. Before the pandemic, about one-third of respondents (32.1%) had used prescriptions by mail order, 21.3% had used home delivery from the pharmacy, and 39.2% had used extended supply.

These percentages are somewhat higher if we look at just respondents who regularly take prescription medication. Among this group, 43.9% received prescriptions by mail order, 29.9% had used home delivery, and 52.6% had received an extended supply prescription. A minority of respondents reported being aware of prescription medication relief efforts and using them during the pandemic. Even among respondents who have prescriptions, 14.6% reported benefiting from reduced payments, 23.4% indicated that they used prescriptions by mail order during the pandemic, 17.9% used home delivery, and 25.7% used extended supply. Most respondents reported that their health insurer either did not promote prescription relief or they did not know if these benefits were promoted.

Telehealth Appointments and Access

Many health insurers offered or expanded telemedicine benefits during the pandemic, to varying degrees. New access to telehealth could certainly be important when people are unable to make it to their in-person medical appointments for the reasons discussed above. Change was extensive, with several major commercial insurers, many states’ Medicaid programs, and Medicare loosened restrictions on telehealth coverage for their members.^29,30 Some insurers, such as Aetna and CMS, expanded telehealth coverage by adding coverage or expanding the types of medical care eligible for telehealth appointments.^22,30 Insurers like Blue Cross, Cigna, and Emblem temporarily waived cost sharing or removed copays for telemedicine appointments.^31–33

Thus, in our survey, we asked respondents about their telehealth usage during the pandemic. We also measured respondents’ awareness of whether telehealth was covered by their insurance or promoted by their health insurer, employer, or health care provider during the pandemic.

About half of respondents have utilized some form of telehealth since March 1, 2020. The most popular forms of telehealth were video and telephone calls. Almost 30% of respondents reported that they had a video call with a primary care provider, specialist, or mental health care provider, while about a quarter reported having telephone calls with these types of providers (Table 5).

Among those 418 respondents with health care insurance, 55.0% reported that their health care plan covers some types of telehealth appointments (n = 230). However, almost 40% did not know whether telehealth appointments were covered by their health insurance. Overall, 29.5% of respondents indicated that telehealth services were promoted by their employer, health insurer, or primary care provider.

Respondents who recalled telehealth services being promoted by their health insurer, primary care provider, or employer were more likely to report that their health care plan covered telehealth appointments (84.3%) compared to those who had not seen telehealth appointments promoted (49.4%) (Table 6). Similarly, respondents who recalled promotions of telehealth services were more likely to report having used telehealth (65.4%) than respondents who said that telehealth was not promoted (42.6%) or could not recall whether it was promoted (34.1%).

Specifically, among those 133 respondents who recalled telehealth being promoted, the majority utilized both telephone and video telemedicine appointments (57.9%). Furthermore, 24.8% of those used only video appointments and 17.3% used only telephone appointments; however, that difference is not statistically significant at p < 0.05 (one-tailed t-test, video > audio, p = 0.067).

Awareness of Benefit Changes from Health Insurers or Employers

We also asked the 418 respondents with health insurance about nine potential benefit changes their health care insurer may have made due to the pandemic. For each of these nine benefits, at least half of these respondents did not know if their insurer had made the specified change (ranging from 53% to 62%). The most common benefits reported as being added during the pandemic were added or expanded telehealth services (28.0%), offering free COVID-19 testing (26.6%), and adding home delivery or mail order of prescription medications (24.2%) (Table 7).

We asked those 188 respondents who reported part-time or full-time work with an employer about eight potential changes their employer may have made to their benefit programs due to the COVID-19 pandemic. The most common benefit changes were promoting employee well-being programs (34.0%), providing a support hotline for mental health concerns (29.8%), and adding, expanding, or promoting telemedicine services options (28.2%) (Table 8). The least common was expanded paid time off or vacation programs, with 22.9% reporting that their employer has done this, and 45.7% reporting their employer has not done this. Similarly, only 21.8% reported their employer allowed employees to enroll or switch health care plans outside the usual enrollment period, with 43.1% reporting their employer did not allow this.

For three benefits, (1) enrolling or switching health care plans, (2) making changes to spending accounts, and (3) offering telemedicine options, we found that the number of respondents who took advantage of the change was about the same as the number who were aware the change was allowed, but chose not to make one. On the other hand, even among respondents who were aware of such options, a minority reported using employer-provided mental health services, such as hotlines, employee assistance programs, or virtual mental health services.

Employed respondents (n = 188) also report somewhat high unawareness of what changes to benefits had been made by their employers, although awareness was higher than when asking about what changes insurers had made. For each of the eight benefits queried, about 31–38% of employed respondents reported not knowing if their employer had adopted the benefit change (Table 8). The highest unawareness was around offering virtual mental health services, whereby 38.3% reported not knowing if their employer has offered this during the pandemic.

Discussion

Our survey found that the majority of Americans delayed and avoided medical appointments in the first 7 months of the COVID-19 pandemic, and that access to new prescriptions was also an issue for some patients. Understanding the prevalence of and reasons for delaying medical care is important because delaying or avoiding medical care can lead to increased morbidity and mortality. Indeed, there is evidence that delaying health care can result in negative health consequences.³⁴

Early studies have shown that delays in seeking medical care due to the pandemic have led to adverse outcomes for some patients, including cardiac patients, breast cancer patients, and pediatric cancer patients.^35–37 Furthermore, in one nationally representative survey, 11% of Americans who self-reported delaying medical care during the pandemic said that their conditions had worsened because of that delay.³⁸

One May 2020 survey asked Americans about their conscious tradeoffs between social distancing and a hurting economy, finding the most popular stance to be that many Americans would rather stay home and have the economy take a bigger hit if it means reducing the risk of COVID-19 to themselves and others.³⁹ Our results suggest that, in the early months of the pandemic, patients may have made similar tradeoffs around health care as the most common reasons for delaying or avoiding medical appointments included avoiding COVID-19 exposure, following local guidance or restrictions, or wanting to preserve resources for those with COVID-19.

Telehealth appointments may therefore be an important way in which Americans, during an emergency or times unable to access in-person medical care, may be able to maintain continuity of care. In response to the pandemic, players in the health care field have implemented changes to patients’ benefit plans that have the potential to help patients overcome impediments to accessing medical care. However, our survey finds that many Americans remain unaware of whether such expanded benefits are available to them. Crucially, those respondents who recalled telehealth and prescription medication delivery benefits being promoted were more likely to report using such benefits.

The lack of awareness surrounding new or changed benefits that have come about during the COVID pandemic could be due, in fact, to inadequate communication about the availability of such benefits as the focus of many health care institutions may have been on aspects of pandemic response other than communication. In other words, e-mail and mailers may not be sufficient communication tools for educating patients about new or changed benefits and how to access them. Future research should look at the effectiveness of different types of communication channels.

Some of the benefits in the health care system that were implemented as a result of the COVID pandemic, such as an increase in telehealth, may continue to be beneficial in the future of health care. Providers have increased their telehealth offerings, and improved reimbursement and patient access in this area could aid patient management, particularly as in-person appointments were so reduced during the pandemic. Expanded telehealth services may also benefit disabled patients and other patients whose health care suffers as a result of transportation issues. Telehealth may offer these patients increased opportunities to consult with their physicians for ailments that they might otherwise have delayed seeking care. Evaluating the longer-term benefit of these complementary services is warranted to ensure improved patient health.

While the pandemic continues, telehealth offers an opportunity for patients to receive care. The distribution of COVID-19 vaccines to the general population will take many months, perhaps lasting through much of 2021 and the surge in COVID-19 cases in December and January strained many local health care resources. Telehealth services may help reduce delays and avoid care like those observed at the beginning of the pandemic.

As health care payers make changes to benefits and policies to improve patients’ access and usage of health care resources, it is important to study how those changes are communicated to patients and whether such communications are effective in facilitating awareness. Changes to access are helpful, but only to the extent that people are aware of them and can take advantage of them. Our survey results suggest greater attention to health literacy surrounding changes to benefits and access conditions can help promote participation in the system by patients and have the potential to lead to improved health outcomes and greater adherence to treatment plans. Future research should look at the factors that impede patients from learning about and making use of benefit changes.

Disclosure Statement

No competing financial interests exist.

Funding Information

The study was sponsored by Upjohn, a division of Pfizer, Inc., now part of Viatris, with research support from NERA Economic Consulting.