Virtual doctor visits are increasing, but use differs by patient race, age and insurance

December 04, 2020

When the COVID-19 lockdowns began in mid-March 2020, hospitals and clinics faced a new challenge: How could they continue to provide care to those who could not leave their homes?

The answer lay in virtual visits -- doctor visits that take place over the phone or through videoconferencing -- but for many healthcare providers, these virtual visits were a new frontier.

University of Chicago Medicine, like many hospital systems across the country, quickly built a telehealth infrastructure to support these visits. From mid-March to the end of May, the system provided nearly 50,000 virtual visits to patients.

A new study published December 4, 2020, in the journal JMIR Medical Informatics examines the increase in these visits, and recommends adopting policies that encourage virtual visits going forward.

"Oftentimes, virtual visits are just as good as in-person visits, and we found that telephone visits are particularly important going forward if we are going to keep providing service to communities that do not have access to the technology needed for video visits," said Craig Umscheid, MD, Vice President of Healthcare Delivery Science and Chief Quality and Innovation Officer at the University of Chicago Medicine and co-author of the study.

When the University of Chicago Medical Center and its five practice sites began giving patients the option of rescheduling their appointment or switching to a virtual visit, either via videoconferencing or over the phone, it entered a new era of widespread telehealth.

Though technology has existed to make virtual visits possible, the Centers for Medicare and Medicaid Services (CMS) and commercial insurance providers generally did not cover those visits. That changed during the COVID-19 public health emergency, when CMS expanded coverage to include virtual visits. Many commercial insurance companies followed suit.

To understand the effects of these visits, a UChicago research team, including senior author Sachin Shah, MD, Associate Chief Medical Information Officer for UChicago Medicine, set out to analyze the data to find out who was using the virtual visit option during the first 11 weeks of the stay-at-home order.

In that timeframe, 60 percent of UChicago Medicine visits were virtual. Of those, 60 percent were by video and 40 percent were by phone.

But use of virtual visits was not equal across demographics. Virtual visits were more likely among patients with Medicare. Those less likely to use virtual visits included men, the very young and very old, and patients with Medicaid.

The research team also studied the demographics of video visit use versus telephone visit use. Telephone visits were more likely to be used by older patients, Black patients, and patients with Medicare and Medicaid (as opposed to commercial) insurance.

In fact, Black patients were half as likely as white patients to use video for their virtual visits. Though video visits generally provide a higher quality experience, many patients do not have access to a computer or the internet, or do not have the digital literacy to download and use a mobile application.

After analyzing the data, the researchers made five recommendations for virtual visits going forward, including creating a reimbursement parity between video and telephone visits. Right now, physicians who conduct a video visit are reimbursed for all time spent on patient care for that visit, including time spent on documentation. For telephone visits, they can only bill for time spent in direct communication with a patient.

Many are worried that once the pandemic is over, insurers will stop covering virtual visits or will only cover video visits. "Our research shows that if telephone visits aren't covered going forward, many patients will not have the same access to healthcare," Shah said. "There is widespread agreement among patients and providers that virtual visits shouldn't go away. But we need to make sure that policymakers understand how different types of virtual visits benefit different populations."

The researchers recommend developing legislation that makes virtual visit reimbursement permanent. But because virtual visits aren't appropriate for every visit, they recommend that guidance be developed to distinguish which visits are best suited for the virtual environment.

They also recommend that the usability of video visits be improved, and they advocate for universal broadband access to close the digital divide among populations. "A lot of software isn't as easy to navigate as you might think," Shah said. "We should incentivize companies to make it more usable for providers and patients."

The researchers hope to continue to study virtual visits, since it will continue to be a significant part of healthcare delivery in the future.

"There has been a lot of excitement around the pivot to virtual visits, because it allows us to broaden our reach to communities that don't normally leverage the services of UChicago Medicine," Umscheid said. "This is opening a completely new frontier around patient engagement and accessibility and ultimately the quality of care we deliver."
Additional authors of the study, "Growth of Ambulatory Virtual Visits and Differential Use by Sociodemographics at one Urban Academic Medical Center During the COVID-19 Pandemic: Retrospective Analysis," include first author Sarah Gilson, MD; Neda Laiteerapong, MD; Graeme Ossey, MBA, and Kenneth J. Nunes, MD.

About the University of Chicago Medicine & Biological Sciences

The University of Chicago Medicine, with a history dating back to 1927, is one of the nation's leading academic health systems. It unites the missions of the University of Chicago Medical Center, Pritzker School of Medicine and the Biological Sciences Division. Twelve Nobel Prize winners in physiology or medicine have been affiliated with the University of Chicago Medicine. Its main Hyde Park campus is home to the Center for Care and Discovery, Bernard Mitchell Hospital, Comer Children's Hospital and the Duchossois Center for Advanced Medicine. It also has ambulatory facilities in Orland Park, South Loop and River East as well as affiliations and partnerships that create a regional network of care. UChicago Medicine offers a full range of specialty-care services for adults and children through more than 40 institutes and centers including an NCI-designated Comprehensive Cancer Center. Together with Harvey-based Ingalls Memorial, UChicago Medicine has 1,286 licensed beds, nearly 1,300 attending physicians, about 3,200 nurses and over 1,100 residents and fellows.

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University of Chicago Medical Center

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