What do patients think about telehealth?

A review of scientific and survey data on telehealth services given the impending Medicare telehealth policy cliff

The rapid expansion of telehealth services during the peak COVID-19 years led to increased acceptance and adoption across diverse patient populations. Although telehealth has been around for almost two decades as a concept, we have heard ad nauseum that COVID-19 was a magic moment. While we often speak about telehealth services from the perspective of the clinican or system, this article examines how different patient groups perceive and experience telehealth services, highlighting both common themes and unique considerations for specific populations. In short, what do patients think about all this?

First, many Americans used telehealth during the peak Pandemic years of 2021 and 2022, see Figure 1, below.

This article is timely because while many commercial insurers and Medicaid programs have made telehealth a permanent facet of their coverage, Medicare has not been able to do so without action from Congress. Medicare expanded telehealth flexibilities during the public health emergency and did enact an extension of them to December 31, 2024.

Thus, there are three likely scenarios for beneficiaries on traditional Medicare in the coming weeks as we approach the telehealth policy cliff:

1. A two year extension of current flexibilities (this has been the primary discussion on Capitol Hill)

2. A three month extension (essentially sending it to the next Congress allowing Republicans to take credit and to determine how to pay for it¹)

3. No extension and a return to previous telehealth rules which will limit in-home access and only allow the provision to rural areas using strict rules

(Note: Medicare Advantage plans, which now cover about half of Medicare beneficiaries, are allowed to offer telehealth services regardless of Medicare Part B policy)

Flexibilities in Telehealth Allowed during Public Health Emergency

Medicare's approach to telehealth underwent a dramatic transformation during the COVID-19 Public Health Emergency (PHE), marking a sharp departure from previously restrictive policies. Before the PHE, Medicare limited telehealth coverage primarily to rural patients who had to travel to physical qualifying medical facilities (known as originating sites) to receive virtual care. The program maintained strict requirements around provider licensing, required established patient-provider relationships, and only covered a narrow range of services using HIPAA-compliant video platforms. These limitations significantly constrained the widespread adoption of telehealth services.

The onset of the PHE catalyzed unprecedented flexibility in Medicare's telehealth policies. Geographic restrictions were waived, allowing patients to receive care from any location, including their homes. Medicare expanded the types of eligible practitioners and services covered, including audio-only visits. Technology requirements were relaxed, enabling providers to use common video chat applications like FaceTime and Skype. Payment parity between virtual and in-person visits was established, and documentation requirements were simplified to facilitate rapid adoption.

These changes fundamentally transformed health care delivery under Medicare, improving access to care particularly for vulnerable populations who previously faced transportation barriers. Healthcare providers quickly integrated telehealth into their standard workflows, developing hybrid care models that combined virtual and in-person services. The expanded flexibility led to significantly increased utilization of telehealth services, with providers adapting their care protocols to also include remote monitoring tools and virtual check-ins.

Patient experience improved through greater convenience, reduced wait times, and better access to specialists, while providers gained new tools to deliver care more efficiently (and, many worked from home for the first time in their lives).

But, what DO patients across different geographic and demographic categories think about telehealth services?

General and Consistent Patient Perceptions

The overall patient response to telehealth has been largely positive, with convenience and accessibility emerging as primary benefits. Research shows that patients particularly value the elimination of travel time, reduced wait times, and the ability to receive care from familiar environments. A study by Powell et al. found that patients appreciated the efficiency of video visits and the opportunity to avoid transportation barriers. Most patients report feeling comfortable communicating with their health care providers via video, though some note a slight loss of the personal connection experienced during in-person visits.

Interestingly, if you review the patient-centered telehealth and remote patient monitoring research, there is consistently reported fear from patients that they might lose that personal connection or relationship with their provider. Good telehealth services will seek to maintain patient-provider relationships virtually and train their providers on how to show empathy without the communication value of body language that is possible in-person.

Cost considerations also play a significant role in patient satisfaction with telehealth services. Patients frequently cite savings in transportation costs, parking fees (e.g, you know those expensive hospital parking garages), and reduced time away from work as significant advantages. Additionally, many patients report that telehealth visits result in shorter wait times compared to traditional office visits, contributing to overall satisfaction with the service.

Privacy emerges as both a benefit and a potential concern. While some patients appreciate the privacy of receiving care from home, others, particularly those connecting from workplaces, report challenges in finding suitable private spaces for their appointments. Research indicates that patients have developed various strategies to address privacy concerns, such as using headphones or scheduling appointments during times when they can be alone.

It is important to note that there are also differences across demographics and geographies in how patient populations experience and access telehealth services.

A good book that covers more about patient perceptions and program design can be found here.

Rural Patient Perspectives

Rural patients present unique perspectives on telehealth services, often viewing them as transformative solutions to longstanding health care access challenges. For these patients, telehealth eliminates significant geographic barriers that historically limited access to both primary and specialty care. The reduction in travel time and associated costs is particularly meaningful for rural populations who might otherwise need to drive hours for specialist appointments.

One study examined how travel time for cancer treatment differs between rural and urban patients in Pennsylvania using 2010-2014 cancer registry data. The researchers analyzed nearly 200,000 cases and found substantial differences in average roundtrip travel times - metro area patients traveled about 42 minutes, while rural patients in the most remote areas traveled about 129 minutes. Several factors were associated with longer travel times, including seeking care at higher-ranked hospitals and traveling for certain cancer types like cervical/uterine and ovarian cancers, which had fewer available providers. The study revealed that not only do rural patients face significantly longer travel times overall, but the impact of various patient, facility, and clinical characteristics on travel time differs between rural and urban populations. For example, rural patients who needed to see multiple facilities or specialists faced particularly large increases in travel time compared to urban patients. The researchers conclude that health care providers and systems need to understand these travel burden differences when organizing services and support for rural cancer patients, particularly for certain cancer types that require traveling to specialized treatment centers. Telehealth services should be enabled for this patient population when it is clinically appropriate (e.g., follow-up visits, visits without testing).

In 2017, when my mom was very sick from chronic myeloid leukemia, she traveled to MD Anderson Cancer Center in Houston for a visit that very well could have been a telehealth visit. The visit was a review of records and a quick suggested treatment plan after a two day trip by car from Atlanta in order to avoid infection risk on an airplane. A less than 30 minute visit after a long and difficult journey was very disheartening for her. While we lived in suburban Atlanta and had reasonable access to services, it was necessary for her care to travel to Houston for a very specialized visit, so distance to travel for patients is a primary concern in rural areas, but also applies to patients in many circumstances particularly those looking at clinical trials as their next option in treatment.

While promising, rural patients face distinct challenges with telehealth implementation. Internet connectivity and technology access remain significant barriers in many rural areas. Government programs aimed at broadband internet connectivity can help support these populations. Despite these technical challenges, rural patients generally express high levels of satisfaction with telehealth services when they can access them successfully, particularly appreciating the ability to connect with specialists without leaving their communities.

Older Adult Perspectives

Older adults represent a unique demographic in telehealth adoption, with varying levels of acceptance and comfort with technology. Research indicates that while some older adults initially express hesitation about telehealth services, many become more accepting with experience and support. The COVID-19 pandemic has significantly influenced this acceptance, with studies showing increased openness to telehealth among older adults who previously preferred in-person visits exclusively.

A scientific systematic review examined older adults' satisfaction with telemedicine during the COVID-19 pandemic, analyzing 10 studies with a total of 4,191 patients. The review found that older adults were generally highly satisfied with telemedicine services, with satisfaction rates ranging from 70% to 97.6%. Most patients preferred telemedicine over in-person visits during the pandemic, primarily due to safety, convenience, and cost savings. However, several key barriers were identified, particularly technical issues like poor internet connectivity, difficulties with digital platforms (e.g., digital literacy), and the need for assistance from family members or caregivers. Patient-related factors such as educational level and socioeconomic status also influenced satisfaction levels. The study revealed that age itself did not significantly impact satisfaction, though older adults with hearing or cognitive impairments faced additional challenges. The researchers concluded that while telemedicine was broadly successful with older adults during the pandemic, improvements in technology and support systems specifically designed for older users are needed to increase adoption and satisfaction beyond the pandemic period.

Technology proficiency remains a primary concern for this population. Older adults often require additional support in setting up and navigating telehealth platforms. However, once comfortable with the technology, many older adults appreciate the convenience of telehealth, particularly those with mobility limitations or chronic conditions requiring frequent follow-up care. There are specialized software companies that do build telehealth systems specifically for older adult populations that have performed intensive user research on accessibility, readability, and usability.

Some older adults do express concern about the quality of care delivered virtually, particularly regarding physical examinations. However, research suggests that these concerns often diminish with experience, especially when telehealth is used in combination with in-person visits for appropriate care needs. My experience at Avenue Health operating an older adult focused remote patient monitoring and virtual care program aligns well with this conclusion from the study.

Importantly, for older adults who may be prone to loneliness, a visit to their doctor may also be one of a limited set of social opportunities, so it is important to recognize that telehealth may be convenient, but there are other factors that drive a desire for in-person visits.

Physician and Clinician Perceptions of Telehealth for Older Adults

Given the discussion around Medicare’s telehealth policies, it is also interesting to look at how clinicians perceive telehealth services for older adults. A nationwide survey study examined telehealth use and perceptions among US clinicians caring for older adults (≥65 years). Among 7,246 respondents (55% response rate), over half were licensed independent practitioners, with most practicing in geriatric medicine (22%) or primary care (9.7%).

The survey found that telehealth was commonly used in hospitals (53%), long-term care facilities (47%), and outpatient settings (47%). The majority of clinicians (55%) believed telehealth improved health care for older adults by enhancing engagement between stakeholders, though primary care clinicians reported less support for telehealth use compared to geriatric specialists. Most respondents (65%) reported using age-friendly telehealth practices, with 40% using them often and 25% always. However, the study revealed concerns about the future of telehealth services, with 24% of respondents indicating they would eliminate telehealth services if CMS waivers expired, and 43% saying they would need to reduce services.

The findings suggest that while clinicians generally view telehealth as beneficial for older adult care, continued support through policy and reimbursement is crucial for maintaining these services.

Pediatric Patient and Caregiver Perspectives

Parents and caregivers of pediatric patients offer unique insights into telehealth services. Research demonstrates high satisfaction rates among families using telehealth for pediatric care, particularly for chronic condition management and follow-up visits. Parents appreciate the convenience of not having to transport children to medical facilities, minimizing disruption to school, work, and family schedules.

A systematic review looking at pediatric services analyzed 14 studies examining satisfaction with telehealth versus in-person pediatric care during the COVID-19 pandemic. The review found that in most studies (9 out of 14), caregivers and pediatric patients reported higher or comparable satisfaction with telehealth services compared to in-person visits. The main benefits of telehealth included convenience, time savings, reduced need for transportation, and protection from COVID-19 exposure.

However, key challenges were identified, including technical difficulties, limited ability to conduct physical examinations, and less personal interaction with health care providers. Only one study specifically assessed satisfaction from adolescent patients' perspectives, finding slightly higher satisfaction with video visits compared to in-person visits, though the difference wasn't statistically significant. Most studies (13 of 14) were from developed nations and focused primarily on caregiver satisfaction rather than direct patient feedback. The researchers concluded that while telehealth was generally well-received, improvements are needed in areas like technology access, physical examination capabilities, and provider-patient rapport to optimize telehealth delivery for pediatric care both during and after the pandemic.

The pediatric telehealth experience often benefits from children's natural comfort with technology. Some studies show that younger patients adapt quickly to virtual visits, sometimes showing less anxiety than during in-person appointments. Parents report particular satisfaction with telehealth for behavioral health services and routine follow-up care which are often more frequent in nature.

However, caregivers express some specific concerns about telehealth for pediatric care. These include challenges in keeping young children engaged during virtual visits and concerns about the thoroughness of physical examinations. Some parents also report difficulties in accurately describing physical symptoms or capturing clear images of concerns like rashes or injuries when asked to submit images for review.

Looking to the Future

As telehealth continues to evolve, understanding these varied patient perspectives becomes increasingly important for healthcare providers and systems. The research suggests that successful telehealth implementation requires considering the unique needs and preferences of different patient populations while maintaining flexibility in service delivery models.

While technical challenges and concerns about care quality persist across all groups, the overwhelming response to telehealth has been positive when appropriately implemented and supported. Health care providers can use these insights to better tailor their telehealth services to meet the specific needs of their patient populations, potentially improving both access to care and patient outcomes.

The future of telehealth will likely involve hybrid models of care delivery, combining virtual and in-person visits based on patient needs and preferences as well as the incorporation of remote patient monitoring technologies to collect physiological data directly from the home. Understanding and responding to diverse patient perspectives will be crucial in shaping these evolving healthcare delivery systems to ensure they truly serve all populations effectively and equitably.

Critically, reimbursement and policies are likely to further shape the availability of these types of services and the amount of innovation that occurs over the next five to ten years.

1. The Congressional Budget Office estimates significant costs associated with telehealth flexibilities due to increased utilization. This makes sense since many Medicare beneficiaries struggle to access services in certain areas, so providing ease of access also results in more expense.