Financial Factors That Influenced Telemedicine Delivery During the COVID-19 Pandemic

ABSTRACT

Objectives: Studies report that finances are a barrier to providing telemedicine. However, few studies have explored how finances are a barrier to providing and using telemedicine for providers and patients. This study aims to describe reimbursement issues that influenced telemedicine provision and use for patients with chronic conditions and their providers during the COVID-19 pandemic.

Study Design: Semistructured interviews were conducted asking about participants’ experiences with telemedicine during the pandemic. All interviews were audio recorded and transcribed verbatim.

Methods: We recruited adult patients (n = 65) and primary care providers (n = 21) across 4 medical centers that were part of the National Patient-Centered Clinical Research Consortium Network in 3 states (New York, North Carolina, and Florida) between March and October 2021. An inductive approach was applied to coding. Transcripts were analyzed for themes relating to financial issues around telemedicine use.

Results: Provider and patient perspectives on financial issues that influenced use of telemedicine differed. Provider concerns were associated with reimbursement, whereas patients were mainly concerned about out-of-pocket costs. Three major themes emerged: (1) relaxing reimbursement regulations alleviated the burden of uncompensated work for providers, (2) reimbursement will determine sustainability of telemedicine, and (3) telemedicine addresses some cost concerns for patients.

Conclusions: Policy changes that supported financing of telemedicine catalyzed the rapid expansion of telemedicine to offset reduced in-person patient encounters during the COVID-19 pandemic. Sustainability of telemedicine will likely depend on reimbursement parity and recognition and reimbursement for provider uncompensated services. Given that patients shared that telemedicine reduced their out-of-pocket costs, more research should examine whether telemedicine improves access among underserved populations while maintaining care quality.

Am J Accountable Care. 2023;11(2):7-14. https://doi.org/10.37765/ajac.2023.89379

In early 2020, with the onset of the COVID-19 pandemic, it became clear that telemedicine visits would be needed to support the delivery of health care services and maintain continuity of care for individuals with chronic conditions.^1-3 In the United States, 6 in 10 adults have at least 1 chronic disease,⁴ and the impact of COVID-19 on those with chronic diseases has been profound.⁵ Individuals with chronic disease are more likely to have severe COVID-19 complications and mortality.^6,7 Additionally, government restrictions on elective and nonurgent encounters during the initial part of the pandemic decreased the number of health care visits for individuals with chronic conditions, resulting in worsening of chronic disease symptoms and problems with obtaining prescription medicines.^1,8 Social distancing policies, shortages of health care resources, and patient avoidance of or delay in medical care resulted in many canceled or postponed visits for individuals with chronic conditions.⁹

Before the COVID-19 pandemic, studies reported increasing but modest use of telemedicine.¹⁰ The adoption of telemedicine before the pandemic was slowed by barriers such as lack of insurance coverage, a dearth of digital health platforms that were compliant with the Health Insurance Portability and Accountability Act, and lack of patient access to technologies (eg, smartphones) and broadband high-speed internet.¹¹ Additionally, lower reimbursement rates for telemedicine visits compared with in-person visits contributed to lower rates of utilization and implementation of telemedicine services.^12,13 Before 2020, only 20% of states had laws that directed pay parity (equitable reimbursement) between telemedicine visits and in-person visits.¹⁴

At the beginning of the pandemic, lower reimbursement rates for telemedicine continued to hinder its use.^15,16 As the pandemic persisted, federal, state, and private payers temporarily relaxed reimbursement policies to support telemedicine.^17-20 CMS revised reimbursement for Medicare and Medicaid by granting several waivers to expand reimbursement eligibility for services, including reimbursing health care professionals who were previously not eligible to bill for services (eg, physical therapists, occupational therapists), allowing for reimbursement for services provided via audio-only equipment, and relaxing geographic location restrictions such as allowing offsite screening to prevent COVID-19 transmission.¹⁷ To the authors’ knowledge, few studies have elucidated the role that finances have played in telemedicine use for both patients with chronic conditions and providers during the pandemic.

We used data from a large qualitative study about telemedicine in primary care to further describe financial issues related to delivering and receiving telemedicine during the COVID-19 pandemic.

STUDY DESIGN AND METHODS

Participants

This study is part of a larger study examining telemedicine use during the COVID-19 pandemic. Primary care patients and providers were recruited across 4 medical centers in 3 states (New York, North Carolina, and Florida) between March and October 2021. New York covered telemedicine services before the pandemic, whereas North Carolina and Florida did not require payers to cover telemedicine services before the pandemic.²¹ During the pandemic, all 3 states expanded reimbursement policies for telemedicine.²² The 4 medical centers are part of the National Patient-Centered Clinical Research Consortium Network. To be included, patients had to: (1) be 18 years or older, (2) speak English or Spanish, (3) be able to participate in a video or telephone interview, and (4) have a diagnosis of 1 or more chronic diseases (asthma, chronic obstructive pulmonary disease, congestive heart failure, diabetes, and hypertension). Providers needed to work in an ambulatory internal medicine or primary care setting at 1 of the 4 medical centers in the study. Maximum variation samplin was used to ensure that participants were diverse in age, race, ethnicity, and practice locations and had differing levels of technology use experience. Participants were recruited by local research teams, including using the help of clinical champions and a stakeholder advisory board composed of informatics experts, patients, practice leaders, providers, and insurance payers involved with the larger study. This study was approved by the Biomedical Research Alliance of New York Institutional Review Board.

Measures

Semistructured interview guides (eAppendices A and B [available at ajmc.com]) were developed in collaboration with the stakeholder advisory board. Provider interviews focused on experiences with delivering telemedicine to patients, whereas patient interviews focused on access and experiences with receiving care via telemedicine during the COVID-19 pandemic.

Approach

Individual interviews with participants were conducted via telephone or videoconferencing. The length of each interview ranged between 30 and 60 minutes. Interviews were audio recorded after participants provided their consent. Recorded interviews were transcribed verbatim for analysis. The data analyzed during the current study can be made available from the corresponding author upon reasonable request.

Analysis

Interviews were professionally transcribed and, if needed, translated into English. An initial round of content analysis coding was performed using the categories of the interview guide, along with additional codes generated from the data. Each transcript was coded independently by 3 researchers (K.A., K.A.M., J.J.L.) who met to resolve discrepancies. Final codes were entered into Dedoose version 9.0.46 (SocioCultural Research Consultants). Codes pertinent to costs, reimbursement, and related concepts were selected for the current analysis, and the relevant text was then analyzed for themes. Thematic analysis was applied using a data-driven approach.²⁴ First, data were relabeled by R.M. by generating codes that were more nuanced to capture more details associated with finances and telemedicine. The codes were then organized by shared meaning to conceptualize themes. The main themes were selected based on frequency of mention by participants. Finally, the full team reviewed and refined the themes to reflect the context of the data and relate the themes to existing literature.

RESULTS

A total of 65 patients and 21 providers participated in this study. Among patients, 60% were women (n = 39) and 71% were older than 40 years (n = 46); 42% self-identified as White (n = 27), 1% as Asian (n = 1), 23% as Hispanic (n = 15), and 25% as Black (n = 16). Among providers, 62% identified as women (n = 13) and 71% were older than 40 years (n = 15); 48% self-identified as White (n = 10), 25% as Asian (n = 5), 14% as Hispanic (n = 3), and 10% as Black (n = 2). Patients and providers were uniformly distributed across the 3 states included in this study (Table).

Three main themes emerged regarding financial barriers and facilitators to use of telemedicine during the COVID-19 pandemic: (1) telemedicine revealed the burden of uncompensated “invisible” work, (2) reimbursement will determine the sustainability of telemedicine, and (3) telemedicine addresses some cost concerns for patients.

Theme 1: Telemedicine Revealed the Burden of Uncompensated Invisible Work

Providers shared that providing telemedicine services during the pandemic drew attention to the types of previously uncompensated invisible work that became billable via telemedicine delivery. Examples of uncompensated services that were provided prior to the pandemic included making phone calls to review patients’ test results, performing medication reconciliation, updating prescriptions, and answering additional patient questions. One provider shared: “I use the phone a lot to report on laboratory work and also to do acute care management as issues arise for patients.… And I probably have more than 30 meaningful interactions with patients over a week.… That basically goes uncompensated…” (provider 20, North Carolina).

Some providers suggested the need to sustain reimbursement models that were supported during the pandemic that compensate for the time spent taking care of and following up with patients: “I would actually like to see capitated care, because I do a lot of things that are still not compensated, and I think really we should be compensated for the number of patients we take care of” (provider 20, North Carolina). Some providers also shared that follow-up conversations through online patient portals are not billable yet require provider time and effort. Patients sought patient portals as a way to reach out to their providers during the pandemic without having to visit or make phone calls. Providers shared that portal messages require dedicated effort and are not billable: “My MyChart [patient portal] emails are not ‘thank you’ and ‘hey, what is this?’. [The] majority of them explain from day 1 to whatever that they have, so it’s like a visit”(provider 9, New York).

Providers mentioned the need to define the minimum amount of time that should be billable for following up with a patient, which would reduce invisible work. One provider said, “It’s ridiculous that if you’re in clinic or you’re on my schedule and I spend 20 minutes with you that I bill a visit, but if I’m on the phone with you for 20 minutes doing coordination of care that counts for nothing”(provider 18, North Carolina). Most patients shared that they are not billed for follow-up phone calls.

Theme 2: Reimbursement Will Determine the Sustainability of Telemedicine

Subtheme 1: Differential reimbursement rates for telemedicine compared with in-person visits. During the start of the pandemic, there was lower reimbursement for synchronous audiovisual telemedicine appointments compared with in-person visits, and even lower or no reimbursement for telephone (audio)-only visits. As the pandemic persisted, there were policy changes across payers that resulted in variability in telemedicine payment rates and policies among payers.

Providers expressed frustration that telemedicine was “reimbursed at a fraction of the amount” (provider 16, North Carolina) they expected, which was particularly problematic for high-complexity visits. Providers felt that the lack of reimbursement for telephone-only visits “is actually the exact opposite of what it should be” (provider 16, North Carolina), especially because many of the telephone-only visits occurred when patients needed a visit but could not access video.

One provider said, “There is this notion that if you can see the patient, you can charge for an in-person visit, but if it’s just telephone, you charge less, which seems very inappropriate to me. You’re spending the same amount of time and working just as hard whether you see the patient or not, and maybe even working harder”(provider 20, North Carolina).

Although patients mainly talked about their financial burden—“I noticed with video you pay for it, and telephone you don’t” (patient 27, North Carolina)—some patients did notice that providers were earning less from telemedicine. One remarked, “From what I hear, they were getting paid pennies for the phone call visits, but that didn’t really concern me” (patient 28, North Carolina).

Subtheme 2: Sustaining telemedicine use. Providers shared that the sustainability of providing telemedicine beyond the pandemic depends on solving reimbursement challenges, and several felt that reimbursement of telemedicine services should be equal to reimbursement of in-person visits. One provider shared: “We need people to really commit to that, but I think because we don’t know how long we’re going to be able to be reimbursed at the same rate, people are kind of unwilling to invest in [telemedicine] right now”(provider 5, Florida).

Providers shared that insurance coverage increased access to and use of telemedicine. Some providers cited that Medicare reimbursement played a role in their ability to provide telemedicine widely given the high volume of patients who are covered by Medicare in their clinic: “At least…50% of my patients were Medicare. So that opened up the opportunity to see those people”(provider 14, Florida). Providers also felt that Medicare reimbursement of telephone visits allowed them to reach patients who were not able to successfully connect through video visits: “If that was an urgent appointment that we needed to see, we turned that intojust a phone call appointment, which actually Medicare was kind enough to allow those to happen” (provider 14, Florida).

Some patients shared that the availability of telemedicine increased their access to providers who do not usually accept their insurance. One person covered by Medicaid shared: “I had North Carolina Medicaid, and in the office it’s hard to find people to take adult Medicaid.… But when it comes to telehealth, the same doctor [who] told you no will say yes over the phone” (patient 25, North Carolina).

Theme 3: Telemedicine Addresses Some Cost Concerns for Patients

Telemedicine was often more affordable than in-person care for patients who were uninsured. This led to unusual accommodations, such as this one described by a provider: “We had one case in which the patient was self-pay and the televisit is less expensive than a regular visit for self-pay. So we ended up giving him an iPad [to do a] televisit in the office.… It was very weird, but…yes, it was for a skin infection, so you could do it through televisit, and it wouldn’t be a problem” (provider 14, Florida).

Insured patients also reported that telemedicine visits were less costly. Patients shared that understanding which telemedicine services are reimbursable with their payers determined which services they were able to access. One patient stated that an in-person visit resulted in higher out-of-pocket costs compared with if they had been provided with a telemedicine appointment: “I ended up with a $550 bill because it’s an outpatient hospital visit basically. All I was going in for was to see a sleep specialist. They could do that anywhere, for instance, telehealth…I had no extra charge at all [with telemedicine]” (patient 34, North Carolina).

Some patients reported that using alternatives to in-clinic visits such as commercial subscription health services provided affordable access to providers via telemedicine. One patient shared their experience: “I do 98.6, if you’re familiar with that app, where you get telehealth appointments unlimited per month, and then follow-up appointments are $1, but you pay a blanket amount. So I [got] a subscription for that just through August” (patient 23, North Carolina).

Although patients reported lower costs for telemedicine visits, patients also agreed that the duration of the follow-up visit should determine the cost of the service. One patient shared, “And [the follow-up visit] lasted less than 2 minutes, literally, but it was charged as if it was for a regular visit, and didn’t even give me the chance to ask questions or anything. [They] just said ‘This is the result, goodbye’” (patient 6, North Carolina).

DISCUSSION

Although payer removal of regulatory and financial barriers for telemedicine during the pandemic encouraged use of telemedicine and improved access to health care services, we found 3 primary themes about financial issues related to telemedicine. Providers talked about how the increased use of telemedicine during the COVID-19 pandemic heightened awareness of uncompensated invisible work²⁵ that providers were performing prior to the pandemic. Providers also discussed the lack of parity in reimbursement rates for virtual visits compared with in-person visits. Finally, patients overall reported lower out-of-pocket costs for telemedicine visits compared with in-person visits.

During the pandemic, patients with chronic conditions were more likely to use telemedicine compared with those without chronic conditions.²⁶ Consistent with the literature, physicians reported that services essential for providing routine continuity of care for patients with chronic conditions—such as follow-up calls to discuss patient questions, acute evaluations, medication management, laboratory follow-ups, and other services—transformed into billable services when delivered through telemedicine.^27,28

Another source of uncompensated time identified was managing patient portals, which are online applications that allow patient-provider interaction and communication. Patients with chronic conditions often engage with secure messaging portals as a quicker and more direct avenue to reaching providers than calling the providers’ offices.²⁹ Similar to previous studies, patients in our study shared that portals allowed them to reach out to providers about questions they had, knowing that communication with providers is not billable.^29,30 Training providers and patients on effective communication on portals, including time expectations and consistent guidelines for responding to communication, may lower the burden of uncompensated effort for providers.^29-31 One study found that physicians who provided care via telemedicine during the pandemic had higher levels of electronic health record work burden outside of work hours.³² There is a need to explore optimal billing structures, including time-based billing for provider follow-up communication, especially for providers who care for patients with chronic conditions.

Patients shared reservations about being charged for very brief virtual visits, which aligns with previous findings on patient opinions.^33,34 This illustrates an opportunity for improvement in telemedicine delivery. Physicians may need to communicate the goals of telemedicine visits and to encourage patients to ask questions and describe concerns more explicitly to ensure that providers address patient concerns.^27,35 Our study highlights the need to address uncompensated follow-up services that support coordination and continuity of care.

Our findings reiterate the importance of supporting provider parity in reimbursement payments of telemedicine visits compared with in-person visits for sustaining telemedicine beyond the pandemic.³⁶ Similar to previous studies,¹⁹ providers specified that differential reimbursement rates were a barrier to providing telemedicine services to patients during the pandemic. Although payment parity for telemedicine visits may be a concern because of increasing cost for payers, providers in this study highlighted the importance of payers supporting reimbursement of telemedicine during the pandemic to ensure continuity of care for patients with chronic conditions while preventing disease spread. During the pandemic, increased uptake of telemedicine was determined by policy changes, including allowing reimbursement for telephone visits, relaxing geographic location restrictions, and expanding covered services.^19,20 Major payers, including Medicaid and Medicare, were instrumental in the adoption of telemedicine services in health care systems as they provided financial incentives to roll out the services.^19,37 Providers in our study shared that their health care systems became more amenable to implementing telemedicine services once the largest payers began reimbursing for virtual encounters.

Some patients reported that providers who typically may not have accepted Medicaid for in-person visits accepted Medicaid via a telemedicine visit, highlighting persistent disparities in access to care for publicly insured patients. Patients with limited abilities to afford health care may benefit from telemedicine, as both providers and patients reported that telemedicine encounters were less costly than in-person visits for uninsured or underinsured patients. This cost differential may drive patients to prefer telemedicine visits,³⁸ although patients are also concerned about the quality of care delivered through telemedicine.³⁹ It is imperative, therefore, to ensure that care delivered via telemedicine does not result in lesser quality of care for uninsured patients.

Additionally, patients living in areas without internet access are less likely to choose a telemedicine visit compared with patients with internet access.⁴⁰ Physicians also report concerns about inequitable access to telemedicine among patients with limited access to technology or who lack technology literacy.²⁷ Patients’ limited access to internet and technology necessitated delivering telemedicine via audio-only visits. Similar to other studies, providers in our study championed for parity in reimbursement despite modality (audio or video visits), because lack of support for audio-only visits will likely contribute to widening disparities by decreasing access for patients who are unable to access video visits.^41-43 Studies are needed to determine whether the quality of care delivered via audio-only visits differs from the quality of care via video visits given the limited nature of types of care that can be delivered via audio-only visits.⁴⁴ It is likely that patients who experience cost barriers to health care may also face intersectional barriers to utilizing telemedicine.

Limitations and Strengths

This study has some limitations. First, interviews were conducted during March to October 2021 and thus may not fully capture financial related trends of telemedicine utilization during the earliest or later stages of the COVID-19 pandemic. Although we recruited a diverse sample of patients and providers, our findings can be generalized only to the states that participated in this study. Self-selection bias may have occurred with those who were willing to be interviewed. Patient and provider reflections of their experiences with telemedicine during the pandemic may also be affected by recall bias. Our interview questions did not include specific questions about costs and reimbursement, so the findings of this study reflect themes that emerged; having specific questions about costs and reimbursement and differences by specific payer type (eg, public vs private insurance) may have resulted in more detailed and nuanced understanding of cost- and reimbursement-related factors that affected the use of telemedicine during the pandemic. Finally, because payer reimbursement of telemedicine differs across states¹⁶ and continues to evolve, our findings may apply only to the time period during which the data were collected, although Medicare coverage findings may generalize. Additionally, providers at academic institutions do not personally deal with patient billing or collections, so the providers in this study may have limited knowledge about cost and reimbursement policies.

Our study also has several strengths. We recruited a robust number of patients with chronic conditions as well as providers across 4 medical centers in 3 states with practices ranging from urban to rural locations. This sample provided a relatively large and diverse array of perspectives and experiences from providers and patients with health conditions that involve significant costs and utilization.

CONCLUSIONS

There is a need to address provider concerns about uncompensated services (eg, responding to patient portal requests, phone calls) necessary for care coordination of patients with chronic conditions. Payer reimbursement of telemedicine services plays a key role in the wide adoption of telemedicine services, and the sustainability of providing telemedicine beyond the pandemic will depend on parity of reimbursement policies for in-person and virtual visits.

Acknowledgments

The authors would like to thank all participants and stakeholders involved who made this research possible. The statements in this publication are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute, its Board of Governors, or its Methodology Committee.

Author Affiliations: University of Alabama (RM), Tuscaloosa, AL; Indiana University (CAH), Indianapolis, IN; Weill Cornell Medicine (KA, RK), New York, NY; Icahn School of Medicine at Mount Sinai (KAM, JJL), New York, NY; Pace University (KAM), New York, NY; University of Florida (CM, DG, AS), Gainesville, FL; Vanderbilt University Medical Center (JSA), Nashville, TN.

Source of Funding: Patient-Centered Outcomes Research Institute (PCORI) COVID-2020C2-10791.

Author Disclosures: Dr Harle reports research grants received and pending to his institution from the Agency for Healthcare Research and Quality, National Institutes of Health, and PCORI. Dr Ancker received the above-
mentioned PCORI grant (COVID-2020C2-10791). The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RM, CAH, JSA, RK, JJL); acquisition of data (CAH, KA, KAM, CM, DG, AS, JJL); analysis and interpretation of data (RM, KA, KAM, JSA, JJL); drafting of the manuscript (RM, KA, DG, JSA, JJL); critical revision of the manuscript for important intellectual content (RM, CAH, KA, KAM, CM, DG, AS, JSA, JJL); provision of study materials or patients (KA); obtaining funding (CAH, CM, JSA, RK); administrative, technical, or logistic support (KA, KAM, CM, AS, RK); and supervision (CAH, JJL).

Send Correspondence to: Rahma Mkuu, PhD, University of Alabama, 117 Russell Hall, Tuscaloosa, AL 35487. Email: rsmkuu@ua.edu.

REFERENCES

1. Kendzerska T, Zhu DT, Gershon AS, et al. The effects of the health system response to the COVID-19 pandemic on chronic disease management: a narrative review. Risk Manag Healthc Policy. 2021;14:575-584. doi:10.2147/RMHP.S293471

2. Koonin LM, Hoots B, Tsang CA, et al. Trends in the use of telehealth during the emergence of the COVID-19 pandemic — United States, January-March 2020. MMWR Morb Mortal Wkly Rep. 2020;69(43):1595-1599. doi:10.15585/mmwr.mm6943a3

3. Weiner JP, Bandeian S, Hatef E, Lans D, Liu A, Lemke KW. In-person and telehealth ambulatory contacts and costs in a large US insured cohort before and during the COVID-19 pandemic. JAMA Netw Open. 2021;4(3):e212618. doi:10.1001/jamanetworkopen.2021.2618

4. About chronic diseases. CDC. Updated July 21, 2022. Accessed September 30, 2022. https://www.cdc.gov/chronicdisease/about/index.htm

5. Hacker KA, Briss PA, Richardson L, Wright J, Petersen R. COVID-19 and chronic disease: the impact now and in the future. Prev Chronic Dis. 2021;18:E62. doi:10.5888/pcd18.210086

6. Liu H, Chen S, Liu M, Nie H, Lu H. Comorbid chronic diseases are strongly correlated with disease severity among COVID-19 patients: a systematic review and meta-analysis. Aging Dis. 2020;11(3):668-678. doi:10.14336/AD.2020.0502

7. Zheng Z, Peng F, Xu B, et al. Risk factors of critical & mortal COVID-19 cases: a systematic literature review and meta-analysis. J Infect. 2020;81(2):e16-e25. doi:10.1016/
j.jinf.2020.04.021

8. Ismail H, Marshall VD, Patel M, Tariq M, Mohammad RA. The impact of the COVID-19 pandemic on medical conditions and medication adherence in people with chronic diseases. J Am Pharm Assoc (2003). 2022;62(3):834-839.e1. doi:10.1016/j.japh.2021.11.013

9. CzeislerMÉ,Marynak K, Clarke KEN, et al. Delay or avoidance of medical care because of COVID-19–related concerns — United States, June 2020. MMWR Morb Mortal Wkly Rep. 2020;69(36):1250-1257. doi:10.15585/
mmwr.mm6936a4

10. Barnett ML, Ray KN, Souza J, Mehrotra A. Trends in telemedicine use in a large commercially insured population, 2005-2017. JAMA. 2018;320(20):2147-2149. doi:10.1001/jama.2018.12354

11. Ortega G, Rodriguez JA, Maurer LR, et al. Telemedicine, COVID-19, and disparities: policy implications. Health Policy Technol. 2020;9(3):368-371. doi:10.1016/j.hlpt.2020.08.001

12. Harvey JB, Valenta S, Simpson K, Lyles M, McElligott J. Utilization of outpatient telehealth services in parity and nonparity states 2010-2015. Telemed J E Health. 2019;25(2):132-136. doi:10.1089/tmj.2017.0265

13. Lin CCC, Dievler A, Robbins C, Sripipatana A, Quinn M, Nair S. Telehealth in health centers: key adoption factors, barriers, and opportunities. Health Aff (Millwood). 2018;37(12):1967-1974. doi:10.1377/hlthaff.2018.05125

14. Lacktman NM, Acosta JN, Levine SJ. 50-state survey of telehealth commercial payer statutes. Foley & Lardner LLP. December 2019. Accessed September 30, 2022.
https://bit.ly/3nNgH6Y

15. Erikson C, Herring J, Park YH, Luo Q, Burke G. Association between state payment parity policies and telehealth usage at community health centers during COVID-19. J Am Med Inform Assoc. 2022;29(10):1715-1721. doi:10.1093/jamia/ocac104

16. Lee NT, Karsten J, Roberts J. Removing regulatory barriers to telehealth before and after COVID-19. Brookings Institution. May 6, 2020. Accessed September 30, 2022. https://bit.ly/42SHmOk

17. COVID-19 emergency declaration blanket waivers for health care providers. CMS. March 30, 2020. Accessed September 30, 2022. https://go.cms.gov/44SwiTl

18. Demeke HB, Merali S, Marks S, et al. Trends in use of telehealth among health centers during the COVID-19 pandemic — United States, June 26-November 6, 2020. MMWR Morb Mortal Wkly Rep. 2021;70(7):240-244. doi:10.15585/mmwr.mm7007a3

19. Kichloo A, Albosta M, Dettloff K, et al. Telemedicine, the current COVID-19 pandemic and the future: a narrative review and perspectives moving forward in the USA. Fam Med Community Health. 2020;8(3):e000530. doi:10.1136/fmch-2020-000530

20. Kircher SM, Mulcahy M, Kalyan A, Weldon CB, Trosman JR, Benson AB. Telemedicine in oncology and reimbursement policy during COVID-19 and beyond. J Natl Compr Canc Netw. 2021;19(13):11-17. doi:10.6004/jnccn.2020.7639

21. Volk J, Palanker D, O’Brien M, Goe CL. States’ actions to expand telemedicine access during COVID-19 and future policy considerations. The Commonwealth Fund. June 23, 2021. Accessed September 30, 2022. https://bit.ly/44TCcUc

22. Summary of state directives to expand telemedicine services in response to COVID-19. American Medical Association. Updated April 27, 2020. Accessed September 30, 2022. https://bit.ly/3W0G5CL

23. Coyne IT. Sampling in qualitative research. purposeful and theoretical sampling; merging or clear boundaries? J Adv Nurs. 1997;26(3):623-630. doi:10.1046/j.1365-2648.1997.t01-25-00999.x

24. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa

25. Daniels AK. Invisible work. Soc Probl. 1987;34(5):401-415. doi:10.2307/800538

26. Ng BP, Park C, Silverman CL, Eckhoff DO, Guest JC, Díaz DA. Accessibility and utilisation of telehealth services among older adults during COVID-19 pandemic in the United States. Health Soc Care Community. 2022;30(5):e2657-e2669. doi:10.1111/hsc.13709

27. Gomez T, Anaya YB, Shih KJ, Tarn DM. A qualitative study of primary care physicians’ experiences with telemedicine during COVID-19. J Am Board Fam Med. 2021;34(suppl):S61-S70. doi:10.3122/jabfm.2021.S1.200517

28. Saliba-Gustafsson EA, Miller-Kuhlmann R, Kling SMR, et al. Rapid implementation of video visits in neurology during COVID-19: mixed methods evaluation. J Med Internet Res. 2020;22(12):e24328. doi:10.2196/24328

29. Hefner JL, MacEwan SR, Biltz A, Sieck CJ. Patient portal messaging for care coordination: a qualitative study of perspectives of experienced users with chronic conditions. BMC Fam Pract. 2019;20(1):57. doi:10.1186/s12875-019-0948-1

30. Kong Q, Riedewald D, Askari M. Factors affecting portal usage among chronically ill patients during the COVID-19 pandemic in the Netherlands: cross-sectional study. JMIR Hum Factors. 2021;8(3):e26003. doi:10.2196/26003

31. Sieck CJ, Hefner JL, Schnierle J, et al. The rules of engagement: perspectives on secure messaging from experienced ambulatory patient portal users. JMIR Med Inform. 2017;5(3):e13. doi:10.2196/medinform.7516

32. Lawrence K, Nov O, Mann D, Mandal S, Iturrate E, Wiesenfeld B. The impact of telemedicine on physicians’ after-hours electronic health record “work outside work” during the COVID-19 pandemic: retrospective cohort study. JMIR Med Inform. 2022;10(7):e34826. doi:10.2196/34826

33. Imlach F, McKinlay E, Middleton L, et al. Telehealth consultations in general practice during a pandemic lockdown: survey and interviews on patient experiences and preferences. BMC Fam Pract. 2020;21(1):269. doi:10.1186/s12875-020-01336-1

34. Javanparast S, Roeger L, Kwok Y, Reed RL. The experience of Australian general practice patients at high risk of poor health outcomes with telehealth during the COVID-19 pandemic: a qualitative study. BMC Fam Pract. 2021;22(1):69. doi:10.1186/s12875-021-01408-w

35. Gordon HS, Solanki P, Bokhour BG, Gopal RK. “I’m not feeling like I’m part of the conversation”: patients’ perspectives on communicating in clinical video telehealth visits. J Gen Intern Med. 2020;35(6):1751-1758. doi:10.1007/s11606-020-05673-w

36. Yelverton V, Qiao S, Weissman S, Olatosi B, Li X. Telehealth for HIV care services in South Carolina: utilization, barriers, and promotion strategies during the COVID-19 pandemic. AIDS Behav. 2021;25(12):3909-3921. doi:10.1007/s10461-021-03349-y

37. Payán DD, Frehn JL, Garcia L, Tierney AA, Rodriguez HP. Telemedicine implementation and use in community health centers during COVID-19: clinic personnel and patient perspectives. SSM Qual Res Health. 2022;2:100054. doi:10.1016/j.ssmqr.2022.100054

38. Predmore ZS, Roth E, Breslau J, Fischer SH, Uscher-Pines L. Assessment of patient preferences for telehealth in post–COVID-19 pandemic health care. JAMA Netw Open. 2021;4(12):e2136405. doi:10.1001/jamanetworkopen.2021.36405

39. Ladin K, Porteny T, Perugini JM, et al. Perceptions of telehealth vs in-person visits among older adults with advanced kidney disease, care partners, and clinicians. JAMA Netw Open. 2021;4(12):e2137193. doi:10.1001/jamanetworkopen.2021.37193

40. Reed ME, Huang J, Graetz I, et al. Patient characteristics associated with choosing a telemedicine visit vs office visit with the same primary care clinicians. JAMA Netw Open. 2020;3(6):e205873. doi:10.1001/jamanetworkopen.2020.5873

41. Chen J, Li KY, Andino J, et al. Predictors of audio-only versus video telehealth visits during the COVID-19 pandemic. J Gen Intern Med. 2020;37(5):1138-1144. doi:10.1007/s11606-021-07172-y

42. Huang J, Graetz I, Millman A, et al. Primary care telemedicine during the COVID-19 pandemic: patient’s choice of video versus telephone visit. JAMIA Open. 2022;5(1):ooac002. doi:10.1093/jamiaopen/ooac002

43. Chang JE, Lindenfeld Z, Albert SL, et al. Telephone vs. video visits during COVID-19: safety-net provider perspectives. J Am Board Fam Med. 2021;34(6):1103-1114. doi:10.3122/jabfm.2021.06.210186

44. Hammersley V, Donaghy E, Parker R, et al. Comparing the content and quality of video, telephone, and face-to-face consultations: a non-randomised, quasi-experimental, exploratory study in UK primary care. Br J Gen Pract. 2019;69(686):e595-e604. doi:10.3399/bjgp19X704573