The COVID Seesaw: Telehealth Visits Way Up, In-person Visits Down

November 5, 2020
Peter Wehrwein
Peter Wehrwein

RAND study puts some numbers to telehealth surge but also shows evidence of disparities along income, racial/ethnic lines.

It is no secret that much of routine and preventive healthcare ground to a halt in March and April because of the COVID-19 pandemic. But the details of by how much and for whom are still getting filled in.

Using Castlight Health claims data from a total of 200 self-insured employers and health plans, a research team led by Christopher M. Whaley, Ph.D., of the RAND Corporation, are reporting results in today’s JAMA Network Open that serve up some of the missing particulars. Their data show steepest declines in utilization in cancer screening tests, specifically colonoscopies and mammograms, and in musculoskeletal and cataract surgery. Differences in the use of statins and medications for diabetes and asthma were small or nonsignificant, although the prescriptions for asthma medications increased by 32.7% in March 2020 relative to March 2019, perhaps because people were concerned about COVID-19 affecting their breathing.

Here is a table showing the relative difference between March 2019 and March 2020 and April 2019 and April 2020:

Health care serviceMarch 2019 vs. March 2020April 2019 vs. April 2020
Colonoscopy- 43.9%- 92.9%
Mammography- 41.6%- 90.4%
HbA1c test- 35.1%- 68.9%
Vaccines- 18%- 22.6%
Angioplasty- 15.2%- 33.0%
Chemotherapy- 3.6%- 7.4%
Labor and delivery- 0.5%- 3.5%
Musculoskeletal surgery- 28.9%- 66.0%
Cataract surgery- 31.3%- 91.1%
MRI- 28%- 62.6%
Statin prescription2.6%- 8.1%
Diabetes medications3.9%- 6.6%
Asthma medications32.7% 2.6%

The Castlight claims data also adds to the mountain of evidence that American healthcare pivoted to telehealth in those spring months. Relative to March 2019, the number of telehealth visits per 10,000 persons in March 2020 increased by 1,270% (17.4 visits in 2019 to 239.1 in 2020). The relative increase from April 2019 to April 2020 was 4,081%, reported Whaley and his colleagues.

At the same time, their data show that in-person visits plummeted — which is also

"old news" but Whaley and his colleagues provide supporting data. The relative decrease in in-person visits was smaller than the huge relative increase in telehealth visits, but in absolute terms, the increase in telehealth visit offset only about 40% of the drop-off of in-person visits.

Misgivings about telehealth have faded because of the pandemic and the surprising (at the time) pivot from in-person care. Healthcare executives and providers have largely embraced (and applauded) the change, although this research by Whaley and his colleagues justifies the concern that the adoption telehealth could worsen rather than ameliorate healthcare disparities that follow the contours of race and income. Their results show a smaller increase in telehealth usage among people living in ZIP codes in which 80% or more of the residents who are members of a racial/ethnic minority group than in ZIP codes that more White people. When they grouped people by income, the pattern was the same: There were fewer telehealth users in lower-income ZIP codes than in higher income ones. Also, the same populations thgat had lower rates of telehealth use had smaller decreases in the use of in-person care.

“The extent to which access barriers to telemedicine contribute to lower rates of in-person care deferral and thus increases in potential exposure to COVID-19 should be examined in future work,” note Whaley and his colleagues.

The Castlight Health data gives researchers a window into the commercially insured population that research that depends on data from the public payers, Medicare and Medicaid, can’t. The 2020 data used in this research included health and pharmacy claims for 6.8 million people whose average age is 34.5