Telehealth Experiences and Preferences Among Californians with Low Incomes MAY 2023 AUTHOR Jen Joynt, Independent Health Care Consultant Contents About the Author 3 Executive Summary This report was written by Jen Joynt, Key Findings independent health care consultant. The Looking Forward: Implications for Health Systems and research was designed, conducted, and Policy analyzed by NORC at the University of Chicago (NORC). NORC is an objective and 5 About the Study Participants nonpartisan research institution that deliv- 7 Background: The Evolving Role of Telehealth ers reliable data and rigorous analysis to in Health Care Delivery guide critical programmatic, business, and policy decisions. Study design, data col- 8 Findings: Telehealth Experiences Among lection, and analysis were led by Rebecca Californians With Low Incomes Catterson, MPH, principal research direc- Access to Care with Telehealth tor at NORC, and Lucy Rabinowitz Bailey, Experience with Telehealth Visits MPH, research scientist at NORC. Yohualli Future Preferences for Telehealth B. Anaya, MD, MPH, provided input throughout the research process and edito- 22 Looking Forward: Implications for Health rial support during the writing of this report. Systems and Policy 24 Appendix A. Study Methodology About the Foundation The California Health Care Foundation 25 Endnotes (CHCF) is an independent, nonprofit philanthropy that works to improve the health care system so that all Californians have the care they need. We focus espe- cially on making sure the system works for Californians with low incomes and for com- munities who have traditionally faced the greatest barriers to care. We partner with leaders across the health care safety net to ensure they have the data and resources to make care more just and to drive improve- ment in a complex system. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. Executive Summary Key Findings S ince the beginning of the COVID-19 pandemic in early 2020, telehealth has increasingly While interviewees report different levels of comfort, become an important part of the health care satisfaction, and future interest in telehealth, many delivery system, driven by the need for reduced commonalities in experiences and future preferences in-person contact, by changes to reimbursement, for telehealth emerge from this research. Specific and by patient preference. As telehealth's role in findings from the research are presented below. health care grows, it is important to ensure that all Californians have equal access to and satisfactory Telehealth increases access to health care for experiences with telehealth. To better understand many Californians with low incomes. Telehealth the telehealth experiences of Californians with low removes many barriers, such as financial costs and incomes, the California Health Care Foundation transportation challenges, that can make it difficult (CHCF) engaged NORC at the University of Chicago to access health care. Interviewees appreciate the (NORC) to recruit and interview Californians with ease of access and convenience of telehealth visits, low incomes who reflect the diversity of the state. especially interviewees with disabilities, those with From July to November 2022, NORC interviewed mental health conditions, and those who identify as 73 Californians with low incomes who had received transgender or nonbinary. a telehealth visit in the last year. Interviewees' experiences with video visits reveal "Well, of course, when I have my physical and some trade-offs. Many interviewees report expe- riencing occasional audio and video connectivity then the cardiologist, I always see a person issues during visits. At the same time, they feel that because she wants to listen to my heart and their provider is more engaged in their care in video test me. So I usually go in person . . . . But for visits, which helps them to build trust with their pro- viders and in telehealth. A minority of participants the convenience, I'd rather do the telehealth. report discomfort or no experience with the types It cuts a lot out of my activity, where I get out of digital technology that may be used for video of breath. And, plus, my son is not available visits. Ultimately, many participants who experience both phone and video visits see the value of each to take me. It has saved him a lot of trips visit modality in different situations. and taking him away from his responsibilities and his home and work. I started it actually Telehealth helps patients build stronger rela- tionships with their providers. Overwhelmingly, because I didn't want him coming over so participants report high levels of satisfaction and much. And then when I realized how easy and trust with the care that they receive via phone or convenient it was for me, not having to get video. Moreover, many feel that their relationships with providers are strengthened through more fre- dressed, not having to get in and out of the quent and easier contact. car, then I started to prefer the telehealth." - 84-year-old White female in Riverside County Telehealth Experiences and Preferences Among Californians with Low Incomes 3 Telehealth visits with language-concordant pro- Looking Forward: Implications for viders are effective for delivering high-quality Health Systems and Policy care. Participants who prefer to receive care in a Taken together, our interviewees' experiences with non-English language who receive such visits report telehealth reveal ways in which telehealth is not high levels of satisfaction and confidence in their yet reaching its full potential as a critical part of the communications with their providers. As with other health care delivery system. Several key areas for patients, telehealth visits help these participants future focus from health systems and policymakers build trust and strengthen their relationships with emerge from this research. providers. Embrace telehealth, via both phone and video, Californians with low incomes want telehealth to as an essential part of care delivery. Californians play an integral role in their future care. When with low incomes want telehealth to play a signifi- asked about their future preferences, most inter- cant role in their future care. And participants value viewees say they would like to receive at least half both phone and video visits for receiving care. of their care via telehealth in the future. At the same Health systems and policymakers should continue time, they recognize the value of in-person visits to invest in telehealth and support access to both for physical examinations, health screenings, and phone and video visits. meeting new providers. A minority of participants want all their future care to be in person. Ensure that patients have a choice about visit modality. Participants express personal and specific Patients want to choose or be involved in deci- preferences for the visit types that they would like sions about the modality of their visits. The depending on their health care concern, and want majority of interviewees want to have an active role an active role in the choice of those visits. Health in choosing which type of visit (i.e., phone, video, systems need to integrate choice of visit type into or in-person) makes sense for their specific health their workflow and educate and support patients in concern. Most of these patients like the idea of making decisions about the most appropriate type partnering with their provider in making this choice. of visit for a given concern. Integrate interpretation services and provide access to language-concordant providers in phone and video visits. The health care delivery system needs to continue to invest in the infra- structure to ensure language-accessible visits for all patients, whether that means seamless inte- gration of high-quality interpretation services or California Health Care Foundation www.chcf.org 4 improved access to language-concordant provid- ers. In addition, health systems need to ensure that About the Study all communication and educational materials are Participants available in all languages. Between July and November 2022, NORC researchers conducted in-depth interviews with 73 Support the use of telehealth for patients with Californians with low incomes to gain an under- disabilities, those with mental health conditions, standing of telehealth experiences since the start and those who identify as transgender or non- of the COVID-19 pandemic. All study participants binary. Telehealth provides an important mode of lived in California, had annual household incomes access to health care for people with disabilities, below 200% of the federal poverty level, and had with mental health conditions, and who identify as a telehealth appointment within the last year. A transgender or nonbinary. Telehealth can also help telehealth appointment was defined as a visit with address geographic shortages of providers and a primary care doctor, specialist, therapist, nurse connect patients to a broader pool of providers. practitioner, or other medical professional via video Health systems and health plans should support or a phone call. these patients by ensuring that they are aware of telehealth options and are provided sufficient edu- The NORC team implemented several recruit- cation to connect to providers via telehealth. ment methods (detailed in Appendix A) to ensure the study population would be representative of Improve technical support and connectivity for the population of Californians with low incomes, telehealth visits. Health systems should assess including ensuring representation by race/ethnic- the digital literacy of their patients and provide up- ity, language, region, age, and type of telehealth front assistance and education for telehealth visits appointment (e.g., behavioral health). Of the 73 (especially video visits). In addition, health plans, interviews, 51 were conducted in English, 10 in systems, and clinics should work with their individ- Spanish, 6 in Cantonese, and 6 in Vietnamese. ual providers to ensure that they have the devices, See page 6 for a demographic breakdown of the connectivity, and literacy to effectively engage in interviewees. telehealth visits from wherever they are providing care. Participants are more likely to have had a telehealth visit by phone (89%) than by video (56%). Nearly half of participants (45%) report having received both a phone and a video visit. More than one in three interviewees (36%) report a mental health condition, with depression being the most reported condition (n = 20). Most participants report having a usual place where they receive care, which is typically a private medical practice or a Federally Qualified Health Center. For the complete methodology, see Appendix A. Telehealth Experiences and Preferences Among Californians with Low Incomes 5 Table 1. Demographics of Research Participants (N = 73) NUMBER PERCENTAGE NUMBER PERCENTAGE GENDER INSURANCE COVERAGE Female 39 53% Medi-Cal 42 58% Male 29 40% Dually eligible 9 12% (Medi-Cal and Medicare) Transgender or nonbinary 5 7% Medicare 6 8% RACE/ETHNICITY Covered California 5 7% Asian 14 19% Employer-sponsored 5 7% Black 11 15% Uninsured 5 7% Latino/x 19 26% Private, not 1 1% White 19 26% Covered California Other 10 14% REGION LANGUAGE IN WHICH INTERVIEW WAS CONDUCTED Bay Area 11 15% Cantonese 6 8% Central Coast 6 8% English 51 70% Inland Empire 5 7% Spanish 10 14% Los Angeles 27 37% Vietnamese 6 8% Northern & Sierra 8 11% AGE Other Southern California 7 10% 11 to 17 3 4% Sacramento 4 5% 18 to 29 12 16% San Joaquin 5 7% 30 to 49 26 36% Source: Individual interviews conducted by NORC, 2022. 50 to 64 21 29% 65+ 11 15% California Health Care Foundation www.chcf.org 6 Background: The telehealth. In 2022, more than 4 in 10 Californians with low incomes (42%) received a phone telehealth Evolving Role of visit. And about 4 in 10 (39%) received a video tele- Telehealth in Health health visit.4 RAND's research of California safety-net providers found that by the summer of 2022, the Care Delivery number of in-person visits at California safety-net providers had rebounded to 70% of primary care The COVID-19 pandemic accelerated Californians' appointments, but telehealth still composed about utilization of telehealth for medical and behavioral 30% of visits (23% phone and 7% video). Telehealth health care. A NORC/CHCF survey conducted use was more prevalent for behavioral health care, in summer 2020 found that nearly two in three with 63% (39% phone and 24% video) of appoint- Californians with low incomes (65%) who received ments conducted either by phone or video as of care during the pandemic reported that they had June through August 2022.5 a telehealth visit.1 In addition, research conducted by the RAND Corporation found that between California has some of the most expansive Medicaid February and April 2020, telehealth visits for primary telehealth coverage and reimbursement policies care, conducted either by phone or video, increased in the nation.6 After California ended the public from zero to 148 visits per 1,000 patients at safety- health emergency on February 28, 2023, many net health care providers in California.2 In contrast, pandemic-era rules became law, with equal cover- in-person care dropped from about 230 to 65 visits age and payment for telehealth visits for Medi-Cal per 1,000 patients during that time frame, RAND enrollees, including phone and video visits, as for found.3 in-person visits. California's Department of Health Care Services (DHCS) will also require that Medi-Cal providers support patient choice of visit modality. Specifically, providers who are offering phone ser- vices will need to offer those same services via live video. And providers who are offering telehealth services will be required to offer patients in-person care or a referral to in-person services; these new requirements will happen no sooner than January 1, 2024.7 In addition, DHCS will require that Medi-Cal pro- viders obtain consent and provide additional For most Californians with low incomes, these explanations to ensure that enrollees understand pandemic telehealth visits represented their first their right to choose between a telehealth and experience with telehealth. While the use of tele- an in-person visit. Looking forward, most health health has declined since the end of the acute experts predict that telehealth will continue to play phase of the pandemic, many Californians with an important role in people's health care. low incomes continue to receive some care via Telehealth Experiences and Preferences Among Californians with Low Incomes 7 Findings: Telehealth Access to Care with Telehealth Experiences Among Californians With Low The Takeaway For many Californians with low incomes, telehealth Incomes effectively removes barriers, such as financial costs The acceleration of telehealth use among and transportation challenges, that have impeded Californians since 2020 coupled with the new poli- their access to care in the past. Participants cies affecting access to telehealth make it important report that accessing telehealth visits works well, especially when links for logging in are sent via to understand the experiences of Californians with email or text prior to visits. The ease of access to low incomes. For this report, NORC interviewed 73 telehealth visits allows patients to make and keep Californians with low incomes about their experi- appointments that they might not have been able ences with and future preferences for telehealth. to do in person. A notable minority of participants lack access to technology for video visits. People While personal experiences and preferences among with disabilities, with mental health conditions, research participants vary, many common insights and who identify as transgender or nonbinary are emerge from the research. Key findings are orga- especially likely to say that access to telehealth is nized into three main topics: important to them. $ Access to care with telehealth Telehealth effectively removes many barriers to $ Experience with telehealth visits accessing health care faced by Californians with $ Future preferences for telehealth low incomes, especially financial and transporta- tion barriers. For Californians with low incomes, the indirect financial costs associated with attending in-person health care appointments can cause them to delay or avoid care altogether. Interviewees discuss the challenges of having to take time off work for the visit itself, for traveling to and from the visit, and for time spent waiting in the clinic or doctor's office. For many, an in-person visit necessitates taking at least a half day off work (or in many cases, a full day), requiring them to forgo those wages or use a vaca- tion day. Beyond lost wages, in-person visits bring with them the additional expenses of transportation to and from the visit, parking, and potential child care costs. Telehealth offers both patients and care- givers the opportunity to avoid these costs and to save time. California Health Care Foundation www.chcf.org 8 "We need that appointment, but we hesitate "Travel is something I struggle with . . . because we can't ask for time off . . . . [With just dealing with high traffic. So not having telehealth], we can work around our lunch or to have that obstacle has been incredibly break schedule . . . and they're more likely to helpful. It saves me a lot of time, and I'm say yes than [to] requesting a whole day." not as exhausted from having to sit in traffic - 44-year-old Latina/x female in Los Angeles or having to think about the drive home in more traffic. And being at home . . . I'm a For many, traveling to and from visits presents a sig- bit more at ease. I'm not like, interacting nificant barrier to care, as some people do not have a vehicle, rely on public transportation, or live in an with a bunch of people I don't know, or I'm area with significant traffic. not comfortable with, to get to that point. [Telehealth has] definitely increased my use of "I don't have a vehicle, so telehealth allows health care generally." me to utilize care that I just would not have - 29-year-old White male in Contra Costa County access to otherwise. I couldn't travel to San Francisco regularly to see a specialist. I Many participants cite the ease and convenience suppose sometimes as well, given the nature of telehealth in helping them to make and keep appointments that they might not be able to do of my disabilities, I don't always remember in person. my appointments or have a general ability to get myself mobile enough to get to them. So Many participants report that they are usually able to make an appointment for a telehealth visit faster having providers who are aware of that, who than they are for an in-person appointment, with can then contact me and still maintain the many scheduling a telehealth appointment for appointments is incredibly helpful." within a few days compared to waiting a week or longer for an in-person appointment. - 30-year-old nonbinary person in Northern California "I'm more likely to get care [because] I know I'm going to be able to reach out and get an answer quickly, instead of trying to reach out and go through a prolonged process, only to have to make an appointment and then hear 'the schedule is fully booked.'" - 23-year-old Black male in Los Angeles Telehealth Experiences and Preferences Among Californians with Low Incomes 9 Others report being able to make telehealth appointments outside of the regular business hours for in-person visits, increasing their access to care. A few participants mention seeking urgent care via telehealth through platforms outside of their regu- lar provider or health center, which can prevent the need to go to an urgent care center or emergency room to receive care. "Telehealth made it easier to see my provider because I didn't have to take time off from Most participants note that the process of attend- work. I didn't have to wait in a waiting room ing a telehealth visit runs smoothly, especially when and be exposed to maybe other people that they receive a link by email or text prior to the visit. Also, some participants appreciate receiving had COVID." a pre-call or assistance from office staff to facilitate - 45-year-old Latino/x male in San Joaquin a successful connection. Some experience a learn- ing curve during their first visit, when they have to download an application or become familiar with Without the financial and transportation barriers new technology, but are then comfortable access- associated with in-person visits, telehealth allows ing future telehealth visits. many participants to make and attend appoint- ments that might have been challenging for them A minority of participants encounter technologi- in person, leading to more timely care delivery and cal challenges with telehealth appointments. better continuity of care. A few interviewees note that their provider will call them during the appoint- A minority of participants report challenges access- ment time if they forget to call, helping them keep ing their appointments. Either they do not receive appointments that they might miss in person. Many a link for their appointment or forget to use the link participants note that they receive more health care to start the appointment. Others complain that their now with the option of telehealth visits than they provider has called the wrong phone number. had when care in-person was their only option. In addition, many participants cite avoiding expo- "I don't know what I was doing wrong - sure to COVID-19 or other illnesses as an important because I think they like send you a link. Do advantage of telehealth visits. they send you a link for the telephone one? The process of accessing telehealth visits works Or was it for the video call? I always know, well for most participants, especially when doc- it's some kind of link or something that I have tors' offices and clinics send links via email or text for logging in prior to the visit. to press, and I'll be messing up because they sent it to my phone. And, yeah, I've got to get the hang of that. I don't do too well with it." - 57-year-old Black female in Orange County California Health Care Foundation www.chcf.org 10 In addition, a minority of participants express dis- "Every time I do go to the doctor, I'm really comfort or have no experience with the types exhausted the rest of the day and the next of digital technology that may be used for video visits. When asked about their comfort with com- day. So with the telehealth, I remain well, I puters, touchscreen technology, and smartphone remain doing the activities I'm able to do, and apps, a sizeable number of participants report that I don't get [shortness of breath] and wiped they are somewhat or very uncomfortable with one or more of these technologies. A few have never out where I lose a whole day." used them. One participant describes traveling to a - 84-year-old White female in Riverside County county health center to use one of their computers to attend a telehealth video appointment. Participants with Mental Health Conditions People who are neurodivergent or have acute behav- Participants appreciate having the option to ioral health conditions face challenges in accessing choose the modality of their health care visit. in-person care, including overstimulation and diffi- culty communicating their needs to multiple people Most interviewees note that they were not given a before they see their doctor (e.g., office managers, choice of coming in person or doing telehealth in medical assistants). Several participants with men- the earlier part of the last year - the doctors auto- tal health conditions say that telehealth helps them matically scheduled their visits via telehealth due to avoid the stress associated with in-person visits and concerns about or protocols related to COVID-19. enables them to have more appointments, allowing for more comprehensive treatment of both behav- More recently, many are being given the choice ioral and physical health needs. between in-person, phone, or video and opt for the modality that makes the most sense to them. Some prefer phone, some video, and some in-person. "I've been struggling with anxiety and Others note that they choose whichever option is depression, [and] not having to go in makes available first, which is often a telehealth visit. it more likely that I'll actually do it. You know Interviewees with disabilities, with mental health sometimes, I just really, really don't feel conditions, and who identify as transgender or like getting on a call, but it's like you know, nonbinary highly value access to telehealth. it's right here [so] I might as well do it . . . . Participants with Physical Disabilities I feel like it makes it easier to get care on People who have physical disabilities face accessi- some things that you wouldn't necessarily bility barriers when seeking in-person care. Going otherwise, you know? Instead of only getting to regular medical visits can present many physi- cal challenges and be exhausting (or impossible care when it's something really serious." without the right supports, such as appropriate - 50-year-old White female in San Joaquin County transportation). Telehealth provides an easier, more accessible way for these patients to receive the care Participants with mental health concerns especially they need. appreciate the ability to minimize stress and opti- mize their comfort by having behavioral health visits at home. Telehealth Experiences and Preferences Among Californians with Low Incomes 11 "I trust [telehealth] a lot. It's just always been "Finding a primary care provider that I feel easier for me. And I just feel like definitely comfortable sharing my pain with and my with therapy, it's helped me at least to be experiences with has been kind of difficult . . . . able to be in my own space while talking There were some days when I was really sick to someone. And so the experience has and I could not get out of bed . . . . I'm so sick definitely been good for me." that I cannot move, whether it be physically - 17-year-old White nonbinary person or I'm sick because of a mental health-related in Northern California thing . . . . Having the convenience of . . . Participants Who Identify as Transgender or someone to come to me. Having telehealth Nonbinary has been really useful with that . . . . For those who identify as transgender or nonbinary, telehealth provides access to gender-affirming care "With telehealth, I feel more part of my and peer support regardless of where they live. treatment. And the fact that I get to be in my Telehealth also broadens the pool of providers, home while I'm going through appointments enabling patients to search for providers who are more compassionate to their specific needs. is very helpful just to have, like, familiar things around me. Doctors' offices are very "I would say the physical health visits [by overwhelming for me with the bright LED video] were incredibly good because of the lights, and everyone's running around and in technology that they were using, but also I like a white lab coat, is very overwhelming guess the personability of the providers, and for me, just to have so much external their knowledge base. It just was a lot more stimulation. But to be at home and to talk to professional and a lot more considerate of my the doctor feels very comfortable, because being genderqueer." then I feel comfortable enough to open up - 30-year-old nonbinary person in Northern California and ask questions." - 21-year-old multiracial nonbinary person Participants who identify as transgender or nonbi- in Northern California nary share how receiving care from providers who are not understanding of their specific needs leaves them feeling isolated or dehumanized. These nega- tive experiences have the potential to discourage people from seeking care in the future, leaving physical and mental health concerns unaddressed. California Health Care Foundation www.chcf.org 12 Experience with Telehealth Visits "As a matter of fact, I wouldn't mind telehealth because I don't have to get in the The Takeaway car and go to the office. And I think I would Californians with low incomes report high levels get just as much out of it as I do except, you of satisfaction and trust with care received via phone or video, especially when they have a prior know, he can't, you know, test my heart or relationship with the provider or health clinic. Par- anything like that. I think it's a great thing that ticipants appreciate the efficiency, convenience, and reduced stress of telehealth visits. Most we are doing that. We've got the technology. participants feel that telehealth enables them to And, you know, it saves time. And staying out build stronger relationships with their providers of the doctor's office particularly, with COVID through easier access and increased contact with them. The main drivers of unsatisfactory visits are and everything else that's going around, I'd lack of sufficient interpretation services for people just stay home . . . . I have an iPad that I use who prefer to receive care in a non-English lan- guage and telehealth visits that require in-person to get together with my children, and we use follow-ups. Zoom. So I'm pretty knowledgeable on how to get in and do things." - 89-year-old White female in Sacramento County Overwhelmingly, participants express high lev- els of satisfaction with the care they receive via telehealth. Participants who prefer to receive care in a non- English language report high-quality telehealth Most interviewees report being satisfied with their experiences when their visits involve a language- telehealth experiences. The research found no concordant provider (see page 16 for experiences meaningful differences in telehealth experiences or of participants who receive care in a non-English satisfaction by race/ethnicity, education level, age, language). or insurance coverage. Although a few older par- ticipants express difficulty using video technology, Also, there are no meaningful differences in satisfac- many older participants noted their comfort with tion related to different types of providers or health video visits, as they had become accustomed to systems. While more Kaiser Permanente patients using video platforms to interact with their families experienced telehealth before the pandemic, their during the pandemic. experiences remain very similar to those of par- ticipants receiving care from other providers or in other settings. Telehealth Experiences and Preferences Among Californians with Low Incomes 13 While participants express satisfaction with both "With him, I think I've gotten the same quality phone and video visits, more participants report of care whether I see him in person or on the feeling that their providers are engaged and listen- ing to them in video visits than in phone visits (see phone. It's been fantastic. He's so pleasant, page 17 for the relative advantages of phone and and he has all the information before he video visits). calls me. I mean, extremely personal and Telehealth strengthens patient-provider relation- extremely professional at the same time." ships, with participants feeling that their time - 84-year-old White female in Riverside County with doctors is better spent and more efficient than it is during in-person visits. Most phone and video visits last between 5 and 25 minutes, with no meaningful difference between For most participants, their experience with tele- the types. Many participants report that their time health during the pandemic has helped them to with the provider is the same for their telehealth develop trust in receiving care via phone or video. visits as their in-person visits, and a few even feel Post-pandemic, most interviewees do not feel like like they have more time with the physician dur- they are compromising by having a telehealth visit ing their telehealth visit than they might in person. rather than an in-person visit. Rather, many inter- Furthermore, participants appreciate the increased viewees report feeling that their telehealth visits efficiency of telehealth visits, due to being able to offer the same or better quality experience as an save additional time associated with in-person vis- in-person visit. In addition, interviewees appreciate its, such as waiting to be checked in; waiting to see the opportunity to connect and build relationships a provider; and waiting for additional services, such with their providers from the comfort of their homes. as blood work. "I think [the telehealth visit] was more one- Telehealth facilitates patient trust in providers on-one. So he was just focused on me. He through more frequent and easier contact and better follow-up with them. didn't have to rely on other people. Because sometimes when I go in person, the doctor is For many participants, an established relationship going back and forth with the nurses. So I feel with a provider is a key factor that drives satisfac- tion with and trust in telehealth. Telehealth further like this time it's more personal." strengthens these relationships and facilitates bet- - 24-year-old male in Los Angeles ter and more frequent communication, leading to Californians more actively participating in their care, either by communicating via telehealth platforms or by seeking needed care without delay via phone or video visits. California Health Care Foundation www.chcf.org 14 "I think now, at this point, some of the "First of all, I would say the most important advantage for me is being able to actually talk thing is for them to understand you in your to my doctor, confer with my doctor if I'm not own language. Because truly, at least in my allowed to come in the office or maybe I'm experience, everything that has to do with in a health situation where I can't physically legal or medical things, I prefer to speak come in. So I think that is an advantage. And Spanish because I like to always know how I will say that having the option to telehealth to interpret what they're saying. A lot of or telephone appointment with a physician, to times when they speak to you in English, me, is a good thing." you understand half of it, but you don't - 56-year-old Black female in Riverside County understand the other half. And those are the types of things that can cause concern. So for Many participants use patient portals to share brief me that would be one of the biggest things updates, photos, or messages with their providers. And they note that their providers call to follow up that goes into having and receiving good on recommendations and prescribed medications service. That's the way I see it. That way they to make sure everything is going well. can treat you in your own language." - 58-year-old Latina/x female in San Bernardino County "They're very aware of my health and everything. A lot of it we communicate Californians who prefer to receive care in a non- through the computer system, if I need English language report positive telehealth anything or if I need an appointment. And I experiences when their visits include a language- concordant provider (e.g., a primary care provider like the fact that a lot of that stuff can be over who speaks their language or a nurse who can the phone or they do the video appointments interpret synchronously). In these telehealth visits, and everything." patients report feeling confident both that the pro- vider understands their health care concerns and - 44-year-old Latino/x male in Los Angeles that they understand what the provider is commu- nicating to them. However, not all interviewees are satisfied with their patient portal and email communications with their By allowing easier access and more regular contact providers; one participant expresses frustration at with their providers, telehealth with language- the lack of responsiveness from their provider to concordant providers helps patients who prefer their messages. to receive care in a non-English language build trust and strengthen their relationships with their Telehealth is an effective way to deliver care providers. to patients who want to receive care in their preferred language when visits incorporate lan- guage-concordant providers. Telehealth Experiences and Preferences Among Californians with Low Incomes 15 "I have a non-Vietnamese-speaking doctor, "I need interpreters. My insurance company but there are many Vietnamese-speaking requires that I send in the request usually nurses. Either way, I can speak English three weeks in advance. If the appointment a bit, but I am not familiar with medical made by my doctor is less than the three terminology. Therefore, there is always a weeks, then there's no guarantee that my Vietnamese-speaking nurse at the office insurance company would be able to provide to sometimes interpret for me so I can one for me. Besides, even if they were able understand clearly about my condition and to provide me with an interpreter, there how to take care of myself." is still a chance I won't get one. One time - 45-year-old Asian female in San Diego when I arrived there, the interpreter never showed up. Thus, I had to be stuck with going Many of the Spanish-, Vietnamese-, and Cantonese- through with it myself. The choices I faced speaking participants in this study report having doctors who speak their language or staff at their were to either cancel the appointment or doctors' offices who speak their language. For go ahead with trying to communicate and patients who prefer to receive care in a non-English express myself, not fully and completely." language but lack access to language-concordant - 64-year-old Asian female in Los Angeles providers, seamless integration of interpretation services into telehealth visits is critical. This study likely understates the challenges of suf- Some of the non-English-speaking interviewees ficient access to telehealth and effective telehealth report having family members (such as spouses or visits for Californians who prefer to receive care in children) serve as interpreters during telehealth vis- a non-English language, as all participants received its. While the participants do not directly speak to a telehealth visit in the year prior to being inter- this as a challenge, the use of nonqualified inter- viewed. Therefore, the study does not capture the preters is a barrier to receiving quality health care, experiences of those who want but are unable to and not offering a qualified interpreter violates fed- receive a telehealth visit due to the lack of inte- eral and California laws.8 grated interpretation. Some participants whose preferred language is not Participants see value in both phone and video English report challenges with setting up or access- visits. ing telehealth appointments when the scheduling or setup calls are in English. The challenge of pro- While most participants express satisfaction with viding adequate interpretation services for health both phone and video visits, their experience of the care appointments for these patients is not solely a visit and their future preference for phone or video telehealth issue, as many clinics and doctors' offices visits varies by the type of health concern and pur- struggle to provide needed interpretation services. pose of the visit. California Health Care Foundation www.chcf.org 16 Participants report feeling that their providers are Table 2. Interviewees See Different Advantages of more engaged and listen to them more in video vis- Phone and Video Visits its than in phone visits, which helps them to build trust with their providers and with telehealth. This TYPE OF VISIT ADVANTAGES is especially true for behavioral health visits. On the Phone $ Easier setup than video other hand, participants report experiencing fewer $ Fewer bandwidth or connection technological challenges with phone visits and issues or concerns appreciate the ease of phone calls for follow-ups Video $ Provider can perform some exami- and check-ins with their providers. nations $ Easier to establish rapport with "If the doctor's already seen me once or provider $ More confidence that the provider twice, I would say that there's no reason for is paying attention video unless the doctor requests it. Maybe I didn't comb my hair." A common source of dissatisfaction with tele- - 44-year-old Latino/x male in Los Angeles health visits is patients needing to follow up with an in-person visit to completely address the patient's health concern. "The body language is the thing that I think you are missing out on . . . [on] a phone call, Participants find telehealth visits frustrating when you're not going to get any of that. You're the provider cannot address their health care issue on the phone or via video, and they have to schedule just talking to them. For all I know, on a an additional in-person visit to address the issue. In phone call, they can be just concentrating some cases, participants feel like the only purpose on something else on the computer while of their telehealth visit is to act as a gatekeeper to getting an in-person appointment. Thus, it feels like you're talking and just only half paying a waste of time. Some participants are more under- attention to me." standing of needing follow-up care when they are - 46-year-old Latino male in San Joaquin referred to a new provider or specialist than they are with having to see their primary care provider multiple times via telehealth and in person. In either case, participants stress the importance of personal choice and preference in selecting tele- Other participants report feeling frustrated by health visits. For many, their preference for visit needing to go in person for a visit that could have type is informed by their prior experiences with been handled as a telehealth visit. telehealth, as well as their preferred options for how they want to engage in care. Looking toward future visits, many participants see the value in both phone and video visits depending on the purpose of their visit. Telehealth Experiences and Preferences Among Californians with Low Incomes 17 "I needed to see a dermatologist recently, which impacts the quality of the visit. These issues and I knew that I would need to see them in include needing to log off and log back in through- out the appointment due to an unstable connection person, but I had to do a video visit first and and having difficulty hearing or seeing the provider that felt kind of annoying." due to poor connections (either on the patient end - 44-year-old White male in San Joaquin or provider end). Some rural participants note chal- lenges establishing stable video connections, likely due to the lack of broadband in their communities. "I was just trying to get somewhere else In some cases with poor connections, the provider because I was experiencing certain symptoms needs to pivot to a phone visit, which is frustrating to participants taking part in mental health visits. that I just wanted to be checked. And it was like, 'Well, I can't give you a referral over the "The second time we met . . . we couldn't get phone even though you've been referred it to work right and so he ended up having before for certain issues. I need to see you in to call me and we had to do the session person.' And then actually had the in-person on the phone, which for some reason with visit, and it was just the same thing as, like, we therapy specifically, really bothers me. I think could have literally done this over the phone because . . . being sure somebody is actually because we didn't check anything. There paying attention to you - and also, there's was no blood drawn . . . . There was, really, something about when you're talking about nothing else done besides me just relaying very personal things, being able to see the what symptoms I had. So that's why it was just person's face you're talking to, so you know like, 'This could have saved me a whole lot of you can trust them to not be judging you or time if this was just done over the phone.'" dismissive or something - you can tell a lot - 28-year-old White female in Shasta County about somebody by their body language. So I didn't love that." Most of the technological challenges encoun- - 50-year-old White female in San Joaquin County tered during visits are related to video, including lacking the necessary technology and experienc- ing connectivity issues during the visit. A few participants who prefer to receive care in a non-English language encounter difficulty working While only one of the participants notes any connec- through technical issues if the person on the other tivity issues related to phone visits, many (but not line does not speak their language. all) participants encounter some issues with either audio or video connections during video visits, California Health Care Foundation www.chcf.org 18 Future Preferences for Telehealth those who need regular prescription refills prefer to connect with their doctor via phone or video for follow-up or monitoring visits. The Takeaway Research participants overwhelmingly view tele- While participants appreciate the ease and conve- health as a trustworthy, convenient, and reliable nience of telehealth appointments, they recognize way to get needed health care, and they want that in-person care is important for physical exami- telehealth to be an integral part of their care in nations, health screenings, and tests. Some the future. That said, participants want choice as participants also appreciate in-person visits for to when and what type of telehealth visit makes the opportunity for providers to deliver health sense for their specific concerns. education. "I would really like a hybrid, a mixture. I Participants want telehealth to be an integral would like my initial appointments to be via part of their care in the future. telehealth so I can tell my doctor what's kind When asked about their future preferences, most of going on, what I feel, what I've been doing. participants say that they would like to receive at And then if the doctor decides, you know least half of their care via telehealth going forward, and a handful of participants want even more or all what, we should run some labs, or I would of their care delivered via telehealth in the future. like to see you in person just so I can get a Participants consider phone or video visits to be better understanding of your symptoms - preferable for most nonurgent health concerns. Most participants with chronic conditions and then I feel comfortable going into the office because I've already met this doctor online, we talked about what's going on, what they think my treatment might be. But I know that this appointment is [worth my time]." - 21-year-old nonbinary person in Northern California A minority of participants would prefer in-person care for all their future visits because they feel more comfortable receiving care and feel a stronger con- nection with their provider in person. Telehealth Experiences and Preferences Among Californians with Low Incomes 19 "[An in-person visit] just seems more real, "If something requires a thorough physical more solid. It's just that being with another examination, it would be best for an in-person human being and talking in person, in the appointment. And then for everything else, flesh." like video and telephone, you can kind of do - 24-year-old male in Los Angeles either/or in most cases." - 66-year-old Asian male in Los Angeles A small number of participants do not want tele- health visits due to privacy concerns. "I think all mental health care I will continue "I did see a therapist, maybe about three to get via telehealth." - 23-year-old White female in Los Angeles months ago, but I haven't been back to see him. He wanted to do telehealth. But I said no because I have concerns over security. "The primary care should only be video, and We're going to be talking about some pretty for other specialty care, it could be through personal stuff, and I don't feel safe giving that the phone." - 27-year-old Black female in Los Angeles information over the internet to somebody." - 45-year-old Latino/x male in San Joaquin County However, there are some commonalities in prefer- ences for modality of visit: phone for standard follow Preference for modality of visit (phone, video, in- ups and check ins; video for behavioral health; in- person) is very personal. person for eye care, dental care, dermatology, and cardiac-related concerns. Many participants express Participants report strong and differing opinions a preference for in-person care when meeting a new about what modality of care is best for them for provider or seeking care for a more serious health accessing different types of care. concern. California Health Care Foundation www.chcf.org 20 "I would rather see a doctor in person first . "I think as a patient I would prefer to have . . because when you're in person, you kind the right to make a decision because isn't that of get to develop whether you may have what I'm paying for? I'm paying the doctor to a good working relationship with a doctor help me out on whatever format there is. Isn't or a professional relationship or not. And that the other way around where the doctor just talking to somebody over the phone . . who I'm paying is going to dictate to me what . it's impersonal. And when you're actually he wants or she wants?" in somebody's presence, you can kind of - 66-year-old Asian male in Los Angeles establish whether this doctor is there to maybe really want to care for you or [is] "Well, I think it should be a dual role. I think it listening to what you have to say. And on should be an option that the teleprovider or the phone, you can't always get that. So their medical providers say, 'You know what? especially [for] a first-time visit, I think it's Maybe next appointment, I'm recommending important." a televisit or a video visit.' And then as the - 56-year-old Black female in Riverside County patient, I think you have the right to say, 'You know what? Yeah, but I need to come in,' or, Most participants want to choose themselves 'Okay, I agree with that.' So I don't think it's or decide with their provider which type of visit (phone, video, in-person) makes sense for their a problem with medical providers suggesting specific health concern. it. However, I think the option should be open and given that the patient may say, 'You know Overwhelmingly, interviewees want to have an active role in choosing which type of visit they what? I really feel like I need to come in,' or, should have, with many wanting to discuss with 'Okay. I'm okay with the telephone or video their provider which type of visit makes sense, while conference.'" others prefer to make the decision themselves. - 56-year-old Black female in Riverside County Telehealth Experiences and Preferences Among Californians with Low Incomes 21 Looking Forward: overwhelmingly want to be involved in the deci- sion of which type of visit they should have. While Implications for Health new Medi-Cal policies incorporate patient choice Systems and Policy as a principle, it will also be important to ensure that patients are engaged and educated on their Listening to the telehealth experiences and prefer- choices and that the health system is prepared to ences of Californians with low incomes imparts a support and educate its patients in choosing the powerful story of the importance of telehealth in best type of visit for a given health concern. the health care delivery system. For many of our participants, telehealth has facilitated a benefi- Provide easy access to and reimbursement of cial cycle of developing and strengthening trust both phone and video telehealth visits. Patient between patients and providers. Strengthened preferences and technological comfort with dif- trust is particularly important for people who ferent modalities vary. But a clear finding from have historically experienced mistreatment by the research is that there is a strong desire for and health care providers and institutions resulting appreciation of both phone and video visits for in disengagement and health inequities. These health care that might have previously only been strengthened relationships, in turn, enable more delivered in person. Policy and providers need to equitable delivery of appropriate preventive care, support access to both modalities for physical and necessary follow-up, and generally better care for behavioral health concerns. these patients. At the same time, our participants' experiences with telehealth reveal ways in which Integrate interpretation services and provide telehealth is not yet reaching its full potential as a access to language-concordant providers in critical part of the health care delivery system. phone and video visits. Patients who prefer to receive care in a non-English language and have Several key strategies emerge from the research had telehealth visits want telehealth to be part of for moving telehealth policy and practice forward their future care delivery. The health care delivery in California. system needs to continue to invest in the infrastruc- ture to ensure language-concordant visits for all Embrace telehealth as an essential component their patients, whether that means seamless inte- of care delivery. Patients want telehealth to be gration of high-quality interpretation services or an integral part of their care going forward. And improved access to language-concordant provid- positive patient experience with telehealth leads ers. In addition, health systems need to ensure that to stronger patient-provider relationships and bet- all communication and education related to being ter continuity of care. Providers, health plans, and informed about, setting up, and accessing tele- policymakers should respond to this preference by health visits are available in all languages. continuing to invest in telehealth and by offering telehealth options to patients as often as possible. Support the use of telehealth for Californians with disabilities, those with mental health con- Ensure that patients have a choice about visit ditions, and those who identify as transgender modality (telehealth versus in-person, and or nonbinary. Telehealth provides an important phone versus video). Participants express very mode of access to health care for people with dis- personal preferences related to the types of visits abilities, with mental health conditions, and who they would want for specific health concerns and identify as transgender or nonbinary. It is important California Health Care Foundation www.chcf.org 22 for providers and health plans to recognize this and required from physicians and other staff to respond ensure that these patients are aware of telehealth to these messages and consider the best systems, options and are provided sufficient education to schedules, and staffing models to support truly connect to their providers via telehealth. In addi- responsive patient communication. tion, telehealth offers the possibility of better connecting patients to providers regardless of Ensure good connectivity for providers and clinic where they live, supporting the ability of patients offices. Many participants report that their providers to access the care they need - for example, peo- experience connectivity issues during video visits. ple who identify as transgender or nonbinary and Health plans, health systems, and clinics should desire gender-affirming care. work with their individual providers to ensure that they have the devices, connectivity, and digital lit- Offer telehealth options for behavioral health eracy to effectively engage in telehealth visits from care. Many Californians with low incomes prefer wherever they are providing care. New Medi-Cal to receive at least some of their care for behavioral policies will include exceptions to the requirement health care concerns via video or phone. Health sys- that providers offer video visits, to reflect the avail- tems and health plans should ensure that they are ability of broadband access based on Federal offering telehealth visits for behavioral health care. Communications Commission speed standards. Telehealth also helps address geographic shortages of behavioral health providers by widening the pool Improve support for accessing and joining tele- of potential providers that a patient can access. health visits. Our research finds that most patients are able to use telehealth effectively if they are Improve integration of telehealth and in-person given the right support to access their visits. The visits to improve continuity of care. There are level of support needed varies by patient and multiple stories in our research of patients feeling according to previous telehealth experience, but frustrated by having to do one type of visit to be health systems and health plans should assess the able to access a different type of visit. This suggests digital literacy of their patients and provide up- an opportunity for providers and health plans to do front assistance and education for telehealth visits a better job of coordinating care and developing (especially video visits). In addition, patients should better work flows for how to integrate phone and be provided with multiple options for accessing video visits into the course of care for various types visits through patient portals, links in emails and of health concerns. texts, and phone call reminders. Use email, text, phone, or patient portal commu- One caveat to this research is that all of the partici- nications to support continuity of care (especially pants had a telehealth visit in the year prior to being when telehealth or in-person appointments are interviewed; therefore, we did not hear the stories limited or not timely). Patients appreciate having and desires of those who lack options for receiv- additional options for connecting with their pro- ing telehealth. To ensure that all Californians have viders, and this is a key driver of satisfaction with access to telehealth going forward, it will be impor- telehealth and trust in their providers. However, at tant to educate patients about their telehealth least one patient notes a lack of responsiveness options and to support providers and staff in the from his providers, who have told him they do not provision of telehealth services. have the time to respond to messages. Health care systems and plans need to be mindful of the time Telehealth Experiences and Preferences Among Californians with Low Incomes 23 Appendix A. Study $ 15 participants were recruited in person at several health centers in partnership with the California Methodology Primary Care Association. NORC conducted the California Health Care $ 9 participants were recruited through social media Foundation's (CHCF's) Telehealth Experiences Study advertisements on Facebook and Instagram in between July 22 and November 28, 2022. NORC English and Spanish.9 The advertisements ran researchers conducted in-depth interviews with 73 from October 31 through November 18, 2022. Californians to gain an understanding of telehealth experiences since the start of the COVID-19 pan- In addition to the aforementioned eligibility criteria demic. All study participants lived in California, (i.e., California residency, annual household income had annual household incomes below 200% of the less than 200% FPL, and a telehealth visit within the federal poverty level (FPL), and had a telehealth last year), participants recruited from clinics or social appointment within the last year. A telehealth media were also screened based on digital barriers appointment was defined as a visit with a primary to ensure that the study population included peo- care doctor, specialist, therapist, nurse practitioner, ple who may not be fully comfortable with using or other medical professional via video or a phone computers, touchscreens, or smartphone apps that call. Interview participants received a $100 gift card may affect their experiences with telehealth. to thank them for their participation. Participants were recruited from all eight regions Of the 73 interviews, 51 were conducted in English, of California (i.e., Bay Area, Northern and Sierra, 10 in Spanish, 6 in Cantonese, and 6 in Vietnamese. Sacramento, San Joaquin, Los Angeles, Central Three of the English interviews were conducted Coast, Inland Empire, and other Southern with adolescents between the ages 14 and 17. California) to ensure geographic diversity in the study population. Los Angeles had the largest por- To ensure the study population was representative tion of participants, with 27 of the 73 interviewees of the population of Californians with low incomes, residing there, followed by the Bay Area with 11 the NORC team implemented several recruitment participants. Twenty-nine of the participants identi- methods: fied as male, 39 as female, and 5 as transgender or nonbinary. The average age of the participants was $ 49 participants were recruited through California 48 years. Of the 73 participants, 42 were covered market-based research firms. The majority of by Medi-Cal, 9 were covered by both Medi-Cal and these were recruited by Atkins Research, a Los Medicare, 6 had Medicare only, 5 had plans through Angeles-based market research organization. Covered California, 5 had plans through their cur- Atkins Research sent NORC's screening survey to rent or former employer, 5 were uninsured, and 1 its database of California English- and Spanish- had a private plan not purchased through Covered speaking residents; people who qualified for the California. study were scheduled for an interview. Atkins Research worked to ensure that participants rep- resented the diversity of California (e.g., region, race/ethnicity, age, etc.). California Health Care Foundation www.chcf.org 24 Endnotes 1.Jen Joynt, Lucy Rabinowitz Bailey, and Rebecca Catterson, Listening to Californians with Low Incomes: How They Experience the Health Care System and What It Means for the Future, California Health Care Foundation, May 25, 2021. 2.Lori Uscher-Pines et al., Experiences of Health Centers in Implementing Telehealth Visits for Underserved Patients During the COVID-19 Pandemic: Results from the Connected Care Accelerator Initiative, RAND Corporation, 2022. 3.Lori Uscher-Pines et al., "Telehealth Use Among Safety- Net Organizations in California During the COVID-19 Pandemic," JAMA 325, no. 11 (Mar. 16, 2021): 1106–7. 4.Lucy Rabinowitz Bailey et al., The 2023 CHCF California Health Policy Survey, California Health Care Foundation, February 16, 2023. 5.Uscher-Pines et al., Experiences of Health Centers in Implementing Telehealth Visits. 6.Jared Augenstein and Jacqueline Marks Smith, "Executive Summary: Tracking Telehealth Changes State-by-State in Response to COVID-19," COVID-19 Update (Mannatt newsletter), March 10, 2023. 7.Post-COVID-19 Public Health Emergency Final Telehealth Policy Proposal (PDF), California Department of Health Care Services, December 2022. 8."Language Assistance," California Department of Managed Health Care, accessed February 9, 2023. 9.Uscher-Pines et al., Experiences of Health Centers in Implementing Telehealth Visits. 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