Jul, 13, 2021

Considerations for Telehealth Equity

Karen Siegel, Health Equity Solutions and JoAnn Volk, the Georgetown University Center on Health Insurance Reforms

Since March 2020, many states have rapidly leveraged federal and state flexibilities under the public health emergency to expand telehealth capabilities and reimbursement through both public and private payers.[1] About 30 percent of weekly visits to health centers were virtual in January through November 2020.[2] Now, some states are extending telehealth for the long term or expanding their existing telehealth programs.[3]

Increased uptake of telehealth could reduce administrative costs, transportation costs, and wait times. It also could exacerbate existing disparities if barriers to care for populations experiencing these disparities are not addressed. To realize telehealth’s potential for increasing equity in access, [4]states must analyze the impact of these services. The rapid increase in telehealth services in 2020 and 2021 offers an opportunity to ask key questions and take steps to maximize the potential of telehealth care to improve equity.

Utilization, Cost, and Experience

Pre-pandemic research suggested that lower income and Black survey respondents were less likely and less willing to utilize telehealth services than other demographic groups.[5] Avoidance of in-person services during the COVID-19 pandemic may have shifted openness to virtual visits, but early indicators suggest utilization disparities may have been exacerbated with use of telehealth increasing among non-Hispanic White patients and decreasing among Black, Latino, and Asian patients.[6] Another analysis found that Black and Hispanic/Latino adults were more likely than white adults both to have had a telehealth visit and to have been unable to receive a telehealth visit they wanted.[7] These conflicting data points suggest a need for more robust evaluation.

Longitudinal analysis of utilization, patient satisfaction, cost, and outcomes data stratified by race and ethnicity would clarify which types of telehealth services have had a positive or negative impact on disparities. For example, telehealth has the potential to limit avoidable emergency department use for physical, mental, and oral health care, but may drive up health care utilization in other ways.

States may also consider how disparities differ by service type and sector (consider oral, behavioral, and medical health care). If some disparities grow while others decrease, community engagement may identify best practices, services best suited to telehealth, and barriers to accessing virtual services.

Stratifying data by race and ethnicity will be particularly important because of the longstanding disparate burden of disease experienced by Black, Indigenous, Latino, Asian, and other people of color. Evaluating disparities in access to specialty care could identify barriers to telehealth care management for chronic diseases with wide and persistent health disparities. Across the U.S., subspeciality visits declined and telehealth services by specialty varied widely.[8] Longitudinal analysis may clarify how effective telehealth is in reducing avoidable emergency department use for various populations and point to policy recommendations for promoting equity.[9]

Barriers to Accessing Telehealth

Reports suggest some providers may be requiring preliminary telehealth assessments for procedures that would require a second, in-person visit regardless of the assessment.[14] Such an approach may have helped to limit the number of people in an office to aid in infectious disease control but will only present an impediment and greater cost as providers return to fully open status.

Finally, policymakers can consider whether insurers are using lower or no cost sharing for virtual visits to discourage in-person visits or relying on dedicated telehealth providers to meet network access standards. Either practice could have a negative impact on patient satisfaction and outcomes, as detailed below.

Cultural and Linguistic Appropriateness and Socioeconomic Factors

Addressing disparities requires considering cultural needs and socioeconomic factors that impact access to care. Due to structural racism—including practices such as redlining and limited access to generational wealth—people of color are more likely to live in densely populated households with limited privacy. Other barriers may include disabilities, poor internet service, or lack of familiarity with technology.[15]

Further, people with limited English language proficiency or who need sign language interpretation may face barriers depending on how well interpretation services are embedded in telehealth platforms.[16] Examining patient satisfaction and any variation in outcomes between in-person and virtual care may point to opportunities to address inequities, including those related to language access.[17]

A 2018 report[18] found patients were more likely to opt for in-person visits when offered a choice of telehealth vs a traditional visit. This could be for any number of reasons, including a need for care the patient is uncomfortable disclosing on a form, lack of comfort establishing a relationship with a new provider remotely, or issues related to the cultural and linguistic appropriateness of care.  

Some individuals may be unable or unwilling to explain these barriers in a message or call requesting an appointment; therefore, policymakers may want to ensure that virtual visits are a choice rather than an obligation in a post-pandemic world.[19] Closely considering patient experience with telehealth may highlight services for which choice is especially important.

More robust evaluation, including consideration of differences in patient satisfaction with in-person compared to telehealth for each service type, will help states understand if telehealth is living up to its promise in addressing disparities.

——

[1] Volk J., Palanker D., O’Brien M., Goe C. (2021). States’ Actions to Expand Telemedicine Access During COVID-19 and Future Policy Considerations. Retrieved from: https://www.commonwealthfund.org/publications/issue-briefs/2021/jun/states-actions-expand-telemedicine-access-covid-19

[2] Centers for Disease Control and Prevention. (2021) “Trends in Use of Telehealth Among Health Centers During the COVID-19 Pandemic—United States, June 26-November 6, 2020.”

Morbidity and Mortality Weekly Report. DOI: https://dx.doi.org/10.15585%2Fmmwr.mm7007a3

[3] Manatt. (2021) “Executive Summary: Tracking Telehealth Changes State-by-State in Response to COVID-19.”  Retrieved from: https://www.manatt.com/insights/newsletters/covid-19-update/executive-summary-tracking-telehealth-changes-stat

[4] Families USA & PCORI. (2020) “Advancing Health Equity through Telehealth Interventions during COVID-19 and Beyond: Policy Recommendations and Promising State Models.” Retrieved from: https://familiesusa.org/wp-content/uploads/2020/07/HE-98_-Policy-PCORI-Telehealth-_Issue-Brief_7-22-20.pdf

[5] Fischer S., Ray K., Mehrotra A., et al. (2020) “Prevalence and Characteristics of Telehealth Utilization in the United States.” JAMA Network Open. DOI: 10.1001/jamanetworkopen.2020.22302

[6] Nouri S, Khoong E., Lyles C., & Karliner L. (2020) “Addressing Equity in Telemedicine for Chronic Disease Management During the COVID-19 Pandemic.”  NEJM Catalyst Innovations in Care Delivery. DOI: 10.1056/CAT.20.0123

[7] Barrie Smith L. & Blavin F. (2021) “From Safety Net to Solid Ground: One in Three Adults Used Telehealth during the First Six Months of the Pandemic, but Unmet Needs for Care Persisted.” Retrieved from: https://www.rwjf.org/en/library/research/2021/01/from-safety-net-to-solid-ground-one-in-three-adults-used-telehealth-during-the-first-six-months-of-the-pandemic-but-unmet-needs-for-care-persisted.html

[9] Centers for Disease Control and Prevention. (2020) “Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic—United States, January-March 2020.”

Morbidity and Mortality Weekly Report. DOI: http://dx.doi.org/10.15585/mmwr.mm6943a3 

[10] Families USA & PCORI. (2020) “Advancing Health Equity through Telehealth Interventions during COVID-19 and Beyond: Policy Recommendations and Promising State Models.” Retrieved from: https://familiesusa.org/wp-content/uploads/2020/07/HE-98_-Policy-PCORI-Telehealth-_Issue-Brief_7-22-20.pdf

[11] Zhai Y. (2020) “A Call for Addressing Barriers to Telemedicine: Health Disparities during the COVID-19 Pandemic.” Psychother Psychosom DOI: 10.1159/000509000

[12] https://www.manatt.com/insights/newsletters/manatt-on-health/audio-telehealth-services-post-pandemic 

[13] Jared Augenstein, Jacqueline Marks, Executive Summary: Tracking Telehealth Changes State-by-State in Response to COVID-19 – January 2021. Retrieved from https://www.jdsupra.com/legalnews/executive-summary-tracking- telehealth-8692451/ and Washington COVID-19 (Coronavirus), News & Media (2020). Retrieved from https://www.governor.wa.gov/news- media/washington-colorado-nevada-and-oregon-announce-coordination-telehealth

[14] Urban Institute. (2021) “Impact of the COVID-19 Pandemic on Primary Care Practices.” Retrieved from: https://www.rwjf.org/en/library/research/2021/02/impact-of-the-covid-19-pandemic-on-primary-care-practices.html

[15] Zhai Y. (2020) “A Call for Addressing Barriers to Telemedicine: Health Disparities during the COVID-19 Pandemic.” Psychother Psychosom DOI: 10.1159/000509000

[16] Nouri S, Khoong E., Lyles C., & Karliner L. (2020) “Addressing Equity in Telemedicine for Chronic Disease Management During the COVID-19 Pandemic.”  NEJM Catalyst Innovations in Care Delivery. DOI: 10.1056/CAT.20.0123

 And Center for Care Innovations. (2020) “Telemedicine for Health Equity: Considerations for Reaching and Engaging Diverse Patients.” Retrieved from: https://www.careinnovations.org/resources/telemedicine-for-health-equity-considerations-for-reaching-and-engaging-diverse-patients/ and

IMPAQ Health and American Institutes for Research. “Issue Brief: The Expansion of Telehealth: Equity Considerations for Policymakers, Providers, & Payers.” Retrieved from:  https://impaqint.com/sites/default/files/issue-briefs/The%20Expansion%20of%20Telehealth_Issue%20Brief_1.2.pdf  and

Rodriguez A., Saadi A., Schwamm, Bates D., & Samal L. (2021) “Disparities in Telehealth Use Among California Patients with Limited English Proficiency.” Health Affairs. DOI: https://doi.org/10.1377/hlthaff.2020.00823

[17] See, for example: Quigley D., Elliot M., Hambarsoomian K., et al (2019) “Inpatient Care Experiences Differ by Preferred Language within Racial/Ethnic Groups.” Health Serv Res DOI: 10.1111/1475-6773.13105 and

Weech-Maldonado R., Elliot M., Pradhan R. et al (2012) Med Care. DOI:  10.1097/MLR.0b013e3182610ad1

[18] Reed M., Huang J., Graetz I., et al. (2020) “Patient Characteristics Associated with Choosing a Telemedicine Visit vs Office Visit with the Same Primary Care Clinicians.” JAMA Netw Open. DOI:10.1001/jamanetworkopen.2020.5873

[19] Nouri S, Khoong E., Lyles C., & Karliner L. (2020) “Addressing Equity in Telemedicine for Chronic Disease Management During the COVID-19 Pandemic.”  NEJM Catalyst Innovations in Care Delivery. DOI: 10.1056/CAT.20.0123