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By Jacqueline Lisk
The COVID-19 pandemic exacerbated health care inequities in the United States. Racial and ethnic minority groups are disproportionately represented among COVID-19 cases, and Black, Hispanic, and Latino COVID patients are statistically more likely to be hospitalized than non-Hispanic white patients, according to multiple studies.
But the pandemic also fast-forwarded the adoption of a promising tool in combating health inequity: telemedicine. In response to the pandemic, the federal government, state Medicaid programs, and private insurers expanded coverage for virtual health services, allowing providers to rapidly scale their telehealth solutions. According to a McKinsey study, just 11% of U.S. citizens had utilized telehealth in 2019. In 2020, that figure jumped to 46%.
Telemedicine has the potential to help mitigate health care disparities — the differences in access or availability of medical services, and variances in disease occurrence and prognosis tied to demographic and socioeconomic factors — by allowing people who don’t have health care providers in their community or time to see a doctor in person to more easily seek care.
“Patients in underserved communities traditionally have lower utilization rates of preventive and primary care,” says Nilesh Chandra, a health care technology expert at PA Consulting, an innovation and transformation consultancy.
If telehealth can increase preventive and primary care adoption for at-risk communities, it could lead to better health care options for these patients.
An outdated system
Garry Welch, a former Harvard professor and co-founder and chief scientific officer of SilverFern Healthcare explains that the primary care system was not designed for “the 21st-century challenge of chronic conditions.”
Meeting with a physician briefly once or even a few times a year is ineffective for helping patients prevent and control diseases like diabetes, hypertension, heart disease, and mental illness. Telehealth could be an integral part of a new system that uses emerging technology to better combat chronic illness and facilitate collaborative virtual team care.
“Doctors and their teams are being disrupted in a positive way to embrace not only virtual care but to begin to work with extended clinical care teams that have a wider range of expertise in chronic disease management and behavior change,” Welch says, explaining that “MD ‘quarterbacks’” could serve as the care team leaders.
Welch believes the adoption of telehealth and virtual team care would have taken five to ten years longer without COVID-19. The key will be making sure this new system is built to serve everyone. Kate Burke, MD, a senior medical advisor at Boston-based PatientsLikeMe, witnessed health care disparities every day while working as an E.R. doctor at Milford Regional Medical Center, a community hospital in central Massachusetts. Today, she observes larger-scale inequities when reviewing data on PatientsLikeMe, a community health management and data platform where patients track their health and learn from peers, and life science companies and health care professionals can review anonymized data to better understand patient needs.
Burke explains those living below the poverty line are less likely to have health insurance or access to quality care. These health care disparities can be self-perpetuating: “If you’re unable to afford health care, you get sicker and are less able to find a new job, and less able to find some kind of coverage.”
Barriers to adoptionTelemedicine “is all about meeting patients and their families where they are,” says Burke, so it could be particularly valuable for high-risk populations. Of course, it wouldn’t replace in-person care entirely. For example, it is hard to do an abdominal examination remotely. But hybrid delivery of care could create more equitable outcomes, if we can overcome a number of obstacles.
Some communities don’t have the bandwidth or infrastructure to support virtual care, and not everyone has access to mobile devices, computers, or the internet. Seven percent of Americans don’t use the internet at all, according to Pew Research Center. Age, education, and income are indicators of a person’s likelihood to be offline. These factors also contribute to health care disparities, so in some cases, the people who need the benefits of telehealth the most will be the hardest to reach.
Robbie Hughes, founder and CEO of Lumeon, a digital health company headquartered in Boston, says the “stark reality is that the majority of patients are neither digitally savvy nor health-savvy.”
If telehealth is to address disparities in health care, virtual solutions must be designed to fit each patient’s “preferred language, device, communication channel of choice, socioeconomic background, pre-existing conditions, and health insurance coverage — and proactively guide them every step along the way,” Hughes explains.
In addition to navigating digital apps and tools, patients may need to get lab work done in advance of their visit, fill out a questionnaire, or in the future use equipment to measure their vital signs remotely. Patient education will be paramount. David Hunt, founder and chief marketing officer of Cosán Group, a preventative care coordination company, notes telemedicine can be particularly challenging for seniors, “among which only one in ten patients used telehealth prior to COVID-19.”
Ann Kriebel-Gasparro, nurse practitioner and faculty member for Walden University’s Master of Science in Nursing program, has used telehealth to evaluate patients for their annual Medicare visits. She has found telehealth beneficial, as well as challenging.
“Since my patients are older, there is often a learning curve, and older adults are often not familiar with video calls,” Kriebel-Gasparro explains. “However, once you’ve moved past these initial difficulties, video calls can elicit a lot of valuable information from patients, and providers can offer education about screenings needed for health promotion and disease prevention.”
By 2030, all Baby Boomers in the United States will be 65 or older, so solutions should be designed with this age group in mind, Hunt says.
Lastly, the country may need to rethink the reimbursement model.
“Until 2020, most payers did not cover telehealth services with the same level of reimbursement as in-person care,” Chandra explains. “This has shifted in the last year, as an increasing number of payers have begun covering telemedicine visits.”
Telemedicine’s meteoric rise won’t continue unless payers continue to cover these visits,” Chandra says. But with the right regulation and the infrastructure, “it is highly possible for telehealth to become mainstream in a few years, amidst communities large and small,” he says.
Burke is also optimistic. “I have a deep hope that the global embracing of telemedicine as a tool in the toolbox of health practitioners,” she says, “and researchers will help to create a more equitable health care system.”