By Jenna Becker
Telehealth can and should be used in an intentional effort to reduce health disparities.
Increased COVID-19 mortality rates in communities of color have been a constant, tragic reminder of the ways in which systemic racism causes poor health outcomes in the United States. Immigrants are facing an increased risk of illness and limited access to care. Rural Americans may face an increased risk of serious illness.
Telehealth can reduce barriers to care that these groups face, such as lack of access to transportation, culturally-competent providers, and childcare.
The last six months have seen rapid growth in the use of telemedicine in response to the COVID-19 pandemic. In response to urgent need, regulatory agencies and private insurance companies have loosened requirements that previously inhibited the use of telehealth.
The expansion of telehealth and removal of traditional barriers to care may lead to more equitable health outcomes.
Impact of telehealth on health disparities
Telehealth has the potential to significantly increase health care access and reduce health disparities.
For example, transportation barriers are more likely found among Black, Indigenous, and Latinx individuals. For appointments that can be conducted online, telemedicine eliminates these barriers. Virtual appointments can similarly reduce burdens on low-income patients, like lost wages and the cost of childcare.
Proximity to specialists and culturally-competent providers presents another barrier to quality health care. A 2015 survey of transgender people in the U.S. found that nearly 30% of respondents needed to travel over 25 miles to receive transition-related care, with 15% of respondents traveling over 50 miles. Telehealth can be used to expand access to care for people with trans experience.
However, telehealth requires that patients have access to technology and the internet, as well as technological literacy. This creates a digital divide, which disproportionately disadvantages Black and Latinx individuals, elderly people, rural populations, and people with limited English proficiency. This digital divide has the potential to increase health disparities with the increased use of telemedicine. Reducing health disparities using telehealth will require a coordinated effort to both expand coverage of telehealth services and close the digital divide.
Telehealth reimbursement policies
Before the COVID-19 pandemic, regulatory hurdles were a key factor limiting the expansion of telehealth services. In March, the Centers for Medicare and Medicaid Services (CMS) announced significantly expanded telemedicine coverage for Medicare beneficiaries. All states have expanded telehealth access for Medicaid beneficiaries. Private insurers have followed suit.
Unfortunately, the Medicare telehealth expansion is likely temporary, reverting at the end of this public health emergency. With the declining use of televisits over the summer, some private insurers already have begun rolling back their coverage of telemedicine.
A number of bills have been introduced by both Democrats and Republicans in Congress to permanently expand CMS telemedicine coverage. Some states, like New Hampshire, are moving to permanently expand coverage for telemedicine. Such changes would increase the availability of virtual appointments, which in turn would help reduce barriers to care for at-risk individuals.
Expanding access to telehealth
In addition to solidifying telehealth reimbursement, lawmakers and health care providers will need to work together to make televisits accessible and reduce the digital divide.
State and federal lawmakers and agencies have increasingly prioritized making affordable broadband access widely available. However, with at least 19 million Americans lacking access to broadband, there is still a way to go.
State and federal governments have a number of tools at their disposal to close this gap. States can allocate funding towards developing broadband infrastructure and providing digital technology to households in need. As suggested in a recent Health Affairs article, the federal government may be able to require all internet providers to provide low-cost internet plans using the Defense Production Act.
Although health systems may not be equipped to provide internet access to their patients, they still can facilitate access in important ways. Health care providers can identify patients who face increased barriers to in-person visits, and prioritize setting them up for tele-visits. They can also institute programs to improve technological literacy among their patients.
A number of health care systems and local health departments have announced a commitment to reducing health disparities within their own patient populations. Providence, a large, multi-state health system, recently committed $50 million to address racial disparities in health care. Such health care organizations could additionally assist in procuring devices for their patients who need them.
Telehealth on its own will not lead to health equity. Access to in-person visits is only one factor that contributes to health disparities. However, expanded carefully, telehealth could provide a method to reduce disparities in health care access and outcomes.