The COVID-19 public health emergency (PHE) has been an amplifier and catalyst for numerous issues. The pandemic has impacted health care delivery significantly, and inequities for the Black community are more apparent. Federal and state rules for telehealth compliance/reimbursement were relaxed to preserve health care access during the PHE. While we are still in the data collection and observation phase, some concepts are clear: Telehealth positively impacts health care access, quality, and equity.
A common barrier to telehealth access is internet or mobile data access. Black Americans are the largest minority group barricaded by the digital divide. Telehealth is the future of health care delivery. If we do not take steps now to ensure equitable telehealth access, we risk creating a two-tier health care system in which vulnerable populations continue to face disproportionately negative health outcomes.
Pre-COVID health care disparities for Black patients
The Black community has significantly higher rates of diabetes and cardiovascular disease than white Americans; and a disproportionate share of disease morbidity, mortality, disability, and injury. Social determinants such as income, employment status, and residential segregation—products of structural racism in the United States — contribute significantly to these health disparities. A critical social determinant is access to medical providers. Although primary care access reduces deaths for African Americans, majority African American zip codes face a primary care physician shortage.
Patients of color may be more likely to feel comfortable with and take health recommendations from doctors who look like them, but only about 6 percent of U.S. physicians are Black. Black Americans are disproportionately impacted by structural factors such as racism, poverty, and culture that affect mental health, but are less likely to receive mental health treatment. Despite significant disparities having long been identified, health disparities for the Black community persist.
Pre-COVID barriers to telehealth access
Telehealth is an innovative solution to connect patients to quality care. Expansion of telehealth access must address the challenges that have historically hindered utilization.
For providers, financial deterrents have included geographic and originating site restrictions prohibiting reimbursement for telehealth services outside rural areas or in patient’s homes, and states declining to require that insurers reimburse telehealth services on par with in-person services. Other barriers include rules requiring licensure in the state where a patient is located and burdensome telehealth credentialing paperwork.
For patients, the digital divide is a super social determinant of health. Even today, people who are members of racial or ethnic minority groups, older, or of lower socioeconomic status have lower rates of broadband access and technology adoption. A recent study showed that 37 percent of Black Medicare enrollees have no digital access at home. There is not much variation in telehealth adoption by race/ethnicity currently, likely due to short-term policies allowing audio-only telehealth reimbursement. In the long term, it is important to ensure all patients have telehealth access via their preferred technology.
Telehealth expansion and reducing disparities
The PHE rapidly changed the status quo with temporary waivers of many of the historical barriers to telehealth access. Without regulatory and legislative reform, the waivers will expire when the PHE ends. Permanent telehealth expansion promises to health care access with the goal of ultimately reducing disparities. Projections on health care worker shortages abound, we face an aging population with mounting chronic disease, and young people of color are often caregivers for aging family members. The pandemic has exacerbated these issues. Increased telehealth access can alleviate these demands, and hopefully prevent disparities from widening. Telehealth holds promise for health care access, outcomes and cost-effectiveness.
Access and continuity of care. Pre-PHE, telehealth improved acute stroke care access for racial and ethnic minorities in Texas and enabled better health care access to a rural underserved population via virtual urgent care. In a more recent study, behavioral health visits remained stable at safety net organizations during the pandemic because telehealth visits, particularly by telephone, replaced in-person visits.
Outcomes. Telehealth may be more effective than standard care for slowing decline in kidney function among African Americans, and is more likely to achieve improved metabolic control and reduced cardiovascular risk in both an urban African American diabetic population and an ethnically diverse urban population.
Cost-effectiveness. Compared to standard care, diabetes case management telehealth intervention has high implementation cost, but similar expenditures. Telehealth is beneficial and cost effective for diabetic retinal screening. Pre-hospital telehealth emergency medical service is associated with cost-savings of $2,468 per emergency visit averted.
Patient sentiment
Patient sentiment towards telehealth is positive, but additional education is required. Studies show that people living with HIV
favored telehealth and would use it for HIV care if it was made available and their privacy was maintained, and HIV-positive African American youth described telehealth as less intimidating than in-person visits. Reported benefits included convenience and decreased travel time, despite concerns about data security and effective communication. In another study, patients with glaucoma also had favorable attitudes towards using telehealth for glaucoma care.
Comfort with telehealth varies with digital literacy. In a 2019 survey, individuals who were older, Black, or reported lower levels of education expressed less willingness to use videoconferencing. In a study of underserved Hispanic communities, over 90 percent had never heard of telehealth. Once the term was defined, the majority reported being more likely to use telehealth services.
Lingering barriers
Although there was a substantial increase in telehealth use in 2020, significant disparities remain. A study evaluating telehealth utilization for COVID-19 in New York indicates that many of the disparities seen in traditional medicine exist in telehealth. Black patients and those with lower mean income and higher average household size were less likely to use telehealth, and Black patients had higher odds of testing positive for COVID-19. Disparities in telehealth remained, even early in the pandemic, when the motivation to use telehealth was high.
Conclusion
The COVID-19 pandemic has forced us to reimagine health care delivery. While long-standing health inequities are more apparent, we must seize the opportunity to reinvent American health care as equitable health care by capitalizing on the momentum behind telehealth to improve health care access for vulnerable populations. An equity-focused approach to telehealth expansion is crucial to avoid worsening disparities.
Gjanje L. Smith is a urologist. Wanneh A. Dixon is a health equity advocate. Maria Phillips is an attorney.
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