Why achieving health equity is so hard in the telehealth age

Timothy M. Smith , Contributing News Writer

Telehealth has become almost synonymous with video visits during the COVID-19 pandemic. But in leapfrogging phone visits, many health care organizations have done the opposite of what they set out to do: They’ve made it harder for the most at-risk patients to get in front of a physician.

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A webinar hosted by Massachusetts General Hospital (MGH), “Crossing the Virtual Chasm: Rethinking Curriculum, Competency and Culture in the Virtual Care Era,” featured a presentation on who is being left behind in the sudden shift to telehealth and what needs to be done to bridge this new iteration of the digital divide.

The daylong virtual conference included five panel discussions with experts from around the country and focused on defining a framework for assessing competency for training in virtual care, as well as addressed challenges, workflows, strategies and best practices in virtual care enabled education. 

“Among Americans over 65—who are 18% of the population and hence most likely to need chronic disease management—only about 55–60% of these patients own a smartphone or have home broadband access,” said Christian Dankers, MD, associate chief quality officer at MGH, citing figures from the Pew Research Center.

“And of the 73% of this population that uses the internet, only around 60% were able to send an email, fill out a form, find a website,” he added. “That presents some pretty significant barriers to setting up a virtual visit.”

But older Americans are far from the only at-risk group struggling to get online, he noted. Among low-income Americans, who make up roughly one-eighth of the population, just 53% have basic digital literacy. They also have low rates of smartphone ownership, broadband access and internet use.

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The upshot of it all, Dr. Dankers said, is that patients already at risk of low access to health care have, in fact, made up a smaller proportion of visits during the pandemic.

A commentary published in The New England Journal of Medicine, “Addressing Equity in Telemedicine for Chronic Disease Management During the Covid-19 Pandemic,” notes that while video visits skyrocketed from 3% to 80% in the early days of COVID-19, the proportion of visits by patients 65 or older fell from 41% to 35%. Among patients with non-English preference, such visits dropped from 14% to 7%, and the proportion of visits by patients insured by Medicare and Medicaid also dipped.

Read more about why so many patients still can’t connect to doctors via telehealth. Also find out why understanding your “webside manner” is essential to succeeding with telehealth as a physician.

The health system has been built for a narrow socioeconomic profile, said Aswita Tan-McGrory, director of the Disparities Solutions Center at MGH and administrative director at the Mongan Institute. That’s someone who speaks English first, can make sense of patient portals, has internet access and isn’t concerned with immigration coming after them, she said, noting that efforts such as distributing tablets free of charge to at-risk patients tend to fall short.

Can the physician practice or health system “work remotely with a patient to help them download Zoom, download the patient gateway, download email?” she asked, noting that’s not the end, because patients often need help learning how to use these new tools.

Recognizing that virtual care was creating new barriers to equitable access to care, Mass General Brigham is launching this fall an alternative video platform to facilitate easy access to the care team with a one-click, browser-based solution with integrated medical interpretation on demand.

Providing assistance to patients trying to navigate telemedicine visits is one of many value-added roles that medical students have assumed during the COVID-19 pandemic. Further engaging learners in these visits is a goal of the AMA Accelerating Change in Medical Education Consortium.

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This presentation was part of a panel, “Keeping the Patient in the Center: The Impact of Virtual Care on Patient Experience,” which included an in-depth look at surveys of patient experience during the explosion of telehealth.

Acknowledging that many patients are unable or unwilling to access telemedicine that contains a video component, the Centers for Medicare & Medicaid Services responded to physicians’ concerns and raised payments for audio-only telephone visits to match rates for office and outpatient visits.

The AMA quick guide to telemedicine in practice and the AMA Telehealth Implementation Playbook been developed to help physicians swiftly ramp up their telemedicine capabilities.