After "COVID-19," one of the terms most people will remember best from 2020 is likely to be "social distancing." While it most commonly applies to social gatherings with family and friends, it has impacted the way many receive medical care. Historically, the U.S. has been relatively slow to broadly adopt telehealth, largely emphasizing in-person visits.
But the coronavirus pandemic, especially in the spring of 2020, necessitated increased use of virtual or phone call visits, even prompting the Center for Medicare and Medicaid Services to relax some of its regulations, primarily for video-based telehealth. These large-scale changes made virtual care exponentially more popular than it had been even at the start of the calendar year.
While this was a positive for those who otherwise would have delayed or foregone care due to the pandemic, a new study led by researchers in the Perelman School of Medicine at the University of Pennsylvania, published in JAMA Network Open, uncovered significant inequities, particularly by race/ethnicity, socioeconomic status, age, and when someone needed to use a language other than English.
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WHAT'S THE IMPACT
The researchers, including lead author Lauren Eberly, MD, a clinical fellow in cardiovascular medicine, examined data for nearly 150,000 patients of a large, academic medical system. All of these patients had been previously scheduled to have a primary care or ambulatory specialty visit between March 16 and May 11, 2020. This time period coincided with the first surge of coronavirus in the health system's region, and was also amid stay-at-home orders in the area.
Of the patients who had visits previously scheduled, a little more than half, roughly 81,000 (54%), conducted their visits via telehealth, the data showed. And within that segment, less than half, nearly 36,000, (46 percent) had visits conducted via video.
When these visits were broken down by the patients' characteristics, some clear inequities were found. Overall, patients who were older than 55 were 25% less likely than the average patient to successfully participate in a telehealth visit, with people older than 75 being 33% less likely. People who identified as Asian were 31% less likely to conduct a telehealth visit, and those who did not speak English were 16% less likely. Using Medicaid for insurance also made patients less likely to successfully conduct a virtual visit by 7%.
Because of the relaxation of CMS rules surrounding video-based telehealth early in the pandemic, it's important to consider that mode of telemedicine in a class by itself -- so when those numbers were examined, some of the same groups showed even less favorable numbers than they had for overall telehealth use. For instance, people over 55 were at least 32% less likely to conduct a video visit, with those over 75 being 51% less likely.
Meanwhile, some groups of people were shown to have significant disparities in video-based telehealth even if they hadn't displayed them for overall telehealth use. This likely means they didn't have problems accessing virtual care if it was phone or audio-based, but video was not as accessible to them. Moreover, women were 8% less likely to participate in a video visit than men, Latinx patients were 10% less likely than white patients, and Black patients 35% less likely than white people. Patients with lower household incomes were also less likely to conduct a video visit, with those making less than $50,000 being 43% less likely.
While CMS has recently attempted to make phone call-based telehealth easier to access from a reimbursement perspective, the researchers believe their findings show that there needs to be equal consideration for all forms of telehealth moving forward.
THE LARGER TREND
In 2020, virtual care is estimated to account for more than 20% of all medical visits in the U.S., which in turn is projected to drive $29 billion in total healthcare services.
Those numbers were revealed this month in Doximity's 2020 State of Telemedicine Report, which also found that up to $106 billion of current U.S. healthcare spend could be virtualized by 2023. This highlights the high rates of adoption among both patients and physicians, and the impetus felt among providers to offer safe, secure and easy-to-use virtual services as demand for telehealth continues to grow.
In August, the National Poll on Healthy Aging found that patient comfort levels with telehealth have increased. Back in 2019, most older adults expressed at least one serious concern about trying a telehealth visit. But by mid-2020, the percentage with such concerns had eased, especially among those who had experienced a virtual visit between March and June of this year.
Yet hurdles remain. A recent report from research firm KLAS found that nearly half of the 19 healthcare executives surveyed say that either telehealth functionality or capacity has been their primary problem to solve during the early stages of the COVID-19 crisis. Other major challenges include remote patient monitoring, interoperability, real-time data analytics, work-from-home resources and patient surveillance.
The Centers for Medicare and Medicaid Services is proposing to make some temporary telehealth flexibilities under the public health emergency permanent, based on an executive order from President Trump.
However, one big hurdle not yet addressed is whether the parity in payment between an in-person and a virtual visit will remain.
On Tuesday, the Taskforce for Telehealth Policy released its final report and recommendations to safeguard the future of telehealth following the end of the COVID-19 pandemic.