Access and Equity in Telehealth

Introduction

Access and Health Equity are long standing issues in medicine throughout the United States and the world. With the rise of telehealth and telemedicine during the ongoing global Covid-19 Pandemic, health equity and access remain concerns. With the digital divide already impacted by generational issues where some people accessing healthcare are digital natives, able to use the internet and technology to their benefit, others, digital immigrants, are in greater danger of being left behind. Ensuring access and health equity should be a goal of health organizations at multiple levels and the facilitators and barriers to each should be examined more fully.

Search Methods

In conducting this literature review the primary purpose was to determine the facilitators and barriers to access and equity in telehealth/telemedicine. Search methods began by accessing Google Scholar, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Cochrane Library. The keywords that were searched were: telemedicine, telehealth, access, equity, health-equity, health equality, facilitator, and barrier. Queries in these databases produced significant results, many of which were duplicates. Articles were reviewed based on the following limits: English language, concerned access or equity in relation to telehealth/telemedicine, and were published within the last five years. Hundreds of articles were screened for inclusion criteria by title, keywords and abstract. Exclusion criteria included studies done outside the United States, articles that focused on health equity and access but only provided a fleeting mention of telehealth/telemedicine, editorials, letters to the editor and articles which lacked adequate peer review. Given the smaller scope of this literature review, five articles, each article will be reviewed, followed by a summation and synthesis of the information learned, with a discussion of the implications and future needs to ensure access and equity in telehealth.

Literature Review

Rural Health Equity

Rural Americans have long faced inequities in education, poverty, joblessness, and other areas of involving the social determinants of health. Rural American’s health disparities are so profound that simply living in a rural area puts them at higher risk for early death compared to their urban peers (Hirko et al., 2020). Rural hospitals and health clinics also face challenges with patient capacity, leading to a closing of many critical access medical centers over the last five years (Hirko et al., 2020). With all these considerations, rural areas are primed to take advantage of changes in legislation related to telehealth, according to research by Hirko et al. (2020).

Telehealth has numerous far-reaching benefits for rural communities. In looking at a rural health system in Michigan, Munson Health Care (MHC), Hirko et al. (2020) find a model for telehealth change. With the removal of barriers to reimbursement and forms of reimbursable telehealth visits, MHC expanded telehealth services with 530 providers across 75 ambulatory practices. MHC has increased telehealth appointments from 150 in the year prior to the Covid-19 Pandemic to 14,000 telehealth appointments in 2020 (Hirko et al., 2020). This has shown that telehealth is a feasible route to expand access of care in rural populations.

In a theme that will recur throughout this literature review Hirko et al. (2020) identified that a significant barrier to access is the availability of broadband internet in rural areas. Broadband internet of at least 25 megabits per second is recommended by the Federal Communication Commission to support video-based telehealth visits. This poses a significant challenge to rural communities where 40% of residents lack access to broadband internet. Given the prevalence of health conditions in rural areas like obesity, diabetes, Heart Failure, Chronic Obstructive Pulmonary syndromes, and other chronic diseases, increased access to broadband internet can save patients time and can provide much needed care. Hirko et al., (2020) as an aside note that lack of internet in rural areas also keeps patients from video conferencing with family and friends which can provide a much-needed social outlet in areas that are impacted by stay-at-home orders.

Hirko et al., (2020) conclude that hospital systems and the healthcare industry must work together to mitigate access issues. Evaluations should be performed by rural health systems to identify local barriers to telehealth implementation. Rural health systems should also advocate at state and federal levels to ensure that payment parity continues, and that funding is obtained for infrastructure improvements to rural broadband systems.

Cost-Effective Care

In a systematic review of literature, Mahtta et al. (2021) discuss the advantages of telehealth and the areas that require improvement, largely focusing on increased need for equity and access in telehealth services. Starting with the Covid-19 Pandemic Mahtta et al. (2021) note that the rapid expansion of telehealth has reinvigorated the argument that telehealth is an excellent way at increasing access for patients in an efficient and cost-effective manner. With newer legislation because of the Corona Virus Aid, Relief and Economic Security (CARES) Act, there has been an increased reliance on telehealth to provide high-quality care that keeps patients and providers safe from possible transmission of the Covid-19 virus.

In discussing the benefits of telehealth Mahtta et al. (2021) note its cost-effectiveness in delivering care. This improves access to care for patients because it reduces travel time, missed time off from work, and reduces strain placed on emergency departments and walk-in clinics. Travel is a major difficulty for patients when it comes to accessing care, another area that telehealth helps to bridge gaps in care for patients. Mahtta et al. (2021) found that 25% of adults, in the last year, reported difficulty accessing care due to costs and distance. Telehealth largely erases both of these concerns, because care can take place in the patient’s home and can be billed to a patient’s insurance like an in-office visit. Crucially, telehealth can help bridge the provider-patient supply-demand mismatch. Telehealth provides clinicians flexibility to deliver care on their schedules, which has led some retired clinicians to reenter the workforce to deliver telehealth to patients. This can help underserved communities access specialty care that they may have previously lacked access to.

Telehealth is of course not without its challenges. The disparities in technology use and internet access could see digital natives accessing telehealth services at rates significantly more than their digital immigrant peers. Rural and underserved populations who lack equitable access to internet and technological literacy are at risk of being left behind in the ever-widening digital divide. In what is a recurring theme, internet access is crucial for adequate telehealth services, and Mahtta et al. (2021) note that 33% of rural populations lack internet access. In areas that there is adequate penetration of broadband services, underserved Black and Hispanic communities are often greater impacted by lack of digital literacy and less likely to report use of the internet. Mahtta et al. (2021) found that patients who require larger usage of healthcare resources due to comorbidities were 26% less likely to have internet access and performed worse on digital literacy evaluations. Greater still is the lack of access shown in one review, noting that patients with Medicaid and patients in the third and lowest quartile of median household incomes were significantly less likely to utilize telehealth services.

Mahtta et al. (2021) conclude that telehealth certainly expands access to care for patients across the healthcare spectrum. However, patients in rural and traditionally underserved communities, are at a desperate need for health equity. Here it is suggested that policy implications will play the greatest role in narrowing inequalities in healthcare delivery. Policy should be drafted in a conscientious manner while considering the profound health needs of the stakeholders who will benefit the greatest.

Policy and Telehealth

In a review of policy changes because of the Covid-19 Pandemic, Ortega et al. (2020) examined key areas they believe act as the main barriers towards equity and access to telemedicine. They identified three main policy points: (1) disparities in access to high-speed internet and technology, (2) barriers to reimbursement of telehealth services, (3) lack of commitment to telehealth at institutional levels.

Ortega et al. (2020) estimate that as few as 21 million people in the United States lack fixed access to high-speed internet services, while acknowledging that the number is likely higher. While some funding has been allocated as part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, there have been difficulties at local levels to identify regions in need of service coverage, potentially worsening aspects of the digital divide. Ortega et al. (2020) recommend that stakeholders be identified at the federal and local levels to ensure accountability of internet service providers. Internet access and technology access is largely divided along racial lines in America, with 79% of white Americans enjoying access to highspeed internet compared to 66% of Black and Hispanic Americans. Notably, a quarter of Black and Hispanic Americans rely on mobile phones as their primary means of internet access. Ortega et al. (2020) advocate for greater support from the Federal Communications Commission (FCC) as a means of ensuring increased access to high-speed internet, particularly given its bipartisan support at the federal level.

During the early months of the Covid-19 Pandemic the Centers for Medicare and Medicaid Services (CMS) expanded reimbursement for telehealth services that occurred over audio, video and web portal communications (Ortega et al., 2020). Importantly the inclusion of audio only reimbursement helped increase access to care for patients with literacy barriers. These changes also allowed for rapid and broad expansion of services, helping limit potential exposures to Coronavirus and crucially expanding access and health equity to patients in rural areas who face greater barriers to care due to decreased access of high-speed internet and technology. Ortega et al. (2020) recommend that the federal changes become permanent, because they lessen disparities in care, are cost effective and because much of the initial legislation is already in place.

Ortega et al. (2020) lastly identify hospitals and healthcare institutions as important advocates for change within the medical establishment. Given the success of telehealth during the Covid-19 Pandemic and as hospitals work to expand access to telehealth, they have a responsibility to patients to develop and maintain equitable access. To this end, it is suggested that hospitals develop a task force specifically focused on digital health equity. This way disparities in digital care can be adequately addressed, and targeted efforts can be developed, particularly in areas like education, technology training, and subsidized access to high-speed internet.

Racial Differences in Telehealth Use

Rivera et al. (2020) conducted a cross-sectional analysis of electronic medical records of geriatric patients in New York City during the surge of Covid-19 cases to analyze if there are any racial or socioeconomic disparities to receiving telehealth care. They reviewed 4571 patient records, finding that 2438 patients were eligible for the analysis as they had accessed and set up their online patient portal. Among the early key findings, patients that had activated their online portal were more “likely to be younger, White, male, English speaking, married or partnered and did not have dementia” (Rivera et al., 2020). 

Substantial differences emerged as the analysis continued. Patients that relied on Medicaid for health care coverage were less likely to have set up their online portal and were less likely to use it. Patients of African American descent were less likely than their White peers to have set up an online portal and were more likely to decline activation outright. Critically, Rivera et al. (2020) note that once the online portal was activated, patients across the socioeconomic spectrum were equally likely to access telehealth services by video or telephonic means. This suggests that patients had access to some form of technology to access their portal, either a phone or computer, and were interested in the services that were provided electronically. Further this suggests that a patient’s ability to access telehealth services should be assessed as part of an intake appointment.

Social Determinants of Health and Telehealth

Smith and Raskin (2021) examine health equity and access to telehealth from the prospective of providers as advocates for patients and as shapers of public health policy. While the other articles reviewed here briefly discuss the social determinants of health, Smith and Raskin (2021) directly address it as the foundation of their arguments, specifically as it addresses health care access and quality. Foundational to their argument for policy change is the rapid expansion of telehealth during the Covid-19 Pandemic and the limitations it highlighted in our neighborhood and built environment domains, showing that policy needs to address equitable access to telehealth services. 

Increasing access to broadband internet was identified as a part of Healthy People 2030¸ noting that only 55.9% of US adults had broadband access. Further compounding access is one-quarter of the rural population that reports significant access difficulties to the internet and the reports of low-income people having limited access to the internet via mobile devices. Smith and Raskin (2021) note that in these two areas we are at significant risk of expanding the digital divide. 

Telehealth services are widely accepted by patients, the American Hospital Association found that 75% of patients would use telehealth services prior to the Covid-19 Pandemic. Their chief reason for wanting access was to ensure timely access to care. The same survey found that a barrier to access was low buy-in from providers that telehealth was a viable means of providing care, although providers in rural areas were more interested in using it as a means of seeing patients. Further barriers found by Smith and Raskin (2021) include prior issues with payment parity, privacy concerns, and questions surrounding interstate licensing. Largely due to loosening of policies due to the Covid-19 Pandemic, Smith and Raskin (2021) found that many of these concerns have been solved. 

The authors advise that to achieve equitable healthcare via telehealth, that we must work to address the social determinants of health. They argue that telehealth allows patients to access providers that they are used to seeing, as opposed to accessing emergency or urgent care. Here they argue that we must carefully examine the built neighborhoods of patients advocating for strengthening broadband access and technological access in communities that need it. Interestingly, Smith and Raskin (2021) are the only article that addresses the housing crisis that occurred during the pandemic. Noting that changes to Medicare rules allowed patients to access telehealth from their home for the first time. They note that this was a good change to policy, but conversely question what should happen if a patient is unhoused or lacks consistent stable housing. Suggesting that nurse advocates should support changes for compassionate, equitable housing policies that will provide stability for patients that are at highest risk. The authors also mention another area that has not been touched upon in other literature, that telehealth expands access, but only if providers are adequately trained on how to use telehealth systems. Here they recommend enhanced training opportunities for providers and allied health personnel to ensure that they know how to use telehealth systems to best benefit their patients. 

Smith and Raskin (2021) conclude with a call to action. Providers and healthcare professionals, they argue should advocate for policy changes that will benefit underserved populations. Here they specifically list payment parity, housing reform, expanded access to broadband internet, and enhanced training as the key areas to focus on to improve access and equity for patients. 

Data Synthesis

Several themes became apparent during this literature review. Each article mentioned that telehealth was certainly a method to expand access of care to patients, with estimates of 50% to 150% increase in telehealth appointments over the last two years (Smith and Raskin, 2021). While increased access is good, all the authors noted that access does not equate to equity. Here the theme of access to broadband internet was mentioned by each author as a significant barrier for underserved communities and rural communities as a method for addressing equity. While only one article directly addressed the social determinants of health as an impediment to care, all of them indirectly touched on them and advocated for different policy changes to ensure better equity to care. Here arguments for housing policy, technology literacy training, and subsidies for internet were mentioned. Equity, they all argue, is a matter of public policy at this juncture, with need for significant investment in the public sector to address the needs of rural and underserved communities. 

Telehealth provides great promise for improving the health and the lives of many Americans. Telehealth provides greater flexibility in appointment times, allowing people to access care from their homes and workplaces, this helps reduce travel burden and need to miss work or school for patients. Telehealth has also shown improved patient satisfaction scores, with patients enjoying shared decision making with their providers.