For years, the story of telehealth in the United States had been one of unfulfilled promise and limited niche market use. The extraordinary circumstances surrounding the COVID-19 pandemic, and the urgent need to provide safe access to medical care for millions of Americans during the public health emergency, led to the rapid decision by the Centers for Medicare and Medicaid Services (CMS) and private insurers to begin reimbursing virtual telephone (audio only) and video visits in March 2020. Since that moment, telehealth has been suddenly and irrevocably transformed into a ubiquitous and indispensable part of our health care system.
According to multiple surveys, patients report high levels of satisfaction with telehealth visits, which can help reduce barriers associated with in-person care. And although the majority of health care visits in the US have transitioned back to in-person, telehealth is expected to continue to play an important role moving forward. Virtual visits can offer convenience and improved access for patients by reducing the need to take time off work, secure child and elder care, and find transportation. Higher uptake of patient portal use can improve patient engagement and activation and reduce burdens on practices by giving patients the agency to self-schedule appointments, request refills, review test results, and communicate asynchronously with care teams using secure messaging and eVisits. Telehealth also offers wide-ranging opportunities for flexibility and innovative improvements in health care delivery by enabling new models for low-acuity care and chronic disease management.
However, virtual care can also exacerbate existing health disparities, as access to the requisite technology, broadband, and digital literacy vary widely among patient populations. Without intentional action to help mitigate digital barriers associated with age, race, location, preferred language, and socioeconomic status, permanent expansion of telehealth could have the unintended consequence of reinforcing existing inequities in health access in our highest risk and most underserved communities.
Telehealth is here to stay, but what it will look like, who it will benefit, and who it will leave behind in the months and years ahead remains unsettled. It will largely depend on congressional action and policy decisions around which virtual services CMS and commercial payers will continue to cover, and at what rates. Here, we offer some perspective as clinicians and researchers, along with policy recommendations and advocacy goals for the coming months.
What We Learned: The Digital Divide
Every clinician and health system using telehealth services over the past 17 months likely cares for patients with limited access to technology, low levels of digital literacy, or inadequate or non-existent broadband. These barriers are found most frequently in rural populations, the elderly, racial and ethnic minorities, those with lower socioeconomic status and limited health literacy, and non-native English speakers. Without significant policy changes, our most vulnerable patients will be the ones least likely to benefit from telemedicine implementation.
As primary care physicians on the South Side of Chicago, we see firsthand the longstanding inequities many of our patients face, including low income, limited education, unemployment, and violent crime. Add to that inadequate health care infrastructure, pharmacy deserts, and countless forms of entrenched structural racism, and it becomes clear how vulnerable this community is and why our patients were already disproportionately burdened with chronic disease and lower life expectancy compared to their peers in other parts of Chicago.
As the University of Chicago, like health systems across the country, rapidly pivoted to virtual visits in March 2020, we were acutely aware of the digital redlining already present in many of our highest-risk neighborhoods, and the risk of further exacerbating the inequities that were already present. From late March through the end of May 2020, while Chicago’s stay-at-home order was in effect, 60 percent of all ambulatory visits were completed virtually. We studied all 50,000 of these virtual visits and found that 60 percent were done using video conferencing and 40 percent by telephone only.
Our analysis found that older adults, Black patients, and Medicare and Medicaid beneficiaries—the patient populations with lower levels of internet access and less comfort with technology—were least likely to complete video visits. Other studies on virtual visit use during the pandemic showed similar results and also found that patients who were unhoused had lower socioeconomic status, lived in rural areas, or were non-native English speakers were among those at highest risk of being unable to complete video visits.
Over the first full year of the pandemic, between March 2020 and March 2021, there were more than 210,000 virtual visits completed at the University of Chicago. A full 20 percent continued to be telephone-only encounters for chronic disease management, behavioral health, primary care, and other essential health care—especially for patients who are Medicare beneficiaries, Black, and living in some of the most economically disadvantaged neighborhoods on the South Side of Chicago.
Our colleagues share our concerns about the digital divide. In a survey of nearly 350 University of Chicago clinicians, we consistently heard that the difficulties patients faced with access to technology, digital literacy, and an overall reluctance to even attempt video visits were the greatest barriers to successful telehealth visits. When we asked our patients about their experiences with virtual visits, as part of a qualitative assessment, we heard remarkably similar themes.
Steps To Promote More Equitable Digital Health Access
The pandemic has reinforced how low digital health literacy perpetuates digital health inequity, and limited access to virtual health information worsens the digital divide. Older, non-White people are the groups most vulnerable to low digital literacy and face more barriers in accessing digital health information than younger, White people. Digital health developments are far outpacing efforts to bridge the digital divide, widening that divide and exacerbating existing health inequities. Tools such as patient portals that promote access to health information and patient engagement; shared decision-making aids that help inform conversations with clinicians; and self-scheduling and virtual visit options that provide convenience, access, and agency for patients while reducing barriers are not widely accessible to older, lower-income, minority, and non-English speaking patients and those with low health literacy. Without a clear focus on supporting these individuals in learning how to access digital health and telemedicine tools, we will only further marginalize and disenfranchise them.
Fortunately, awareness around the digital divide and its impact has grown considerably since the start of the pandemic. We have now begun to hear the term “digital poverty” more widely in policy discussions, which helps more aptly acknowledge the complexity and scope of the issue by recognizing how essential digital resources have become for individual and collective well-being and how serious the consequences of digital exclusion can be.
Digital capabilities are now a crucial part of not only access to health care but also education, housing, livelihood, economic growth, social services, and food. Whereas even two decades ago, low digital literacy may not have been a major disadvantage, today the consequences of digital poverty and digital exclusion are profound.
Engagement And Education, With An Equity Lens
To more precisely understand the scope of digital poverty and exclusion in health care, we must start by closely monitoring access to telehealth through an equity lens, focusing intentionally on our most vulnerable patients. As we observe the disparities in access to digital resources, we must work to understand the root causes first and foremost by asking our patients. Community surveys and qualitative needs assessments with a patient-centered focus are essential to understanding patients’ perspectives and lived experiences. Stories, testimonials, and partnership from our patients in underserved communities must guide the interventions we consider to help address digital health inequities.
While a significant portion of older and less digitally literate patients may have smartphones, tablets, and laptops, many are hampered from fully using those devices by a fear of technology. They often need additional guidance on how to use their devices and on how to interact with poorly designed user interfaces. Education and outreach by health care teams, in partnership with civic organizations and faith communities, can help reach patients who could benefit from digital support and coaching. While older and non-White patients may face more barriers to technology use, providers and care teams should not make these assumptions based on demographics alone. Instead, health care organizations should standardize processes to screen for technology barriers, encourage all patients to schedule video visits, and provide resources to support and enable them to do so successfully. To further reduce barriers, health systems should share technology resource guides with appointment confirmation and reminder messages along with multilingual community and neighborhood-based digital literacy resources, whether or not a patient has portal access.
Health care teams can further support patients by sharing step-by-step patient guides for virtual visits, making available simple videos walking patients through a video visit, sending real-time direct text messages with video visit links, and including basic digital navigation by medical assistants at the time of virtual patient triage before the video visit. Even minimal digital support and coaching for less tech-savvy users can promote engagement with digital tools, improve success rates with video visits, and build trust with clinicians and care teams.
Another important strategy employs predictive analytics to help identify patients at highest risk of being unable to complete a video visit. By implementing such a model to help stratify patients by risk, limited resources can be targeted to those patients most likely to benefit from digital navigation.
There are many critical telehealth legislative and policy decisions that will be made in the coming months. While CMS and commercial payers have shown support for continued widespread telehealth use, their enthusiasm for ongoing telehealth reimbursement parity will not last if it results in overuse, fraud, or higher costs without added value, as we’ll discuss next.
It’s essential that we make forward-thinking investments and take concrete steps to help technology recapture some of its promise as a potential social and economic equalizer instead of serving as another structural barrier to opportunity, exacerbating inequity and pushing the most vulnerable further behind.
Value-Based Care And Reimbursement
Although its remarkable uptake and popularity among patients and even health care professionals is encouraging, understanding telehealth’s value is imperative to inform long-term policy decisions and will ultimately determine how significant a role it plays in health care delivery models moving forward. Although research in this area is ongoing, as long as there remains uncertainty about the quality of telehealth, the associated outcomes of virtual care, and the degree of cost and utilization impacts, continued reimbursement at the state and federal level for telehealth services will consist of temporary extensions rather than permanent expansions.
While more a consequence of extraordinary events than clear strategy, telemedicine has begun to play an important role in digital care delivery transformation and has the potential to improve value, especially for primary care and behavioral health. Telemedicine can help us forge a more continuous relationship with our patients by offering more consistent access and lowering the cost of preventive health and lower-acuity chronic disease management. It can also enable the sharing of expertise irrespective of geographic constraints and support to underresourced health care settings to build capabilities and capacity.
Synchronous telehealth visits, asynchronous eVisits, and remote patient monitoring—coupled with team-based care, population-level analytics, and risk stratification—can reduce barriers to care by providing complementary or alternative options to in-person visits. Conventional in-person office visits could in turn become more focused on higher-acuity patients with more complex care needs. Telehealth use since the pandemic began has primarily been substitutive rather than additive and should help reassure policy makers who fear continued reimbursement and parity would lead to significant overuse and cost increases. A temporary extension of the current state fee for service telehealth reimbursement is sensible as we continue to collect data on cost, use, and quality to help inform a more transformative shift to alternative and permanent payment models.
Value-based payment for telemedicine services could also help incentivize more flexible and innovative models of care while reducing the limitations, administrative burdens, and focus on volume-based services inherent to fee-for-service reimbursement. Value-based telehealth payments can help accelerate integration of a broad range of digital health and telemedicine tools to provide high-value care, thereby increasing the impact of virtual care on our health care system.
Developing a digital community vulnerability index—similar to the COVID-19 community vulnerability index used to target high-risk neighborhoods for additional testing and vaccine resources during the height of the pandemic—could be useful as we look to identify and reduce telehealth inequities. Capitated payments for telehealth and virtual models of care delivery that are risk adjusted on such an index could incentivize programs to focus on the most vulnerable patients at highest risk of suffering the consequences of digital exclusion.
We must also ensure Medicare, Medicaid, and commercial payer alignment to secure telehealth accessibility for all, without geographic restrictions or originating site requirements. Medicaid coverage for telehealth cannot lag behind Medicare and commercial payers.
Protecting Telephone-Only Visits
Since early in the pandemic, virtual visits done by either video or telephone (audio only) have been covered at the same rates as conventional, in-person office visits, ensuring telehealth access for many elderly and underserved patients who do not have the means to use video visits.
While ongoing coverage for video visits seems secure, the future of reimbursement for telephone visits is in danger, as CMS has proposed ending reimbursement for telephone-only visits when the public health emergency ends.
While video visits have some advantages over telephone visits, only those with sufficient technology access, connectivity, and literacy will be able to reap those rewards. Supporting telephone-only visits can help reduce certain health care disparities, as these low-tech visits provide crucial health care access for many whose alternative is no care at all. Telehealth access that excludes telephone-only visits, however, will further exacerbate existing health inequities.
As we wrote in a recent op-ed, Congress must act to continue reimbursement for telephone-only visits even after the public health emergency ends. Eliminating coverage for voice-only telephone calls would disproportionately impact underserved communities that face barriers to accessing video technology. Likewise, payment parity must continue between in-person, video, and telephone visits to avoid introducing a structural disincentive to virtual telephone visits with those who may not be able to participate in video visits.
Given the disproportionate burden of chronic disease and illness shouldered by Medicare and Medicaid beneficiaries, digital health innovation and advocacy that focuses on these patients will lead to progress on health equity. This means health systems, innovators, funding sources, and policy makers must resolve to focus on those who have been left behind and take intentional steps to develop connections with underserved communities to help address digital poverty. If the trend of innovating exclusively for the most connected, digitally literate, and well-off patients continues, the digital divide will inevitably grow wider.
Technology Access Initiatives
Programs to provide low-cost technology to patients lacking access will be essential to promoting equitable access to telehealth. Devices such as computers, tablets, or smartphones are critical for patient engagement in a rapidly emerging digital health care system that relies on mobile apps. And while 81 percent of Americans own a smartphone, the wide spectrum of digital health literacy and comfort level using these devices across age, race, ethnicity, and socioeconomic status presents a challenge. Telecommunication devices required for participation in digital health and telemedicine should be covered as a medical necessity, especially given the correlation between poverty and telemedicine unreadiness.
Addressing Digital Health Literacy
Low digital health (or eHealth) literacy further disenfranchises many of our most vulnerable patients, but many are willing to learn how to use telemedicine tools with some additional support. Digital health interventions must be designed and implemented in a way that makes them accessible to patients with low digital health literacy, and commercial vendors must tailor digital health tools to linguistically and culturally diverse populations.
Strategies may include academic-industry partnerships, bringing together the expertise of clinician researchers with a wealth of knowledge and experience caring for patients in underresourced settings and a tech industry with expertise in designing, building, and implementing patient-centered solutions at scale.
Reinstating programs such as the Community Technology Centers program, run by the Department of Education, to develop and expand spaces for underserved residents from economically distressed rural communities to access technology and training, would be another important step forward.
Digital Patient Navigation
Digital patient navigation programs are essential to helping prevent further marginalization. Many patients need help downloading and logging in to mobile apps, connecting to the internet, and walking through the steps on their devices to successfully complete a virtual visit with their clinician. Having dedicated care team members supporting patients with basic digital navigation and troubleshooting can have a major impact on telehealth success rates. Virtual visits require just as much support, if not more, than in-person visits.
Digital Health Tools Design And Usability
At the start of the pandemic, commercial vendors took existing video-conferencing technology and rapidly pivoted to video visit use cases in telehealth. Additional telemedicine tools, such as patient portals and remote patient monitoring apps, have also seen expanded use. However, design barriers, such as complex user interfaces and a high burden of data entry that fail to account for different levels of literacy, numeracy, and education persist, and remain a common obstacle for patients seeking to benefit from digital health access. An inclusive, patient-centered design requires evaluation and understanding of users, tasks, context, and environment. There must be a renewed focus on usability testing with clinicians, patient groups, and patient advocates from the design phase all the way through implementation of digital health tools. Accessibility accommodations, such as embedded translation and closed captioning for the hearing-impaired, are another obvious standard enhancement and easily integrated into virtual visits with existing technology.
Access To Broadband
Access to broadband is a social determinant of health, yet an estimated 21 million Americans still lack access to broadband. While many areas are plagued by inadequate digital infrastructure, prices are also highest in the poorest communities for unreliable internet service. Rural communities and poorer urban neighborhoods with predominantly minority residents are less likely to have adequate broadband compared to predominantly White communities, and public library closures have made Wi-Fi access even more difficult.
We must start with connectivity data and transparency by requiring publication of updated maps showing broadband coverage. States must allocate funding toward developing broadband infrastructure and providing digital technology to households in need. At the federal level, all internet providers, including those who did not sign on to the Federal Communications Commission’s (FCC’s) Keep Americans Connected initiative, should be required to provide low-cost internet plans. Programs such as the FCC’s Connected Care Pilot Program, which covers up to 85 percent of the cost of broadband connectivity and equipment for underserved and digitally excluded patients, should be expanded.
Unprecedented circumstances have aligned to bring telehealth forward as a crucial opportunity to help modernize our health care system while improving the value of care we provide. However, thoughtful next steps in policy and advocacy are essential to seize this moment and realize its promise. Community and health care leaders, in partnership with state and federal policy makers, must work together to enact forward-thinking policy to support high-value growth of telehealth alongside multimodal strategies to narrow the digital divide. Unless this approach also includes investment in universal broadband, telemedicine infrastructure, and digital support for patients to address existing inequities, digital health and telemedicine will continue to fall short of their vast potential to transform health care delivery in a meaningful and lasting way.