Can Telehealth Address the Disparities in Health Equity?
A few years back I wrote about how the COVID-19 pandemic was fueling growth in telehealth as a viable and cost-effective alternative to traditional, in-person healthcare delivery channels. It is now clear that telehealth (which is broader and more encompassing than telemedicine) was well accepted by providers and patients. Some of the latter were probably even a little surprised they liked it. This would be especially true for those who would never have imagined themselves doing a doctor visit on Zoom, having their blood pressure or glucose levels monitored remotely, getting virtual psychotherapy, or accessing their medical files on their smartphones.
For their part, many providers realized cost savings, much of which dropped straight to their bottom lines. One operational area where these savings can most readily be seen is in the ED. There is evidence that having access to telehealth tends to divert patients away from this type of costly care setting.
It is also safe to assume that the pandemic’s waning will not mean a return to patients accessing healthcare as they did pre-pandemic. Telehealth is here to stay. It will only continue to grow as more patients and providers get more comfortable using it. In fact, a recent survey by the AMA shows that nearly 85 percent of physicians surveyed indicate they are using telehealth and almost 70 percent report their organization “is motivated” to continue using it.
The larger question now is how – and if – telehealth can address and remedy disparities in health equity (where everyone receives the healthcare they need) in historically underserved, marginalized, or disadvantaged communities. And, if not, will it end up exacerbating current inequities in healthcare delivery and treatment outcomes or will it even create new ones.
It is always important for providers to consider these questions now to help ensure that telehealth helps create greater health equity rather than inequity. Providers need to get telehealth “right” from the beginning by not repeating previous mistakes.
The encouraging news is that there are already some signs in the market that telehealth can help address disparities in heath equity. On example is an analysis done by Brigham and Women’s Hospital on EHRs of new patients seeking consultations within the hospital’s Division of General and Gastrointestinal Surgery. It showed increased use of telemedicine among some historically underrepresented patient groups. The study’s author explained that the study demonstrates that digital health can be effectively used to engage communities that historically did not have the best access to healthcare by taking healthcare to them.
The study, which was limited to one surgical division, showed that Black patients, for example, utilized telemedicine more than white patients even as in-person consultations increased. Older patients, those with lower education levels, and those who did not consider English as their first language were not as likely to use this platform. Study authors also found that women were more likely to use telemedicine than men.
Addressing Barriers to Health Equity
To get a better idea of how telehealth can help reduce – or even eliminate – disparities in heath equity, it is important to recognize their underlying causes and then look at how providers can use telehealth to mitigate them. The following are three key challenge areas to achieving healthcare equity that telehealth is ideally suited to address:
1. Physical Proximity Challenges
One of the greatest barriers to underserved, disadvantaged and/or marginalized communities receiving the healthcare they need is being too far away from competent healthcare practitioners. A look at a map showing the distribution of physicians and other practitioners across the United States clearly shows that they are usually concentrated in urban areas and typically near major research and teaching hospitals (which themselves tend to be in major cities). With telehealth, whether a patient and doctor are separated by one block, or one hundred miles does not matter. It also eliminates the need for a patient to drive or take public transportation.
2. Patient Diversity Challenges
Research has consistently shown that patients prefer and feel more comfortable with doctors and healthcare practitioners they can identify with, who they feel “look like me,” and that share a similar cultural heritage, experience, and worldview. This could also include language, religion, sexual and gender identity, education, and age. It could also be argued that the more similar a doctor and a patient are, the less that implicit bias may influence diagnostic and treatment decisions. By allowing direct access to a wider pool of physicians and other healthcare practitioners, telehealth makes it much easier to “match” a patient with a physician with whom they will feel more comfortable and can more effectively communicate.
3. Trust and Confidence Challenges
Many disadvantaged, marginalized, or underserved communities have a collective distrust and skepticism about the healthcare profession and its practitioners. This is rooted in well-known historical reasons, such as the infamous Tuskegee Syphilis Study, to personal experiences with doctors and hospitals where patients felt they were treated unfairly, discriminated against, or made to feel inferior to other groups. Key to overcoming this distrust and to building more solid relationships with these communities it being seen as “part of the community” and making an ongoing effort to do so. Since telehealth is not bound to any brick-and-mortar locations, providers and their teams can visit and engage with patients literally where they live via workshops, presentations, and demonstrations on telehealth and how easy it is to use. Ideally these encounters would be led by members of the community being visited.
What Providers Should Consider
While telehealth clearly has the potential to mitigate or even, in some situations, eliminate disparities in healthcare, progress will unfortunately be limited by three factors: the first is current inequities in broadband internet access with some patients and providers having ultra-high speed internet with others still living in the days of “dial up” speeds; the second is access to hardware which can limit which telehealth features a provider/patient can use (for example, a late model smartphone versus a basic cellular); and understanding how to use information and communications technologies (ICT), especially among the elderly and provider patient-facing staff.
There are a several things that providers can and should be doing to help telehealth realize its potential to address disparities in healthcare. These include, but are not limited to:
- Increase investment in the technologies that enable telehealth for providers and patients
- Work with the local community to lobby for high-speed broadband Internet if it does not already have it (by some estimates, more than 20 million people in the U.S. have no or limited broadband)
- Work with local governments to ensure there is sufficient access to free high-speed internet and appropriately enabled computers at libraries and community centers (with a certain number in a private area for patients to speak confidentially with their healthcare practitioners)
- Evaluate the possibility and cost-benefit ratio of creating a horizontal, stand-alone telehealth support function that would serve as an expert resource to all provider patient-facing areas and ensure consistency of telehealth across the provider organization
- Continue to review and work with payors to ensure that new agreements and reimbursement rates will cover telehealth services at parity with in-person services
- Develop a comprehensive, formal, and ongoing staff training program to bring all team members to a shared level of digital literacy
- Consider partnering with other providers and payors to share the expense of expanding telehealth services in the community (this would create a win-win for everyone)
- Encourage the community to be a partner in developing and promoting a provider’s telehealth services (including being a community representative on a telehealth task force or steering committee)
- Work with other providers and associations to promote and support positive resolution of such issues as licensure, privacy and liability which can limit the expansion and adaptation of telehealth to address current healthcare inequities
Telehealth presents providers – and the healthcare industry in general – a unique opportunity to mitigate disparities in healthcare equity. But all players need to “get it right” from the beginning or run the risk of telehealth just becoming a repeat of the current situation of healthcare “haves” and “have nots.”