As Covid-19 drives many patients away from in-person care and toward virtual visits, experts warn that the nation’s most vulnerable members may be shut out of the booming telehealth business.
Federal policymakers temporarily relaxed regulations to make it easier to provide virtual care during the pandemic, fueling a shift toward telemedicine that has become so popular among patients and providers that there are now a number of proposals to make the changes permanent. Just this week, President Trump signed an executive order that would permanently extend some of those policies.
But a pair of new studies published this week show that there are barriers to virtual visits that regulatory changes alone can’t fix.
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“The temporary reform due to Covid allowed telemedicine visits from a patient’s home, but it presumed that patients had access to the technology to engage in those visits,” said Eric Roberts, a health policy researcher and at the University of Pittsburgh and a co-author of one of the papers. “We’re showing that there’s a substantial number of Medicare beneficiaries who lack access to that technology.”
The paper, published in JAMA Internal Medicine, found that 1 in 4 Medicare beneficiaries were stranded on the far side of the digital divide in 2018, with neither a home computer with a high-speed internet connection or a smartphone with a wireless plan.
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That translates to 15 million people in the U.S. who, if they wanted to, wouldn’t be equipped to make the leap from in-person to video visits. The study found that this technology gap disproportionately impacts people of color, low-income individuals, and senior citizens — altogether, “a very vulnerable population both in terms of their health profile and their economic profile,” Roberts said.
One way to potentially narrow that gap, according to the authors: expand the federal Lifeline program, which subsidizes phone and internet services for impoverished families, to cover more low-income Medicare beneficiaries.
They cautioned, however, that the program is limited and does not pay for devices themselves. Yet another problem is that people who can afford devices aren’t always able to use them.
“It actually bears emphasizing that simply putting an iPhone in someone’s hand or a laptop in someone’s hand does not necessarily imply the ability to receive a telemedicine visit,” Roberts said.
The technology itself has to also be accessible to the patients who need to use it.
“If your goal is really to get everyone connected, then you will also need to handle issues about disability, with vision and hearing impairment as well. That’s not insubstantial,” Kenneth Lam, a geriatrician at University of California, San Francisco, who co-authored another study, also published in JAMA Internal Medicine, on telehealth disparities in seniors on Medicare.
That study looked at 2o18 data from more than 4,5o0 Medicare beneficiaries over 65 who were part of a national dataset. Lam and colleagues found that 20% of those individuals were “unready” to use telemedicine services due to difficulty hearing, seeing, or communicating, in addition to dementia. Others simply didn’t have the experience needed to use the technology. All told, the study found 38% of Medicare beneficiaries over 65 weren’t prepared for virtual care.
The problem only grew more prevalent with age. A whopping 72% of people aged 85 and above were considered unready. Again, the study found that people of color and low-income individuals accounted for a disproportionate share of people who were considered unready.
Lam said the accessibility gap in telemedicine is unacceptable.
“When you think of building buildings, there are rules and regulations in place to make sure that they’re accessible,” he said. “It’s the responsibility of the person to make sure there are ramps and elevators — especially if it’s a medical facility — and my worry is that in this rush to suddenly go to telemedicine, we have forgotten that there are still issues of accessibility when it comes to a virtual clinic.”
Lam said digital literacy programs and live captioning services for virtual visits could help make care easier for more people to access. And for many others, in-person visits will remain crucial.
“Covid has probably ushered in a new normal, where telemedicine is going to be an increasingly prominent component of health care delivery,” Roberts said. “This [disparity] is certainly not a problem that can be conquered overnight, but one that will require sustained and diligent efforts, given the likely sustained impact that Covid will have on how we deliver care.”
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Telemedicine is booming — but many people face barriers to virtual care - STAT
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