Exploring Inequities in Telemedicine
By Rachel Werner, MD, PhD
January 29, 2021
Rachel Werner is the executive director of the Leonard Davis Institute of Health Economics* and Robert D. Eilers Professor of Medicine and Health Care Management at the University of Pennsylvania. She is also a member of the 2021 Tradeoffs Research Council.
COVID-19 has transformed the way we deliver health care in the United States. With declining in-person visits, the use of telemedicine has taken off, spurred in part by regulatory changes that expanded telemedicine reimbursement by Medicare, Medicaid and private insurers.
There are potential upsides to the expanded use of telemedicine. It offers more convenience for patients, increases access to care in areas with physician shortages such as rural America, and, in some cases, lowers no-show rates. And, during the pandemic, it has offered access to health care for many people who otherwise would have delayed or foregone care. But there are also potential downsides, and a recent paper in JAMA Network Open highlights one of them – increasing inequities in health care access.
A team of researchers from the University of Pennsylvania, led by LDI Fellows Lauren Eberly and Srinath Adusumalli, examined data for nearly 150,000 patients who were scheduled for telemedicine visits in a large health system during the first two months of the COVID-19 pandemic. A little more than half of patients completed their telemedicine visits (as opposed to cancelling or failing to show up), and 46% completed their visits by video, the preferred mode of telemedicine. But there were significant inequities in the completion of these visits. Patients were less likely to complete their telemedicine visit if they were older, insured by Medicaid, of Asian descent, or spoke a preferred language other than English. When patients did complete visits, those who were older, female, Black, Latinx, or had a lower household income were more likely to use telephone instead of video.
The authors couldn’t pinpoint the exact reason patients did or did not complete their visit, but their findings are in line with research showing that older patients are less likely to use technology-based tools and that patients who are low-income or from minority groups are less likely to have access to the tools needed to use telemedicine: computers and reliable broadband.
Many of the changes to how telemedicine is paid for that have contributed to its increased use are temporary, and the debate over whether to make them permanent is ongoing, as policymakers weigh the tradeoffs of increasing access to telemedicine and fears over possible abuse and overuse. In the meantime, little has been done to increase access to the technology needed for telemedicine or to address the systemic inequities in the health care system that would promote equitable access to care. If telemedicine does become a more permanently and widely available option, more systemic changes will need to be made in order to ensure it is equally accessible to all who can benefit from it. If these inequities go unaddressed, they will likely compound existing inequities in care. Just as the burden of COVID-19 continues to fall on more marginalized populations, so too have the socioeconomic, racial, and gender inequities in access to virtual care.
*The Leonard Davis Institute of Health Economics is one of Tradeoffs’ financial supporters, and their support has no influence on their inclusion in Research Corner.