Since March of 2020, many states have rapidly leveraged federal and state flexibilities under the public health emergency to expand telehealth capabilities and reimbursement through both public and private payers.[1] About 30% of weekly visits to health centers were virtual in January through November 2020.[2] Now, some states are extending telehealth for the long term or expanding their existing telehealth programs.
To realize telehealth’s potential for increasing equity in access[3] to health care, states must analyze the impact of these services on equity. Increased uptake of telehealth could reduce administrative costs, transportation costs, and wait times, yet exacerbate existing disparities in access. The rapid increase in telehealth services in 2020 and 2021 offers an opportunity to ask key questions and take steps to maximize the potential of telehealth care to improve equity.
Utilization, cost, and experience
Telehealth utilization increased across the U.S. over the past year, but were new people served or did a subset of people already connected with providers simply moved to virtual visits? Pre-pandemic research suggested that lower income and Black survey respondents were less likely and less willing to utilize telehealth services than other demographic groups.[1] Avoidance of in-person services during the COVID-19 pandemic may have shifted openness to virtual visits, but early indicators suggest utilization disparities were exacerbated with use of telehealth increasing among non-Hispanic White patients and decreasing among Black, Latinx, and Asian patients.[2]
To identify the causes of these likely disparities, it will be necessary to analyze utilization, patient satisfaction, cost, and outcomes data stratified by race and ethnicity. Telehealth has the potential to limit avoidable emergency department use for physical, mental, and oral health care, but may drive up health care utilization in other ways.
States may also consider how disparities differ by service type and sector (consider oral, behavioral, and medical health care). If some disparities grow while others decrease, community engagement may identify best practices, services best suited to telehealth, and barriers to accessing virtual services.
Stratifying data by race and ethnicity will be particularly important because of the longstanding disparate burden of disease experienced by Black, Indigenous, Latino(a), Asian, and other people of color. Evaluated disparities in access to specialty care could identify barriers to telehealth care management for chronic diseases with wide and persistent health disparities. Across the U.S. subspeciality visits declined and telehealth services by specialty varied widely.[1] Longitudinal analysis in 2021-2022 may offer insights regarding how effective telehealth is in reducing avoidable emergency department use for various populations and point to policy recommendations for promoting equity.[2]
Barriers to Accessing Telehealth
Virtual appointments could improve access to health care by eliminating the need for transportation and, in some circumstances, dependent care, as well as by limiting time spent at appointments by minimizing wait times and eliminating travel time. Yet, other barriers, such as digital fluency, access to technology, and access to broadband internet services limit access to telehealth for some. Many states required insurers to cover audio-only visits, which can reduce barriers for people who lack the devices or broadband needed for an audio-visual visit. Other states are considering ways to increase access to broadband in the longer term.
Reports suggest some providers may be requiring preliminary telehealth assessments for procedures that would require a second, in-person visit regardless of the assessment.[1] Such an approach may have helped to limit the number of people in an office to aid in infectious disease control but will only present an impediment and greater cost as providers return to fully open status.
Finally, policymakers can consider whether insurers are using lower or no cost-sharing for virtual visits to discourage in-person visits or relying on dedicated telehealth providers to meet network access standards.
Cultural and Linguistic Appropriateness and Socioeconomic Factors
Addressing disparities requires considering cultural needs and socioeconomic factors that impact access to care. People of color are more likely to live in densely populated households with limited privacy, for example. Other barriers may include disabilities such as hearing impairments, poor internet service, or lack of familiarity with technology.[1]
Further, people with limited English language proficiency may face barriers depending on how well interpretation services are embedded in telehealth platforms.[2] Identifying policies to address inequities will benefit from examining patient satisfaction with the quality of services received, and any variation in outcomes between in-person and virtual care.
Patient satisfaction can be a useful proxy for cultural and linguistic appropriateness. A 2018 report[1] found patients were more likely to opt for in-person visits when offered a choice of telehealth vs a traditional visit. This could be for any number of reasons, including a need for care the patient is uncomfortable disclosing on a form or lack of comfort with establishing a relationship with a new provider remotely.
Some individuals may be unable or unwilling to explain these barriers in a message or call requesting an appointment; therefore, policymakers may want to ensure that virtual visits are a choice rather than an obligation in a post-pandemic world.[2] Closely considering patient experience with telehealth may highlight services for which choice is especially important.