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MEDICINE FOR ALL

How telehealth could make healthcare more equal

Dr Greg Gulbransen takes part in a telemedicine call with a patient while maintaining visits with both his regular patients and those confirmed to have the coronavirus disease (COVID-19) at his pediatric practice in Oyster Bay, New York
Reuters/Lucas Jackson
A doctor where you need it.
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The most groundbreaking aspect of telehealth isn’t the technology. It’s access.

That’s not to discount the tech. Sure, soon a wearable device will track your vital signs, then transfer them to a program that monitors them and notifies you if they seem amiss. It might even set up a video call with your doctor if anything needs medical attention.

Yet in many ways, this futuristic scenario says less about the potential of telehealth—literally, healthcare delivered from any distance—than the fact that a doctor can guide a patient through a visit via a phone call.

Because while sophisticated technology gives more options to patients who already have access to healthcare, technology as basic as a phone call helps to bring health care where there isn’t any.

The Covid-19 pandemic vastly expanded telemedicine, raising it from the sidelines of delivering care to the main event, and the $3.8 trillion US healthcare industry took notice. Venture capital is pouring money into telehealth startups, while financial dealmakers are rushing to consolidate the biggest players. But even as telehealth becomes big business, it also has the potential to help address the most pernicious problem in US healthcare, one which industry has failed to solve: how to get treatment to everyone who needs it.

Where is healthcare access missing?

About 29 million Americans are uninsured. They are disproportionately concentrated in rural areas, where they face other challenges accessing healthcare, such as a lack of nearby providers that accept specific insurance types, or a shortage of appointments past office hours. Overall, this means about a quarter of the 60 million Americans who live in rural areas can’t get medical care every time they need it.

The inability to see a provider, both in urban and rural settings, disproportionately affects ethnic and racial minorities, members of the LGBTQ community (and particularly transgender people), and individuals with disabilities. Often the underserved groups intersect, too—the uninsured or underinsured are mostly non-white, and tend to live in rural areas.

A lack of access to medical care is an issue globally, too. Although state-sponsored systems in high- and middle-income countries outside the US mean almost everyone in those nations is covered, the lack of available medical providers is a struggle in rural areas everywhere. It’s also something that telehealth can help solve, bringing the doctor or nurse to the patient, albeit virtually, if the patient can’t reach the doctor.

Getting the patient to the doctor

Because telehealth isn’t dependent on getting to a specific location and more affordable than in-person visits, it’s an important tool for those who would otherwise forgo care. Even prior to Covid-19, pilot projects had shown telemedicine could help expand access to care in rural areas, for instance by providing pregnant women routine check-ins with ob-gyns or midwives.

In the US, however, these experiments had been somewhat limited by financial issues. Until about a year ago, Medicare and Medicaid would only reimburse telehealth appointments if they took place in a physician’s office. A higher percentage of those living in rural areas are covered by public insurance compared to those living in urban ones, and since many of them might struggle to find transportation to a doctor’s office, or can’t take the time off work, this rule made the impact of telehealth on rural communities negligible.

The pandemic forced a change in policy. Starting in March 2020, reimbursement was expanded to include remote visits from home, and the results have been encouraging. The adoption of telehealth was quick. Half of Medicare visits were delivered online or by phone in the first half of 2020, suggesting patients were inclined to use the medium if it was available.

Even though Covid-19 in some cases dissuaded people from seeking any care, early data shows telehealth resulted in expanded access to healthcare, particularly for otherwise underserved groups. Between March and June 2020, for instance, 26% of Medicare users had a telehealth visit. In the same period, so did 34% of those who were eligible for Medicare and Medicaid—seniors over 65 or with disabilities with a low income.

Telehealth isn’t just more convenient for these patients—it also reduces the added costs that can make healthcare unaffordable, even for the insured, such as transportation, losing hours of work, or having to arrange childcare. Without these expenses, patients are more likely to get care, says Brian Hasselfeld, a pediatrician and internist at Johns Hopkins Community Physicians, and the organization’s director of telemedicine. And patients who are able to see doctors regularly are less likely to need emergency care in the future, he says.

“An hourly employed individual certainly can have far less flexibility than someone who can easily take off half a day or a full day to go and medical appointment. The ability to do that is not allocated equally,” he says.

Similarly, those who don’t speak English as their first language, or who have disabilities compatible with the delivery of telehealth, might find that getting medical care remotely caters more specifically to their needs.

Getting the doctor to the patient

Having a doctor a video call away doesn’t help much, however, when that video call can’t be made. Areas where remote care has the highest chances of increasing healthcare access also tend to be the ones with worse internet penetration, and the elderly population that could benefit more from remote care is usually less comfortable with digital technology.

This is where the telehealth industry, in its pursuit of cutting-edge technologies, might actually be moving away from the communities that would most benefit from it. Higher-level technology, tracking devices, and even augmented reality—all of which telehealth companies have begun to explore as a way to connect patients and doctors—don’t do much for those who don’t have the latest computer or smartphone, much less broadband to connect them.

“Access to technology is a new, more important social determinant of health,” says Hasselfeld.

Telehealth should work with lower levels of technology when that is all that’s available. Otherwise, it risks cutting off those who could derive the greater benefit, as it’s been so far during the pandemic, when issues of connectivity drastically reduced the penetration of telehealth services in rural areas, as found by a study published in November 2020 in the Journal of the American Medical Informatics Association.

Older populations, for instance, use audio calls twice as often as younger patients to connect to their health providers, says Hasselfeld, and they might not be comfortable or familiar with video. So, he says, the focus has to meet them where they are.

Telehealth vs in-person vs no care

Being able to access any care, however, isn’t the same as being able to access good care. Telehealth, says Hasselfeld, needs to be evaluated in two separate ways.

On the one hand, when telemedicine is compared to no care at all, it’s an easy win.

But that cannot be sufficient. The goal should be to include telehealth in the menu of available services. “It can’t be ‘either-or,’ you need ‘both and,’” says Monica McLemore, a professor of family health at the University of California, San Francisco and an expert in community health. This is why, to assess effective improvements, telehealth must be compared to in-person care.

In some cases, remote treatments can be preferable, particularly when it comes to ongoing care, or following up after initial diagnoses. “In our older populations, for instance, I no longer have to just hear a verbal kind of retelling about why a particular thing at home is a physical impediment or decreases their activities of daily living […] I can see it, I can see it and visualize it and make better recommendations,” says Hasselfeld.

Telehealth also makes it easier to include close relatives in medical appointments, when required and appropriate. It helps doctors observe a patient’s condition in their home, which might help evaluate conditions, such as hypertension, that might change due to the stress of leaving the home and getting to a doctor’s office. There are other situations in which telehealth might be a better choice. Members of the LGBTQ community, for instance, are often more inclined to use remote care because of lower chances of being misgendered, addressed with the wrong pronouns, or simply discriminated against.

Women seeking abortions through medication (which legally can be done prior to the 12th week of pregnancy), too, might prefer doing so via telehealth—which would help overcome the financial and logistical burdens often associated with clinic visits. Initial studies show that remote prescription of misoprostol is safe. Still, McLemore—who participated in the evaluation of one such program of remote prescription of medical abortion—notes that even in these cases telehealth cannot fully replace other options. For instance, a woman might not have enough privacy for a consultation at home or be in an abusive domestic environment, which visiting a clinic gives her an opportunity to leave.

Making sure that healthcare delivered remotely is the better option, and not the only option, has to be the overall goal when it comes to including telehealth as one of the forms of care. It’s especially important to pursue this when it comes to underserved communities, says McLemore. Otherwise, the risk is settling for any care where there was none, rather than investing in infrastructure that would provide equitable, high-level care regardless of income, location, or race.