Pandemic era telehealth grew most in wealthy and metro areas, RAND study shows

In another reminder of the ongoing digital divide, the report shows that providers and policymakers need to think about health equity and help make sure virtual care works for everyone.
By Mike Miliard
03:44 PM

(Photo: Yoshiyoshi Hirokawa/Getty Images)

Telehealth experienced sudden and massive growth starting a year ago, but it didn't happen everywhere. A new report from the RAND Corporation suggests that the biggest upticks in virtual care availability occurred in more affluent and metropolitan communities, and that telemedicine services were mostly enjoyed by patients with private insurance.

That study, Who Is (and Isn't) Receiving Telemedicine Care During the COVID-19 Pandemic, adds to an already substantial body of evidence that the public health emergency is exacerbating disparities in access and use of technology-enabled healthcare.

For the report, RAND researchers examined insurance claims from more than six million people with employer-based health insurance in 2019 and 2020. They examined the number of care encounters and types of services received by these enrollees from January 2019 through July 2020.

In its findings, RAND points to a twentyfold increase in telehealth visits starting in March 2020.

"Conversely, the incidence of office-based encounters declined almost 50% and was not fully offset by the increase in telemedicine," said researchers.

The boost in virtual care offerings was experienced most by patients in counties with lower poverty levels – about 48 visits per 10,000 people, compared with 15 per 10,000 people in high-poverty areas – according to the RAND report.

There were 50 visits per 10,000 people in metro areas, meanwhile, versus about 31 visits per 10,000 people in rural areas.

"There is a concern that the pandemic will exacerbate existing disparities in overall healthcare utilization and telehealth utilization," said RAND researchers. "Few national studies have examined changes in telehealth use during the COVID-19 pandemic."

Disparities in access to care "have long pervaded – including by geography, income, race/ethnicity, and age," they said. The pandemic has exposed similar disparities in "telehealth utilization by the mean income of the patient's ZIP code."

To help address that, "policymakers should continue to expand reimbursement for telehealth services and also update clinical guidelines to encourage healthcare practitioners to use telehealth," researchers said. "Given the results, policymakers should make a more concerted effort to reach populations that are deferring in-office care and not replacing it with telehealth visits."

The COVID-19 public health emergency has put larger questions of health equity in focus. That's been especially apparent when it comes to the "digital divide," where the salutary benefits of health IT aren't available to the communities who could most use them.

Policymakers are thinking harder about how to address the challenge.

U.S. Rep. Robin Kelly, D-Ill., chair of the Congressional Black Caucus Health Braintrust and co-chair of the House Tech Accountability Caucus, recently introduced a bill, Evaluating Disparities and Outcomes of Telehealth During the COVID-19 Emergency Act of 2020, to make some progress on the health equity front.

"Some Americans don't have or can't afford a phone," said Kelly. "Will we allow them to be left behind in this revolution?" 

And newly-minted National Coordinator for Health IT Micky Tripathi has spoken recently of what he called health equity by design.

Often, he said, policymakers "embraced technology and moved forward with standards and processes that didn't explicitly take into account the consequences that our actions and activities might have on health equity.

"And then you catch up later, and you sort of do some measurement, and you realize, 'Oh wow, this created some health disparities we didn't realize, and now we have to go back and rectify and mitigate,'" he said.

"This study expands our understanding about the growing use of telehealth as the pandemic progresses," said Jonathan Cantor, a policy researcher at RAND who was lead author of the telehealth study, in a statement. "Given our findings, policymakers should consider increasing efforts to reach populations that are deferring in-office care and not replacing it with telehealth visits.

"More intensive training for parents and pediatricians about telehealth, as well as efforts to address barriers to children's access to telemedicine, may be necessary," he added.

Twitter: @MikeMiliardHITN
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