Social Determinants of Health Stymied Pandemic Telehealth Use

Telehealth compensated for much of the care delivery gap brought on by COVID-19, however social determinants of health effected utilization rates significantly, according to a study published in JAMA Network Open that raises concern for care access disparities.

From March to June of 2019, telehealth claims made up less than 0.3 percent of total outpatient consults. One year and a pandemic later, telehealth claims made up a quarter (24 percent) of privately insured outpatient consults, based on claims data for more than 36.6 million working-age, privately insured members who were continuously enrolled from March through June of 2020.

Overall, the researchers found that outpatient visits in brick-and-mortar locations decreased by 37 percent, with 1.63 visits per enrollee in 2019 and 1.02 visits per enrollee in 2020.

Telehealth visits were able to fill in some of the gap; the total combined in-person and virtual encounter rate dropped just 18 percent between 2019 and 2020. 

In total, 15 million telehealth claims were submitted during the study period. Most telehealth visits were conducted using video (74 percent), one in ten were done over the phone, 3 percent were conducted by email or chat, and 13 percent were unspecified. 

The study found that persons living in areas with limited social resources were less likely to use telehealth. In the most socially advantaged neighborhoods, 27.4 percent of consults were conducted virtually, compared to 19.9 percent of medical encounters in disadvantaged neighborhoods.

Additionally, 24 percent of appointments in urban areas were conducted virtually, compared to 14 percent of visits for beneficiaries in rural settings, drawing telehealth care access concerns for those who may not have broadband internet.

The study’s lead author, Jonathan Weiner, DrPH, co-director of the Center for Population Health Information Technology and, noted that this report will aid stakeholders as they work to eliminate health disparities due to social determinants of health such as the digital divide.

“Telehealth has been around for a long time, but the recent increase has been enormous,” Weiner, who is also professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, said in a press release. “These findings will not only help doctors and other clinicians plan for the future, they will also guide policymakers and technology companies, especially as we learn more about the challenges of accessing telehealth among older patients, the uninsured, and low-income patients.” 

The researchers also found that COVID-19 “hot spot” states, where the prevalence of COVID-19 was at least 1.5 times the national average, saw greater utilization of telehealth. In these hot spots, 36 percent of all consults were conducted via telehealth, compared to 21.6 percent in areas with lower COVID-19 prevalence.

Virtual care was more popular for mental health consults compared to medical consults. Specifically, 46 percent of mental health visits took place via telehealth and 22 percent of medical consults were conducted virtually. Age and number of chronic diseases were associated with more frequent telehealth use as well, with members age 18 to 49 and those with more than two chronic conditions using telehealth the most. 

From 2019 to 2020, overall medical costs dropped 15 percent, from $358 to $306 per person per month. Members with at least one 2020 COVID-19-related had three times as many medical costs of those with no COVID-19-related services; $1,701 per member per month compared to $544.

“Even though some of our findings are unique to the COVID-19 era, we need to consider what telehealth will look like beyond the pandemic,” said Weiner. “We will need to continue to assess and modify telehealth strategies to maximize value during this digital age, particularly given the challenges of the digital divide across social and geographic lines.”