Telemedicine Care Disparities Draw Concern For Health Equity

Characteristics such as age, race, language preference, sex, and household income lead to lower rates of telemedicine visits during the early phase of COVID-19, based on a new study that draws health equity concerns.  

COVID-19 has required healthcare providers to rapidly evolve their telemedicine capabilities to fit the needs of patients. At the onset of the pandemic, outpatient care clinicians moved from conventional care to near-exclusive use of telemedicine. 

Researchers studied 148,402 patients scheduled for telemedicine visits, including primary care and medical specialty outpatient care, at a large academic health system during the early phase of COVID-19.

The study found that older age, non-English as the patient’s language preference, Asian race, and Medicaid were associated with fewer telemedicine visits. Additionally, older age, female sex, Black race, Latinx ethnicity, and lower household income were linked with lower use of video for telemedicine visits.

The researchers pointed to possible causes for these access to care disparities and suggested ways telemedicine can be improved upon to promote health equity.

Older age was associated with both lower telemedicine use and lower video use, consistent with evidence that older age is associated with lower internet access and technology adoption.

“Although there is a lack of research on effective care delivery via telemedicine, specifically for older patients, an appropriate design of telemedicine platforms to address audio, visual, and motor impairment and the provision of broadband coverage, as well eliciting and alleviating concerns about privacy, may improve uptake in this population,” the authors explained.

Patients with a non-English preferred language had 16 percent lower telemedicine visits which suggests language may be a barrier to telemedicine care.

Asian race was also associated with lower rates of telemedicine use. This disparity could be due to poorer patient-doctor relationships and negative experiences based on biases in care as demonstrated by some Asian American patients.

Black and Latinx patients, as well as patients with a median household income below $50,000, had significantly lower rates of video-based telemedicine visits. This disparity could be attributed to the digital divide among lower-income and minority cohorts. Additionally, Black and Latinx patients are overrepresented in low-paying essential industries which may make video use during working hours difficult.

While there is insufficient evidence that video visits provide superior care compared to telephone visits, the authors pointed to a few potential benefits such as the clinician’s ability to conduct a physical examination, share screens with patient laboratory results, and the ability to see a patient’s home environment (and conduct a home safety evaluation if applicable).

“Telemedicine has the potential to be leveraged to increase access to care among patient groups that may have traditionally faced barriers to in-person care. However, we must be intentional with implementation to ensure that all patients are equipped to effectively participate in telemedicine care,” the authors wrote.

Female sex was associated with less telemedicine use in specialty care and less video use generally. Now that many schools have closed due to COVID-19, it is likely that women disproportionately bear the burden of childcare, making time for specialty telemedicine visits difficult.

Additionally, financial strains for specialty care may affect this cohort more due to the greater increase in unemployment for women due to COVID-19.

“As we develop and refine our telemedicine practice, we must intentionally design our system to mitigate inequity. Although many have anxiously awaited a return to “normal,” we must acknowledge that our previous “normal” was a US health care system and digital connectivity landscape fraught with inequity,” according to the authors.

“A new ‘normal’ must prioritize the needs of those who have been historically marginalized to ensure that health equity is achieved,” they concluded.