Telehealth use skyrocketed during the COVID-19 pandemic, filling a critical access gap for millions of Americans. While in-person visits have since rebounded, virtual care has moved decisively from the sidelines to the mainstream where its role will only continue to expand. But over the past year, communities with higher poverty rates saw significantly lower telehealth use than others, and rural areas saw lower use than urban areas.
As we accelerate toward a new standard of hybrid care, we must be sure not to leave behind the very underserved populations who can benefit the most from these advances. As the authors of a recent framework for digital health equity put it, “the innovation curve cannot reinforce the social gradient of health.” A Health Affairs study looking at telehealth adoption during the pandemic, however, reinforces the need for action.
Recent conversations with colleagues across the industry reveal a common sense of urgency around the need to double-down on digital health equity, ensuring that the convenience, cost, and health benefits of digital health accrue equally to all.
Digital determinants of health
Most discussions of digital health equity begin with infrastructure — and rightly so. Broadband access, or lack thereof, is widely regarded as a social determinant of health. In 2018, 18 million households lived without a broadband service, either from lack of availability or affordability. The pandemic highlighted the fragility of living without broadband in the digital age, with millions of families struggling to stay connected to schools, doctors, and loved ones.
“It’s not just broadband,” says Dr. Shereef Elnahal, CEO of University Hospital in New Jersey, the state’s only public hospital and one of the hardest hit by the pandemic. “It’s access to devices that are compatible with telehealth: smartphones, tablets, computers. This was a big gap we noticed immediately in the first surge.” As an emergency stopgap, the hospital used most of a large donation to purchase smartphones and tablets for families of hospitalized COVID patients just so they could communicate with doctors and access virtual care for at-risk family members at home.
As Elnahal argues, you can’t sustainably solve these basic issues until you regard digital access as a public good. President Biden’s infrastructure plan takes major strides in this direction, expanding broadband access while pressuring the telecom industry to bring down prices. Recently, New York became the first state to require ISPs to offer a low-cost, $15 a month, internet service for low-income consumers. Amwell, one of the nation’s largest telehealth providers, is also working vigorously behind the scenes on these infrastructure and access issues through the Alliance for Connected Care, says chief medical officer Dr. Peter Antall. “Our vision is to democratize healthcare, and we know that thoughtful, well-designed telehealth can help level the playing field for all.”
Meeting people where they are
Ensuring equitable access, however, requires more than a good internet connection and a compatible device. Digital literacy is a challenge for many underserved populations and it’s essential to design digital experiences inclusively, with the widest diversity of experiences in mind. The launch of vaccine registration websites was a window into the consequences of this literacy gap, with tech-savvy people from higher-income communities deftly navigating online booking systems — often grabbing slots in lower-income communities — while others struggled and fell behind.
“The fact is most digital health solutions were built for higher income people and the commercial market,” says Abner Mason, founder and CEO of ConsejoSano (Spanish for “healthy advice”), a California-based multicultural patient engagement platform. “Digital literacy begins with actually engaging patients in their language of preference,” Mason says. Most telehealth and digital health offerings are designed primarily for English speakers, he stresses, with limited access in other languages. ConsejoSano is helping to bridge these language and cultural gaps through multi-channel communication and engagement in Cantonese, Mandarin, Arabic, Farsi and many other languages.
The cultural competence and sensitivity of providers is equally important — considering, for example, whether a patient has a private space within a crowded living situation to discuss her health virtually, or might have cultural or religious beliefs that make certain virtual interactions uncomfortable. “At Amwell, we’re investing heavily in growing our capabilities and training providers in language and cultural competence. We know we can always improve and expand our reach,” says Antall.
Meeting everyone where they are means interacting on their terms and in the most accessible and convenient modes for them. For most people these days, especially in lower-income and multicultural communities, this is via text, says Mason. And yet, federal regulations still make it very difficult to easily and securely interact with patients and members via text, an issue he is focused heavily on.
Aligning incentives with equity
Telehealth has thrived in large part because regulatory barriers were lifted during the pandemic, allowing providers to bill for virtual care at the same rates as in-person. Making these changes permanent, especially for managed Medicaid plans and providers like FQHCs serving Medicaid recipients, will be critical for expanding access. Mason would also like to see the best examples of payment transformation applied to Medicaid. “Imagine if Medicaid plans were incentivized to close disparity gaps and could get bonuses for doing so. They would get creative, and they would pressure digital health companies to follow suit.” To that end, he founded HealthTech4Medicaid, a non-profit coalition focused on bringing the fruits of entrepreneurship and health-tech innovation to traditionally disadvantaged populations.
As telehealth and hybrid digital/in-person models come to define a new standard of care, it’s essential that we design those models and experiences to work as well for underserved populations as they do for anyone else — not as an afterthought or add-on, but as a starting point and priority area of focus. Bridging the digital divide and closing gaps in access are not only the right thing to do, but the only way to reduce healthcare costs and improve outcomes for all.
Ashwini Zenooz, M.D. is the President & Chief Medical Officer of Commure, and former Chief Medical Officer and GM for Healthcare and Life Sciences at Salesforce.
John Fox, Ph.D. is principal and strategy lead at Slipstream, a healthcare content consultancy.
