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Can Telemedicine be Equitable?
New Studies Say "It Depends"
Telemedicine surged with the COVID-19 pandemic. But does offering care by phone or video improve or worsen disparities? Should policies to facilitate telemedicine become permanent?
The dramatic rise in telemedicine is documented in a study by LDI Fellows Ari Friedman, Hummy Song, Angela T. Chen, Alon Bergman, and Guy David, collaborating with the data team from Independence Blue Cross based in southeast Pennsylvania. Using claims data, they found that weekly telemedicine visits among plan members increased from a mean of 773 before pandemic stay-at-home orders to more than 45,600 afterward.
The impact of telemedicine on follow-up care after a hospital stay was the focus of an article in the Journal of General Internal Medicine by LDI Fellow Eric Bressman and colleagues. The post-discharge period is critical for recovery and reducing risk of hospital readmission, but is a time with known disparities. Rates of follow-up appointment attendance are higher for white patients than Black patients.
Bressman et al. examined records from five University of Pennsylvania Health System hospitals from January 2019 through April 2021, looking at adult primary care follow-up appointments within 30 days of hospital discharge. The analysis indicated positive effects: Time to first follow-up visit decreased by 1.4 days with telemedicine. Visit completion rates increased from 62% in January 2020 to 72% in June 2020.
The big gains in follow-up appointments occurred among Black patients—an increase from 52% to 70% —which erased disparities in attendance rates at post-discharge primary care visits. There were no changes in appointment attendance rates among white patients. Bressman and colleagues note that equitable telemedicine requires digital access. They did not analyze the quality of care. Nonetheless, the results suggest the potential of telemedicine to reduce disparities, possibly through eliminating travel to appointments, which can be difficult after a hospital stay.
Nuances about the impact of telemedicine on equitable access are raised by a paper in the Journal of Medical Internet Research Pediatrics and Parenting by LDI Fellows Simone Schriger, Rinad Beidas, and colleagues. They studied community mental health settings, where telemedicine also expanded rapidly. In fact, Friedman and colleagues found that the vast majority of telemedicine visits were for mental and behavioral health: These were uncommon before pandemic-related reimbursement changes. An American Psychological Association survey found clinicians using telemedicine rose from 20% to 96% within six months of the pandemic start.
Schriger and colleagues surveyed 45 clinicians who provide trauma-focused cognitive behavioral therapy for youth in 15 Philadelphia clinics about their perspectives on telemedicine within the first six months of the pandemic. Respondents were generally satisfied. Among widely noted benefits were greater creativity and collaboration, higher attendance and easier scheduling, greater caregiver involvement, and a better understanding of their clients’ home situation.
However, open-ended clinician comments revealed variation in individual experiences and potential exacerbation of disparities. Challenges included clients not having a private space for sessions and clinicians being unable to read client body language. These clinicians’ clients were three to 21 years old and some had attention difficulties. Some were too young to engage via screen. The authors conclude that telemedicine is simply a better fit for some than others. It can make care more convenient and accessible, but hinder those who lack needed devices or internet access and proficiency. Digital disparities most likely affect people with lower income and education, older people, rural residents, people living with disabilities, and racial minority groups. The study authors note that longer-term impacts and the individuals for whom telemedicine is appropriate need to be studied, including by asking clients themselves.
Telemedicine has great potential to reduce barriers to care—a goal that argues for making it a permanent part of our health care system. We expect further research will address questions about its impact in most outpatient clinical settings. And there are still a lot of difficult questions to resolve about reimbursement and allowances for delivering services across state lines. But this is an opportunity—provided we recognize and address digital disparities to create telemedicine that is effective, efficient, and equitable.
The study Telemedicine Catches On: Changes in the Utilization of Telemedicine Services During the COVID-19 Pandemic was published in January 2022 in The American Journal of Managed Care by Ari B. Friedman, Stephanie Gervasi, Hummy Song, Amelia M. Bond, Angela T. Chen, Alon Bergman, Guy David, Julie M. Bailey, Ronald Brooks, and Aaron Smith-McLallen.
The study Association of Telemedicine with Primary Care Appointment Access After Hospital Discharge was published in January 2022 in the Journal of General Internal Medicine by Eric Bressman, Rachel M. Werner, Claiborne Childs, Amanda Albrecht, Jennifer S. Myers, and Srinath Adusumalli.
The study Community Mental Health Clinicians’ Perspectives on Telehealth During the COVID-19 Pandemic: A Mixed Methods Study was published January 13, 2022 in the Journal of Medial Internet Research Pediatrics and Parenting by Simone H. Schriger, Melanie R Klein, Briana S. Last, Sara Fernandez-Marcote, Natalie Dallard, Bryanna Jones, Rinad S. Beidas.
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