While COVID-19 has created unprecedented challenges for the U.S. health care system, it has also accelerated innovation, including the use and adoption of telemedicine. Hospitals and other providers have turned to telehealth and remote monitoring technologies at an unprecedented rate to maintain access to routine care for non-COVID patients and monitor COVID patients at home. However, just as the burden of COVID-19 morbidity and mortality continues to fall on more marginalized populations, so too have the socioeconomic, racial, and gender inequities in access to virtual care.

In a recent study in Circulation, Lauren Eberly, Sameed Khatana, Ashwin Nathan, Srinath Adusumalli, and colleagues examine how the use of telemedicine for outpatient cardiology care affected existing inequities in access to care for certain populations. They examined the electronic medical records of 2,940 patients at the Hospital of the University of Pennsylvania’s cardiology clinics who were scheduled for ambulatory telemedicine visits from March 16, 2020 to April 17, 2020, after local shelter-in-place orders went into effect. They compared the characteristics of patients with completed and non-completed visits, as well as patients with video and phone visits.

About 46% had completed a telemedicine visit, while the remaining 54% cancelled or did not show up to their visit. Compared to patients who did not complete a telemedicine visit, patients who had a telemedicine visit were slightly older, more likely to be male, and more likely to speak English. Among patients who completed their visits, patients with video visits were more likely to be male, less likely to be Black, and had a higher median household income than patients who completed telephone-only visits.

Overall, the authors found that being female and being non-English speaking were independently associated with less telemedicine use. Additionally, older age, female gender, and median household income less than $50K were independently associated with less video use (vs. telephone-only use) for telemedicine visits. Non-English speaking patients were over 50% less likely to have a completed telemedicine visit. Females were 26% less likely than males to have a completed telemedicine visit  and, among those with completed visits, 28% less likely to use video, while individuals with a median income of less than $50K were roughly 50% less likely to use video for telemedical care.

A number of barriers likely exist for the patients who did not complete a telemedicine visit. Access to telemedicine could be particularly challenging for low-income patients and patients in more remote areas, who may lack reliable internet access or adequate insurance coverage.

This study provides one example of how the COVID-19 pandemic may be “the great unequalizer,” reinforcing longstanding disparities in coverage and access to care. Some payers have responded by increasing reimbursement for telehealth visits. For instance, under the National Emergency Order, the Centers for Medicare and Medicaid Services (CMS) have expanded telehealth reimbursement for all Medicare beneficiaries, including visits conducted over the telephone. States also have regulatory flexibility to expand telehealth access for Medicaid patients, and many private payers have increased reimbursement or waived copays for telemedicine care. Many of these regulatory changes, however, are temporary, and fail to achieve full payment parity between video and audio visits for all payers.

Future studies should investigate the barriers to telemedicine access for certain patient populations and identify more targeted solutions. For example, further research could determine whether child care responsibilities or employment strains contribute to inequitable access to telemedicine care for women. Additionally, electronic documentation of patient language preference, seamless integration of translation services into telemedicine technology, and translation of all telemedicine visit instructions may help to engage non-English speaking patients. In some health care settings, some of these efforts are already underway. Finally, permanent policy changes at the federal and state level and complete payment parity for telehealth are necessary to avoid penalizing more marginalized patients in an already uncertain economy.

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The study, “Telemedicine Outpatient Cardiovascular Care during the COVID-19 Pandemic: Bridging or Opening the Digital Divide?,” was published in Circulation on June 8, 2020. Authors include Lauren A. Eberly, Sameed Ahmed M. Khatana, Ashwin S. Nathan, Christopher Snider, Howard M. Julien, Mary Elisabeth Deleener, and Srinath Adusumalli.