Can Telemedicine Become an Equitable "Medical Bridge" in the Post-Pandemic Era?

Before the outbreak of COVID-19 in early 2020, telehealth solutions faced difficulties in gaining traction among patients in the United States, both within and outside the framework of employer-sponsored health plans.

Sources cited multiple reasons for the slow growth trend before the pandemic. According to Zachary Predmore, an associate policy researcher focused on healthcare services at the nonprofit RAND Corporation, two of the most important factors were connectivity and comfort.

He said that in the past, healthcare providers reported more difficulties connecting with patients because patients' internet connections were generally less stable than they are today. Meanwhile, the general population had not yet developed the video conferencing familiarity characteristic of the pandemic era.

However, the situation changed rapidly. By April 2020, Cigna told HR Dive that its virtual care usage had tripled compared to 2019. Other healthcare providers reported similar significant increases in the following months.

Entering 2022, there are few signs that the telehealth boom is slowing down. A recent national survey of employer-sponsored health plans by HR consulting firm Mercer found that among employers with more than 500 employees, telehealth utilization reached 15% in 2020, compared to an annual average of 9% in previous years. In the first half of 2021, this rate remained at 12%.

As clinics closed, this format showed appeal to both patients and healthcare providers, said Bipinchandra Mistry, chief medical officer at benefits outsourcing company Alight Solutions. He noted that going to places like emergency rooms during the pandemic "was a scary thing," so telehealth could step in, providing space for patient interaction.

There has been much discussion about the advantages of this technology, but observers like Predmore are evaluating telehealth services by a different standard: accessibility, especially for patients in underserved populations. Sources told HR Dive that in this regard, the technology has both barriers and opportunities.

How do demographic characteristics affect usage?

Notably, employers may view telehealth accessibility from a positive perspective. "It is undoubtedly a bridge to healthcare services, and perhaps also a way to make more affordable healthcare accessible to a broader population," said Ellen Kelsay, president and CEO of the Business Group on Health. "Telehealth breaks down barriers."

But Ian Tong, chief medical officer at telehealth provider Included Health, pointed out that the technology is also an extension of the broader healthcare system, which itself has inherent inequalities. Underserved populations may have less access to types of healthcare services such as primary care, which affects their engagement with telehealth.

"The issue is not just about access to virtual care," Tong said in an interview. "Actually, pure access itself is the problem."

Tong said this lack of access could lead to far-reaching consequences, combined with implicit biases held by healthcare providers themselves, affecting these patients' ability to build trusting relationships with providers. In turn, this creates hesitation in seeking medical care.

"Now, introduce a new technology, and then you have a group of employees from the Black community... they will still have a certain level of skepticism about it," Tong said of telehealth, "possibly due to a lack of trust in the system."

But even basic familiarity with virtual care may prompt patients to use this format again later. In an original survey published in JAMA Network Open, Predmore and a team of researchers at RAND studied telehealth usage among U.S. adults and found that experience with telehealth was associated with a preference for video visits over in-person visits.

The survey also found that 33.5% of participants believed video visits played no role in their medical care, a group typically composed of patients who are older, live in rural areas, and have lower education levels.

The researchers wrote: "Although telehealth, if deployed in a targeted manner, can expand access to healthcare for underserved populations (e.g., those with low household income, lower education levels, belonging to racial and ethnic minority groups, and those living in rural areas), the results of this survey suggest that these populations may be the least likely to request telehealth, and ongoing efforts to promote equitable access to telehealth need to consider these preferences."

Mistry said employers need to be culturally aware and understand how underserved employees view their own health to address accessibility issues. This includes social determinants of health faced by different employee groups, such as income, education, and physical environment.

This may also include rethinking how virtual care options are communicated. "Many employees of color will learn about these programs through their employers, and the way they are explained or rolled out is designed for the majority," Tong said. "This is a very real experience."

Tong gave an example of a family benefits program that only included images of cisgender, heterosexual couples. This could mean failing to address the concerns of employees in the LGBTQ+ community. Appropriate representation in communication materials can open the door to benefits for people across communities, Tong continued.

Barriers to equitable access

Mistry said awareness may be hindered by other factors, including language. Kelsay added that virtual care options, though well-intentioned, may exacerbate existing inequalities. "Not everyone has access to a smartphone or broadband," she said. "Maybe their living or working environment is not suitable for video visits."

All of this underscores the need for employers to carefully consider how they deploy different technologies, Kelsay continued. This may also indicate the need to supplement improvements in virtual care with increased access to in-person healthcare providers.

"You have to think tactically," Mistry said. "This is a great opportunity to try to provide the right solutions for the right populations."

Predmore pointed out the importance of cost in the telehealth discussion. The RAND survey found that patients who preferred in-person care were more willing to pay for in-person care than those who preferred virtual care, while the latter had lower willingness to pay for virtual care.

"If you want telehealth to be part of the services you offer, you really cannot make the barriers to telehealth access too high," he said. "People like telehealth... but they are not willing to pay too much for it."

Diversity among healthcare providers is another pain point, although this is not unique to telehealth. Tong said this is reflected in the overall demographics of the U.S. healthcare industry. For example, data from the Association of American Medical Colleges in 2019 showed that only 5% of active physicians nationwide were identified as Black or African American, while about 56% were identified as White.

"There is no doubt that we have a problem in this area," Tong said.

When asked how employers can better evaluate healthcare providers' handling of diversity, equity, and inclusion (DE&I) issues, sources offered multiple suggestions. Kelsay said employers may want to ask providers questions about provider diversity and their approach to providing culturally competent care—a method, she explained, where a provider can treat diverse populations even if its medical professional workforce is not diverse.

For example, if a provider does not have transgender doctors, employers can still ask about that provider's ability to handle health issues specific to the transgender community. "You may not be a transgender provider yourself, but can you treat transgender patients in a culturally competent, empathetic, and thoughtful way?" Kelsay said.

Mistry said this cultural knowledge also extends to the staff responsible for patient navigation, adding that it may also be important for navigators to receive appropriate cultural training.

Tong added that, nevertheless, seeking culturally concordant care for employees remains important—that is, finding care providers who look like the patient and may share common experiences. This can allow patients from underserved groups to better engage with and build relationships with providers.

Employers can also evaluate providers' and vendors' track records on DE&I, Tong continued. Leadership composition at the board, executive, management, and medical director levels may all be considered. Additionally, they may choose to review providers' hiring practices and training for frontline staff.

However, just because a provider is not perfect on DE&I "does not mean there is a problem," Tong said, "but it does mean there are potential blind spots. They may not be aware of their implicit biases, or how these biases affect different groups."

He added that identifying whether a provider or vendor treats DE&I practices as a competitive advantage may also be helpful.

Finally, employers can ask providers for data to understand how providers treat diverse populations, Kelsay said.

Focusing on the individual employee

Mistry said no two patients experience healthcare the same way, underscoring the importance of maintaining a personalized approach to care. This is also where telehealth can play to its strengths.

Take mental health, for example. Mistry continued that employee stress levels rose sharply during the pandemic. Even as provider shortages persist, telehealth can offer faster and more frequent care opportunities. "Having another way to have a visit is fantastic," Mistry said.

Additionally, Predmore said telehealth cannot replace all in-person care, but it may be particularly effective for patients who have long-term relationships with the same provider, or those with chronic conditions requiring frequent check-ups or medication refills.

Kelsay noted that improving telehealth accessibility is just one aspect of an organization's health equity efforts. Employers are also studying programs targeting specific needs, such as maternal health, to more inclusively accommodate how patients seek healthcare and lifestyle.

Tong said employers can also consider partnering with groups focused on issues in underserved communities, such as employee resource groups and affinity groups. Engaging employees in these groups may be particularly effective because participants are already advocates for colleagues with similar backgrounds.

But most importantly, for employers, the key may lie in avoiding the status quo in healthcare. "Everyone wants to do the right thing now, but they may not be sure what to do," Tong said. "If I could wave a magic wand, I would want everyone to realize that the biggest enemy in the room is inaction, or staying the same as before. If we do not make any changes, we already know what the care outcomes will be."