Inequalities of Telehealth Access in Lower-Income Minority Populations


16, Nov 2020. 16:20pm

The COVID-19 pandemic has made telehealth a top-of-mind topic for many professionals across the healthcare space, as well as for patients. 

Telehealth is defined as “the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration,” according to the Health Resources & Services Administration

Only 18% of doctors said they treated patients via telehealth in 2018, but the adoption rate jumped to 48% following the onset of the pandemic, according to CB Insights. And 60% of Americans said they would be willing to try a telehealth service since the virus appeared. Long-distance care and education are vital during this time of social distancing, and the industry is worth $43 billion today, but telehealth had a huge impact on some populations long before the pandemic struck. 

Telehealth is a gateway to efficient care for 81 million U.S. citizens living in Health Professional Shortage Areas (HPSA), where access to primary, dental, and mental healthcare services are very limited. Residents are generally of lower incomes and are more apt to be uninsured. A network of almost 1,400 locally- and federally-funded community health centers (CHCs) serve these populations—a disproportionate number of which are minorities—and provide quality care at affordable costs. 

Sadly, that’s only true for those who can log on. While 44% of the nation’s health centers offered telehealth services in 2017, according to the National Association of Community Health Centers (NACHC), many people of color can’t access those resources. Telehealth services require internet-enabled devices as well as broadband connectivity, but in 2019, 39% of Hispanic and 34% of Black households lacked broadband, according to Pew Research Center

Although adoption rates have improved among many telehealth providers, CHCs specifically have seen a roughly 50% drop in weekly telehealth visits since the pandemic started. For poorer minorities, who also happen to be those most affected by COVID-19, this statistic shows that patients aren’t getting the care they need. 

All this means that there are opportunities for health and wellness brands to step in and help. 

Intricacies of access

Around 75% of all doctor, urgent care, and emergency room visits “are either unnecessary or could be handled safely and effectively over the phone or by video,” according to the American Medical Association. For lower-income people of color, getting care by telehealth over in-person visits has many benefits; it drastically lessens—or simply eliminates—worries about finding transportation, taking time off work, finding childcare, and spending hours in waiting rooms. Health professionals and institutions benefit from virtual services as well, because they can see more patients in less time and extend operations beyond normal clinic hours.

But for the millions of minorities that lack internet, accessing telehealth can be just as challenging as going in person. Broadband is widely available in most urban areas, but steep monthly costs can dissuade many from subscribing. To avoid high internet costs, about a quarter of all Hispanic and Black people are totally reliant on their smartphones to get online. While they could technically access telehealth services on mobile devices, their access can be limited by pay-to-use data restrictions from cellular carriers and online services that aren’t optimized for mobile use. 

“Almost 95% of the patients we see are coming through on smartphones,” said Howard Reis, CEO of the virtual dentistry consultation platform TeleDentists. “So if people don’t have access to smartphones or a computer, that’s certainly a barrier.”

Dr. Elizabeth Nelson, a family medicine provider at OU Medicine, told Healthcare IT News that connectivity issues are a barrier as well. She said spending 15 minutes trying to connect with a patient for a 10-minute call is “silly,” and poor connections can interfere with her ability to diagnose.

“Those nonverbal cues are so helpful to me,” Nelson said. “There are plenty of times when I’m looking at a rash over video. If it’s super pixelated and I can’t see anything, it’s kind of worthless.”

Reis said a general lack of awareness around telehealth is also an issue. Many low-income individuals simply aren’t aware that they can visit a virtual doctor to address their ailments. 

“With a disadvantaged community, there is still so much work that needs to be done in terms of education, wellness, and prevention,” Reis said. And telehealth can make that possible. 

It’s not all about internet and devices

Even if poorer people of color had all the means necessary to efficiently access telehealth, there are no guarantees their local health center would support it. In 2017, the NACHC reported that only 46% of rural CHCs and 32% of those in urban areas had telehealth infrastructures. There are several reasons these numbers aren’t at 100%, with a lack of reimbursement being one of the most significant.

“People were seeing patients in the virtual space before reforms made it possible to get paid for it,” Dr. Diane Rittenhouse, a senior fellow in Mathematica’s health unit, told Healthcare IT News. “They were doing it essentially for free. There’s this sense: “I like this. Patients like this. We seem to be able to have found success, but how are we going to continue to be paid for it?’”

A 2016 study from Health Affairs found that among the CHCs that had not adopted telehealth, 36% said it was due to non-reimbursement, 23% said they did not have funding for equipment, and 21% said their staff lacked the necessary training. 18% of rural CHCs and 7% of urban ones cited a lack of broadband services as a further barrier to adoption.

How brands can help

Health and wellness brands, both connected to and outside the virtual healthcare world, can help improve telehealth access for lower-income populations of color. As with programs for improving nutrition and food security in these communities, brands addressing disparities in telehealth should first establish goodwill. 

“Within African American communities there are de facto leaders,” Dr. Shelley Cooper, CEO Diversity Telehealth, told MobiHealthNews. “They are leaders who the communities trust, and leaders who the communities are more likely to follow. I think in many cases our religious leaders or our political leaders, and sometimes even our de facto leaders, are people who would gather the information and present it to the communities.”

Allying with locals can give brands insight into the specific factors affecting their communities’ ability to access telehealth. From there, companies and professionals can start building the solutions and partnerships necessary to boost telehealth access from any number of angles, while also raising brand awareness. 

“There are opportunities to build programs to distribute smartphones to people who can’t afford them, or to provide public access computers to people who don’t have smartphones,” said Reis.

Brands could establish temporary or permanent broadband hotspots and phone-charging stations around certain neighborhoods. They could set up events geared toward educating the community on preventative health techniques for issues that commonly affect local residents, as well as on what telehealth resources are at their disposal. Brands could also push for initiatives like legislating permanent parity in telehealth reimbursement for more insurers, or raising funding for more telehealth tech and training at local CHCs. 

No matter the approach, brands have a lot of room to help disadvantaged minorities manage and improve their health virtually, especially as telehealth grows more popular. 

“COVID-19 should be a catalyst for broader change as it relates to health equity,” said Duane Elliott Reynolds, founder and CEO of Just Health Collective, to MobiHealthNews. “These inequities have existed for hundreds of years. But if we don’t take this as a learning opportunity to think about how we make fundamental change in our systems so that all people receive equitable care, I think we will have missed a great opportunity.”