Elaine Khoong meets with patients two days a week over the phone or by video. Most of her patients aren’t native English speakers and are disproportionately Asian, so she often communicates with them in Cantonese. As a researcher specializing in internal medicine at San Francisco General Hospital, a healthcare safety net provider serving marginalized communities, Khoong checks in on her patients whether she can see them in person or no.
Most of Khoong’s consultations are done by phone, which is often easier for patients. Telehealth is a remote healthcare option through which patients can reach their care providers to receive a diagnoses or treatments and has become prevalent in the age of COVID-19, especially in underserved communities.
“Most of our patients are below the federal poverty line and many of them work jobs where they’re not able to get a lot of time off. And then on top of that, there’s travel. Anytime they’re not working is lost income,” said Matthew Ware, a quality improvement coordinator who works with telehealth at the Venice Family Clinic, a federally qualified health clinic in Venice, California.
The COVID-19 pandemic only made these obstacles glaringly apparent, and telehealth can eliminate these barriers. However, amid this new age of accessibility for low-income communities, telehealth has also been met with a host of challenges, like data illiteracy and unmet technology needs.
“This technology gets applied without thinking about what patients go through and really tailoring it to what they need,” said Ware. “We’re a community health center, and we’re not used to doing technical assistance with software. It’s outside of what our traditional role has been, but we’re having to take on these new roles and I think it’s important to the equity that those things are done right.”
In telehealth, there is also a hierarchy of the quality of care a patient can receive based on if they’re publicly or privately insured/uninsured.
“[Healthcare providers for low-income communities] are predominantly providing telehealth via phone calls…whereas on the commercial side…you are more likely to get a video visit,” said Diana Camacho, senior program officer of the Improving Access team at the California Health Care Foundation. CHCF’s Improving Access team works to increase the accessibility of health coverage for low-income Californians.
Under Medicare—a federal health insurance program for people aged 65 or older and certain younger people with disabilities—telehealth coverage was traditionally limited to only beneficiaries living in rural areas. Medicaid—a federal and state health insurance program for eligible, low-income people—adopted telehealth early. While all states and Washington provided some coverage of telehealth, it varied from state to state.
In early 2020, the federal government announced a Public Health Emergency (PHE) due to COVID-19, and Congress and the Centers for Medicare & Medicaid Services expanded Medicare’s coverage of telehealth so all beneficiaries could easily access telehealth to mitigate the spread of COVID-19. Before the pandemic, only 18% of providers of Medicare beneficiaries offered telehealth. Now, 64% do.
“Before the COVID-19 pandemic, generally, coverage of telehealth services in the traditional Medicare program was super limited. About 100 services were covered and…less than 1% of the Medicare population had a telehealth visit. So, when COVID-19 happened…roughly one in four Medicare beneficiaries had a telehealth visit between the summer and fall of 2020,” said Wyatt Koma, who studies Medicare at the Kaiser Family Foundation.
According to research by Kaiser Family Foundation, during the pandemic, a larger group of Black (52%) and Hispanic (52%) Medicare beneficiaries had a telehealth visit than white (43%) Medicare beneficiaries. All three groups mainly accessed telehealth via phone, likely a result of the fact that while more than 80% of beneficiaries reported having access to the internet, smaller shares said they owned a computer (64%) or a smartphone (70%).
Additionally, all 50 states and Washington expanded telehealth access for Medicaid beneficiaries. States were granted flexibility in how services were going to be covered and delivered through telehealth, such as adjusting payment rates, broadening provider types and expanding the eligible Medicaid populations for telehealth.
Medicaid services delivered via telehealth surged during the pandemic, with 68 million services offered between March and October 2020, an increase of more than 2,700% compared to the same period in 2019.
In August, the Biden administration announced a $19 million investment into telehealth for rural populations and underserved communities. This investment will be distributed to 36 award recipients through the Health Resources and Services Administration in the U.S. Department of Health and Human Services.
“I think it’s fair to say telehealth is here to stay. It is not going away, people like it, providers like it,” said Camacho. But we need to address these patient barriers, these policy and coverage issues as well as enable our delivery system to provide access to telehealth in a way that is equitable to all of our patients.”