At the start of the Covid-19 pandemic, the Centers for Medicare and Medicaid Services and private insurers made the timely decision to rapidly expand coverage for telehealth visits, throwing a lifeline to millions of Americans who needed ongoing medical care despite nationwide stay-at-home orders.
At the time, virtual visits done by video or by telephone were covered at the same rates as conventional, in-person office visits.
Since then, telehealth has become an indispensable part of the U.S. health care system, helping provide patients with safe access to medical care. While video visits have some advantages over telephone visits, they require access to technology, digital literacy, and broadband internet access that are far from ubiquitous. Telehealth access that includes telephone-only visits can help reduce certain health care disparities, as these low-tech visits provide access to essential health care for many whose alternative is no care at all.
As primary care physicians on the South Side of Chicago, we care for patients from some of the most underserved neighborhoods in the city who are already plagued by lack of health care infrastructure, medical and pharmacy deserts, and countless other forms of structural racism. Digital redlining — systematically excluding low-income neighborhoods from broadband service and digital technologies — has further worsened long-standing inequities, leaving many vulnerable patients on the wrong side of the digital divide.
We studied 50,000 telehealth visits completed between late March 2020 and the end of May 2020 at our institution, UChicago Medicine. Of these, 60% had been done by video and 40% by telephone. Our research showed that patients with lower levels of internet access and less comfort with technology were less likely to have completed video visits. These tended to be older adults, Black people, and Medicare and Medicaid beneficiaries. These findings were not an anomaly: Our data matched other studies on virtual visit use during the pandemic. After a full year and more than 210,000 virtual visits, 20% of telehealth visits at our health system continue to be telephone-only encounters for primary care, chronic disease management, and other essential health services for high-risk patients.
Concerns over disparities perpetuated by virtual visits were echoed by clinicians in a survey we conducted of nearly 350 providers at our medical center. Clinicians reported that their greatest barriers to virtual visits were patient barriers, highlighting limitations in patients’ digital literacy, access to technology, and reluctance to attempt video visits. When we surveyed patients about their experiences with video and telephone visits, we heard similar sentiments: “Everything is, ‘Go online. Go online,’” or, “We old-schoolers know nothing about going online. We’re limited in the information we can get.”
Meaningfully addressing the digital divide will require targeted patient outreach and education efforts, in addition to addressing technology access.
Eliminating coverage for telephone-only telehealth visits would disproportionately affect underserved communities that face barriers to accessing video technology. We urge CMS, commercial payers, and state governments to heed the call from groups like the American Medical Association and state medical associations to continue reimbursement and payment parity for telephone visits as a matter of health equity.
As CMS’s own long-term strategy for value-based programs states, health care should be incentivized and reimbursed based on the value of the care provided. Telehealth should be afforded the same flexibility, allowing coverage based on the quality and outcomes of the care provided to patients based on their needs, regardless of whether it is delivered in person, by video, or by telephone.
Community and health care leaders, in partnership with state and federal policymakers, need to work together to develop multimodal strategies to narrow the digital divide with investment in universal broadband, telemedicine infrastructure, and support for patients. Until we can adequately address these inequities, telephone visits remain an essential low-tech, high-value alternative to video visits and a vital bridge across the digital divide for many of the country’s highest risk patients.
Sachin D. Shah is an internist and pediatrician, associate professor of medicine and pediatrics, and associate chief medical information officer at the University of Chicago. Lolita Alkureishi is a pediatrician and associate professor of pediatrics at the University of Chicago. Wei Wei Lee is an internal medicine physician, associate professor of medicine, and associate dean of professional development and engagement at the University of Chicago.