Rick Newell, MD MPH is CEO of Inflect Health, Chief Transformation Officer at Vituity, and passionate about driving change in healthcare.

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As healthcare continues to evolve, new technologies like remote patient monitoring, virtual reality and telemedicine have expanded the scope of care delivery. McKinsey reports 46% of consumers used telehealth solutions in 2020, up fourfold from just the prior year. As the CEO of a healthcare innovation and investment hub, I believe that in the future, conceivably 90%-95% of all interactions have the potential to be done without an in-person visit.

This shift in patient-physician interaction from same-location to location-agnostic means patients could soon receive the vast majority of their care from anywhere, delivered by a provider who is anywhere. This paradigm shift could produce greater access to care for anyone, including, and especially, for historically underserved or otherwise marginalized communities. The upshot: the vast potential for improved outcomes and a narrowing of the care gap between communities. 

Although this sounds great in theory, would it actually work in practice? How do we know if telehealth would help serve as an equalizer rather than exacerbating preexisting inequities? This is especially important when it comes to where, how and the extent of care people can receive and, crucially, afford.

An Unlevel Playing Field

A late 2020 study published in the journal Population Health Management examines telehealth use inequities during the pandemic. People in urban areas — where doctors and care facilities are already plentiful in supply — were more likely to use telehealth solutions than those in rural areas. The same was true of people in wealthier versus less affluent locales. Telehealth users were also more likely to be employed, insured and younger. In short, “Preliminary findings indicate that inequities in telehealth use persist and require ongoing monitoring.”

Part of this inequity can be explained by a gap in connectivity: The study found that 97% of those living in affluent urban areas have reliable access to broadband. When that same figure was measured in rural or remote areas, it dropped to 65%.

Still, addressing those imbalances in telehealth adoption may come down to a matter of trust. Dessiree Paoli writes in Medical Economics, “Many communities don’t trust healthcare institutions because of a history of discrimination. Patients in minority communities are more likely to feel like they can’t openly communicate with their doctors and nurses and fear poor quality of care.”

Growth Potential

Through my experience in the telehealth space, I've seen that these services can help with chronic disease management and shift the focus from illness to wellness, particularly for underserved populations. Historically, care has been episodic and transactional, but for telehealth to become more holistic and relationship-centric, there’s work to be done to make broadband real for communities that still don’t have it. 

Assuming greater technology access, the providers who flourish will be those who develop trusting relationships, offer a wide array of services and effectively engage the patient and community in their own care.

A way to help facilitate that trust is to increase representation from marginalized communities in medical programs and work telemedicine into an educational curriculum. Marginalized populations may be less likely to trust caregivers, but that distrust could be alleviated when patients and their providers share similar ethnicities, genders, cultural literacy or lived experiences.

Reimbursement And Rethinking

Perhaps the biggest obstacle to solving telehealth inequities may lie in the U.S. care delivery ecosystem itself, particularly around reimbursement. According to Becker’s Hospital Review, 72% of healthcare workers (registration required) cite reimbursement as their firm’s number one challenge. Healthcare executives agree: Nearly two-thirds named declining reimbursements as their organization’s top challenge.

Reimbursement is substandard and particularly so with government payers. Medicaid and Medicare make up more than half of health plan premiums combined, and government payer reimbursement lags disproportionately affect the most marginalized. Challenges are many, and well-defined codes to support novel delivery models are few. The private sector adjusted to and adopted telehealth technologies far more quickly and efficiently.

Governmental payers have a significant opportunity to address payment reform and further aid underserved populations. These reforms should compensate providers in a way that makes economic and common sense for all. 

By addressing the payer ecosystem, increasing equitable representation to education in the health sciences, fostering trust between providers and patients, and expanding broadband connectivity to rural and remote areas, I believe inequities in telehealth adoption can be mitigated. 

Yet this summary should give us pause: Telehealth on its own does not appear likely to democratize care equitably unless more work is done in and around the greater healthcare system. If we’re not mindful, instead of using telehealth to help us win the battle against inequality, we may find it instead contributes to it.