- A pair of studies published in JAMA Internal Medicine on Monday morning outline the many difficulties facing older adults, especially low-income seniors, in accessing telemedicine despite historic availability amid the COVID-19 pandemic.
- One found more than 41% of Medicare beneficiaries lacked access to a computer with high-speed internet access at home, and almost 41% lacked a smartphone with a wireless data plan. More than a fourth of beneficiaries didn't have either option, making it almost impossible for them to have a real-time video visit with a clinician at home.
- An estimated 13 million seniors, or 38% of all older adults in the U.S., were not prepared for video visits at all, mostly due to inexperience with technology, the second study found.
The Trump administration threw open regulatory barriers to telemedicine use for the duration of the national public health emergency beginning in March. Usage snowballed as a result among the commercially insured and those in public payer programs, like Medicare, which previously had very little access to telehealth.
Almost 1.3 million Medicare beneficiaries received virtual care services in the week ending April 18. That's compared to just 11,000 in the week ending March 7, according to CMS claims data.
Despite the surge in use, many experts are concerned that America's seniors, a demographic at high risk for serious complications from COVID-19, may not be getting the full benefits of telemedicine — especially its ability to keep them out of doctor's offices and hospitals, where they may be at higher risk for virus transmission.
And the gallop to digital delivery of care may have left more marginalized populations without access to high-speed internet, a smartphone or even a computer, behind.
One of the studies published Monday analyzed almost 640,000 Medicare beneficiaries' responses to the American Community Survey conducted in 2018, looking at computer access, internet speed and other digital access factors.
The 26.3% of members without access to an internet-enabled phone or computer were much more likely to be low-income, researchers found. Slightly more than half of beneficiaries below the federal poverty line lacked digital access, compared to just 11.5% of those with incomes 400% or more above the federal poverty line.
The population of Medicare beneficiaries without digital access was more likely to be 85 or older, widowed, have a high school education or less, be Black or Hispanic, have a disability or be covered by Medicaid, researchers Ateev Mehrotra, associate professor of healthcare policy at Harvard Medical School, and Eric Roberts, assistant professor of health policy and management at University of Pittsburgh, found.
In the second study, geriatrics researchers at University of California, San Francisco's department of medicine used results from last year's National Health and Aging Trends Study of 4,525 adults to analyze seniors' "unreadiness" of telemedicine.
Researchers defined unreadiness as difficultly hearing, difficulty seeing clearly, problems speaking or communicating clearly, having dementia, not having access to internet-enabled devices or knowing how to use them or not using email, texting or internet in the past month.
They found an estimated 13 million seniors unprepared for video visits, which require users to be online and operate or troubleshoot audiovisual equipment or software. That number dropped to 10.8 million, or 32% of seniors, assuming those who have caregivers or other social supports have people to help them set up and conduct the visits.
A fifth of older adults were probably unready because of dementia or problems hearing or communicating. Unready seniors were more likely to be older, men, unmarried, Black or Hispanic, residing in a rural area, lower educated, poorer and having worse health.
Since older adults make up roughly a fourth of all U.S. doctor visits and are more likely to have chronic conditions, disabilities and severe complications from COVID-19, ensuring equitable access to telemedicine is essential, researchers from both studies said.
During the national emergency, CMS is reimbursing for audio-only telelmedicine visits at the same rate as video visits, making telephone visits a good option for seniors without access to the internet, leery of novel technology or with visual impairments.
But experts worry audio-only visits may not have the same quality of care as an in-person or even video visit, especially in the many situations when visuals are important, like looking at a skin rash.
Researchers from both studies called on the federal government to address disparities in digital access and enact policies to bridge the digital divide. This could include expanding Federal Communications Commission programs to subsidize phone and internet service to poor Americans, investing in broadband access in underserved communities and requiring telehealth vendors to include more accessibility accommodations into their platforms.
"Although many older adults are willing and able to learn to use telemedicine, an equitable health system should recognize that for some, such as those with dementia and social isolation, in-person visits are already difficult and telemedicine may be impossible," UCSF researchers wrote.