- Telemedicine use skyrocketed last year amid the coronavirus pandemic, varying widely across patient demographics, medical needs and clinical specialties. But use was significantly lower in low-income areas, according to a new study of insured patients published in Health Affairs.
- In the first few months of the pandemic, more than 30% of all visits were provided via virtual care, and the weekly number of telemedicine visits increased twenty-three-fold compared with pre-COVID-19. But telemedicine use was much lower in communities with more poverty, with utilization for the lowest and highest quartiles of poverty rates coming in at about 32% versus 28%, respectively.
- The study also found specialties such as psychiatry, endocrinology and neurology had the highest uptake of virtual care, and the smallest decline in overall visits. That was especially true when compared to specialties like ophthalmology, which lost most of its volume early on in COVID-19 and had little telehealth use.
The new findings illustrate the magnitude of deferred care during the coronavirus pandemic. Even as telemedicine use soared to connect patients to healthcare, overall visits plummeted by 35%, according to the study, which analyzed total outpatient visits and telemedicine use from a database of almost 17 million commercially insured and Medicare Advantage enrollees from January to June of last year.
Though the scope of the drop varied across different clinical specialties and patient demographics, every segment of the healthcare system saw a drop in volumes, including patients managing high-risk chronic conditions, raising fears of worse health outcomes down the line.
By comparison, plummeting visit volume for low-risk respiratory conditions, such as bronchitis, are unlikely to have a lasting impact on the healthcare system as it likely reflects less virus transmission from social distancing measures and other COVID-19 mitigation efforts last year.
But overall, systems are likely to struggle making up deferred care, researchers said. The U.S. is still grappling with COVID-19, though newly reported cases and deaths are trending slightly down from mid-January highs. How easy it is to bring in delayed care will likely vary across specialties, as telemedicine adoption has been uneven based on specialties' need for physical exams or testing, according to the study.
Across specialties, telehealth use ran the gamut from a whopping 68% of endocrinologists, to just 9% of ophthalmologists. Ophthalmology clinics could have particular challenges resuming delayed care for retinal care using virtual methods, as diagnostic exams need specialized equipment.
By comparison, cognitive specialties like psychiatry rely less on the physical exam, and had the greatest uptick in telemedicine and smallest declines in overall visits. And chronic conditions were somewhere in between those two extremes, with conditions like hypertension and diabetes seeing a big drop in care volume mitigated by a large increase in telemedicine use.
As a result of the findings, researchers said health systems should allocate resources to reach out to patients with conditions that saw the largest drop in visit volume, while allocating more clinical capacity to specialties with the biggest backlog of delayed care and targeting people with chronic conditions for population management moving forward.
The study also found higher telemedicine use among insured people living in wealthier counties with a higher minority presence among residents during the pandemic, which is throwing a stark spotlight on existing inequities in the U.S. healthcare system.
Telemedicine use and overall outpatient access during the pandemic were lower in rural areas than urban areas, with just 24% of all care being performed virtually in rural counties versus 31% in urban. That's potentially due to lower broadband availability and consistent with the so-called "digital divide" in health access, researchers said.
The study didn't parse out the incidence of audio-only telehealth, which previous research shows is a valuable tool for low-income populations to access telemedicine without broadband or a smartphone. However, another study published in JAMA on Tuesday looking at telemedicine use at California federally qualified health centers from March to August found high use of audio-only visits among low-income patients.
In those months, 48.5% of all primary care visits occurred via telephone, compared to 48.1% in person and just 3.4% via video. Telephone visits peaked in the month of April, making up 65.4% of all primary care visits.
But the future of audio-only telehealth is unclear, as CMS has signaled it will stop reimbursing for telephone visits after the COVID-19 public health emergency ends. Nixing the audio-only coverage is likely to disproportionately affect low-income populations, exacerbating the digital divide, researchers warned.