David Sandman

David Sandman

It seems like we were forever being told that telehealth was going to be a bigger and bigger part of health care.

We’d gotten used to doing everything else online — shopping, banking, keeping up with friends and family on social media — so health care couldn’t be far behind. The most optimistic acolytes said it would improve access, lower costs, and be convenient. And since millennials are thought to do almost everything online, telehealth was certain to grow. Except it didn’t. A 2019 survey found that only 8% of patients had used telehealth (although two-thirds said they were interested in trying it). The revolution never happened.

But then COVID-19 happened. A health care facility was about the last place anyone wanted to be if they could avoid it. We were sheltering at home, and visiting a doctor, clinic, or hospital didn’t seem safe. If you could avoid or postpone care, you did. Spending on health care services (excluding prescription drugs) was down 38% in April 2020 compared with the previous April, with particularly sharp drops in dental services (down 61%), hospitals (down 43%), and physician services (down 37%).

I’m one of those statistics. I’m in good health except for high cholesterol that I manage with medication, diet, and exercise. I get my blood tested every six months and then see my primary care doctor to review the lab results and refill my prescriptions. Very routine. So I put off my care. There was no need to go anywhere near a lab or my doctor’s office, and I was living about 100 miles away from home anyway, so it was impractical. I figured the trade-off of delaying care was worth it.

That was months ago, and COVID-19 is still very much a threat. The situation isn’t nearly as dire in New York City as it had been months ago, but it’s still real. And after months of waiting, it was time to check in with my doctor. The best solution was a telehealth visit with him.

I’m hardly the only one to make that choice for the first time. Since COVID-19, the telehealth revolution arrived in force and virtually overnight. Before the pandemic, one analysis found that telehealth accounted for less than 0.01% of all ambulatory health care visits in the United States. In April 2020, 69% of visits were done by telehealth. It has leveled off some since then — by July, telehealth represented 21% of all visits. But still, the growth is phenomenal.

In my own experience with telehealth, I found it easy to book the appointment. In fact, the mega health system that my doctor belongs to sent multiple emails and texts practically begging me to come back for care, and telling me how safe and sanitized everything was in the office. And if I wanted to, I could have telehealth instead. I booked an appointment through the portal and that was that. For me, it worked just fine. My visit was short and straightforward, and it really was a better, safer, and more convenient substitute. But had my needs been more complex, I’m not sure it would have worked so well or that I’d have had confidence in it. If I was sick or had symptoms that needed to be examined, I’d want an old-time, in-person visit.

So yes, I do think telehealth is here to stay — at least to a greater extent than ever before. In something of a silver lining, it was remarkable how fast the regulatory and reimbursement barriers that had existed for years melted away almost overnight. Providers built their capacity pretty quickly, insurers started paying for it, and people adapted during a crisis. There’s still work needed to refine the rules and payment levels. But the train has left the station.

And like every other technology, telehealth could either narrow or widen disparities. For people in rural areas, who may have to travel long distances to see a doctor in person, telehealth offers obvious advantages. Access to health care is a top issue in rural communities, where health care professional shortages are common and transportation may be limited, particularly for older and low-income residents. Telehealth offers a solution to those barriers. But a lack of high-speed internet access in many rural communities creates challenges for reliable telehealth services.

We also see substantial disparities in access to telehealth services by race and ethnicity. A study of telehealth use in New York City during the pandemic found that Black and Hispanic patients were less likely to use telehealth — rather than seeking in-person care in the emergency room or a doctor’s office — than their white or Asian counterparts. These disparities persist even after accounting for other factors like age, illness, and language preference. The researchers found that barriers to telehealth for Black and Hispanic patients could include “disparities in digital access, digital literacy, and telehealth awareness, as well as issues of cost and coverage, and mistrust of digital appointments where physical examinations, labs and vitals cannot be taken.” As telehealth goes mainstream, we need to make sure its growth is equitable and doesn’t leave some patients behind.

One last thing: turns out my doctor is always late for our appointments, whether in person or virtual. I’m used to sitting in his waiting room and stewing. I put up with it because he’s a good clinician. But staring into the screen for 30 minutes and being unsure of whether he’d even show up was extra annoying. No matter where it happens, care needs to be patient-centered, compassionate, and responsive to each patient’s needs and preferences. That revolution has to happen now.

By David Sandman, President and CEO, New York State Health Foundation
Published in Medium on October 19, 2020
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