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Report highlights uneven use of telehealth services based on age, ethnicity, access to technology

Erica Taylor, nurse director for the Telehealth Program at Landstuhl Regional Medical Center, demonstrates using the Telehealth cart otoscope to conduct a real-time tympanic membrane exam. On screen is Physician Assistant Steven Cain who from a remote location can see and evaluate the patient and provide an appropriate plan of care.
Phil Jones
Army Medicine
Erica Taylor, nurse director for the Telehealth Program at Landstuhl Regional Medical Center, demonstrates using the Telehealth cart otoscope to conduct a real-time tympanic membrane exam. On screen is Physician Assistant Steven Cain who from a remote location can see and evaluate the patient and provide an appropriate plan of care.

The shift toward telehealth as a regular method for care illuminated the digital divide across different socioeconomic lines, according to a new report by researchers and health plan organizations.

Noticing the longstanding health inequities that the COVID-19 pandemic brought to light, the Massachusetts Association of Health Plans (MAHP) began the study early in the pandemic to research the uneven uptake of telehealth usage, said MAHP vice president of advocacy and engagement Elizabeth Leahy.

"In the very early stages of the COVID-19 pandemic, we were already starting to see a very disparate impact of the virus, and we knew Black and brown communities were seeing higher rates of infection," Leahy said. "Even in those early days, our health plan members were seeing inequities in uptake of telehealth usage."

MAHP partnered with the Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute, along with Massachusetts Health Quality Partners (MHQP), to look at telehealth use before and during the COVID-19 pandemic.

"Telehealth is here to stay," said Alon Peltz, researcher on the report and Harvard Medical School assistant professor of population medicine.

Researchers concluded that the oldest and youngest Bay Staters visit the doctor in-person more frequently, as do lower-income, minority and rural populations, after analyzing data from 1.8 million health plan members between January 2019 and December 2021.

Seniors and children received less of their primary care by telehealth compared to adults, visiting the doctor online 24 percent and 23 percent of the time, respectively.

Nathalie McIntosh, senior director of programs and research at MHQP said, for seniors, low telehealth use could be caused by a combination of technology barriers and the routine and comfort of visiting their doctor in person.

"We found older people who were very tech savvy... and we found older people who were very anxious about using the technology," McIntosh said. "We also had people whose preference it was to see their doctor in person. And that seemed to be a cultural preference, they felt they had more of a relationship."

Researchers spoke to some people -- including seniors and those who don't speak English as a first language -- who do not own a cellphone or, if they do, don't know how to use the video feature, McIntosh said. "Audio telephone visits were really helpful" for these populations, she said.

For younger adults who did not use telehealth, she said this was not as much a matter of digital literacy, but an indicator of limited access to primary care providers in general.

"To have a telehealth visit, you really need to have a usual source of care, because it's a scheduled visit," she said. "For those individuals I spoke to who did not use telehealth at all, it was more or less related to not having a usual source of care. And for the most part, these were younger people who didn't feel they needed a usual source of care, and if they had an emerging acute condition they would go to the ER."

Regionally, telehealth uptake was higher in greater Boston and other densely populated areas of eastern Massachusetts and lower in central and western Massachusetts -- except some cities and towns in the Pioneer Valley, where telehealth made up more than 43 percent of visits.

Still, telehealth usage was high across the state for behavioral health care, with an average 75 to 80 percent of all mental health visits conducted virtually each month.

With the vast majority of patients already using telemedicine for their mental health, Gov. Charlie Baker signed a telehealth law in January 2021 that mandated permanent payment parity for telemental health services.

At the time, he told the News Service the law would give people "more options to access care and supports."

People who have less access to technological devices and broadband internet, or lack the digital literacy to use the technology, used telehealth less than others in the state, the study found, leading to socioeconomic and racial divides in telehealth access.

Virtual visits made up about 26 percent of all doctor's appointments in poorer communities compared to 31 percent in more affluent towns and cities, the report found. However, there was little difference between communities in the rates of telehealth use for care of chronic conditions.

These lower income communities also had higher numbers of Black and Hispanic residents than other areas of the state.

The issue of equity and accessibility across the "digital divide" is not a new topic -- just at a new frontier with health care.

Former Boston Mayor Thomas Menino said in 2006, "It is critical for us to close the digital divide that separates us into have and have-not populations," when he created a task force to bring wireless Internet to the city.

Peltz said health plans can use this data to "drive policy moving forward to close inequities that have formed" in access to telehealth care.

Researchers included 10 recommendations for health plans to help close this gap. The issue of health equity appears to be at the forefront of health care policy decisions across Massachusetts, as it was also a key goal in this year's annual health care cost trends report from the Health Policy Commission.

For the MAHP/Harvard study, researchers recommended that health plans enhance screening for digital affordability and streamline enrollment in underutilized public benefit programs to make the internet and devices more affordable, as well as building referral partnerships with community-based organizations that can provide digital literacy trainings.

The report also says adopting simplified and uniform approaches to telehealth coverage would improve accessibility.

Finally, the researchers recommended publishing a new report every three years on overall progress toward digital health equity in Massachusetts.

"We have a health equity workgroup, so we'll share these recommendations... and prioritize," Leahy said. "There's a lot of coalition building that will need to happen as we move forward."

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