Telehealth and the COVID-19 pandemic
— Adapted from Cancer Support Community, our national headquarters —
Telehealth and tele-mental health services are medical care and mental health services that are provided to patients from their doctors over a computer, smartphone, tablet, or via the telephone. Use of these services experienced a rapid growth during the COVID-19 pandemic. In 2019, before the pandemic, only about 11% of people across the United States used telehealth services (Bestsennyy et al., 2020). Soon after the public health emergency (PHE) was declared in early 2020, federal and state government agencies provided new flexibilities for telehealth and tele-mental health services to allow patients to see their doctors from the safety of their homes and to reduce interruptions to care. Just a couple of months into the pandemic, telehealth usage grew significantly to 46% (Bestsennyy et al., 2020).
As the use of telehealth and tele-mental health services continued to grow, disparities in access and usage were also exposed. The COVID-19 and Cancer Coalition is a group of nearly 40 key cancer patient and provider organizations that work to understand the pandemic’s impact on the cancer community and develop evidence-based solutions. The group met recently to focus in on health equity both during the pandemic and beyond. The coalition was joined by Larry Irving from the Irving Group to discuss the role of telehealth in supporting health equity.
How can telehealth support health equity?
Telehealth has helped increase access to medical care and mental health services at a time when the pandemic limited patients’ ability to see doctors in-person. As we begin to look beyond the pandemic, there is an opportunity to continue to leverage telehealth and tele-mental health services in a way that breaks down barriers to care and advances health equity. Health equity is achieved only when everyone has the opportunity to be as healthy as possible and no one is disadvantaged from achieving these health outcomes because of socially determined circumstances (National Cancer Institute, 2020).
Virtual doctors’ appointments can help reduce barriers (for example, lack of transportation, the inability to take off work, and finding childcare) that have prevented people from accessing in-person health care. In cancer care, studies have shown that telehealth appointments in addition to in-office visits can provide beneficial mental health and symptom relief to patients experiencing certain types of cancers (Larson et al., 2020).
Proximity to doctors and specialists presents a barrier to quality health care for many people living in rural areas. While nearly 20% of people in the United States live in rural communities, fewer than 10% of U.S. physicians practice in rural communities (NCSL, n.d.), and historically these communities have “faced lower access to healthcare, health services, and health insurance compared with urban settings” (Hirko et al., 2020). The expansion of telehealth and tele-mental health services holds huge potential for reducing health disparities for patients who live in rural areas (Hirko et al., 2020).
Some of the new flexibilities that were created in 2020 expanded the usage of telephone-only (also known as audio-only) visits. This has been vital for people without internet access, those without a device with video capability, people with disabilities, and those unfamiliar with technology. One recent study showed a decline in rates of missed appointments in patients experiencing homelessness, due in part to them accessing telehealth services, particularly telephone visits (Salhi et al., 2021).
While many people have been able to access care using only a telephone, patients may need to access telehealth and tele-mental health services via video, which requires internet and a technological device, like a computer or smartphone. This requirement can create an additional barrier to care, and it is critical that increased access to high-speed internet be prioritized so that everyone can utilize telehealth and tele-mental health services when appropriate.
The COVID-19 pandemic has highlighted longstanding disparities in our health care system. Health disparities occur when certain populations have an unequal burden of disease, like cancer or COVID-19, due to social, environmental, and economic factors.
The pandemic exposed similar disparities in access to internet connectivity across the United States — known as the digital divide. This digital divide is due in part to a lack of a broadband access (high-speed internet) for many people. Recent data reveals that 23% of adults in the United States still do not have home broadband (Pew Research Center, 2021), and access to the internet varies across different demographic groups. For example:
- 80% of white adults in the United States have home broadband, while only 71% of black adults and 65% of Hispanics do (Pew Research Center, 2021)
- 92% of people making $75,000 or more a year have home broadband, while only 57% of people making less than $30,000 do (Pew Research Center, 2021)
- Only 72% of rural households have access to broadband at home (Pew Research Center, 2021)
- Nearly 7 in every 10 residents on tribal lands lack home broadband (American Library Association, 2018)
For many people who do have access to the internet, other factors such as the relatively high cost of high-speed internet or low skill or comfort level with technology may keep them offline and possibly unable to access telehealth services. The Pew Research Center found that:
- 25% of people 65 years and older do not use the internet compared to just 3% of people 30-64 years old
- 99% of people making $75,000 or more a year use the internet, while only 86% of people making less than $30,000 do
During the COVID-19 and Cancer roundtable, Larry Irving discussed how internet access is close to a human right, as someone cannot be a full participant in today’s society without it. The lack of connectivity impacts a person’s ability to participate in school, work, and health care. For example, lack of internet access or limited digital knowledge meant that millions of people could not register online for COVID-19 vaccinations.
Advancing health equity using telehealth requires a combined effort to:
- Expand coverage of telehealth and tele-mental health services
- Close the digital divide
- Break down other barriers that may prevent people from receiving health care virtually
It is critical that Congress, the Biden Administration, and state governments examine ways to expand broadband and increase connectivity to ensure that everyone has the tools needed to access telehealth and tele-mental health services. The Cancer Support Community strongly recommends that policymakers permanently extend current flexibilities in telehealth and tele-mental health services beyond the public health emergency, including telephone-only, to ensure cancer patients may continue to safely access health care services into the future. As Congress begins to re-shape telehealth and tele-mental laws, it is important that patient perspectives be incorporated to ensure policymakers fully account for the needs of all people, including those with cancer.
While telehealth can reduce disparities caused by unequal health care access, it is only one strategy to achieving health equity. The inequitable access to comprehensive, quality, and affordable care, including cancer care, is a public health crisis. It is vital that all people have an opportunity to achieve the best health outcomes, no matter their race, ethnicity, gender, age, sexual orientation, socioeconomic status, or zip code.
American Library Association. (2018). A Broadband Imperative.
Bestsennyy, O., Gilbert, G., Harris, A., & Rost, J. (2020). Telehealth: A quarter-trillion-dollar post-COVID-19 reality? McKinsey & Company.
Hirko, K. A., Kerver, J. M., Ford, S., Szafranski, C., Beckett, J., Kitchen, C., Wendling, A. L. (2020). Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities. Journal of the American Medical Informatics Association.
Larson, J. L., Rosen, A. B., & Wilson, F. A. (2020). The effect of telehealth interventions on quality of life of cancer survivors: A systematic review and meta-analysis. Health Informatics Journal, 1060–1078.
National Cancer Institute. (2020). Cancer Disparities.
National Conference of State Legislatures. (n.d.). Closing the Gaps in the Rural Primary Care Workforce.
Pew Research Center. (2021). Internet/Broadband Fact Sheet.
Salhi, R. A., Abir, M., & Salhi, B. A. (2021). No Patient Left Behind: Considering Equitable Distribution Of Telehealth. Health Affairs Blog.