Research Teams: Policy, Payment, Issues Need to Be Addressed to Advance Telehealth Among Seniors

Recently, two teams of medical researchers looked at telemedicine readiness in the context of the COVID-19 pandemic. One of the teams published an article in JAMA Internal Medicine, and the other, a research letter affiliated with that article, also in JAMA Internal Medicine; both items were published on August 3.

“Assessing Telemedicine Unreadiness Among Older Adults in the United States During the COVID-19 Pandemic” was authored by Kenneth Lam, M.D., Amy D. Luc, M.D., Ying Shi, Ph.D., and Kenneth E. Covinsky, M.D., M.P.H., and published on August 3. And “Assessment of Disparities in Digital Access Among Medicare Beneficiaries and Implications for Telemedicine,” a research letter, was written by Eric T. Roberts, Ph.D., and Ateev Mehrotra, M.D., M.P.H.

As Lam et al wrote in the full-length article, “There has been a massive shift to telemedicine during the coronavirus disease 2019 (COVID-19) pandemic to protect medical personnel and patients, with the Department of Health and Human Services and others promoting video visits to reach patients at home. Video visits require patients to have the knowledge and capacity to get online, operate and troubleshoot audiovisual equipment, and communicate without the cues available in person. Many older adults may be unable to do this because of disabilities or inexperience with technology,” they noted, stating that “This study estimated how many older adults may be left behind in the United States in the migration to telemedicine.”

As Lam et al noted, “Older adults account for 25 percent of physician office visits in the United States and often have multiple morbidities and disabilities. Thirteen million older adults may have trouble accessing telemedical services; a disproportionate number of those may be among the already disadvantaged. Telephone visits may improve access for the estimated 6.3million older adults who are inexperienced with technology or have visual impairment, but phone visits are suboptimal for care that requires visual assessment. Policies should recognize and bridge this digital divide,” they emphasized.

“As of early 2020, the Centers for Medicare & Medicaid Services was reimbursing telephone visits at rates matching in-person and video visits, aligning reimbursement with reality for those who cannot use video visits. As telemedicine becomes ubiquitous, telecommunication devices should be covered as a medical necessity, especially given the correlation between poverty and telemedicine unreadiness. Furthermore, accessibility accommodations, such as closed captioning for those with hearing impairment, should be extended to virtual visits. A major limitation of this study was selection bias resulting from loss to follow-up, which would underestimate the prevalence of unreadiness if loss to follow-up was associated with poor adherence to telemedical care. Although many older adults are willing and able to learn to use telemedicine,6 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. For these patients, clinics and geriatric models of care such as home visits are essential.”

Meanwhile, in “Assessment,” Drs. Roberts and Mehrotra wrote that, “In response to the coronavirus disease 2019 (COVID-19) pandemic, Medicare temporarily expanded its coverage of telemedicine to all beneficiaries, included visits in the patient’s home, and began paying for audio-only visits at the same rate as video and in-person visits. Previously,” they wrote, “Medicare (with a few exceptions) limited telemedicine coverage to video visits for rural beneficiaries and required video visits to take place at a medical facility, such as a physician’s office, rather than at a patient’s home. Access to technology at home and the ability to use technology may affect use of video or audio-only telemedicine visits by Medicare beneficiaries. Although evidence on the efficacy of video vs audio-only visits is lacking,4 audio-only visits might be inadequate in some situations, such as when visual monitoring or diagnosis is important for care. We examined disparities in digital access (i.e., access at home to technology that enables video telemedicine visits) among Medicare beneficiaries by socioeconomic and demographic characteristics.”

Further, Roberts and Mehrotra noted, “Using data from 2018, we found that 26.3 percent of Medicare beneficiaries lacked digital access at home, making it unlikely that they could have telemedicine video visits with clinicians. The proportion of beneficiaries who lacked digital access was higher among those with low socioeconomic status, those 85 years or older, and in communities of color. Although Medicare’s payment for audio-only visits at the same rate as video and in-person visits may be associated with improved access to care for those without digital access, the inability to have a video visit may be associated with increased disparities in access to care. Moreover, some Medicare beneficiaries are unable to use technology for video or even audio visits. Limitations of our study include the lack of data in the ACS on beneficiaries’ ability to use technology or community-level broadband internet availability. During the COVID-19 pandemic, federal telemedicine policy has focused on reimbursement and clinicians’ capacity to deliver care remotely.1 Our results underscore a need to address disparities in digital access among patients. Expanding programs such as Lifeline, a program of the Federal Communications Commission that provides reduced cost phone or internet service to families with incomes 135% or more below the federal poverty level,5 may help reduce disparities. However, Lifeline does not pay for devices, and patients may also need assistance using technology for video visits. Addressing these factors associated with digital access in populations with low socioeconomic status will be important as the use of telemedicine increases.”

Following the publication of both articles, Dr. Roberts spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding these important issues. Below are excerpts from their interview.

With regard to the challenges involved in shifting to virtual care, what were some of the core questions you and your fellow author wanted to examine?

We were interested in understanding whether, on the user side, these barriers would be challenging.

Was that 26.3 percent figure higher than what you had expected, lower, or about what you had expected?

I don’t know that it was particularly surprising. We know that older populations have lower technological access. What was interesting was drilling down—that becomes 50 percent when you look at very-low-income, disabled, and very elderly populations.

And another paper [Lam et al] looked at ability to access digital technology. They estimated that 13 million Medicare beneficiaries lacked help or social support to use digital technology. So to put that into perspectives, roughly 55 million Medicare beneficiaries overall. So one-quarter of Medicare beneficiaries, according to this other estimate, face challenges in getting help using digital technology.

So that’s a sizeable portion of the Medicare population that would not easily be able to receive telehealth visits, both because they lack the technology, but also because they lack the ability to use it. We found that that percentage is heightened when it involves highly disadvantaged seniors.

Would it help a lot for health systems to provide seniors with iPads and other technologies?

I think how they do it would matter, and whether they’re augmenting their efforts by providing help in using the technology.

How do we knock down barriers and make this all more possible?

There are probably a few steps involved here. CMS definitely took a step in the right direction by paying for telephonic visits at the same rate as video-based, under the public health emergency. There’s not certainly that voice-only visits will be covered beyond the end of the calendar year. So flexibilities afforded by coverage of voice-only visits is helpful; I don’t think anyone would argue that voice-only visits could replace what is accomplished in video-based visits. And there are efforts to expand access; FQHCs were given some money from the CARES Act to help them with technology. It has to be accompanied by providing help to individuals; putting an iPad into someone’s hand doesn’t necessary imply that they’re ready to use it.

And when mention in the piece. The Lifeline Program is an FCC-funded program to provide wireless service to low-income individuals; Congress could continue to fund that, for example. Lifeline doesn’t pay for devices right now, so another option might be some subsidy for device purchase for seniors. And there are probably opportunities for partnerships among providers, CMS, and the FCC. The devil will be in the details in terms of targeting those who need it most. So dual-eligibles will be disproportionately lacking, and so should be disproportionately the focus of efforts. And the other key element is that social support, the lack of help needed to navigate the technology.

And a physician noted to me that COVID has become a crisis of loneliness; it has profoundly isolated individuals, including within healthcare delivery. And those populations are both less digitally connected and less socially connected. And a consequence of that is that it’s harder to get them the care they need; and it’s also harder to address their social concerns. We need to address systemic isolation among our vulnerable citizens.

How will this play out in the next few years?

Video and telemedicine are here to stay. I think this is a paradigm-changing event. And CMS will be covering more video-based telemedicine-based care. The upside is that if we’re able to address some of the technological and access issues, there are potential benefits to reducing that physical barrier of going to the doctor, for disabled people. But we probably need a set of prognostic tools to determine who can make use of video tools and who needs to see their doctor in person. And we need to look at the appropriateness of home care for some. There’s probably a subset of the population for whom the video visits are just not enough. So we need to start thinking about whether home visits from nurses or nurse extenders that we haven’t paid for previously.

What should hospital, medical group, and health system leaders be thinking about all of this right now?

We’ve obviously, and rightly so, discouraged the most physically vulnerable from going to the doctor’s office in person, at the height of the pandemic. I think that hospital and medical group leaders recognize that many individuals may have serious concerns about going to a doctor’s office or hospital for care. There will be a subset of patients who are particularly vulnerable, but who are also predisposed to poor health outcomes. So the patients who are being discouraged from coming in for a visit, but who may not have the means to do video visits, are ones we need to be particularly concerned about. So we need to think about technology but also about home care visits to accommodate different needs, at a time when really vulnerable patients face the challenges of technological access but also vulnerability in terms of accessing traditional sites of care.