By Clarissa Donnelly-DeRoven
Early in 2020, as the world shut down, health care providers scrambled to get online as patients clamored to get treatment via telehealth. In mere weeks, the ability to connect with a physician, psychologist or nurse through a computer exploded.
As novel as the explosion of telehealth was, the technology itself wasn’t new.
There are pockets in North Carolina where telehealth has provided access to care for years now. A school-based program in western North Carolina, for example, has existed for nearly a decade, while some clinics in eastern North Carolina have long used a virtual care clinic to connect with far-flung patients.
Although telehealth predates the pandemic, the service has grown massively since the pandemic arrived in North Carolina in March 2020. The unprecedented expansion provided researchers nationwide with a natural experiment: could more telemedicine mean more people will see a doctor? Could the expansion of telehealth help eliminate some disparities in access — especially for rural residents or for people who struggled with getting transportation to and from their appointments?
In North Carolina so far, the results aren’t straightforward: in some cases, telehealth helped people from historically marginalized groups access care more often. In other situations, the same inequalities that existed in person continued online.
“We were nervous about using telehealth with our populations prior to the pandemic and this kind of forced our hand,” said Evie Nicklas, the behavioral health program director at MedNorth, a community health center in Wilmington.
Ultimately, they’ve found that it helped a lot.
“A lot of our patients have last minute life changes — with transportation, with child care, with somebody in the house being sick,” she said. “Previously those things would have all meant no session, right? That we couldn’t have helped them, and now we can.”
Certain things didn’t work online. “Young kids were really challenging to do behavioral health with … so that’s a population we prefer in person” Nicklas said. “But I think overall our message is you need to have a relationship with your patients and talk to them about the pros and cons of telehealth and let them be a partner in deciding whether it’s right.”
The complicated data make sense, researchers say. Telehealth entered into a system that was wildly unequal: internet access isn’t evenly distributed, especially in a state with as many gaps in coverage as North Carolina. State residents also have deep inequities in insurance status or connection to a health care provider. Telehealth was never going to be the panacea for all the inequities plaguing the system.
But research on telemedicine uptake can show where the biggest gaps in these systems are, and who’s falling through them. And, hopefully, it can show policymakers where to focus their attention.
What kinds of care expanded to telehealth?
At the start of the pandemic, the federal Department of Health and Human Services announced a major change: for the duration of the public health emergency, medical providers could see patients via any telehealth medium. Throughout the COVID-19 emergency, these virtual visits did not need to be conducted using a HIPAA-compliant platform. Providers could talk to patients on the phone, or see them over Zoom or Google Meet or FaceTime — any platform they both had access to.
The federal agency that regulates Medicare and Medicaid announced it would expand reimbursement for these virtual visits, and so did many private insurance plans. Also, during these visits, clinicians could prescribe medications to new patients without first seeing them in person, something they couldn’t do in the past.
As people retreated to their houses to stop the spread of the novel virus, nearly everything went online. Just as quickly, researchers in North Carolina began looking at how the transition to virtual went for different kinds of patients receiving different types of care.
A student-run clinic at the UNC School of Medicine offers gender-affirming care to 30 to 40 trans patients. The clinic moved entirely online in March 2020, and after a few months, the students sent a survey to their patients. About half responded and all said they were satisfied with their virtual care.
The finding is limited but can offer encouragement to trans and gender-nonconforming patients who face many barriers to getting medical care, such as poverty, homelessness, and previous trauma associated with medical facilities. Expanding this care could be critical for young people, as at least one survey showed that trans youth who don’t have parental support express wanting access to telemedicine to support their medical transition.
North Carolina prisons also shifted much of their health care online. A survey of this population by UNC researchers showed mixed results. Incarcerated people expressed a more positive view of the telehealth experience if they didn’t have to wait very long and if their provider explained their diagnosis and treatment clearly. However, previous experience — positive and negative — with telehealth seemed to color incarcerated people’s description of their experience.
Mental health care made one of the most seamless transitions online. A national evaluation of telehealth data from private insurers by FAIR Health, a nonprofit consumer advocacy group, found that mental health consistently ranked in the top 10 types of virtual care delivered across the country.
Researchers in North Carolina wondered how moving this care to telehealth could impact no-show rates in psychiatry — a significant problem in the field. Psychiatry no-show rates for initial appointments are twice as high as other specialties, and previous research has shown that people who don’t show up to their appointments are more likely to end up in the emergency room for care later on.
The researchers’ evaluation of psychiatric visits in North Carolina holds promising results. They found that patients who scheduled audio-only appointments — both for first-time visits and returning appointments — had much higher attendance rates than in-person appointments.
An evaluation of a tobacco treatment program found that the clinicians reached more people through telehealth than they did in person and that their telehealth population proportionally had more young patients and Latino patients.
But, they also found virtual patients were less likely to start tobacco cessation medication than patients they met in person. The researchers suggested this could be because they were less effective communicators via remote visits, or it could be that people simply didn’t want to quit smoking with all the added pandemic stress.
What about low-income people?
Researchers at UNC have examined how uninsured residents used telehealth throughout the pandemic, while Duke researchers investigated similar questions about Medicaid recipients.
The UNC researchers found that after the federal expansion of telehealth, uninsured patients sought virtual care in greater proportions. Before the expansion, about 60 percent of patients in their sample who were seen via telehealth didn’t have insurance. After the expansion, that proportion rose to 80 percent.
It’s impossible to know for sure why this number rose so starkly, but the researchers offer two possible explanations: perhaps “uninsured patients resided in regions with limited access to healthcare and the availability of telehealth during the pandemic allowed them to proactively seek care.” Alternatively, some of the uninsured patients post-expansion could’ve already been active patients who lost their jobs and became uninsured due to the pandemic.
Rebecca Whitaker is one of the leaders of the Duke-Margolis Center for Health Policy. At a virtual presentation of her team’s findings, Whitaker said that telehealth is helpful and should be integrated into clinical practices, but it did not close racial and geographic gaps in care.
In one analysis, they found that children and adults who were Black, Latino or mixed race were less likely to become telehealth users than white people. They also found that rural children and adults were no more likely to seek virtual care after the expansion of telehealth than they were before.
They did find that people with Medicaid who were already using telehealth before the pandemic were likely to stick with virtual care, meaning the expansion helped certain low income residents maintain access to their medical providers.
“Those who did use telehealth during the pandemic, we find overall a much larger proportion of beneficiaries with increased medical or behavioral health complexity,” said Rushina Cholera, a pediatrician and professor. “So those in the blind and disabled group, or those eligible for the tailored plan group — those two groups were much more likely to use telehealth to continue access to care during the pandemic.”
They found a similar pattern among Medicaid beneficiaries who received virtual physical and occupational therapy.
“Historically there’s been a lot of barriers to care in [musculoskeletal] services,” said Katherine Norman, an occupational therapist and doctoral student in population health at Duke. There aren’t as many options for care in rural communities as there are in urban and suburban areas, she said, which causes travel time and cost to be a significant burden for those communities.
“Limited research to date has shown that telehealth can solve some of these barriers,” she said.
Her team found that adults accessed virtual physical and occupational therapy more than kids, with the highest proportions happening in the Triangle. While rural residents accessed this care less than people in cities, telehealth did enable many to get the care they needed, which, perhaps, they wouldn’t have been able to before.
Audio-only coverage
While audio-only visits were not very common in the Duke study, the researchers found these visits were disproportionately used by certain populations. For musculoskeletal issues, Black Medicaid recipients as well as those who qualified for the program due to pregnancy or disability used audio-only visits more than video visits. And for behavioral health visits, rural and indigenous Medicaid recipients had high rates of audio-only visits.
Another study examined telehealth uptake among North Carolina patients with liver disease. Those researchers also found that older people, people of color and people on Medicaid all used audio-only visits more than other groups.
Inside the Senate bill proposed to expand Medicaid, lawmakers included a telehealth provision. It would enshrine many telehealth protections, including prohibiting insurers from refusing to pay for a virtual visit that they would’ve covered had it taken place in person. But the bill mostly left it up to insurers whether or not to cover audio-only visits.
Researchers argue that given the evidence showing how historically disadvantaged groups use audio-only visits at high rates, the coverage should remain, or telehealth risks further cementing health disparities.
Nicklas, from the Wilmington clinic, echoed these points. Audio-only visits were not only critical for their Spanish-speaking patients — about 50 percent of their client population— but also for everyone.
“Just anyone and everyone,” she said. “Especially the option even to transition to audio-only — so maybe technology was working well and then something happens. Maybe the kids came home and now they’re using the data, or whatever. Things change so being able to use audio as we need to is super important for us.”
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