Disparities in Telehealth Utilization in a Population of Publicly Insured Children During the COVID-19 Pandemic

The role of increasing synchronous telehealth use during the COVID-19 pandemic on disparities in access to healthcare: A systematic review

INTRODUCTION

The COVID-19 public health emergency led to an unprecedented rapid increase in telehealth use, but the role of telehealth in reducing disparities in access to care has been questioned. The objective of this study was to conduct a systematic review to summarize the available evidence on how telehealth during the COVID-19 pandemic was associated with telehealth utilization for minority groups and its role in health disparities.

METHODS

We conducted a systematic review focused on health equity and access to care by searching for interventional and observational studies using the following four search domains: telehealth, COVID-19, health equity, and access to care. We searched PubMed, Embase, Cochrane CENTRAL, CINAHL, telehealth.hhs.gov, and the Rural Health Research Gateway, and included any study that reported quantitative results with a control group.

RESULTS

Our initial search yielded 1970 studies, and we included 48 in our final review. The most common dimensions of health equity studied were race/ethnicity, rurality, insurance status, language, and socioeconomic status, and the telehealth applications studied were diverse. Included studies had a moderate risk of bias. In aggregate, most studies reported increased telehealth use during the pandemic, with the greatest increase in non-minority populations, including White, younger, English-speaking people from urban areas.

DISCUSSION

We found that despite rapid adoption and increased telehealth use during the public health emergency, telehealth did not reduce existing disparities in access to care. We recommend that future work measuring the impact of telehealth focus on equity so that features of telehealth innovation can reduce disparities in health outcomes.

COVID-19 Modifications in Public Home- and Community-Based Services for Children with Mental Health Needs

Eleven states offer 1915(c) Home and Community Based Services (HCBS) Medicaid waivers to organize and fund programs that provide in-home and community support services to address the unique needs of children and youth with complex mental health concerns and their families. However, as the COVID-19 pandemic-imposed restrictions on community movement and school engagement were enacted, these children and youth lost in-person access to needed supports through school-based programs and professional community providers. The well documented mental health impacts of the pandemic on children and youth necessitates understanding how behavioral health programs and policies were adapted to the constraints of pandemic life for this uniquely at-risk population. This study examines and characterizes trends in modifications made to these programs. Appendix K applications amending HCBS waiver programs targeting children with serious emotional disturbances (SED) were collected from the Center for Medicaid & Medicare Services (CMS) website. In total, 33 applications from 10 states were included in the study. Utilizing a policy mapping approach, applications were coded by hand comparing text from elements in the applications across all 10 states. A summary of program changes reported in applications was created and changes were tracked over the course of the federal public health emergency. States modified programs by adding services for waiver participants, changing the service settings allowed, removing service limit restrictions, and offering electronic/remote service delivery. All states also issued measures to either expand or retain their provider workforce, adding family members as providers, modifying experience requirements, and offering financial incentives via increased payment rates or retainer payments. Modifications to mental health assessment processes ranged from changing the evaluation tools or documentation requirements, extending deadlines, and allowing for remote evaluations. Service plan development processes were adapted by allowing virtual service plan development meetings, allowing participants or representatives to electronically sign plans of care, and permitting verbal consent to begin receiving services. Documenting programmatic adjustments provides a context for further research to understand the experiences of youth, families, and providers in navigating these changes and the relative success or failures of these policies.

A comparison of the characteristics of adult medicine patients seeking telemedicine consultations versus in-person consultations in a Philippine public hospital

Background

Telemedicine employs the use of technology to increase access to health care. This is especially relevant in developing countries where accessibility is an important issue. In developed countries, studies have shown that despite greater availability and accessibility, there are still disparities in telemedicine use. In the Philippines, however, it is unknown what factors are related to telemedicine use since its underutilization precludes proper characterization of telemedicine patients. We sought to compare the characteristics of telemedicine patients and patients consulting in-person in the internal medicine outpatient department of a Philippine public hospital.

Methods

This is a retrospective descriptive study. Chart reviews were done for patients who consulted from May 2021 to July 2021. They were classified as either having telemedicine consults only or having in-person consults only. Each group was characterized and compared according to demographics, socioeconomic characteristics, health behaviors, and reasons for consultation.

Results

Unadjusted analyses showed that younger, single, or employed individuals were more likely to use telemedicine. However, in adjusted analyses, no demographic factors were associated with telemedicine use. Only the patient type and medical concern were significantly different between patient groups in this public hospital setting. New patients and those consulting for clearance/referral purposes or endocrine-related symptoms were more likely to seek teleconsults.

Conclusions

The findings showed which patients are more likely to use telemedicine in the Philippines. Continued telemedicine use for these patients should be explored to complement in-person medical care.

Evaluating Telehealth Uptake Among North Carolina Medicaid Beneficiaries With Musculoskeletal Conditions: Insights From the COVID-19 Pandemic

BACKGROUND

The shift from in-person to virtual visits, known as telehealth (TH), during the COVID-19 pandemic was a significant change for North Carolina (NC) Medicaid beneficiaries seeking treatment for musculoskeletal (MSK) conditions, as remote care for these conditions was previously unavailable. We used this policy change to investigate factors associated with TH uptake and whether TH availability mitigated disparities in access to care or affected emergency department (ED) visits among these beneficiaries.

RESEARCH DESIGN

Using 2019-2021 NC Medicaid claims, we identified beneficiaries receiving treatment for MSK conditions before COVID-19 (March 2019-February 2020) and analyzed uptake of newly available TH during COVID-19 (April 2020-March 2021). We used descriptive analysis and Poisson generalized estimating equations to quantify TH uptake, factors associated with TH uptake, and the association with ED visits during COVID-19.

RESULTS

Black and Hispanic beneficiaries were less likely to use TH compared with White and non-Hispanic counterparts (10%, P <0.001 and 20%, P =0.03, respectively). Adults eligible for Tailored Plans, specialized NC Medicaid plans for those with significant behavioral health needs or intellectual/developmental disabilities, were less likely to use TH [adjusted risk ratio (ARR):0.83, 95% CI (0.78, 0.87)]; youth eligible for Tailored Plans were more likely to use TH [ARR:1.28, 95% CI (1.16, 1.42)]. Lower county-level internet access was associated with lower TH use [ARR: 0.85, 95% CI (0.82, 0.99)]. No statistical difference in ED utilization was observed between TH users and non-users.

CONCLUSIONS

TH has the potential to deliver convenient care to beneficiaries with MSK conditions who can access it. Further research and policy changes should explore and address underlying factors driving disparities and improve equitable access to care for this population.

Declining trends in telehealth utilization in the ongoing COVID-19 pandemic

INTRODUCTION

Telehealth is an important complement to in-person healthcare, with opportunities to overcome barriers to healthcare and improve health equity. Telehealth utilization increased sharply at the onset of the COVID-19 pandemic. This study assessed trends in telehealth utilization for the years 2020 through 2022, both overall and in subgroups.

METHODS

We gathered data from the 2020-2022 National Health Interview Survey. The rates of telehealth utilization were calculated overall and within subgroups based on demographic factors, health conditions, healthcare utilization, challenges of ability, and social needs. Adjusted multivariable logistic regression models of telehealth utilization assessed the yearly trends. We also analyzed the ratios of subgroup utilization relative to the overall rates.

RESULTS

A total of 69,581 patients were identified with complete information. The overall rates of telehealth utilization were 36.2% for 2020, 38.9% for 2021, and 31.3% for 2022. The reduction in telehealth utilization for 2022 was large and statistically significant (OR: 0.64 (95% CI: 0.62-0.67), p < 0.001). Subgroup analyses showed corresponding reductions in 2022 for essentially all patient subgroups. Telehealth was utilized at higher rates by patients with chronic conditions, challenges of ability, and other kinds of medical utilization. Ratio analyses showed evidence of widening disparities for patients of older age, in rural areas, and by geographic region, limited education, and of low income.

DISCUSSION

The study demonstrates declining rates of telehealth utilization are occurring with widening gaps among patient subgroups. Addressing these disparities may be critical to improving equity in telehealth and healthcare overall.

Telehealth utilization barriers among Alabama parents of pediatric patients during COVID-19 outbreak

BACKGROUND

Telehealth can improve access to evidence-based care at a lower cost for patients, especially those living in underserved and remote areas. The barriers to the widespread adoption of telehealth have been well documented in the literature. However, the barriers may not be the same for pediatric patients, who must rely on their parents or guardians to make healthcare decisions. This paper presents some of the leading barriers parents or guardians of pediatric patients report in using telehealth to meet their children's healthcare needs.

METHODS

This cross-sectional survey was conducted in a tertiary care pediatric Emergency Department (ED) at a children's hospital in Alabama between September 2020 to December 2020. The parents or guardians of pediatric patients were asked about their reasons for not using telehealth despite having healthcare needs for their children, whether they canceled or rescheduled healthcare provider visits and facility visits, and whether the child's health conditions changed over the past three months. Descriptive analyses were conducted that explored the distribution of telehealth use across the variables listed above.

RESULTS

Five hundred ninety-seven parents or guardians of pediatric patients participated in the survey, and 578 answered the question of whether they used telehealth or not over the past three months. Of them, 33.1% used telehealth, 54.3% did not, and 12.6% did not have healthcare needs for their child. The leading reason for not using telehealth was that the doctor or health provider did not give them a telehealth option, the second main reason was that they did not know what telehealth is, and the third leading reason was that the parents did not think telehealth would help meet healthcare needs for their child.

CONCLUSIONS

This study highlights the telehealth utilization barriers among underserved pediatric populations, including the need for physicians to proactively offer telehealth options to parents or guardians of pediatric patients. Improving health literacy is of paramount importance, given that a substantial proportion of parents were not familiar with telehealth. Policymakers and healthcare organizations should raise awareness about the benefits of telehealth which can improve healthcare access for underserved pediatric patients.

Telehealth use among pediatric Alabama Medicaid enrollees, March-December 2020: Variations by race/ethnicity & place of residence

During the early days and months of the COVID-19 pandemic, healthcare facilities experienced a slump in non-COVID-related visits, and there was an increasing interest in telehealth to deliver healthcare services for adult and pediatric patients. The study investigated telehealth use variation by race/ethnicity and place of residence for the pediatric enrollees of the Alabama Medicaid program. This retrospective observational study examined Alabama Medicaid claims data from March to December 2020 for enrollees less than 19 years. There were 637,792 pediatric enrollees in the Alabama Medicaid program during the study period, and 16.9% of them had used telehealth to meet healthcare needs. This study employed a multivariate Poisson mixed-effects model with robust error variance to obtain differences in telehealth utilization and found that Non-Hispanic Black children were 80% as likely, Hispanic children were 55% as likely, and Asian Children were 46% as likely to have used telehealth compared to Non-Hispanic White children. Pediatric enrollees in large rural areas and isolated areas were significantly less likely (IRR: 0.90 for both, p<0.05) to use telehealth than those in urban areas. This study's findings suggest that attention needs to be paid to addressing race/ethnicity disparities in accessing telehealth services.