Telemedicine Is Not Enough
It’s 2020, and millions of Americans—now bound to their homes—still don’t have reliable internet access. In a pandemic, that’s a public health crisis.
These days, Dr. Susan Kressly begins appointments by thanking patients for inviting her into their homes. Like many other doctors during the covid-19 outbreak, Dr. Kressly, a pediatrician in Warrington, Pa., has begun practicing medicine over phone or video — even though in-person visits are essential in pediatrics, for good reason. “In young kids, it’s very much like tele-veterinary medicine,” she laughed. “They’re turning the phone upside down and licking it. And they’re not very good at accurately reporting their symptoms.”
Even if it’s delivered by screen or speaker, pediatric care remains critical during a pandemic where families find themselves homebound, she said. Without daily school lunches, some children lack access to adequate nutrition. Previous recommendations for maximum daily screen time have become laughable. And minors, like all of us, are struggling with anxiety, sleeplessness, and fear of the future. On top of it all, Dr. Kressly worries patients without at-home internet won’t be able to connect with pediatricians during the covid-19 pandemic. “We have to take into consideration what technology is available to the family,” she said, “and we have to do the best we can with what they have.”
Over the past month, healthcare providers from psychiatrists to family physicians have rushed to telemedicine through video conferencing or healthcare apps. Treating homebound patients virtually can soften the blow of an infectious disease outbreak like Covid-19, experts say, by reducing traffic to hospitals and doctor’s offices already struggling with limited resources and higher infection risks. It works the other way, too; telemedicine allows quarantined doctors to work from home. “If we’re talking about social distancing in order to alleviate our healthcare centers, telehealth is going to play a major role,” said Christopher Ali, a University of Virginia media studies associate professor and faculty fellow with the Benton Institute for Broadband & Society who focuses on connectivity.
But how is telemedicine supposed to work for the tens of millions of Americans who lack reliable, affordable, at-home broadband (the minimum threshold of acceptable upload and download speeds)? Ali says the answer is simple: “Telehealth is impossible without broadband. The two are synonymous.” He and others are sounding the alarm that internet inequity is now a public health crisis, as rural and urban households that lack—or can’t afford—at-home, high-speed internet are being left out of the massive, pandemic-driven shift toward telemedicine. “Before, the digital divide was a serious problem. It is now a life-and-death problem,” said Angela Siefer, Executive Director of the National Digital Inclusion Alliance, an advocacy group. “This is not rocket science. If someone doesn’t have internet, or a computer, or know how to use an app, they’re not going to use telemedicine. And if they’re not, they’re either leaving home or not receiving care.”
It’s proven difficult to accurately measure the width of this country’s digital divide. The Federal Communications Commission—which spends about $8 billion annually on connecting the disconnected—reported in 2019 that 21.3 million Americans lack cable, DSL, fiber, or wireless access to broadband speeds. In February, when a broadband availability tracking firm manually checked the FCC’s accounting, it doubled that figure to about 42 million Americans. According to Microsoft, it’s even more dire than that: as many as 157.3 million can only access download speeds below the FCC’s current minimum threshold, 25Mbps. Technology policy researcher John Horrigan estimates more than 18 million households across the country (some or most of which contain more than one person) lack broadband. “That’s 12 percent of the population who simply do not have internet access at home or with a mobile device,” Horrigan said. “But there are more dimensions than ‘you have it or you don’t.’”
For one, the digital divide plagues both rural and urban areas. In rural America, where 2018 Pew Center data suggests only 58 percent of residents have home broadband subscriptions, the issue is often infrastructure-related: Providing fast internet in remote, sparsely populated places means investing in expensive fiber or cell tower installation for the benefit of a handful of customers. In cities, that same 2018 Pew data shows about two-thirds of residents were connected to home broadband. Thanks to population density, that means about three times as many metropolitan households are disconnected. For them, it’s often less about access to internet and more about the price of that access. Horrigan’s analysis shows that a third of households with annual incomes below $35,000 (which represents about one-third of all households) lacked home broadband (compared to all but 5 percent of homes with annual incomes at or above than $75,000).
And smartphones cannot and will not fill in the gap. Areas with poor broadband often suffer from bad cell phone reception, Ali says. And research indicates that those who depend on smartphones for their internet access—low-income, low-education, and non-white individuals—are also more likely to reach their plan’s data cap and have their phone cut off due to financial hardship. “There’s not just one digital divide: it is low-income, it is minorities, it is newcomers and travel communities,” Ali said. “There’s this assumption that broadband is ubiquitous in the U.S.—an assumption that everyone has it, and that everyone’s speeds are equivalent to city speeds. This is the hubris of the connected.”
Now, we’re seeing all of this play out during a pandemic. A woman in Cleveland—where about one-third of households lack broadband—recently made headlines after her phone service got cut in the middle of a telemedicine visit. Some of the country’s least connected cities are now covid-19 hotspots, including Detroit, where almost 60 percent of households lack broadband, and Miami, where about half do. In the U.S. covid-19 epicenter, New York City, one in four households doesn’t have an at-home broadband subscription. On the opposite coast, in tech mecca San Francisco, one in eight residents don’t have high-speed home internet service. Under those circumstances, telemedicine can’t be considered a perfect solution for providing healthcare during a pandemic. “The coming weeks will lay bare the already-cruel reality of the digital divide,” wrote FCC Commissioner Geoffrey Starks in a March 19 New York Times op-ed, “tens of millions of Americans cannot access or cannot afford the home broadband connections they need.”
The covid-19 pandemic has completely altered Dr. Colleen Krajewski’s day-to-day medical practice.
Krajewski, a gynecologist in Pittsburgh, continues to provide abortion care, which, along with cancer procedures, are among the few surgeries deemed essential during this time. Routine pap smears and breast exams have largely been deferred, for now. Her patients’ needs have fundamentally changed, too. Some women are now choosing to stay home and get a tele-prescription for diaphragms, Krajewski said, in order to avoid coming in for a long-lasting contraceptive insertion. Others have risked in-person visits to get an IUD or implant if their situation is more urgent—as in the case of intimate partner violence in which a patient may now be quarantined with someone they fear is tampering with their oral contraceptives. She used to see up to 20 patients in-person a day; on Friday, she saw four who needed urgent care. The rest she “sees” over the phone or video. “I was worried it was going to be impersonal,” Krajewski said. “I actually find it’s kind of intimate to see someone in their home.”
It’s one of several silver linings clinicians like Krajewski say they’ve discovered during the industry-wide covid-19-induced pivot to telemedicine. “Ideally, we’d press the flesh,” said Dr. Joe Kvedar, Harvard Medical School professor, dermatologist at Massachusetts General Hospital, and incoming president of the American Telemedicine Association. “Now the world’s different. We want everyone to stay at home and take care of them at home.” With video conferencing, physicians can guide someone through using an at-home blood pressure cuff or reconciling prescriptions from multiple specialists. Dermatologists can examine rashes, pediatricians can peep inflamed tonsils, and physical therapists can watch patients exercise. Doctors can help assess potential covid-19 cases by asking patients to take a deep breath and then count how many seconds they can hold it (to test their oxygen saturation), and they’ve identified emergencies like appendicitis, gallbladder infections, ruptured ectopic pregnancies, and spinal cord compressions by asking patients to, literally, jump up and down. It’s also easier to practice good bedside manner—showing a calm face, not interrupting, expressing empathy—over video, compared to over the phone.
But doctors who need to closely observe, palpate or listen to symptoms quickly reach telehealth’s limits. Kressly, for example, says comprehensive pediatric “well exams” that include vaccination and hearing, vision, height, weight, blood pressure checks are practically impossible over the phone or web. And, she adds, “There’s clinical value in looking a kid in the eye and giving them a hug at the end of the visit.” Other specialists report similar difficulties. Addiction counselors may not be able to do regular urine screenings, and oncologists can’t ask patients to run bloodwork or biopsies at home. For psychiatrists, even video conferencing obscures subtle diagnostic cues, like if a patient is making eye contact or maintaining personal hygiene. “We’re practicing with one hand tied behind our back,” said Dr. Gail Basch, director of addiction medicine at Rush University Medical Center.
Plus, many practitioners were blind-sided by the pandemic. “This is a crash course,” said Mei Kwong, executive director of the Center for Connected Health Policy, a non-profit telehealth policy center. In a matter of weeks, thousands of healthcare providers have installed new apps and updated their understanding of changing regulations around inter-state licensure, prescriptive authority, and patient privacy requirements. “Most clinicians had in the back in their mind that there would be times when they couldn’t meet patients in person,” said Dr. Elie Aoun, a Manhattan-based psychiatrist. “But a lot of people hadn’t set themselves up for that, me included.”
Patients have had to adapt, too. Those with internet at home can download an app and adjust their expectations for what a doctor’s appointment looks like. But things are more complicated for households where the only available telehealth device is a landline phone. Just as the American Medical Informatics Association warned the FCC in 2017: “access to broadband is, or soon will become, a social determinant of health.”
Amy Sheon, executive director of Case Western Reserve University School of Medicine’s Urban Health Initiative, has been concerned about digital divide and health disparities for the last decade. The covid-19 pandemic has lifted certain barriers to care, like transportation and childcare, said Sheon, who is also a senior fellow at NDIA. But disconnected individuals not only lose out on live two-way conferencing, but also patient portals where they can get credible health information, message their doctors, request prescription refills, log blood sugar or blood pressure, and review their medical history, previous care recommendations, lab results, and immunizations. “With covid-19, healthcare closed its doors and went online,” Sheon said, and now some people can’t even knock on telehealth’s door.
Matthew Faiman, an internal medicine physician at Cleveland Clinic and medical director of its virtual, on-demand urgent care program, has been waiting about 15 years for this: In a matter of weeks, the various barriers that have prevented a widespread adoption of telemedicine—issues of licensure, IT, coverage, and reimbursement, for example—have begun to fall away.
“I always knew there would be a lightbulb moment, but I’ve been blown away,” Faiman said. “For patients, from a safety standpoint, we had to do this, and do it safely, and quickly, and properly. I just didn’t think it was going to come as a steamroller.”
Take, for example, telephone consultations. Broadly speaking, pre-covid-19, they did not fall within the definition of “telehealth” for many private and public insurance plans, including Medicare and Medicaid. Some plans even stipulated that, in order to bill for telemedicine, a provider needed to record video of both them and their patient as evidence against fraud and abuse. Some mandated the use of specific telemedicine apps, and not FaceTime or Skype, to ensure patient privacy. And even if you received telemedical care, pre-pandemic, not all states allowed insurance plans to bill for telehealth as they would for the corresponding in-person services.
Much of that has changed in a matter of weeks (which, to be clear, is lightning speed for the healthcare industry). Public and private health plans, as well as federal and state health programs, have scrambled to improve billing and reimbursing telemedicine. “The biggest issue we had to overcome was inertia,” said Mark Fendrick, a primary care physician and director of the University of Michigan’s Center for Value-Based Insurance Design. “This crisis moved it from 5 miles an hour to 100 miles an hour.”
As of Tuesday, Washington D.C. and every state but Hawaii had taken actions like expanding Medicaid and easing licensure or patient privacy requirements, according to the Center for Connected Health Policy. The Department of Health and Human Services continues to relax its policies around HIPAA. The March 27 CARES (Coronavirus Aid, Relief, and Economic Security) Act, among other things, allowed non-covid-19 telemedicine services to be covered, pre-deductible, until the end of 2021. And the Centers for Medicare and Medicaid Services has continued to expand its covered telemedicine services—including allowing phone-only consults when they’re the only options available. “(I)n the context of the goal of reducing exposure risks,” CMS recently explained, “we believe there are many circumstances where prolonged, audio-only communication between the practitioner and the patient could be clinically appropriate yet not fully replace a face-to-face visit.” Along the same lines, Medicare has had to create and implement new billing codes—since pre-covid-19, patients had no option for indicating they received care from home.
Private insurers have also changed telemedicine policies in response to covid-19. Aetna, which serves 39 million people, says it’s offering a $0 copay for telemedicine visits until June 4, 2020. Anthem has offered its 79 million customers to waive member cost sharing for certain telehealth visits for until June 14. UnitedHealthcare now allows members to use familiar digital audio-visual technologies (like FaceTime, Skype, or Zoom) to connect to their own physicians, and has offered a 24/7 virtual urgent care mobile app for covid-19 medical advice and to treat conditions such as seasonal flu, allergies, and pink eye. The number of telemedicine-trained providers in its own care-delivery network grew from 1,000 to 5,000 in a matter of weeks, said Dr. Michael Bess, UnitedHealthcare’s vice president of health care strategies. He hopes to see that number double, to 10,000 providers, by the end of April. “We wanted to make sure people had access,” Dr. Bess said. “We didn’t want to force members to have to go into certain care centers where they could be put at risk of infection.”
But are we witnessing a fundamental shift in healthcare, or will all of this disappear by 2021? Pat Keran, vice president of product and innovation at United Health, says the insurance company is committed to telehealth, and hopes to permanently extend policies that allow physicians to see patients from home into the future. “It is very much a key part of our strategy,” he said. “We hope some of these barriers will continue to be lifted and these policies remain permanent, post-covid-19. I think this is going to be part of the new norm.” (Keran was not clearly specific on which of these policies could remain permanent, other than one allowing physicians to bill for telehealth visits for patients who are at home.)
Others are more cynical, including Dr. Judd Hollander, an emergency medicine specialist and associate dean for strategic health initiatives at Jefferson University’s Sidney Kimmel Medical College in Philadelphia. Covid-19 insurance provisions, he said, may not be as good as they seem. Without widespread testing, it’s unclear how to bill patients; payers say they’ll cover covid-19-related complaints, he said — what about patients who don’t know if they’re positive or negative but are struggling with symptoms like fever and shortness of breath? And because many networks have put a June or July end-date on their policy changes, any relief from insurers may be short-lived, Hollander said, without more permanent commitments to re-adjust premium rates or extend coverage to non-covid-19 telecare. “I’m skeptical they’re doing all they can,” he said. “I think they’re doing enough to appear like they’re doing all they can.”
But Hollander offsets his skepticism that insurers will continue to reimburse telemedicine with his optimism that patients will demand it. “Nothing is going to be able to erase the memories of people who’ve tried it and like it,” he said. “Patients will drive this forward.” Just as doctors are figuring out how to provide it en masse, patients are realizing “seeing the doctor” no longer has to mean scheduling an appointment, paying for parking, sitting in a waiting room, and spending 30 minutes with a doctor. “People put up with all of that because they think there’s no other choice,” Dr. Kvedar said. “It’s a breakthrough. Most people didn’t know they could take advantage of telemedicine.”
In the post-covid-19 world, Dr. Fendrick said, “one of the really positive outcomes is patients will get the care they need without leaving home.” Pregnant women, people with mobility issues, or those without adequate transportation options could avoid traveling for appointments unless it’s absolutely necessary. At-home blood pressure tests might actually yield more accurate results, since they’ll reflect more natural conditions. Subtitles, text-to-voice, and instantaneous language translation tools could transform how patients with hearing and vision impairments, or those with English as a second language, receive healthcare. Pediatricians could regularly witness how children with ADHD behave in the comfort of familiar surroundings, and help parents decide whether a sick child should go to school without asking families to drive to a clinic at 5 a.m. “Everyone needs to color outside of the lines during a time like this,” Kressly, the pediatrician. “What we’re going to see, I think, is there’s no putting the genie completely back in the bottle.”
But even in the rosiest of telehealth visions, Siefer and other broadband advocates worry that millions of patients will be left out. “Both locally and nationally, we’re trying to get people connected,” said Adam Perzynski, an associate professor of medicine and sociology at MetroHealth System and Case Western Reserve University, in Cleveland, who’s researched the digital divide’s health impact. “It’s going to continue to be a critical threat to some communities.”
During recent shutdowns, municipal Wi-Fi providers like libraries have fought to maintain their public hotspots. Internet service providers including AT&T, Verizon, T-Mobile, Sprint and Comcast have eliminated data caps, and some have offered free or low-cost plans. And, realistically, companies could invest in putting up more cell towers to fill in coverage gaps, Ali suggested. But Siefer said she wants to see even more progressive action, like a federal broadband subsidy or a waiver to allow patients to use health insurance to pay for an internet connection and a laptop or tablet (which she says could be considered essential medical devices in the age of telemedicine). Sheon said she’d like to see more community health workers provide tech support to patients with lower levels of digital literacy, as well as see more health systems buy low-cost smartphones and tablets for patients they’ve screened and identified as disconnected. Until permanent fixes are put in place, covid-19 patches to the digital divide are “not in any way covering everyone,” Siefer said. “These are Band-Aids.”
Marion Renault is a science journalist born in France, bred in the Midwest, and now based in Brooklyn. Her work has appeared in The New York Times, Popular Science, and The Atlantic.
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