Before COVID-19 struck in the early months of 2020, telehealth solutions had difficulty gaining traction with U.S. patients, both within and outside the context of employer-sponsored health plans.

Sources cite a variety of reasons to explain that slow pre-pandemic growth trend. Two of the most important were connectivity and comfort, according to Zachary Predmore, an associate policy researcher at the nonprofit RAND Corporation focusing on healthcare services.

In the past, providers cited more difficulty connecting with patients, he said, whose internet connections generally may not have been as strong as today's. Meanwhile, the general population had not developed the type of familiarity with video conferencing characteristic of the COVID-19 era.

Things changed, fast. By April 2020, Cigna told HR Dive that it had seen a three-fold year-over-year increase in virtual care utilization compared to 2019. Other providers reported similarly dramatic increases in following months.

So far, there is little indication that the telehealth train is slowing down entering 2022. HR consulting firm Mercer's recent national survey of employer-sponsored health plans found that telemedicine utilization rates were up to 15% in 2020 among employers with more than 500 employees from an annual average of 9% in prior years. During 2021's first half, that rate held at 12%.

The format proved attractive to patients and providers as offices closed, said Bipinchandra Mistry, chief medical officer at benefits outsourcing firm Alight Solutions. Going to venues such as emergency rooms "was a scary thing during the pandemic," he noted, so telehealth may have stepped in to provide a space for patient interaction.

Much has been made of the technology's advantages, but observers such as Predmore are evaluating telehealth services with a different criterion: accessibility, particularly for patients who are members of underserved populations. In that respect, the technology has its share of barriers and opportunities, sources told HR Dive.

How do demographics influence use?

It is worth noting employers may view telehealth in a positive light when it comes to accessibility. "It certainly is a bridge to care and perhaps a more affordable way to get to a broader population," said Ellen Kelsay, president and CEO of the Business Group on Health. "Telehealth has broken down barriers."

But the technology also is an extension of the broader healthcare system, which has its own set of built-in inequities, according to Ian Tong, chief medical officer at telehealth vendor Included Health. People of underserved populations may have less access to primary care, among other care types, which affects participation in telehealth.

"It's not just access to virtual care that is a problem," Tong said in an interview. "It's really just pure access in general."

That lack of access can lead to profound consequences which, combined with the implicit biases held by care providers in the first place, impact the ability of these patients to form connections of trust with their providers, Tong said. In turn, this creates a hesitance to seek care.

"Now, take a new technology, and then you have a group of employees who are part of the Black community [...] they're still going to view that a little hesitantly," Tong said of telehealth, "because of maybe the lack of trust in the system."

But even a base level of familiarity with virtual care may spur patients to come back to the format later on. In an original investigation published in the Journal of the American Medical Association's Network Open, Predmore and a group of RAND Corporation researchers looked at telehealth use among U.S. adults, finding that experience with telehealth was associated with a preference for video visits compared to in-person visits.

The investigation also found that 33.5% of participants did not see any role for video visits in their medical care, and that this population generally consisted of patients who were older, lived in more rural areas and had lower education levels.

"Although telehealth can expand access to care for underserved populations (eg, those with low family income, with lower educational levels, belonging to racial and ethnic minority groups, and living in rural areas) if deployed in a targeted manner, findings of this survey suggest that these populations may be the least likely to demand it and that ongoing efforts to promote equity of access to telehealth need to consider these preferences," the researchers wrote.

Employers need a cultural awareness of how employees of underserved populations perceive their own health in order to tackle the accessibility issue, Mistry said. That includes the social determinants of health different employee groups face, such as income, education and physical environments, among others.

That also may include rethinking how virtual care options are communicated. "Many people of color in these populations will hear about programs through their employers, and the way it's explained or rolled out is for the majority," said Tong. "That's a very real experience."

Tong gave the example of a family benefits programmatic that only includes images of cisgender, heterosexual couples. That can represent a failure to address the concerns of employees who are part of the LGBTQ+ community. Proper representation in communications materials can open up benefits to an entire community of people, Tong continued.

Barriers to equitable access

Awareness may be hindered by other factors, including language, Mistry said. Kelsay added that virtual care options, though well-intentioned, may exacerbate existing inequities. "Not all individuals have access to a smartphone or broadband access," she said. "Maybe they don't live or work in a place that's conducive to video visits."

All of that underscores the need for employers to be mindful about how they deploy different technologies, Kelsay continued. It could also indicate the need to supplement improvements in virtual care with additional access to in-person providers.

"You have to think tactically," Mistry said. "It's an amazing opportunity to try and target the right solution for the right population."

Predmore noted the importance of cost in the telehealth conversation. RAND Corporation's investigation found that patients who had a preference for in-person care were much more willing to pay for it than those who had a preference for virtual care were willing to pay for virtual care.

"If you want telehealth to be a part of the services that you offer, you really can't make the barriers to access telehealth too high," he said. "People like telehealth [...] but they're not willing to pay a lot for it."

Provider diversity is another pain point, though it is not one exclusive to telehealth. That is reflected in broader demographic statistics on the U.S. medical profession, Tong said. For example, 2019 data from the Association of American Medical Colleges showed that just 5% of the nation's active physicians identified as Black or African American, whereas some 56% identified as White.

"There's no question we have an issue there," Tong said.

Asked how employers might be able to better assess how providers approach diversity, equity and inclusion issues, sources offered a multitude of suggestions. Kelsay said employers might want to ask providers questions about both provider diversity as well as their approaches to culturally competent care – an approach by which a provider is able to treat a diverse population, even if it does not employ a diverse staff of health professionals, she explained.

For example, if a provider does not have transgender physicians on staff, an employer can still inquire about the provider's ability to address health issues specific to the transgender community. "You yourself may not be a transgender provider, but can you treat a trans patient in a way that is culturally competent, resonant and thoughful?" Kelsay said.

That cultural knowledge extends to those in charge of patient navigation, Mistry said, adding that it also may be important for navigators to have appropriate cultural training. 

Tong added that it is nonetheless important to seek culturally concordant care for employees, or care providers who look like the patient and may have a shared experience with them. That could allow patients from underserved groups to better interact and establish relationships with providers.

Employers might also evaluate the DE&I track record of providers and vendors, Tong continued. Leadership composition at the board, executive, managerial and medical director levels all may be considered. Additionally, they may choose to scrutinize providers' hiring practices and training for front-line staff.

However, just because a provider is not perfect with respect to DE&I "doesn't mean there's a problem," Tong said, "but it does mean there are potential blindspots. They may not be aware of their implicit biases or how they affect diverse groups."

It also may be helpful to identify whether the provider or vendor points to DE&I practices as a competitive differentiator, he added.
 

Lastly, employers can ask providers for data that may provide insight on providers' treatment of diverse populations, Kelsay said.

Focus on the employee

No one patient experiences healthcare the same way, which underscores the importance of maintaining a personalized approach to care, said Mistry. This, too, is a spot where telehealth can shine.

Take mental health as an example. Employee stress levels have skyrocketed during the pandemic, Mistry continued. Even as a shortage of providers persists, telehealth can provide faster and more frequent access to care. "Having that other modality to go to is fantastic," Mistry said.

Moreover, telehealth will not be able to substitute for all in-person care, Predmore said, but it may be particularly effective for patients who have had the same provider for an extended period of time, or who have chronic conditions that require frequent check-ins or medication refills.

Improving telehealth access is just one aspect of organizational health equity efforts, Kelsay noted. Employers also are looking into programs that target specific needs, such as parental health, to become more inclusive of the manner in which patients seek healthcare and live their lives.

Tong said employers might also consider working with groups that focus on the issues underserved communities face, such as employee resource groups and affinity groups. Engaging employees in these groups can be particularly effective because participants are already advocates for co-workers who have similar backgrounds.

Above all though, the most important thing for employers may be to avoid the status quo of healthcare. "Everyone wants to do the right thing right now, but they're maybe not sure what to do," Tong said. "If I could wave a magic wand, I'd wish for everyone to realize that the biggest enemy in the room right now is doing nothing, or doing everything the same as what we did before. We already know what the care outcomes are going to be if we don't make any changes."