It is hard to have a conversation about medicine during the COVID-19 pandemic and not discuss telehealth. Telehealth (broadly defined as the delivery of clinical and nonclinical health services using telecommunications technology) use has skyrocketed at the onset of the pandemic, with some estimates suggesting telehealth utilization in Medicare beneficiaries increasing nearly 13,000% over pre-pandemic levels. This increased utilization has been driven by initial concerns over access to personal protective equipment, as well as the need to reduce potential viral exposure for both patients and healthcare providers. Much of the increased utilization of telehealth has occurred in the field of behavioral health, as it is widely recognized to be much easier to deliver behavioral health care over video or audio technology, as opposed to other types of medical care that may necessitate physical examinations. Here in the Department of Psychiatry at UNC, we went from performing essentially no behavioral health care via telehealth prior to the pandemic, to performing over 60,000 video visits and 25,000 telephone visits in the year following the onset of COVID-19. While this has been a challenging transition for all, our providers broadly agree that for most patients, utilization of telehealth has been a highly effective way to continue to deliver care. This fits with extensive scientific evidence supporting the effectiveness of telehealth for the treatment of behavioral health conditions. Indeed, it is now well-established that use of telehealth for behavioral health treatment is as effective as care delivered in person for a wide range of conditions. Further, it is seen as a highly effective means to provide access to behavioral health care for many individuals who could not access it otherwise.
While this rapid growth in telehealth has been life-saving for some, there is growing concern that emphasis on care delivered this way may exacerbate already existing racial and ethnic disparities in our health care system. Large studies conducted on data collected during the COVID-19 pandemic demonstrate that certain populations seem to utilize telehealth at significantly lower rates than others. For example, patients who are older, non-English-speaking, Asian race, and covered by Medicaid utilized all types of telehealth at lower rates in one large study. Older age, female sex, Black race, Latinx ethnicity, and lower household income have also been associated with lower use of video technology for telehealth visits. Our own data here at UNC show that while individuals of all races have utilized telehealth at roughly equal rates during COVID-19, individuals who identified themselves as “Black” or who declined to provide a race had significantly fewer telehealth visits conducted by video compared to those conducted via telephone. Individuals who are listed as having their primary language as “Spanish” also had lower rates of video visits compared to those whose primary language is “English.” These differences in how individuals access telehealth may be important, as there is limited data on the effectiveness of behavioral health delivered via telephone, compared to delivery over video conferencing. Taken together, these findings suggest that even though telehealth is as effective as in-person care in the treatment of most behavioral health conditions, there is inequity in the utilization of these services. A better understanding of why this inequity exists will be vital in shaping how we continue to utilize telehealth to deliver care moving forward. Efforts to increase reliable access to broadband internet sites, development of telehealth hubs or virtual care access points in the community, growth in diverse provider types and providers who can deliver care in languages other than English, and educational programs that improve digital literacy are all possible ways to tackle these emerging telehealth problems.
While there are concerns that reliance on telehealth may perpetuate or exacerbate some health disparities, there is also some evidence to suggest that seeing patients in a standardized way via a video screen has the potential to reduce provider bias. These results suggest that via telehealth, there may be the opportunity for patients of all racial backgrounds to receive equal health treatment. If affirmed, this finding would provide strong support for further development of telehealth programs as a way to combat bias in health care.
Taken together, while telehealth holds much promise for the future of behavioral health, leaders, administrators, and policy-makers must pay close attention to insure that this health care delivery tool is deployed in a way that reduces health care disparities, rather than deepening the divide.
Nate Sowa, MD, PhD
Director of Virtual Care and Integrated Behavioral Health
Department of Psychiatry
University of North Carolina at Chapel Hill School of Medicine