THE POPULARITY OF telehealth has surged during the COVID-19 pandemic, as doctors shut their offices to nonemergency visits, then even once they reopened, patients remained hesitant to go to a medical clinic. But while younger, tech-savvy patients may enjoy the convenience of a virtual visit, new data show that one population has largely been left out of the telehealth revolution: the elderly.
The Massachusetts Association of Health Plans on Thursday is releasing preliminary results from a first-in-the-nation attempt to use health insurers’ data to determine who is using telehealth and whether there are disparities by race and age. The results were inconclusive with regards to race, but they found a stark disparity among age groups, with older adults far less likely to use telehealth.
While the data does not examine the reasons why, some experts suggest it is not solely because seniors require more hands-on care. A lack of comfort with technology or an inability to use technology is also likely to blame.
Dr. Asif Merchant, a geriatrician with New England Community Medical Services, said many of his patients have trouble seeing or hearing, or have dementia. “That’s a barrier,” Merchant said. “They can’t hear you well, or they don’t understand what you’re saying, or they have a hard time figuring out who they’re talking to and why.”
The health plan organization’s preliminary findings, which are being released at the group’s annual conference, are based on data provided voluntarily by seven Massachusetts health plans covering the period between January 2019 and January 2021. Overall, the data showed a tremendous increase in telehealth during the pandemic that continued even after doctors’ offices reopened. In January of 2021, out of 331,900 medical visits reported by the insurers, 128,400 were conducted via telehealth.
However, at every stage during the pandemic, older adults consistently had fewer telehealth visits than any other age group. During the study period, adults over 65 participated in 22 percent of their medical visits via telehealth, compared to 46 percent for all other age groups combined. In January 2021, the percentage of visits conducted via telehealth was in the 30 to 50 percent range for every age group except seniors, where fewer than 20 percent of visits were conducted virtually.
The data broke down visits by type of insurance, comparing commercial insurance with Medicare, which covers older adults, and Medicaid, which primarily covers low-income individuals.
The difference was consistent regardless of the type of visit. Eighteen percent of specialist visits were conducted via telehealth for Medicare patients, compared to 50 percent for commercially insured individuals. Nearly half (49 percent) of primary care visits were conducted remotely for commercially insured patients, compared to 30 percent for Medicare patients. In behavioral health, a specialty that lends itself to telehealth since there is little need for physical contact, 64 percent of Medicare visits were conducted remotely compared to 73 percent for commercially insured patients.
Medicaid patients were also less likely than the commercially insured to use telehealth, but the disparity was much smaller than among patients with Medicare.
One reason for the difference with Medicare patients may be internet access. The report cited statistics showing that only 50 percent of seniors have a broadband internet subscription. “Telehealth is a function of individuals having technology and the ability to use it,” said Alon Peltz, the study’s lead author and a principal investigator at the Department of Population Medicine for Harvard Pilgrim Health Care Institute.
Peltz said interviews conducted with patients and providers as part of the study may also provide more insight into why telehealth use is lower in this population – whether because telehealth is not the preferred method of care in some situations, or because there are other barriers, like technology.
Merchant, the geriatric medicine physician, started using telehealth at the height of the pandemic to care for sick patients, but because older patients often had trouble hearing or answering questions, he found it worked best when another adult was sitting with the patient. He said elderly patients did not always have access to high internet speeds or smartphones.
That said, Merchant said, there were fewer missed appointments with telehealth, and at times when the patient could not visit a doctor’s office, “a telehealth visit was better than nothing at all.”
Dr. Robert MacArthur, chief medical officer at Commonwealth Care Alliance, an insurer that offers plans through Medicaid and Medicare and provided data for the study, said his organization surveyed 9,600 patients over age 65. It found that only half (51 percent) had the basic tools needed to engage in virtual health care. Among those who didn’t, the biggest barrier was the lack of a device.
Commonwealth Care Alliance worked with patients to help them obtain smartphones through a federal assistance program. It contracted with a company to provide technical support.
MacArthur said telehealth can be beneficial for seniors, who may lack transportation or may benefit from more frequent check-ins, which are easier to schedule virtually. Yet there are several factors that lead to lower telehealth utilization by older adults. Their complex medical needs can require hands-on care. Some have cognitive or physical impairments that make it harder to use telehealth. Some live in rural areas that lack high-speed internet, and some may not trust they will get an accurate diagnosis virtually.
“You hear the term digital divide…it’s really not about age, it’s about technical literacy and the ability to use the devices,” MacArthur said.
Al Norman, a 75-year-old long-time advocate for seniors, said he personally has had minor glitches during telehealth visits – a microphone that needed to be turned on or video that wasn’t working. But some seniors who are older than him and less tech savvy don’t even know how to use a laptop or smartphone.
Telehealth, Norman said, is “a little bit of a technology reach for many people, particularly seniors who are in their 80s and 90s.”
“A lot of seniors probably feel like I don’t need that, I’m not interested in that,” Norman said about telehealth visits. Their attitude, he said, is, “If I have to talk to my doctor, I’ll call them up.”