The digital divide becomes a new social determinant of health

Telehealth and other connected health services are not the silver lining to the pandemic that many people thought. Many patients can’t afford or don’t want the needed broadband connection, creating another obstacle for the underserved.

In Orange County, Calif., when COVID-19 forced CalOptima to shut down its health and social care center, Elizabeth Lee, director of the public health insurance system’s elderly program wasn’t too worried. A Program of All-inclusive Care for the Elderly, or PACE, CalOptima quickly set up telehealth and remote monitoring to help patients who, on average, needed about 10 clinical visits a year.

But the promise of telehealth was deflated by a survey that found two-thirds of their 400 patients either lacked a device, lacked an internet connection, or in some cases both.

As a result, for many providers like CalOptima, broadband internet access has become such an important health risk factor that experts have called having connectivity a “super-determinant of health.”

The tens of millions of Americans who do not have access to high-speed, broadband internet services feed a digital divide hindering telehealth’s potential to become a more convenient, cost-effective and equitable pathway to care.

To make matters worse, the lack of access is mimicking what caused the greatest inequities during the past year. Those with the lowest adoption of broadband internet services are among the most vulnerable populations: predominantly low-income and racial and ethnic minority communities.

“The reality is that we’re moving into an era that is heavily dependent on connectivity,” said Gerry Meklaus, vice president of strategy, innovation and population health advisory services at Premier. “Some folks who are in areas where they are less advantaged in that regard may clearly see disparities, and the industry is very concerned about that.”

Estimates vary as to how many people lack broadband access. About 6% of Americans, or more than 21 million people, do not, according to the World Economic Forum. Meanwhile, internet service provider tracking site BroadbandNow Research puts it at 42 million.

Interestingly, the Federal Communications Commission found that the number of Americans lacking broadband access dropped by 18% from 2016 to 2017. The most recent FCC data released last April found 6 million new households in 2019 gained access to fiber broadband networks.

But some contend the FCC’s data misrepresents the problem. Dr. Carmen Guerra, associate professor of medicine and vice chair of diversity and inclusion at University of Pennsylvania’s Perelman School of Medicine, said the agency assumes an entire census block has service if one household on that block has it. The other three-quarters or four-fifths can’t afford internet access, Guerra said.

And that cost factor can prevent people from accessing healthcare during a pandemic. It also presents hurdles to combating another significant social determinant of health—employment.

“Building a career today often requires new skills, which now include digital readiness,” wrote Jefferson Health CEO Dr. Stephen Klasko in an op-ed for Modern Healthcare. “The retraining industry is now online. Indeed, even the interview process demands connectivity. We are walling off the poor from those jobs.”

Data from the FCC reveals other issues. The agency found that states with broadband coverage rates under 80% faced more cases of obesity, diabetes, unnecessary hospitalizations and sick days than national averages.

According to the American Hospital Association, an estimated 76% of U.S. hospitals now provide some type of telemedicine service that requires broadband access with bandwidth fast enough to transmit audio and video.

While there is still the option of good old-fashioned phone calls, “that is not as good as a telemedicine visit where I can see the patient by video and assess different things,” Guerra said.

Susan Hull, a member of the board of directors for the American Medical Informatics Association, said tele- and virtual health approaches were adopted so quickly in the past year that it didn’t leave time for communities and healthcare providers to “take stock” of the digital divide.

“A common misconception is that those in underserved communities have smartphones,” said Dr. Michael Petersen, health innovation lead for global consulting firm Accenture. “What hasn’t been considered are the economic realities in which people shut their phones off to save time on their data plans.”

The average telemedicine consultation costs $70 compared with more than $140 for an in-person visit. But a smartphone can cost hundreds even without the average monthly charge of around $60 for broadband service.

Some stakeholders want providers to take up the issue with local governments. “Hospitals in communities where we’re supporting the construction of broadband networks could work with the broadband providers who won funds from the FCC—they could essentially say, ‘Look, you’re already building out to these 50 homes in this rural community, we want to talk about building the fiber line and extending the reach of your network so that we can do telehealth,’ ” said former FCC Chair Ajit Pai in an interview earlier this year. “That would be very powerful.”

Health insurers could also provide internet service to their members as part of their plans. While many insurers waived patient out-of-pocket telehealth costs during the pandemic, only a few have addressed the issue of broadband availability.

Last April, Anthem Blue Cross donated $100,000 to the United Way’s COVID-19 Response Fund to help low-income people pay their utilities, including broadband access.

“Is it the healthcare system’s responsibility?—I would say yes,” Guerra said. “I would like us to think about ways that we can perhaps pilot novel ways of getting people access to telemedicine.”

Katherine Kim, an associate professor in the department of public health at the University of California at Davis School of Medicine, said she’s encouraged to see some cities build out their publicly owned broadband networks and provide those services at discounted rates. More than 500 communities across the U.S. are served by some form of municipal network.

Both Congress and federal regulators have expressed interest in expanding internet broadband access. Last December, the FCC awarded more than $9 billion over 10 years to rural areas. The agency is assessing how to structure a $3.2 billion program that will provide discounted broadband service to low-income households during the pandemic.

While those measures mean 93% of the country is connected to the internet, Kim said “the last few steps of the last mile” in the journey to connectivity are hindered by affordability. Bridging that last stretch is the focus of a public-private pilot program the University of California at Davis launched last September called the Accountability, Coordination, and Telehealth in the Valley to Achieve Transformation and Equity.

ACTIVATE is working to bring telehealth services to underserved rural residents in Merced County, in California’s Central Valley. This month, ACTIVATE began working with Livingston Community Health to provide program participants with cell phones, tablets and patient monitoring devices, subsidies to enable patients to get Wi-Fi in their homes, and training in health education and digital literacy.

“I think providers want to be community based, but it’s a lot of work and takes a lot of expertise to know how to set up a program that’s really going to help the individual patient or family in their home,” Kim said.

CalOptima PACE’s Lee has also started gifting patients with devices having internet capability. The program has funding for about130 devices with data plans they are in the process of distributing to participants and also provides patients with access to cellular-enabled tablets to use for specific appointments. Lee estimated the initiative will cost CalOptima PACE a minimum of $10,000 a month, which she said is expected to fluctuate as the level of need and actual usage change over time. Despite such efforts, Lee admits this only fixes part of the financial problem.

“That remains a significant challenge,” she said.


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