Why telemedicine is not enough to address racial health disparities

HOUSTON - The COVID-19 pandemic has sparked several conversations on health care, and while the threat seems to be dwindling in parts of the United States, there are some conversations that still need to be had. 

Back in May 2021, Dr. Anthony Fauci, who leads the COVID-19 response in the U.S., noted during a graduation ceremony at Emory University that "the undeniable effects of racism" have led to unacceptable health disparities that especially hurt African Americans, Hispanics, and Native Americans during the pandemic.

"COVID-19 has shone a bright light on our own society’s failings," he said. "Almost all relate to the social determinants of health dating back to disadvantageous conditions that some people of color find themselves in from birth regarding the availability of an adequate diet, access to health care, and the undeniable effects of racism in our society."

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A recent study led by the University of Houston, published by the Journal of General Internal Medicine, argues how the introduction of telemedicine could potentially bridge the gap between health disparities plaguing communities of color but could also result in "unintended consequences" if not properly executed. 

"[Telemedicine] has the potential to improve healthcare use and ensure continuity of care," the background to the article explains. " However, this delivery model could have an unintended consequence of worsening racial/ethnic disparities in healthcare utilization if adoption varies across subpopulations." 

What are Health Disparities?

Dr. Omolola Adepoju, a clinical associate professor at the UH College of Medicine, who led the study, tells FOX 26 in an interview that health disparities do not just mean limited access to healthcare. 

"Health disparities just mean differences in health outcomes across different population groups and disparities are fueled by so many things," she explained. "Oftentimes, we think of social determinants of health, we think of health-related social needs and typically, when you think of health-related social needs, think of things like food - access to healthy food; you think of things like in the social determinants of health section; you think of education, income, those are things that are the impact that can impact our health outcomes." 

"And when we see differences within different population groups, as a result of these social determinants of health, those social needs, we address we call those health disparities," Dr. Adepoju continued. 

Houston’s own health care system is arguably one of the best in Texas and perhaps the country, but experts like Dr. Luis Medina, a clinical psychologist and cultural neuropsychologist at the University of Houston say there are still gaps that need to be addressed. 

"The Texas Medical Center is the largest medical center in the world, we have incredible systems here - in terms of getting access to specialists and specialty care," he said. "However, there are certain communities that just don't have the same access and so healthcare access ends up becoming a big determinant of those health outcomes." 

"Here in Houston, we still have a quite an array of people with levels of food security, housing security, socioeconomic status, and so forth, that really affect how much access they have to those systems," Dr. Medina continued. "A lot of folks don't have access to specialty care for certain conditions, or may not have the kind of health insurance coverage necessary to be able to reduce the risk for many other conditions." 

Who is affected?

Research from the National Institute of Minority Health and Health Disparities (NIMHD) shows that African American and Hispanic communities are among the most affected, and this is stemmed from several factors. Dr. Medina, for example, who specializes in neurodegenerative conditions like dementia says Black and Latino communities tend to be at a greater health risk than their White counterparts, but the reason why is a little more complicated to answer.

"What we're observing is that that's a really complex question and the way we see risks at multiple different levels at the individual level, the community level, and the societal level," he explained. "There's a history related to black communities, not getting access to various different resources here in the United States; and similarly, we see that Hispanic/Latin American communities have sort of been encountering many barriers to access." 

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To simplify it as best as possible, according to Dr. Medina, is that it all boils down to access to health care and the ability to recognize health risk signs beforehand. 

"There are a myriad of explanations for people's health for all the way from early livelihood, their childhood experience in the educational system to adulthood being or having access to nutritional food, or even clean water," he continued. "And so we're seeing that throughout every single one of these different barriers that certain communities are disproportionately affected more so than others." 

All these factors are also coupled with a long history of systematic racism.  

"There's a history of institutional racism, systemic racism, and barriers that really limit how much folks have in terms of having not just equal opportunities, but equitable opportunities for health," Dr. Medina added. 

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Researchers and historians were admittedly well-aware of these health disparities and looked to address them. However, while perhaps some members of the public were left in the dark about these experiences facing communities of color, the COVID-19 pandemic, arguably brought health concerns and other disparities to light.

"I think the COVID 19 pandemic has exacerbated the disparities that we're seeing starting from if you look at the COVID-19, hospitalizations, and deaths, they're over-represented in minority populations, communities of color," Dr. Adepoju said. "I feel like if anything, COVID-19 has preyed on the loopholes and weaknesses in our current healthcare system, the way healthcare is delivered is such that healthcare is delivered in silos." 

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In other words, certain issues where communities of color were at a disadvantage, would result in a domino effect that ultimately bring us back to what factors result in health disparities existing. That means that during the COVID-19 pandemic when people were laid off, unable to feed their families, Dr. Adepoju says, the last thing they might be concerned with was going to the doctors.

"I don't know, if you remember seeing those long lines, in front of food pantries on TV, a lot of people didn't have access to healthy foods, a lot of people had lost employment," Dr. Adepoju said. "So where do you get your rent from? So there are transportation concerns and so with that exacerbation, if you don't have access to healthy food, if you don't have access to a balanced meal, you don't know where your rent is going to come from, then you're less likely to follow up with a primary care provider for a primary care visit, you're less likely to pick up your medication, you're less likely to do your recommended tests, and…so over time, if you're not getting the help that you need, that individual continues to deteriorate." 

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Two years since the COVID-19 pandemic, these health issues (because they were not addressed) have only worsened. 

"And so now two years down the road, we're seeing a number of studies out there that have shown there's been an increase in the number of uncontrolled A1Cs among patients with diabetes… an increase in the number of persons reporting cancer in advanced stages," Dr. Adepoju continued. "Again, all because you have this unintended consequence of just being home, and it's just a compilation effect of social needs, and all of that affecting your outlook over your own health." 

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If this trend continues, health experts like Dr. Adepoju fear things will only get worse.

"I want to say we're still going to see the impact, maybe two or three years down the road in form of significantly increased healthcare spent, because now we're taking care of people who are much sicker, who have a worse prognosis, and all of that, I think cumulatively affects the health of the community as a whole," she explained.

Bridging the Gap through Telemedicine

For those without adequate transportation or the ability to physically go to the doctors, the introduction of telemedicine seemed like a welcomed alternative.

"When the pandemic started, everyone thought that telemedicine was going to be this watershed moment, right?" Dr. Adepoju said. "This is something a lot of healthcare professionals have been waiting for. Can we get reimbursed for telemedicine? Can we see patients in the comfort of their own homes?" 

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By having telemedicine, patients were able to attend doctor’s appointments through their smartphones or computers. These doctors were not limited to just Houston either, but from all over the world. 

In fact, some doctors were even considering keeping virtual doctor appointments in the future as a more convenient way to help everyday people. For one, doctors FOX 26 spoke to back in 2020, noted that telemedicine was more efficient and there would be fewer constraints for patients to spend time talking with their physicians, especially when taking Houston’s traffic into consideration. 

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Telemedicine also seemed like a low-cost option for patients who might have lost their health insurance or couldn’t afford coverage. 

The Problem with Telemedicine

While telemedicine seemed (at least in theory) a way to bridge the health disparities gap, there was a major obstacle that stood in that way: limited or no access to the internet. 

"Because of a technological divide, where folks don't have access to things like a high speed, internet, quality, internet quality signal, or even resources related to the actual electronic device: the tablet or the computer, the laptop, necessary to be able to do some of these visits that are done through teleassessment, telehealth, telemedicine - they just don't have it," Dr. Medina said. 

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As a result of this digital divide, researchers like Dr. Adepoju say affected communities with already limited access to healthcare are not only unable to take advantage of telemedicine, but also may be less willing to use it. 

"One of the things we found in the study that I did with Lone Star Circle of Care was that we fell short of that mark for minority populations," she said. "African Americans had a 35% lower odds of using telemedicine and Hispanic Americans were also had a 51% lower odds of using telemedicine."  

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"And this tells me that if you're not accessing your care, the promise of that positive impact of telemedicine of healthcare use can elude the communities that actually really need that care," Dr. Adepoju continued. 

In addition to limited or no access to the internet, there is the problem of not having a smartphone or being technologically savvy. 

"So one is just having that technology support to connect, The other portion of it is the technological know-how," Dr. Adepoju explained. "So it's one thing to have a smartphone, it's another thing to know how to work it - we see this, especially in our Medicare population; older adults, and even in some of our Medicaid population… ‘How do I set up that appointment?’ ‘What's that appointment going to look like?’"

Is Change Possible?

It’s hard to pinpoint who to hold accountable or whom we can count on to help address the health disparities. However, the experts FOX 26 spoke to for this story agree internet needs to be more accessible first and foremost. 

"The same way we talk about people having access to healthy food, people having access to walkable environments, with parks, maybe we should have internet access as something everyone has, you know, as an equal opportunity," Dr. Adepoju said. "If this is a concern, I this is a big concern, I think more needs to be done, maybe even subsidizing internet access for people."

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"Some communities have been testing out this idea of having even basic internet for all residents of that community," Dr. Medina added. "And so I think having something similar in place where folks have access to those kinds of internet-based resources, will end up helping reduce some of the gaps or at least help bridge some of those gaps, but I think a lot more work has to be done in multiple different levels to help bring health to local communities."

Additionally, the experts argue it’s important doctors do more to reach their patients. For example, Dr. Adepoju suggested outreach programs to help educate patients on health care concerns in a more communal setting. 

"Why can’t we have a big events partner with local community organizations, barbershops, and faith institutions and mosques and churches, and partner them providing screenings in the community," she explained. "Of course, these are not going to be one-time event. These are events that you probably want to do on a regular basis, maybe two times a year, four times a year." 

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"There are some clinics that are resorting to telephone visits," Dr. Medina added. "There's some limited research on that's showing a lot of promise for folks that may not have the technological resources necessary to do full audiovisual coding kind of visits; and so I think that the more work needs to be done in terms of providing those resources because ultimately, a lot of a lot of assessments can't be done over telephone-based assessments alone."

Simultaneously, there are steps patients can take to learn more about potential health risks and even resources for eligible individuals. 

"I think one of the big things, that we hope people will do, is sort of speak up at least or voice their needs so that we can sort of target resources towards folks that need it most," Dr. Medina noted. "So at least learning about what are the available things and one's community is something that we hope folks take advantage of…each year there are a lot of resources that are made available that goes sort of unused because some folks aren't even aware that they exist."

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Dr. Adepoju says it starts with speaking openly with your doctors. 

"I would say that the first thing you want to do is ask your front desk person when you call your front desk, the front desk office of your physician," she explained. "If you want to ask them about telemedicine…ask if they offer it… a lot of clinics offer some kind of technology support, where they have a staff who would conduct like a pre-device testing with you and pretty much just telling you this is how the whole consult your physician is going to go feel free to write down questions."  

As mentioned earlier, those who have dedicated their careers to studying health disparities have done extensive work on how these issues plague communities of color, but experts say it’s not reaching the people affected. 

"We tend to publish these really great articles, which is great, but a lot of times the people who we're trying to reach do not read these journals; and so it's important to communicate in ways that are very simple and effective like taking advantage of social media," Dr. Adepoju noted. "Until I feel like until the healthcare industry becomes more reaction until we become more active instead of just being reactionary, we will continue playing the catch-up game on health disparities." 

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Dr. Medina echoed similar sentiments saying the responsibility should not fall entirely on patients. 

"Communication is a two-way street," he concluded. "And so whatever healthcare providers, clinician-scientists can do to better communicate information in an effective manner for local communities, the better it'll be for all of us involved."