Some Seniors May Be Left Behind as Telemedicine Becomes More Popular

By Linda Carroll

August 05, 2020

(Reuters Health) - Seniors may be left behind in the rush to adopt telemedicine, some because they don't have the equipment or access to the internet, others because disabilities make it difficult or impossible to take advantage of telehealth, two new research letters suggest.

In a survey of over 600,000 Medicare beneficiaries, researchers found that more than one quarter had neither a computer nor a smartphone that could provide internet access, a disparity that was most pronounced among minorities and the poor, one article found. Beyond a lack of technology, a survey of more than 4,500 Medicare beneficiaries found that many seniors lacked experience in videoconferencing or had physical issues, such as hearing loss, vision impairment or cognitive decline that would create difficulties with telehealth, the second study reported in JAMA Internal Medicine.

"COVID has catalyzed a sizeable proportion of the population to change how they get health care," said Eric Roberts, an assistant professor of health policy at the University of Pittsburgh and a coauthor of the study. "Between mid-March and June there was a sharp drop off in face-to-face visits. Some of that was converted to telemedicine visits, but not all. That prompted our interest in finding out whether there were disparities in digital access."

The boom in telemedicine can be tied to the emergence of the COVID-19 pandemic and Medicare's response to it, changing the rules to allow for both tele-video and telephone visits to be reimbursed at the same rate as face-to-face visits.

To explore the possibility that some patients were not taking advantage of the opportunity to do visits remotely due to digital access disparities, Roberts and his colleagues turned to the 2018 American Community Survey (ACS). The researchers focused on non-institutionalized respondents to ACS who indicated they were Medicare beneficiaries at the time of the survey.

The study sample consisted of 638,830 surveyed individuals, representing 54,749,082 individuals in the community-dwelling Medicare population.

Overall, 41.4% of survey participants lacked access to a desktop or laptop computer with a high-speed internet connection at home, while 40.9% did not have a smartphone with a wireless data plan, and 26.3% had neither.

The proportion with neither form of internet access varied by demographic and socioeconomic status, with 50.1% of those whose income was below the federal poverty level not having digital access compared with 11.5% of those with incomes of 400% of the poverty level or greater. Participants who were 85 and older, were widowed, had a high school education or less, were Black or Hispanic, received Medicaid or had a disability were also less likely to have either form of digital access.

Even if every elderly person were to have the right equipment along with a way to access the internet, it wouldn't be a panacea, Roberts said, adding that there are a host of other problems that might stand in the way of seniors being able to use telemedicine.

The second article published in the issue investigated those problems.

That paper explored "telemedicine unreadiness" through a cross-sectional study of 4,525 community-dwelling adults using data from the National Health and Aging Trends Study, which is nationally representative of Medicare beneficiaries aged 65 and older.

"It's not as simple as just getting online," said the study's lead author, Dr. Kenneth Lam, a clinical fellow in geriatrics at the University of California, San Francisco. "There are other issues around disability, dementia and social isolation."

Dr. Lam and his colleagues determined that some 20% of Medicare beneficiaries had a physical disability, such as hearing impairment, vision loss or cognitive decline, that could prevent them from participating in a video visit.

On top of that, many older people are not experienced using the technology needed for telemedicine, Dr. Lam said. And even among those who are familiar with digital communication, many do not use the technology regularly. "Among those over 65, 24% had not emailed, texted or gone online in the past month," Dr. Lam said.

While it's possible that phone visits could be a substitute for those who aren't ready to do video visits, they won't provide enough information when the patient really needs to be assessed visually. "If someone told me 'my grandmother has been coughing' or 'my dad says his stomach hurts,' it makes me uneasy if I can't see the patient," Dr. Lam said.

The new studies "bring up important issues" with the use of telemedicine in seniors, said Dr. Mattan Schuchman, an assistant professor of medicine in the division of geriatric medicine and gerontology at the Johns Hopkins University School of Medicine in Baltimore, and medical director of Johns Hopkins Home-based Medicine.

"It's really been wonderful for people like my patients who have trouble leaving home," Dr. Schuchman said. "However, all the barriers talked about in these research letters ring true in my clinical experience."

Beyond that, Dr. Schuchman said, "ultimately, telemedicine can only go so far. It can only augment care, and certainly in the context of COVID it's better than nothing. But there's a lack of information that is needed for decision making, such as vital signs like blood pressure and pulse."

The new papers highlight the drawbacks of telehealth, said Dr. June McKoy, an associate professor of geriatrics at Northwestern University's Feinberg School of Medicine, in Chicago.

"But we don't want to throw out the baby with the bathwater," Dr. McKoy said. "We should start thinking of ways to deal with them."

"For example, our patients overwhelmingly have stated to us that they prefer telephone calls to televideo," Dr. McKoy added. "It's not because they can't use it, but rather, because they don't want the intrusion into their homes."

Dr. McKoy believes phone visits are fine for follow-up care, depending on the patient. "For new patients, I have to meet them in person," she said. "For people with dementia, I need them to come in because I need to put my eyes on them. Even though televideo can help, there is still a need for the in-person connection with the patient."

SOURCE: and JAMA Internal Medicine, online August 3, 2020.