Improving health equity through virtual care

Recent events—from the COVID-19 pandemic and its devastating impact on the most vulnerable populations, to ongoing violence against Black, Indigenous, and People of Color (BIPOC) and LGBTQ+ communities, to the increased hazard caused by natural disasters—have made it more urgent than ever to address long standing disparities in our healthcare system.

Health disparities, which can be defined as “inequities in the quality of health, healthcare and health outcomes experienced by groups based on social, racial, ethnic, economic and environmental characteristics,” disproportionately impact marginalized and underserved communities.

A variety of factors can contribute to health disparities, including access to quality healthcare, financial and housing stability, access to nutritious food, and social and community support, along with family history and individual behaviors. This presents both challenges and opportunities for health insurance providers as they continue to lead the charge in creating a more equitable healthcare system. Achieving health equity not only requires health insurance providers to value everyone equally, but also to drive focused and ongoing efforts to address avoidable inequalities, historical and contemporary injustices and racism, and healthcare disparities. This includes giving special attention to the needs of those at greatest risk of poor health outcomes as well as meaningfully addressing social determinants of health to ensure everyone has a fair opportunity to live their healthiest lives.

Although health insurance providers have offered telehealth as a care option for years, the COVID-19 crisis accelerated adoption and amplified virtual care’s ability to improve safe and convenient access to care for disadvantaged populations, many of whom already faced significant barriers to health even before the pandemic.

A peer-reviewed study in the Journal of Medical Internet Research (JMIR) analyzing utilization trends of virtual care services during the COVID-19 pandemic found individuals in low-income regions accounted for approximately half of all visits occurring in the early part of 2020.

While the pandemic provided the impetus for skyrocketing adoption, current utilization trends and consumer perceptions indicate virtual care is here to stay, signaling a major shift in how individuals access care in the coming years. An analysis by McKinsey & Company found virtual care utilization has stabilized at levels 38 times higher than before the pandemic. The same analysis showed consumers continue to view virtual care as a key modality for meeting their future healthcare needs, with 40% of consumers stating they believe they will continue to use virtual care going forward (vs. 11% pre-pandemic) and 40–60% of consumers expressing interest in a broader set of virtual care solutions (e.g., digital front door, lower-cost virtual-first health plans).

This paper describes ways health insurance providers can leverage virtual care to expand equitable access to quality care, build trust with the diverse communities they serve, and address social determinants of health—all of which promote health equity. The paper then explores key considerations for ensuring virtual care does not widen the digital divide for disadvantaged communities.

• Black and Hispanic or LatinX people are three times more likely to contract and twice as likely to die from COVID-19 than white people but consistently receive fewer shares of vaccines relative to their shares of cases, deaths, and the total population.
  
  
• Black women are three times more likely to die from pregnancy-related causes than white women, even after controlling for income, education, and access to other resources.
  
  
• LGBTQ+ individuals are 2.5 times more likely to experience depression, anxiety, and substance misuse.
  
  
• Mental illness, chronic health conditions, and substance use disorders are all more prevalent among low-income populations.
  
  
• Rural residents are more likely to die from potentially preventable causes like heart disease, chronic respiratory disease, and unintentional injuries than their urban counterparts.

  
  
• Individuals with disabilities were more than twice as likely to report finding healthcare provider skills inadequate to meet their needs, four times more likely to report being treated badly, and nearly three times more likely to report being denied care.
  
  

1. Addressing barriers in equitable access to quality care and services

Vulnerable populations experience the following barriers to accessing high-quality healthcare and services:

Primary care shortages
Primary Care Providers (PCP) often serve several functions that are vital for achieving optimal health. They are one part urgent care, one part navigator, one part chronic disease management, and one part preventive care. PCPs are also critical in managing member’s relationship to the healthcare system. Severe physician shortages across the country, however, are making it increasingly difficult for individuals to access the care they need, resulting in poor clinical and financial outcomes. Data from the Health Resources and Services Administration shows that while there are currently ~223,000 practicing primary care physicians, the country needs an additional 15,000 primary care practitioners today to fill shortages. Residential segregation is strongly associated with PCP shortage areas. One study found that the odds of being a PCP shortage area were 67% higher for majority Black zip codes. In rural areas, inconvenient hours and low density of PCPs mean care is largely inaccessible for many. A new poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health found that one out of every four people living in rural areas said they couldn't get the healthcare they needed recently, with about a quarter of those saying the reason was that their healthcare location was too far or difficult to get to.

Behavioral health shortages
Behavioral health shortages are just as severe. Over a third of the entire U.S. population lives in areas with severe behavioral health provider shortages, with new patients in some of the largest U.S. cities having to wait an average of 25 days to see a psychiatrist. BIPOC communities are disproportionately impacted by lack of access to behavioral health services. In fact, BIPOC communities are:


• Less likely to have access to mental health services
• Less likely to seek out such services
• Less likely to receive needed care related to behavioral health needs
• More likely to receive poor quality-of-care
• More likely to end services prematurely

Transportation barriers
According to the American Hospital Association, 3.6 million people in the U.S. do not obtain medical care due to transportation challenges. Studies show that transportation barriers lead to missed clinic appointments, unfilled pharmacy orders, increases in hospitalization, and poorer health outcomes particularly for low-income, uninsured, and underinsured communities.

Lower socioeconomic neighborhoods may have longer wait times for emergency vehicles compared to neighborhoods with higher socioeconomic status. Research shows that adults with low socioeconomic status who walked or used public transportation to receive medical care were less likely to have a regular source of care. Overall, a body of research suggests transportation inaccessibility may be associated with less healthcare utilization, lack of regular medical care, and missed medical appointments.

By leveraging virtual care, health insurance providers can provide convenient access to high quality care for vulnerable populations. Because it transcends traditional limitations imposed by brick-and-mortar models around geography and set office hours, virtual care can expand access in multiple ways. This can include providing specialty care that may be unavailable in rural regions, enhancing care between visits with a multidisciplinary team, and increasing referrals or preventive screenings consistent with USPSTF guidelines.

Additionally, health insurance providers can seek to bridge gaps in the mental health landscape. One approach is partnering with a virtual care provider to implement an integrated behavioral and physical health model, expanding access to high-quality, diverse, and culturally-competent behavioral health clinicians. Another example is CMS’ proposal to expand access to mental health services for rural and vulnerable populations. For the first time, Medicare patients would have their mental health visits paid for when provided by Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). These visits will be conducted via interactive telecommunications technology, which is particularly beneficial for those living in rural and other underserved areas.

2. Building trust and enhancing patient-provider relationships

Extensive research shows that mistrust of healthcare providers and the healthcare system results in worse health outcomes. Medical mistrust can drive underutilization of healthcare services, delays in preventive care and routine screenings, and poor adherence to care plans for specific health conditions. Lack of trust is especially high among BIPOC communities, stemming not only from historical research abuse and injustices like the Tuskegee Study but also from their current experiences of racism and discrimination in the healthcare system. For example, a study on racial bias in pain assessment and treatment found Black people are systematically undertreated for pain relative to white people as a result of false beliefs about biological differences between the two. Not surprisingly, BIPOC patients have reported less partnership with physicians, less participation in medical decisions, and lower levels of satisfaction with care.

To address health disparities effectively, health insurance providers must therefore find ways to build and increase trust with the diverse communities they serve. Virtual care partners can play a key role in supporting these efforts by strengthening and enhancing the patient-provider relationship. For example, Included Health has intentionally built a practice of employed, full-time providers (as opposed to part-time independent contractors) that reflect the diversity of communities served, allowing for consistent quality, training, and relationship-building. Our employed providers receive extensive training and continuing education in culturally competent and evidence-based care, deploy patient-centered interventions proven to enhance engagement and satisfaction (e.g., motivational interviewing, shared decision making), and build longitudinal relationships with their patients—all of which strengthen the patient-provider relationship.

A peer-reviewed study in Mayo Clinic Proceedings found that patients who used video-based virtual care visits appreciate their relationships with their physician and overall user experience, including access and convenience. Further, this study found that the majority of patients commented favorably and most frequently on the interpersonal connection and relationship-building aspects of virtual visits and valued “building rapport” with their physician. These findings demonstrate that trust and rapport can be effectively established and maintained in a virtual care setting.

Increasing opportunities for patient-provider concordance, i.e., the shared identity between provider and patient based on such attributes as race, gender, and sexual orientation, is another significant way virtual care partners can support health insurance providers in building trust with diverse communities.

Studies have shown that patients who share the same race or ethnicity as their physician experience greater trust, satisfaction, utilization of services, and involvement in decision making. Historically, however, the lack of diversity among American doctors makes it especially challenging for people from underrepresented communities to find providers with whom they identify. 

For these reasons, Included Health has made significant investments in growing what is arguably one of the most diverse virtual care provider networks in the country. In our virtual care provider network, 43% of doctors are BIPOC, 21% are Black (four times the national average), and more than 60% are women. In addition, 20% of our behavioral health providers identify as LGBTQ+. This helps ensure the diverse members we serve are able to easily see a provider who they feel comfortable with and can relate to.

3. Addressing social determinants of health

Today, health insurance providers face the challenge of balancing fragmented parts of the member experience, including SDOH such as economic stability, physical environment, education, food, social integration, community engagement, and access to care. Lack of stability or access to resources in these areas have been shown to contribute to health disparities. By partnering with virtual care providers, plans can address SDOH issues using the following virtually-based methods:

• Identifying Needs Video-first visits can help surface SDOH concerns, including those related to the member’s physical environment. Member screening conducted by a Care Team trained in the techniques based on unconscious bias can build trust and elicit honest responses to further uncover food insecurity, transportation gaps, domestic safety, and financial concerns.
• Food Insecurity Our clinicians are deeply experienced in a holistic approach to members in video visits, where access to healthy food and related eating habits are always addressed for members with diabetes, hypertension, and cholesterol issues: some members with obesity issues seek out our clinicians with special expertise in healthy weight management. In our Virtual Primary Care plan partnerships, Registered Dieticians add additional expertise to these challenges.
• Transportation As previously mentioned, the convenience of members receiving high-quality care in their home eliminates concerns that often arise related to traveling to appointments.
• Education Promoting healthcare literacy and spending the time needed helps each member understand their diagnosis, prescriptions, and available care options.
• Community Certified social workers on virtual care teams can alleviate SDOH concerns by connecting members with free or reduced-cost community services that help with food insecurity, homelessness, child and elder care, job training, and more.
• Remote Expert Medical Opinions Access to high-quality primary and specialty care varies greatly across the U.S., with multiple challenges in finding expert physicians in many regions. High-quality, virtual expert guidance can be powerful by delivering the best clinical thinking to a member in any zip code. If the next barrier scheduling difficulties for an in-person appointment, a seasoned care team can also take care of this.

Virtual care is by no means a panacea for achieving health equity. While virtual care has expanded access to healthcare, it is not the only factor to consider when solving inequities in healthcare.

Health plans play an important role towards reducing barriers, from community-based services tackling food insecurity and financial literacy, to supporting health management activities like exercise classes, nutrition, and prescription fulfillment.
Programs that address technology gaps or limited broadband can ensure that all members have access to high-quality virtual care. Health insurance providers are already helping bridge this digital divide by collaborating with a variety of partners on innovative strategies and programs. This includes distributing smartphones, tablets, and data plans to underserved communities to offering providers technical assistance and training on the latest virtual care innovations.

Health plans can continue the vital work of strengthening and sustaining equitable access by selecting the right high-quality virtual care partner. Included Health continues to be at the forefront of innovative partnerships with health plans across the country, from virtual-first plan designs and risk-based arrangements, to uncovering health equity opportunities that raise the standard of care for everyone.

Technical review of this paper provided by a team at America’s Health Insurance Plans (AHIP).