United States of Care is pleased to submit the following comments in response to the White House Office of Science and Technology Policy’s Request for Information (RFI) on Strengthening Community Health Through Technology. Our comments will focus on areas 2, 6, and 7 of the RFI.
United States of Care (USofCare) is a nonpartisan, nonprofit organization founded in 2018 with a mission to ensure everyone has access to quality, affordable health care regardless of health status, social need, or income. We were established by a diverse Board of Directors and Founders Council to advance state and federal policies that solve the challenges people face with our health care system. We seek to understand people’s unique needs to drive health policy innovation and partner with elected officials and stakeholders to pass and implement those ideas.
As part of those efforts, USofCare has brought together partners from across the health care system to understand how to use virtual care to remove barriers to access for those who faced challenges accessing care before the pandemic, while also making health care more convenient for those who did not face access challenges. In pursuit of our mission to put people at the center of health care, USofCare researched how virtual care tools—including telehealth—could best be used to address health care access using a mix of research methodologies—including literature reviews, expert input, key informant interviews, national public opinion surveys, and conversations with everyday people. We have focused our response to your information request on opportunities to advance access to health care services through telehealth based on our findings from this research.
United States of Care’s Responses to RFI: Opportunities to Further Use of Telehealth to Support Access to Health Care
Comments in response to the RFI prompt: Barriers
Through our mixed methods research approach of listening to people, we know that people like using virtual care but also have faced barriers to using it to its full potential. Our research indicates that for those who have used virtual care, the majority 1) like using it, 2) find it safer and more convenient than in-person visits, 3) report that it saves time and money, and 4) are able to connect with the provider.
We have learned from people that they face the following barriers in using virtual care:
- Comfort using technology and digital literacy. People experience lack of comfort or unfamiliarity with technology, including computers, tablets, and remote monitoring devices, as well as online platforms. For example, 13% of adults aged 50+ reported in a NORC 2020 survey not being able to get the technology to work for their virtual care visit, and in a 2020 USofCare National Poll 23% of adults aged 50+ cited trouble with technology as what they liked least about their virtual care experience.
- Reliable and accessible internet. Some people have limited, inconsistent, or no access to internet services. Pew research analyses found that only about 60% of older adults aged 65+ are home broadband internet users and that rural Americans are 12% less likely to have broadband at home compared to urban and suburban Americans.
- Quality and personalization. People report concerns that there will not be a personal connection to a provider via virtual care. People also feel concerned that their unique healthcare needs will not be met. In December 2020, the West Health National Poll found that 13% of respondents had used virtual care but did not think it was personalized.
- Concerns about receiving an accurate assessment. People experience concerns that their providers would miss something or would not be able to conduct a thorough physical exam virtually: A NORC 2020 survey found that 20% of adults said that they didn’t trust the provider could get an accurate assessment with virtual care, and 25% were concerned that the provider would miss something.
We know from our research that people want to continue to have the option to use virtual care in the future, but they do not want virtual care to replace in-person visits. It is important that virtual care be designed as a complement to in-person care, and that we remove barriers so that people have the option to use virtual care when clinically appropriate.
Comments in response to the RFI prompt: Health equity
We believe that virtual care has the potential to close longstanding gaps in access, but only if approached in the right way. Our research has focused on those who have historically faced barriers to accessing the health care system, and our recommendations aim to promote better access for more people. Virtual care has already shown success in eliminating barriers to accessing care, such as transportation, stigma, and time-loss–for example, an FQHC in California found that telehealth reduced their no-show rate by 10-15%, and those types of lessons can be used to design equitable approaches moving forward.
Without deliberate effort and careful attention however, a rapid move to virtual care could worsen health inequities rather than reduce them, given that some people lack resources to participate in a virtual care platform. For example, a JAMIA published study conducted in New York City, utilizing data from March 20 through May 18, 2020, found disparities in telehealth usage connected to race, age, and language preference. Researchers also found that Black and Hispanic patients, older adults, and non-English speaking patients utilized telehealth technology platforms less often than other groups.
Comments in response to the RFI prompt: Proposed government actions
Based on our research, we have identified the following opportunities for policymakers to ensure access to quality virtual care options:
- Blend in-person and virtual care: People should have the flexibility to choose whether to receive in-person or virtual care. Policymakers should ensure providers are not incentivized to steer patients to certain methods of care and strive to prioritize value over volume.
- Expand access opportunities: Bring broadband access and audio-only options to all communities. Eliminate barriers people face to getting reliable, quality virtual care. Ensure adequate reimbursement for a multitude of virtual care technology options to ensure equitable care.
- Maximize care locations: Permanently remove location-based reimbursement restrictions to expand access to virtual care in a variety of settings to meet people where they are, including their homes, beyond the pandemic.
- Enhance research: Look at successes and challenges among different populations and locations. Consider quality, cost, and equity implications of care models. It is critical to consider existing disparities in any data collection and measurement activities. Above all, ensure that policy is people-centered and gets them the care they need.
Even though significant barriers to virtual care exist, there are also tremendous opportunities to close gaps and improve access to care. We arrived at the suggestions in this response so that policymakers, providers, patients, payers, and others can work effectively to use virtual care to remove barriers to access. The virtual care system of the future must be centered on people’s needs in order to close such access gaps and improve equitable outcomes. At United States of Care, fostering such collaborations and taking deep dives into the experiences people have with virtual care and combining those learnings with leading research forms the basis of our work.
Thank you for the opportunity to respond to this important RFI. If you have questions or are interested in further discussion on this or any other health care issue, don’t hesitate to get in touch with Jennifer DeYoung, Senior Director, at [email protected].
Co-Founder and Chief Executive Officer
United States of Care