‘Virtual’ doctor’s appointments aren’t just convenient; they’re critical for health equity

Sachin D. Shah, MD, conducts a telemedicine visit with Camilo Garza as he recovers from an injury.
Sachin D. Shah, MD, conducts a telemedicine visit with Camilo Garza as he recovers from an injury.

For Camilo Garza, it was just another beautiful spring Saturday — until it changed in an instant. While working on landscaping in his yard, he slipped and fell off a short retaining wall, landing on a garden stake below. Jammed into his armpit, the steel stake damaged nerves, muscles and tendons, leaving him in agony, despite not requiring surgery.

But this was in May 2020, in the midst of the first wave of the COVID-19 pandemic, and seeing doctors in person was difficult. By the time Garza was out of the hospital and referred back to UChicago Medicine to continue managing his care, many healthcare providers — including UChicago Medicine — had pivoted to offering virtual “telehealth” appointments for patients who didn’t necessarily need to be seen in person.

For Garza, video visits with primary care provider Sachin D. Shah, MD, were incredibly convenient. “After my injury, I could barely walk,” Garza said. “I was in bed for weeks. But I got to meet with Dr. Shah and a number of others many times, and it was wonderful. I was in a lot of pain. The video visits allowed me to just walk over to my dining room table and have a remote appointment with Dr. Shah.

“They weren’t the same as in-person visits, but they were very effective and thorough,” Garza said. “It worked really well for me at a critical time, when it would have been very difficult for me to go in to the doctor in person.”

From Shah’s perspective, the benefits went beyond convenience. In his opinion, telehealth actually improved Garza’s care. “Our telehealth appointments significantly reduced the number of visits that Mr. Garza had to attend in person, which reduced barriers to care, improved his patient experience and allowed us to provide more efficient and continuous care to him during his recovery,” said Shah.

Telehealth makes it easier to access healthcare

In just two years, video visits have become almost ubiquitous in a variety of healthcare settings, making it easier and more convenient for those seeking care to connect with their providers. These visits, in conjunction with necessary in-person testing and procedures and at-home monitoring systems, can dramatically improve the patient experience.

“Early on, a lot of our virtual visits were about adjusting the therapies that Mr. Garza needed, and especially his pain control,” said Shah. “There were a couple of things that needed to be done in person, but those were only maybe 10% to 20% of his visits. That gave us a lot more flexibility. It also speaks to the kind of role that telehealth can play as a really complementary part of how we deliver healthcare. A significant portion of care can be provided just as effectively, or sometimes even more effectively, through virtual care options.”

For Garza, remote visits meant that he didn’t have to travel during a difficult time. Since then, a telehealth option has made it easier to check in about his still-ongoing recovery, as well as to follow up on other issues like his blood pressure medication. Garza can easily check his blood pressure using an at-home monitor, and his physicians can use that information to adjust his treatment without an in-person visit.

But according to Shah, it’s not just about convenience — it’s also about equity.

“Offering telehealth options can help reduce or even eliminate a lot of the major barriers people face to seeking care,” he said. “Things like transportation, taking the time off work, finding childcare during the appointment, finding and paying for parking, and so on. Getting to and from the doctor’s office can pose a significant burden for some people, especially those who are living with disabilities, those who are lower income, or who are older and not as mobile anymore.”

Shah said that the explosion in telehealth options, especially in coverage by insurance, is a silver lining of the COVID-19 pandemic. “Patients and providers have been open to telehealth for a while, but the main barrier has been that it wasn’t covered by insurance,” he said. “Before the pandemic, it was a niche service, and you either paid for it out of pocket or it was offered as a premium benefit on certain health plans. But because of the pandemic, the government healthcare plans began reimbursing for telehealth visits, and the commercial insurance providers followed. The service really took off after that.”

The result is a care model that is more streamlined and continuous, allowing patients to quickly update their physicians on their health status or make requests for medication adjustments, and allowing healthcare providers to rapidly assess and respond to new information. This can make it easier for patients to receive treatment for a wide variety of conditions, and can improve responsiveness, reducing the likelihood that a minor issue will grow into a larger health problem.

Rolling back coverage is already challenging telehealth’s utility

While telehealth has proved to be beneficial for patients like Garza and many others, there is growing concern that coverage for this type of service will be rolled back in a post-pandemic world. For example, many plans already have stopped covering the cost of a telephone-only appointment with a provider, though they still cover video visits.

“While overall, 80% of virtual visits are done by video, and 20% are done by telephone, when we look at some of our most vulnerable patients, the reliance on telephone-only visits is much greater,” said Shah. “When we look at patients who are 65 or older, Black and living on the South Side of Chicago, we see less than half of them are able to take part in video visits, and instead rely on telephone-only encounters. Older patients, people of color, those with lower socioeconomic status, and non-native English speakers are at highest risk of being on the wrong side of the digital divide because of inadequate broadband access, limited digital literacy and lack of needed technology.”

Patients from these groups already typically bear a disproportionate burden of chronic disease and challenges to accessing care. These patients may spend a great deal of their time — and the time of their providers — going to and from the clinic for minor check-ins and updates that could easily be resolved over the phone. This further burdens an already-struggling healthcare system and reduces these patients' ability to access quality care.

At UChicago Medicine, Shah and his colleagues have learned many lessons from their telehealth experiences over the last two years. One key lesson is how basic additional support for patients can go a long way in helping them access virtual care.

“We are training members of our care teams to be able to provide some digital patient navigation — calling ahead of time to check in, texting video visit links immediately before the appointment, walking them through the steps to connect, and even setting up devices during in-person visits — to help reduce barriers to accessing virtual care,” said Shah.

The future of telehealthcare

Recently, Shah and Garza shared their stories and perspectives at a White House roundtable to argue in support of continuing to cover virtual visits.

Garza stresses the importance of access for those who have a harder time getting in-person care. “I have a lot of family in a very remote area of south Texas,” he said. “It takes about an hour and a half to drive to a place where they can get quality healthcare, especially when it comes to seeing a specialist. And I’ve lost relatives my age or even younger because I think they were unable to get the right medical guidance. It’s difficult for them to drive hours to get care. If they could get the information they need remotely, they’d be much better off, health-wise. I’m privileged to have the great care of providers at UChicago Medicine right here at my fingertips, but not everyone is so lucky.”

With his patients in mind, Shah is most concerned with whether or not health insurance companies will ultimately decide that telehealth options aren’t valuable enough to continue covering, and what that will mean for his most vulnerable patients.

“Will companies stop paying for this? That’s the billion-dollar question, literally,” he said. “I really see this as complementary care. Telehealth replaces some of the in-person care, rather than supplementing it, so it’s not really adding to the cost of care. I really see this as a matter of health equity, especially for the population that we serve on the South Side of Chicago. If we focus on the intentional work of helping narrow the digital divide in our most vulnerable communities, virtual care could improve access to healthcare for underserved patients. I think that hospitals want these options because it promotes flexibility and can actually improve access and capacity for necessary in-person visits. And a lot of patients really appreciate the flexibility that virtual care offers.

“For many people, telehealth options can absolutely improve the quality of care they receive by offering a more continuous relationship with their providers and care teams. Providing virtual care options to more patients, when appropriate, can in turn help provide more in-person availability to patients who require higher complexity care and procedures that can only be provided at the office or hospital. We can do our banking online, we can book our travel reservations online, why can’t we do that with healthcare? We can and should empower our patients to have this kind of access.”

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