The COVID-19 pandemic has required patients, healthcare providers, and governments to reimagine how care might be delivered at home, and has revealed opportunities to potentially improve outcomes, reduce costs, and improve patient experience. Telehealthcare adoption1 remains much higher than prepandemic levels (14–17 percent of visits, compared with approximately 1 percent in February 2020), but adoption hasn’t been uniform across clinical conditions, age groups, geographical locations, and types of insurance.2
Using national claims data,3 we estimate that more than 50 million in-person visits per year could be converted to virtual or telemedicine visits if adoption were extended equally across patient segments. In general, patient segments with limited access to in-person care (for example, those in rural counties and those with lower incomes) have relatively fewer virtual visits. While many believe virtual care can improve access for the underserved, the current imbalance in usage suggests that US healthcare stakeholders could consider designing virtual-care models that address structural barriers so that virtual care is more widely accessible.
In the following exhibits, we examine which patient segments are currently underserved by virtual care and why, and offer considerations for healthcare stakeholders regarding ways they might extend access.
Virtual-care adoption is highest for behavioral-health specialties and lowest for procedural specialties
Although virtual-care adoption in behavioral healthcare peaked at 72 percent of visits at the height of the pandemic and has stabilized at 54 percent, procedural specialties such as urology and gastroenterology stabilized at about 5 percent after a brief 15 percent peak.
These differences are expected, given the inherent range associated with the varying needs of visit types across specialties. Specialties such as behavioral health and some primary care in which visits may not require a comprehensive evaluation or intervention (for example, diagnostic, therapeutic, etcetera) can be offered more readily in a virtual setting. Given these inherent differences, stratifying adoption rates by specialty offers a good adoption barometer across payers, geographic locations, and patient demographics.
Virtual-care adoption is four percentage points higher in urban areas when compared with rural areas
Virtual-care adoption is four percentage points higher in urban areas (18 percent) than in rural areas (14 percent).1 This gap is even greater in behavioral health, with urban areas showing an adoption rate of 56 percent versus 47 percent in rural areas.
While some challenges may be structural (such as spotty access to high-quality broadband), care providers could consider taking a more active role in promoting virtual-care adoption in rural areas by offering virtual-setup services at the time of in-person visits, establishing small outpost clinics to support synchronous video, and expanding asynchronous virtual options.
Virtual care is being adopted at a lower rate in areas where the median income is lower than the national median
According to the 2020 census, the median US household income is $67,521.1 Virtual-care adoption is lower in zip codes with a below-average median household income—17 percent, compared with 20 percent in zip codes where the median household income is higher than the national median.
A technology gap and a lack of adequate providers with virtual-care options may be partially responsible. Addressing these issues head-on with deliberate solutions—whether at the macro level (for example, improving health and tech education) or at a micro level (for example, providing lower-tech options such as text- or voice-based offerings in all “menus” for virtual care)—could be key to closing this gap.
Virtual-care adoption is six percentage points higher with payers other than Medicare
There is a large gap in virtual-care adoption between people with Medicare and those with other payers. Those with other payers are clustered around an 18 percent adoption rate, while those with Medicare have a rate of 12 percent. The reasons may be varied: older patients are likelier to have more established relationships with their in-person care providers.1 They are also more likely to have differences in their use of technology (PCs and laptops, compared with smartphones) that may temper their uptake of virtual care.2
However, consumer surveys have shown that in the past few years, the gap in uptake of virtual care has been closing between those below age 65 and those above.3 Additionally, the benefits of virtual care for older populations (eliminating the need for transport, convenience of scheduling, etcetera) could suggest that payers and providers may need a targeted strategy for this cohort.
While Medicaid is associated with one of the highest overall virtual-care-adoption rates, the adoption of virtual care for behavioral health is six percentage points lower in people with Medicare than with people with commercial payers (51 percent, compared with 57 percent). This may point to opportunities to encourage greater adoption through benefits changes (for example, waiving copayments) and to incentivize integrated primary and behavioral healthcare models for this population. Similarly, managed-care organizations could expand awareness of these benefits.
Although virtual healthcare is seen as a boon by many patients,4 its potential to mitigate healthcare differences by improving access and convenience may be currently underutilized. Structural barriers continue to affect patients’ access to all forms of care, including virtual care. The factors that appear to matter in accessing virtual care seem to be location, median income, and type of payer.
There is tremendous potential to improve access to virtual care across all patient cohorts. A few opportunities include the following:
- Address differences in uptake by income. Addressing gaps in technology, awareness, and trust may be necessary. More people than ever have access to cell phones but with variable smartphone and data access. Offering low-data-usage options, including text messages and phone calls, may help to reach those patients.
- Address differences in uptake by location. Solutions might include kiosks for increasing awareness, support, and setup guidance for less experienced digital users and community health workers trained to set up virtual care during at-home visits.
- Address differences in uptake by payer. Waiving copayments and otherwise incentivizing care models for aging or under-adopting populations may help here. Building capabilities for multidisciplinary and multilingual teams in virtual settings (multiple virtual rooms, co-consulting sessions, etcetera), creating specialized virtual-care workflows for specific populations, and generally shaping the future of culturally competent and patient-centric virtual care could all encourage adoption among those whose circumstances make the leap to virtual care less straightforward.
Virtual care is a key element in the future of healthcare delivery in the United States, as shown by its continued adoption and ever-increasing consumer acceptance. Stakeholders (payers, providers, not-for-profit organizations, governments, etcetera) should be thoughtful in building and expanding this mode of care delivery to ensure that the new ecosystem is inclusive and accessible for all—especially those underserved by the traditional US healthcare systems.
