Assessment of Disparities in Digital Access Among Medicare Beneficiaries and Implications for Telemedicine | Health Disparities | JAMA Internal Medicine | JAMA Network
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Table.  Limitations in Computer and Internet Access Among Community-Dwelling Medicare Beneficiaries in 2018a
Limitations in Computer and Internet Access Among Community-Dwelling Medicare Beneficiaries in 2018a
1.
CMS. Medicare telemedicine health care provider fact sheet. Updated March 17, 2020. Accessed April 14, 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
2.
Centers for Medicare & Medicaid Services. Trump Administration issues second round of sweeping changes to support U.S. healthcare system during COVID-19 pandemic. Published April 30, 2020. Accessed May 5, 2020. https://www.cms.gov/newsroom/press-releases/trump-administration-issues-second-round-sweeping-changes-support-us-healthcare-system-during-covid
3.
Mehrotra  A, Huskamp  HA, Souza  J,  et al.  Rapid growth in mental health telemedicine use among rural Medicare beneficiaries, wide variation across states.   Health Aff (Millwood). 2017;36(5):909-917. doi:10.1377/hlthaff.2016.1461PubMedGoogle ScholarCrossref
4.
Grigsby  J, Sanders  JH.  Telemedicine: where it is and where it’s going.   Ann Intern Med. 1998;129(2):123-127. doi:10.7326/0003-4819-129-2-199807150-00012PubMedGoogle ScholarCrossref
5.
Federal Communications Commission. Lifeline support for affordable communications. Updated August 17, 2016. Accessed May 5, 2020. https://www.fcc.gov/consumers/guides/lifeline-support-affordable-communications
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    Research Letter
    Health Care Policy and Law
    August 3, 2020

    Assessment of Disparities in Digital Access Among Medicare Beneficiaries and Implications for Telemedicine

    Author Affiliations
    • 1Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
    • 2Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
    • 3Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
    JAMA Intern Med. 2020;180(10):1386-1389. doi:10.1001/jamainternmed.2020.2666

    In response to the coronavirus disease 2019 (COVID-19) pandemic, Medicare temporarily expanded its coverage of telemedicine to all beneficiaries, included visits in the patient’s home, and began paying for audio-only visits at the same rate as video and in-person visits.1,2 Previously, Medicare (with a few exceptions) limited telemedicine coverage to video visits for rural beneficiaries and required video visits to take place at a medical facility, such as a physician’s office, rather than at a patient’s home.3

    Access to technology at home and the ability to use technology may affect use of video or audio-only telemedicine visits by Medicare beneficiaries. Although evidence on the efficacy of video vs audio-only visits is lacking,4 audio-only visits might be inadequate in some situations, such as when visual monitoring or diagnosis is important for care. We examined disparities in digital access (ie, access at home to technology that enables video telemedicine visits) among Medicare beneficiaries by socioeconomic and demographic characteristics.

    Methods

    For this cross-sectional study, we analyzed public use respondent- and household-level data files from the 2018 American Community Survey (ACS; from January 1 2018, to December 31, 2018), a nationally representative survey of the US population. We selected respondents to the ACS who lived in the community (excluding those in nursing homes) and indicated that they were Medicare beneficiaries at the time of the survey. The University of Pittsburgh Institutional Review Board waived study review because this study used deidentified data and was determined to be non–human subjects research.

    Among Medicare beneficiaries, we assessed the proportion who did not have (1) a desktop or laptop computer with a high-speed internet subscription, (2) a smartphone with a wireless data plan, or (3) either means of digital access. We examined how access limitations differed by, age, sex, race/ethnicity, marital status, educational level, language, income, enrollment in Medicaid, and disability status. We adjusted for person-level survey weights in the ACS to make our estimates representative of the national Medicare population. Analyses were performed using Stata, version 16 (StataCorp LLC). Reported P values were 2-sided and considered to be statistically significant at P < .05. The eAppendix in the Supplement provides more details about the methods.

    Results

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

    Overall, 41.4% (95% CI, 40.4%-42.4%) of Medicare beneficiaries lacked access to a desktop or laptop computer with a high-speed internet connection at home, and 40.9% (95% CI, 40.0%-41.8%) lacked a smartphone with a wireless data plan (Table). The proportion of beneficiaries without either form of digital access was 26.3% (95% CI, 25.5%-27.1%), and this proportion varied across demographic and socioeconomic groups. For example, a 50.1% (95% CI, 49.3%-50.9%) of beneficiaries with income of 100% below the federal poverty level lacked digital access compared with 11.5% (95% CI, 11.0%-11.9%) of those with income 400% or more above the federal poverty level (P < .001). The proportion of Medicare beneficiaries with digital access was lower among those who were 85 or older, were widowed, had a high school education or less, were Black or Hispanic, received Medicaid, or had a disability.

    Discussion

    Using data from 2018, we found that 26.3% of Medicare beneficiaries lacked digital access at home, making it unlikely that they could have telemedicine video visits with clinicians. The proportion of beneficiaries who lacked digital access was higher among those with low socioeconomic status, those 85 years or older, and in communities of color. Although Medicare’s payment for audio-only visits at the same rate as video and in-person visits may be associated with improved access to care for those without digital access, the inability to have a video visit may be associated with increased disparities in access to care. Moreover, some Medicare beneficiaries are unable to use technology for video or even audio visits. Limitations of our study include the lack of data in the ACS on beneficiaries’ ability to use technology or community-level broadband internet availability.

    During the COVID-19 pandemic, federal telemedicine policy has focused on reimbursement and clinicians’ capacity to deliver care remotely.1 Our results underscore a need to address disparities in digital access among patients. Expanding programs such as Lifeline, a program of the Federal Communications Commission that provides reduced-cost phone or internet service to families with incomes 135% or more below the federal poverty level,5 may help reduce disparities. However, Lifeline does not pay for devices, and patients may also need assistance using technology for video visits. Addressing these factors associated with digital access in populations with low socioeconomic status will be important as the use of telemedicine increases.

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    Article Information

    Corresponding Author: Eric T. Roberts, PhD, Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, 130 DeSoto St, Rm A653, Pittsburgh, PA 15261 (eric.roberts@pitt.edu).

    Published Online: August 3, 2020. doi:10.1001/jamainternmed.2020.2666

    Author Contributions: Eric T. Roberts, PhD, had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Both authors.

    Acquisition, analysis, or interpretation of data: Roberts.

    Drafting of the manuscript: Roberts.

    Critical revision of the manuscript for important intellectual content: Both authors.

    Statistical analysis: Roberts.

    Supervision: Mehrotra.

    Conflict of Interest Disclosures: Dr Mehrotra reported receiving grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.

    Funding/Support: This study was supported by grant K01HS026727 (Dr Roberts) from the Agency for Healthcare Research and Quality and grants 1R01MH112829 and 1R01DA048533 (Dr Mehrotra) from the National Institutes of Health.

    Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: This content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or the National Institutes of Health.

    References
    1.
    CMS. Medicare telemedicine health care provider fact sheet. Updated March 17, 2020. Accessed April 14, 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
    2.
    Centers for Medicare & Medicaid Services. Trump Administration issues second round of sweeping changes to support U.S. healthcare system during COVID-19 pandemic. Published April 30, 2020. Accessed May 5, 2020. https://www.cms.gov/newsroom/press-releases/trump-administration-issues-second-round-sweeping-changes-support-us-healthcare-system-during-covid
    3.
    Mehrotra  A, Huskamp  HA, Souza  J,  et al.  Rapid growth in mental health telemedicine use among rural Medicare beneficiaries, wide variation across states.   Health Aff (Millwood). 2017;36(5):909-917. doi:10.1377/hlthaff.2016.1461PubMedGoogle ScholarCrossref
    4.
    Grigsby  J, Sanders  JH.  Telemedicine: where it is and where it’s going.   Ann Intern Med. 1998;129(2):123-127. doi:10.7326/0003-4819-129-2-199807150-00012PubMedGoogle ScholarCrossref
    5.
    Federal Communications Commission. Lifeline support for affordable communications. Updated August 17, 2016. Accessed May 5, 2020. https://www.fcc.gov/consumers/guides/lifeline-support-affordable-communications
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