Owing to a combination of stay-at-home orders and the federal government’s temporary expansion of coverage for telehealth services, COVID-19 catalyzed the adoption of telehealth. But while the surge has benefited both patients (hello, getting diagnosed on the couch) and doctors (who report having more time to speak with patients and caregivers, according to ZS research), a divide has emerged among telehealth haves and have-nots. Indeed, many of the preexisting barriers to care are being replicated in the digital realm.

So, as pharma marketers continue adapting to the world of virtual care, it’s critical to understand who telehealth isn’t reaching — and how their efforts can bolster equity in telehealth access. “In reality, those communities that could benefit the most from telehealth have not,” says Luis Belen, CEO of the National Health HIT Collaborative for the Underserved (NHIT).

The increasing divide serves to blunt industry momentum toward widespread telehealth adoption, which has obvious implications for medical marketers. At the start of the pandemic, point-of-care marketing quickly shifted from physical pamphlets and posters to two-minute informational messaging that plays in the virtual waiting room before patients connect with their doctors. Drug websites now encourage visitors to “click here to talk to your doctor,” connecting patients to vertically integrated tele-health practices.

Indeed, as ZS associate principal Victoria Summers puts it, telehealth has become almost a “marketing call to action.” By way of example, she points to Biohaven Pharmaceuticals’ Nurtec, a migraine medication that launched in 2020 with an assist from Cove, a telehealth firm that specializes in migraine care. Summers notes that success for these types of activations depends on answering the question, “‘Did the telehealth option that brands were offering really solve a problem for the patient?’ If it was just a COVID situation, you didn’t see a lot of volume going through those channels.” 

After stratospheric levels of adoption in 2020 — IQVIA reported a 3,000% increase in users — telehealth claims have plateaued, though at a higher level than many in the industry expected. According to telehealth claims analysis by ZS, they’re “stabilizing at about 30 times higher than it was in 2019,” Summers says. The company anticipates that about 20% of patient visits will shift to telehealth long-term.

“In the beginning of the pandemic, we thought it was going to be either you see your doctor with telehealth or you get comfortable with the risk of in-person,” says Sue Manber, chief patient officer at Publicis Health. “What we’re seeing now is a shift to, ‘How do you use telehealth as a triage, to determine when you need to see patients, especially those at higher risk? Can you get your lab work done ahead of when you need to see a physician?’ Building telehealth into your overall workflow is where the future is going.” 

Dr. Ian Tong, chief medical officer at telehealth provider Doctor on Demand, envisions a post-pandemic “consolidation of virtual services that provide the fully functional virtual health system through remote patient monitoring, devices that enable hospital-at-home and more wraparound services to address the social needs of patients.” Of course, its future will also depend on federal policy, though there’s currently growing support in Congress for an extension in Medicare reimbursement of telehealth services. 

But none of this accounts for the telehealth users who have been left behind. In February, the NHIT helped launch the Telehealth Equity Coalition (TEC), a group of academics, telehealth providers and nonprofits working to identify barriers and advocate for public policy that increases access to telehealth among underserved groups, among them seniors, rural residents and low-income communities of color.

The coalition’s website cites recent NHIT data on telehealth access showing that poorer and more rural states had fewer telehealth claims over the last year. Similarly, a study of COVID-related visits at New York City’s Mount Sinai Health System found that white and Asian patients were the most likely to use telehealth, while Black and Hispanic patients, people over 65 and non-English speaking patients were more likely to seek emergency room care.

First, there is the physical barrier of broadband access: The Federal Communications Commission reports that nearly 30 million Americans do not have access to high-speed internet, including 35% of people who live in rural areas. But according to April Mims, VP of public policy at Hims & Hers, a telehealth platform and member of the TEC, these physical barriers are only “a portion of the problem.”

At least 31.8 million American adults aren’t digitally literate, while many communities of color have a history of distrust in the healthcare establishment. A recent poll by the Kaiser Family Foundation and The Undefeated found that six of 10 Black adults said they trust doctors to do what is right most of the time, compared to eight of 10 white people.

“We want to support organizations that are addressing social determinants of health,” Mims says, pointing to access to public transit, healthy food and safe living conditions. “How can we expect people to utilize digital technologies when their basic human needs are not being met?”

Belen agrees, adding, “Having a safe space for a telehealth visit is another big concern in underserved communities. Many people don’t have a place where they can have a candid conversation with a provider.”

To better understand the interdisciplinary nature of these challenges, the NHIT is providing the Telehealth Equity Coalition and its members with access to the NHIT Data Fusion Center, which incorporates data sets from governmental organizations such as the Centers 

for Disease Control and Prevention, Centers for Medicare and Medicaid Services and the Federal Communications Commission. By layering these data sets on top of each other, TEC can create data visualizations that show “where’s the broadband, where’s the transportation, food insecurity … that helps us see things more from a health equity perspective,” Belen explains. 

Last year, Doctor on Demand saw a surge in demand fueled primarily by visits for behavioral health and chronic conditions. Tong says that while the company has seen a “paradigm shift of patients” during the pandemic, shifting more toward “low-income communities, more senior populations with our enrollment into Medicare Part B and more men,” there’s still a long way to go in terms of achieving equity in telehealth access in low-income communities traditionally populated by people of color.

“They suffer from lack of access not because telemedicine can’t go there, but because the infrastructure of our communities and our public policies have created these deserts,” Tong says. In order for telehealth to level the playing field, he adds, “Those communities need access and affordable data plans in the event of medical emergencies. They also need and deserve options to be seen by ethnically diverse clinicians who can deliver culturally responsive care.”

So how can pharma support equitable access to telehealth? Summers points to the patient support programs most pharma brands already have in place, which offer everything from co-pay cards to health coaches and call centers for answering patient questions.

“There’s a tremendous amount of support pharma can provide to patients to cover some of these disparities that we see with telehealth and care overall,” Summers says.

However, she notes that too often patients and physicians aren’t aware of them: “We need to focus on promoting these programs. Especially as more and more people are getting care remotely, these types of programs could be really helpful.”

For her part, Manber suggests supplying patients with information as a major way for pharma companies to help increase access, in addition to supporting broadband expansion. “How do you think about better informing your patients to have a more productive conversation? If you can help with basic understanding, then you actually do expand access to care,” she explains. 

Meeting patients’ technological capabilities, through increasing the availability of audio-only calls for those without broadband and focusing on mobile-first resources, is also an important piece of the equity puzzle. Advocates are currently pushing the federal government to reimburse audio-only telehealth at the same rates as video calls.

According to a 2019 Pew Research Center study, 26% of adults earning under $30,000 a year are “smartphone-dependent internet users.” Pharma companies need to be thinking about “text-based messaging and reminder programs, short videos, snackable content that will enable them to reach the patient where telehealth is happening,” Summers stresses. 

Coming from the advocacy side, Belen emphasizes the importance of listening to community needs. “When folks approach underserved communities, it’s usually from a consumption perspective — ‘here’s a good medication for diabetes,’ — but they don’t see the communities as partners in the production of health.” He cites TEC partner Hims & Hers as a good example of a telehealth provider making an effort to reach what he calls “last-mile patients”: people who aren’t insured or otherwise part of a health system. 

Mims hopes that Hims & Hers’ work through the TEC will help educate interested companies about “stronger best practices and principles for how to build a more equitable product.” Above all, she says, “we need to ask communities how they want to access healthcare services and operate within that framework, rather than imposing a telehealth solution onto them.”