Access to Care Matters: Remote Health Care Needs During COVID-19

Introduction

As of this writing, there have been >31 million confirmed cases of coronavirus disease 2019 (COVID-19) and ∼1 million associated deaths worldwide.¹ The United States represents a large portion of these data, with >6.8 million confirmed cases, and >200,000 deaths.¹ At the onset of the pandemic, New York City, which now represents ∼3.5% of those cases,¹ experienced the highest rate of infections compared with any other state.² However, despite similar rates of infection throughout the city, there have been disproportionately higher rates of hospitalizations and deaths related to COVID-19 in the Bronx than in any other borough.³ This disparity has been attributed to the fact that the Bronx has the highest rates of chronic medical conditions such as hypertension, diabetes, and asthma in the state,⁴ and it has been well established that having one or several such pre-existing chronic medical conditions dramatically increases the risk of severe COVID-19 disease.⁵ The high prevalence of comorbidities and risk factors in the Bronx are in large part due to socioeconomic inequities,⁶ such as an inability to access health care. The current pandemic has exacerbated these pre-existing conditions (socioeconomic and medical, alike), making the Bronx population particularly susceptible to COVID-19 disease.

Acceleration of Telemedicine Implementation in Response to Crisis

In particular, novel barriers to access have arisen as visits to health care facilities introduce risks of contracting and spreading the virus, endangering health care workers, patients, and their families. Without interventions to bolster care accessibility, many physicians are concerned about a foreseeable surge in preventable illness. In an effort to expand access to care during the pandemic, most institutions have turned to telemedicine services.⁷ Given widespread community concern for asymptomatic transmission, this has beneficially reduced the need for in-person visits and allowed for socially distanced continuity of care. Recently, preliminary reflections have highlighted approaches, successes, and challenges associated with this telemedicine implementation. However, there has been limited discourse regarding widespread socioeconomic disparities underlying this transition, especially within neurological specialties. To provide effective neurological care during and after the pandemic, especially within the Bronx, fundamental changes in professional training, technological accessibility, and health care legislation need to occur.

Telemedicine Challenges from the Health Care Provider Perspective

With the onset of the pandemic, medical centers across the country were tasked with developing and implementing effective infrastructure for delivering telemedicine services to large populations of medically complex patients nearly overnight. In response, health care network resources were largely allocated to the purchase of necessary telehealth equipment, such as Health Insurance Portability and Accountability Act (HIPAA)-compliant clinic desktops and personal laptops.⁸ However, despite these technological precautions to ensure ethical patient interaction, the U.S. Department of Human & Health Services Office of Civil Rights announced waivers on penalties for HIPAA violations to physicians using common communication technologies to administer telemedicine services.⁹ In a sense, the introduction of these waivers signifies that the transition to telehealth has not been smooth. From the primary health care provider perspective, recently highlighted challenges include having to rapidly adapt available technologies and reorganized workflows.⁷ However, institutions have been working hard to address these complications by revamping software programs and introducing mandatory training sessions for physicians. Such technological limitations and solutions have similarly arisen in recent transitions to telemedicine within neurology specialties.¹⁰

Knowledge of the ongoing pandemic and the causative pathogen, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is continuously evolving. More specifically, recent clinical and laboratory observations suggest pathological effects on the nervous system of some patients.¹¹ In the Bronx, patients admitted with acute COVID-19 infection have been found to have new onset seizures, abnormal electroencephalograms, and encephalopathy in a preliminary case series.¹² It is unknown whether these associated neurological sequelae will have long-term effects, making remote follow-up of these patients of urgent importance. Ensuring neurologists are capable of providing this care will, therefore, require resources and programs for proper telemedicine training. The American Academy of Neurologists has already begun providing online resources for neurologists to implement telemedicine in their practice during this time.¹³ To allow for the management of a broader scope of neurological conditions, more of these resources need to become widely available for practitioners as telemedicine use continues to expand and evolve.⁷

Telemedicine Challenges from the Patient Perspective

The previously proposed measures work to fix problems faced by health care providers; however, major challenges regarding the patient side of telemedicine use still need sustainable solutions. Even though hospitals may now be offering telehealth services to patients, pre-existing socioeconomic inequalities have been a major barrier to effective implementation. In particular, this health crisis has drawn attention to technological literacy and access as key components of primary health care delivery in the modern era.¹⁴ There are significant challenges with bridging the technological gap, especially within the Bronx community, where ∼21% of residents do not have a computer at home and 13% do not have a subscription to internet access.⁸ Patients who are unable to access these telehealth services are often the most vulnerable, resulting in insufficient management of chronic conditions and poor outcomes.

A Need for Equitable Access to Telemedicine

Initial solutions to mitigate these exacerbated disparities in primary care include introducing community-based outreach programs to improve digital literacy and providing increased access to necessary technologies.¹⁴ Preliminary reflections indicate that these measures have thus far had a positive impact, allowing for smoother transitions to telemedicine platforms. Therefore, in considering pre-existing gaps within neurological care, the application of such programs in neurology specialties presents new prospects for telemedical care. More specifically, race and ethnicity are closely tied to disparities in neurological outcomes,¹⁵ primarily due to an increased rate in risk factors. However, despite worse outcomes, these disadvantaged groups, primarily comprising black and Hispanic populations, were less likely to access in-person neurological care¹⁶ before the pandemic. Now, in the current telemedicine climate, this access will continue to be limited and this inequality further exacerbated given technological access in these populations is also insubstantial.¹⁷ To prevent this, equitable telemedicine networks should be established by applying current interventions used to bolster patient access to primary care within neurological specialty care.

From the patient perspective, the mass telemedicine transition initiated by the pandemic extends beyond just an increased reliance on technology for health care interactions. Health care policy has also undergone fundamental changes to accommodate widespread telemedicine use in primary care and neurology specialties alike. In response to the pandemic, the Centers for Medicare and Medicaid Services relaxed regulations on the use of and reimbursement for telemedicine services for traditional evaluation and management procedures by a wide assortment of practitioners.¹¹ In New York state specifically, this form of remote care expansion is covered by private insurance, Medicaid, and state employee health plans under “Parity laws.”¹⁸ However, not all states have parity laws, casting uncertainty on the national future of telemedicine use for outpatient health care.¹⁹ Furthermore, the recent Medicare and Medicaid expansions have proven to be temporary and unsustainable as commercial payers have begun to rollback reimbursement policies for these services,¹⁹ a setback that would largely impact the most vulnerable groups relying on these programs for coverage. Even though access to remote health care has improved, there is concern that New York City’s socioeconomically disadvantaged boroughs will inadvertently be left behind. The initial expanded insurance coverage of telehealth services was a necessary and welcomed effort to broaden access, federal and state policy is needed to ensure permanent coverage during and after the pandemic.

Role of Telehealth in Neurology During COVID-19 and Beyond

As the pandemic continues, further studies will clarify whether there is a differential impact on neurological outcomes for patients requiring outpatient management of these chronic neurological conditions. The implementation of an effective long-term strategy for providing telemedicine services to the most vulnerable patients is paramount as recent projections estimate that by October 2020, there will still be >3 million infected people in the state of New York and >53 million across the country.²⁰ Proposed initiatives to mitigate this critical telemedicine access gap include screening for individuals likely to be technologically disadvantaged, expanded funding for permanent low-cost or free broadband internet and telemedicine access, providing training for provider digital skills and public digital literacy, and ensuring coverage for services through sustainable health care legislation (Table 1). We advocate for a coordinated effort to curtail this growing disparity in health care, and appropriately address inequities in telemedicine services for those patients at highest risk.

Authors’ Contributions

J.V., BSc, and T.I. designed and conceptualized the article, played a major role in the literature review, and drafted and edited the article for intellectual content; J.G., MD, contributed to literature review, drafting, editing, and revisions of the final article for intellectual content; J.B., LMSW, GC-C, designed and conceptualized response plan of the article and edited and revised the final article for intellectual content; D.J.C., MD, MSc, senior and corresponding author, mentor to Mr. J.V. and Ms. T.I., played a major role in the conceptualization of the article, reviewed the literature, and drafted, edited, and revised the article for intellectual content.

Disclosure Statement

The authors have no conflicts of interest to report. We confirm that we have read the journal’s position on issues involved.

Funding Information

This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.