The impact of the SARS-CoV-2 strain of coronavirus (also known as COVID-19) pandemic was felt throughout the world in 2020 and will influence the health care landscape for years to come. The COVID-19 pandemic has highlighted existing health care disparities; even when comorbidities are controlled for, Black patients have 2.7 times increased odds of hospitalization from COVID-19 compared to non-Hispanic White patients [1]. Asian Americans have 2.1 times higher percentage of deaths attributed to COVID-19 compared to non-Hispanic White Americans, with 1 in 7 Asian American deaths in 2020 attributable to COVID-19 [2]. The pandemic has also highlighted the importance of reliable primary care use. Primary care physicians or clinicians manage chronic conditions, like hypertension and diabetes, which are linked with increased mortality secondary to COVID-19 [3]. Primary care physicians are essential in decreasing health care disparities. Increased availability of primary care has been associated with reduced effects of income inequality on self-reported health [4] and all-cause mortality [5]. Despite this, before the COVID-19 pandemic, there were already significant racial and ethnic disparities in primary care access. Urban areas with a high proportion of Black patients were up to 28 times more likely to have limited access to primary care providers [6]. Asian Americans are more likely to be uninsured than non-Hispanic White Americans even after the Affordable Care Act [7]. Given the importance of primary care in patient outcomes and mitigation of health care disparities, it is essential that new models of providing primary care be analyzed critically for equity.

Telehealth is defined by the Centers for Medicare and Medicaid Services as “exchange of medical information from one site to another through electronic communication [8].” At the beginning of the COVID-19 pandemic, telehealth infrastructure and reimbursement developed rapidly. Prior to March 2020, telehealth was reimbursed by Medicare in limited capacities only for patients in designated rural areas. In March 2020, Centers for Medicare and Medicaid Services broadened telehealth access to include all Medicare beneficiaries [8]. The US Department of Health and Human Services also waived restrictions on technology use not compliant with the Health Insurance Portability and Accountability Act to increase options for telehealth platforms [9]. Congress provided US $200 million in April 2020 to help US providers expand telehealth through the COVID-19 Telehealth Program [10]. These policy changes resulted in exponential growth of telehealth. Previous research shows that weekly telehealth visits increased 50-fold for one insurer [11].

Despite the swift increase in telehealth use, studies during the COVID-19 pandemic have demonstrated that Black [12] and Hispanic [13] patients, patients insured by Medicare and Medicaid [14], and those in lower-income areas [12] were less likely to use telehealth within subspecialty care. The data for disparities in adult primary care telehealth use is conflicting but overall concerning for racial inequity [15,16]. In pediatric populations, Black and publicly insured individuals were less likely to use telehealth in primary care [17,18]. However, in patients 65 years of age and older, Black patients used telehealth more frequently than White patients [19]. Little is known about the chronological trends of these disparities. One previous study suggested that the disparities in telehealth lessened throughout 2020 [20].

Our study aimed to further characterize telehealth disparities in adult primary care and to assess how the increase in telehealth use impacted existing health care disparities in primary care, specifically examining differences by race or ethnicity, insurance status, and geographic location in who is using in-person office visits versus telehealth intra–COVID-19. We wanted to determine if any existing disparities were significant only at the beginning of the COVID-19 pandemic related to inequity with initial use or if these disparities continued despite increased clinician and institutional comfort with telehealth use.

A total of 81,822 encounters in the pre–COVID-19 time frame and 47,994 encounters in the intra–COVID-19 time frame were analyzed (Table 1). The sample’s racial or ethnic demographics were found to be similar to those of Franklin County, the institution’s primary county [24].

The results of our retrospective cohort study demonstrate that certain patient populations who are more likely to experience health care disparities, including Asian and Nepali patients, those that are insured with Medicare, and patients in areas with high rates of poverty, are not using telehealth at equal rates in primary care settings (Table 5). We found that these disparities persisted throughout 2020. Previous research has shown that disparities in telehealth use in medically underserved areas lessened during 2020 [20]; however, our data contradict this. In addition, patients insured with Medicaid were found to have a new decrease in telehealth use at the end of 2020, suggesting continuing development in disparities that should be explored.

There are several possible explanations for these disparities. Inequitable patient access to telehealth infrastructure is one of the largest concerns. The recent Infrastructure Investment and Jobs Act will allocate US $65 billion for digital-inclusion initiatives, including increasing broadband accessibility [26], in the hopes to curb worsening access disparities. Given the high proportion of refugee populations in Franklin County, including Nepali population, language barriers may make telehealth more difficult to access. As we found disparities in patients insured by Medicare, older patients may lack the education or comfort to adequately use telehealth. Although provider capabilities certainly play a role in telehealth use, one of the strengths of our single center design is that all clinics included in this study had similar telehealth infrastructure and support. With the public health emergency declaration coming to an end in 2022, government officials and insurance payors must decide to what extent telehealth will continue to be reimbursed [27]. If telehealth becomes an increasingly central part of ambulatory care, we may continue to see widening disparities in primary care engagement if telehealth comes at the expense of in-person office visits. Patients must also be included in these conversations to determine what barriers, as well as preferences, affect how they access primary care.

There are some potential opportunities to improve equity within telehealth; quality metric use may improve disparities by allowing providers to offer care options that work best for their patients. Quality metric use was recently shown to decrease racial disparities in postpartum follow-up [28]. Some Medicare plans already incorporate Accountable Care Organizations that have quality metrics [29] that could be modified to be telehealth appropriate. Patient education on electronic portals and telehealth applications is critical to ensuring those with less familiarity with broadband can use telehealth. Interventions as easy as previsit telephone calls have been shown to increase completion of telehealth in underserved populations [30].

Our research does have limitations. As a single-center study, our results may be difficult to generalize to other centers. Additionally, we did not examine the type of care provided during these visits (eg, acute, chronic, and preventative) or if telehealth visits were done by video or telephone, which provides important context. We did not assess patient’s primary language, which may be an additional barrier to telehealth [31]. Our study combined both General Internal Medicine and Family Medicine encounters to develop a comprehensive understanding of primary care telehealth at our institution; however, this may make our data difficult to analyze in the setting of one department.

Nationally, telehealth accounted for 14% of commercially insured ambulatory encounters in 2020 [32], and these rates were maintained into 2021 [33], suggesting that telehealth has entered the mainstream of ambulatory care. The persistent disparities described by our study suggest that ongoing policy discussions about telehealth should focus on health equity to prevent further widening of health disparities in primary care. Our study was also able to examine the changing of telehealth use throughout the year of 2020. By monitoring how the pandemic has continued to evolve, we can determine if changes in telehealth infrastructure are inadvertently affecting specific populations. Continuing to monitor changes in telehealth access is critical to evaluating equity interventions.