For many Americans, finding a specialist, reviewing test results, or applying for a prescription drug assistance program requires no more than a few clicks on a website. But for the millions who don’t have consistent, reliable internet access, those tasks are far more arduous to complete. So many just don’t.
Danya E., who prefers to be identified by her first name only, lives at the edge of the White Mountain Apache Tribal Reservation in rural Cibecue, Ariz. For years she has relied on the Indian Health Service (IHS) for her healthcare. She got diagnosed, received printed copies of patient materials, and was referred to a local clinic. That was all good, she says, and free. But it also limited her access to specialists and, because she didn’t have internet at home, she couldn’t locate them easily on her own.
As Danya, a 37-year-old mother of four, explained, “People who don’t have the internet can’t find doctors outside of Cibecue because there is only one place in town that has free Wi-Fi and that’s the community library.”
As healthcare moves online, the 43 percent of households without internet access are finding themselves left behind, patient advocates say. The adults and children who live in those homes -- most of them already struggling financially -- can't easily contact their doctors, can’t apply for help with the cost of medicines, can’t find COVID-19 testing facilities, or even view their test results.
That means hospitals and other healthcare providers must try to reach patients where they live, sometimes by literally hitting the road and bringing care and medications directly to them. But that’s only an interim solution. Without the internet option, healthcare specialists say there’s a built-in inequality that’s more and more difficult to overcome.
The list of what patients without Wi-Fi can’t easily access is long.
“The healthcare information delivery system operates on the assumption that people have internet access,” said Dr. Elijah Sadaphal, an urgent care doctor at CityMD in the Bronx, N.Y. “The millions of patients without it have to do much more work to get information about their own care.”
For instance, 35 percent of Americans have used an online pharmacy to buy medications, purchases primarily driven by convenience and lower cost, according to a survey by the Alliance for Safe Online Pharmacies. The patient assistance programs funded by pharmaceutical companies in the United States--some 375 of them that have helped more than 36 million people get the medicines they need--often require online applications. And gone are the days when insurance companies mailed paper physician directories; to find a doctor in your plan, you’ll likely need the internet or a phone (and some patience).
None of that is easy for the 41 percent of low-income Americans who don’t own a computer and the 25 percent of low-income adults who don’t own a smartphone, according to the Pew Research Center. The same goes for the 41 percent of Medicare patients who don’t have a computer with a high-speed internet connection or a smartphone with a wireless data plan.
Searching an insurance plan database to find a doctor, comparison shopping for cheaper medications, and applying for assistance with copays all become more cumbersome without the internet. In fact, 63 percent of Black adults and 53 percent of Hispanic adults report that not having high-speed internet puts them at a major disadvantage when it comes to finding doctors or other medical professionals, according to another Pew Research study.
Without access to the web, Dr. Sadaphal’s patients get health information through word-of-mouth, the newspaper, or the doctor’s office. While most have cell phones, Dr. Sadaphal said, many don’t have an email address, which is required to use the urgent care center’s patient portal and view test results.
“We have patients coming back to the office two or three times to get test results or copies of their bloodwork,” Dr. Sadaphal explained. “Without internet, patients have to do a lot more legwork.”
Other poor outcomes: Patients who can’t afford a prescription often go without, unless he can supply them with samples. But because urgent care is transient, that too is hard to make happen.
Asked how her patients and their parents navigate care without the internet, Dr. Vera Bennett, a pediatrician in rural Lakeside, Ariz., said, “The answer is that they don’t. They struggle all the time.”
Most of her patients, Danya among them, are members of the White Mountain Apache and Navajo tribes. If they have cell phones, data plans are limited; phone numbers change frequently. If they need to access the internet, they can go to a public area with a strong Wi-Fi signal, like a bus station, but most patients don’t own cars to get to those places. And, even with internet access, she said patients aren’t using it to find healthcare.
“Most patients here are on Medicaid, which covers most of what they need, even transportation to appointments,” Dr. Bennett said. “If Medicaid doesn’t cover something, most times they just go without.”
The barriers created by lack of internet access are not new, just newly illuminated
“Digital determinants of health, while not new, were brought to light and exacerbated by the pandemic,” said Vidya Ayyr, a community health worker and director of community social impact at Parkland Hospital in Dallas. “There are really three issues for patients in terms of using technology for healthcare: living in an area with broadband services, being able to afford broadband and devices, and being able to use that technology. To truly make a difference, we have to address all three.”
The nation’s third-largest safety net hospital, Parkland has 1 million outpatient visits a year at its hospital and 30 community clinics. Most of Parkland’s patients are employed; most also fall below the federal poverty line. Nearly one-third of them are covered by Medicaid and 29.6 percent qualify for charity care.
While patients don’t need internet access to receive care, the hospital ramped up its telehealth program in response to COVID-19. To improve connectivity, Parkland partnered with nonprofits to provide “internet hubs” where patients can receive telehealth services in safe, private locations. Today most patients apply for financial assistance through its web-based MyChart system, but Parkland navigators are available to help in person or by telephone.
In addition, hospital’s outreach workers help patients obtain smartphones and learn to use them. Then they help patients enroll in programs like the FCC’s Lifeline and Emergency Broadband Benefit, which provide free or low-cost internet services to low-income households.
Zufall Health, a federally qualified health center with nine sites in New Jersey, provides primary medical, dental, and behavioral healthcare to 40,000 uninsured or underinsured people a year--60 percent of whom prefer a language other than English.
Like many facilities, Zufall too increased its use of telemedicine in response to COVID-19. If a patient didn’t have a smartphone, clinicians provided care at a clinic or by landline telephone. For underserved populations, such as seasonal migrant workers, it sends a mobile unit to farms. While there, case managers help patients connect with specialists and apply for patient assistance
“We won’t turn anyone away,” said Shade Cronan, director of Zufall’s fundraising arm. “If they can’t come to us, we’ll go to them.”
While the internet can help some patients find providers and shop for medicines, Dr. Sadaphal said many still don’t understand how to navigate the healthcare system—and no amount of technology can bridge that gap.
“In my experience, even with access to the internet, many patients still don’t know how to navigate our healthcare system,” he said. “Patients don’t understand urgent care, don’t know how to go to their insurance provider’s website and search for a doctor, and don’t know what to do to get care if they don’t have insurance.”
Cronan agrees, adding that underserved patients are typically less educated and have lower health literacy. As a result, they don’t know what questions to ask, with or without access to technology.
“All of these disparities existed before. We’ve known this for a long time, but there’s broader awareness now,” Cronan said. “This is a great time to take advantage of that awareness and increased knowledge and make changes to fix the system.”
For Danya and others in her community, that’s already happening. Since April, most households have been wired with Wi-Fi through a program at the local school. Now, when she or one of her children needs a doctor or medicine, she simply logs on to her health plan’s website.
Jodi McCaffrey is an award-winning freelance health and wellness writer based in New Jersey.
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