Reprinted: Fortune Well, 6/2/2023
The world of health care has gone digital in many ways, from having telehealth appointments to receiving bloodwork results to messaging your doctor to comparing Medicare plans. But many people on Medicare lack digital health literacy and digital health access.
The result for these Americans aged 65 and older due to this digital divide? Worsening health inequities and heightened health problems. Digital literacy and Internet connectivity have been dubbed “super social determinants of health.”
Digital health literacy: A social determinant of health
“I think digital literacy at its core is one of the most important social determinants of health that no one addresses because it’s so hard to solve,” says Stefano Selorio, CEO of Carevocacy, a Miami-based tech tutoring business for older adults.
In fact, “studies have shown that a majority of Medicare recipients often lack digital literacy,” says Brandon Aylward, director of digital health research and advisory services at RTI Health Advance, a health care consulting firm in Durham, N.C.
The digital health divide is especially large among Black, Hispanic and Afro-Caribbean adults aged 60 and older, according to a 2021 study done by Florida Atlantic University, the Dana-Farber Cancer Institute and the University of Massachusetts Medical School.
Study participants were up to five times less likely to have access to digital health information than those who were younger and more highly educated, had a higher income or were European Americans.
Two big barriers to digital health adoption
The Health Equity and Access Leadership Coalition says two barriers to widespread digital health adoption are: access to broadband, hardware and software; and health literacy.
Some 30 million Americans don’t have broadband access and many of them are older adults living in rural areas.
Most Americans eligible for the U.S. government’s small program to expand broadband access and lower costs aren’t using it due to a complicated application process. And the Federal Communication Commission’s Lifeline program subsidizing the cost of smartphones and Internet service for low-income Americans has had rampant fraud.
Among people age 65 and older, just 44% use tablets and only 61% have smartphones, according to Pew Research Center.
One-quarter of Americans 65+ don’t use the internet. By contrast, 98% of people in their 30s and 40s do.
And some Medicare beneficiaries who have smartphones, tablets or computers aren’t sure how to use them for their health.
Understanding how to use their technology
“They need to know how to use their tech,” says Liz Hamburg, founder and CEO of Candoo Tech, a New York City-based tech training company for older adults.
Hamburg cites a woman in California who contacted Candoo Tech after receiving a tablet from a local nonprofit.
“She’d never used a tablet before, so we had a tech concierge show her how. Then she called back a couple of weeks later to say she needed an email address. We got her set up with Gmail. Then she needed to get onto her Medicare Advantage plan to message her doctor,” Hamburg recalls. “So, in two months, she went from never using the tablet to being able to message her doctor.”
Falling numbers for telehealth and Medicare beneficiaries
Telehealth usage by Medicare beneficiaries offers one example of digital health problems for some older Americans.
“One study highlighted that only a little over 35% of Medicare participants knew how to connect to their health care provider via telehealth,” says Aylward.
But telehealth can be extremely useful for older adults with difficulty getting to a doctor’s office due to their health issues, says Selorio.
The percentage of Medicare beneficiaries using telehealth has dropped precipitously lately, however.
Just 15% of people with fee-for-service Medicare used telehealth in the second and third quarters of 2022, the latest statistics available, down from 47% when the pandemic hit in the second quarter of 2020, according to the Center for Medicare and Medicaid Services (CMS) Medicare Telehealth Trends Report. (Medicare will cover telehealth visits anywhere through 2024.)
Partly, Aylward says, the decline in telehealth usage reflects the trend of the overall U.S. population. Now that the COVID-19 risk going to a doctor’s office has lessened, patients are more apt to make their visits in-person, which they tend to prefer.
But doctors may be responsible for this shift, too.
A recent Harvard T.H. Chan School of Public Health survey published in Health Affairs found that four in five primary care doctors who had telehealth visits with patients during the pandemic would rather provide a small portion of care through telehealth in the future, or none at all.
Most doctors surveyed said telehealth’s quality of care was generally inferior to in-person care.
Some medical practices are far more digital-forward than others, encouraging the use of technology for scheduling and rescheduling appointments, answering patients’ questions and providing medical information. This can be very helpful for digitally health literate patients and unhelpful for others. (My primary care physicians and specialists are big on digital tech; my eye doctor is not.)
“You have practices that have gone completely digital as far as their communications and scheduling. But then you have practices that haven’t adopted those kinds of approaches,” says Aylward.
Darwin Hale, CEO and founder of Advocate Health Advisors, an Englewood, Fla. adviser to insurance agents who sell Medicare policies, believes improving digital health literacy for Medicare beneficiaries is “a tremendous opportunity” because “digital health helps you have more accurate and more real-time information to make decisions on.”
A proposal for Medicare Advantage members
One proposal to improve digital health literacy for people with Medicare Advantage plans—the private alternative to Original Medicare, known as Part C plans—came recently from CMS.
The agency aims to require that Medicare Advantage plans offer digital health education to members with low digital health literacy, starting in 2024.
“Low digital health literacy is one of the most significant obstacles in achieving telehealth equity, and many older adults with low digital health literacy experience gaps in access to the health care need,” CMS wrote in its proposed rule.
Whether that proposal will take effect and, if so, exactly how the plans would decide which members need training and how to deliver it are all unknown as of now.
Hamburg says Candoo Tech is working with a Medicare Advantage plan that hadn’t planned to help its members increase their digital health literacy. “Then they went to a Town Hall meeting of their members and said it was one of the number one most requested topics,” she recalls. “So, they came back to us and said: “We’ve got to prioritize this.”
Where to get digital health literacy help
The National Digital Inclusion Alliance, a nonprofit, has a list of organizations around the country providing digital literacy training and resources for reducing Internet and computer costs.
Companies like the software platform Icario offer programs to improve broadband access and education specifically for Medicare plan members. Icario’s Digital Bridge tells those beneficiaries about the availability of free or low-cost devices, broadband internet service and tech support.
Other companies, like Candoo Tech, Carevocacy offer digital health tutoring and training, often through Medicare Advantage plans and senior housing developments.
“One of the learners we worked with was trying to figure out what kind of cardiologist she wanted,” says Selorio. “She wouldn’t have been able to do that if she didn’t know who the cardiologists were in her hospital’s system. We helped her figure that out and she was able to make a pick that was of her own choosing, rather than a recommendation from the hospital.”
A Candoo survey found that 60% of its users have accessed telehealth or researched medical information since receiving the company’s training.
“We’re working with a hospital system that uses a remote patient monitoring device so patients who’ve been released from the hospital record their weight and blood pressure and communicate with the doctor for seven or eight days. They found that if they can get them onto the system, there’s a significant decrease in rehospitalization,” says Hamburg. “But they’re finding a lot of patients can’t get onto the system, so we’re working with those patients.”
Nonprofits such as AARP’s Older Adult Technology Services (OATS) and public libraries offer digital health literacy instruction, too.
The 2020 Patients Accessing Technology at Home (PATH) Project from OATS and Maimonides Medical Center, for example, trained 19 chronically ill older adults living at home — and their family caregivers — how to use computers to enhance their health, using tech tools and encrypted email from geriatric medical providers.
Making digital health content user-friendly
Aylward says it’s important for digital health content to be tailored to users, especially for older patients.
“Information that’s presented in a clear and concise manner, that’s easy to understand and doesn’t include a lot of medical jargon,” he suggests. “Plus, visual aids or videos or interactive tools to really enhance engagement and comprehension.”
Advocate Health Advisors, Hale says, is creating a series of digital health content that’s tailored to veterans and for people on Medicaid.
Hamburg says digital health access and literacy can be so helpful for patients of all ages. “I can go to a doctor and all of my blood tests and results are now accessible electronically. So instead of my bringing a huge file of stuff, everything is on there,” she says. “That really wouldn’t have been possible even five years ago.”