Disparities in Telehealth Use during COVID‐19 across Federally Qualified Health Centers: Findings from National Survey Data

RESEARCH OBJECTIVE: Federally Qualified Health Centers (FQHCs) provide primary care services to 28.4 million low‐income patients across the US. In 2019, less than 1 in 4 FQHCs across the US were using any type of telehealth to provide real‐time virtual care directly to patients. The COVID‐19 pandemic transformed the landscape of primary care with rapid shifts to telehealth. The extent to which telehealth was implemented across FQHCs, and for whom, has significant implications for access to and equity of care for this population. Thus, our objective was to use a novel, nationally representative data set to evaluate differential trends in telehealth use across urban vs. rural areas; racial/ethnic groups; linguistic groups; and states during COVID‐19. STUDY DESIGN: Our primary data source was weekly HRSA Health Center COVID‐19 Survey data (April through June 2020), which included an average response rate of 71% per week. Our secondary data source was the 2019 Uniform Data System. Using generalized estimating equations with exchangeable correlation structures, we evaluated temporal week‐to‐week rates of telehealth visits (% of all visits that were virtual) across urban vs. rural areas; racial/ethnic groups; linguistic groups; and states. Models adjusted for the percent change in average weekly visits relative to the pre‐COVID time period, used state fixed effects, and clustered errors at the FQHC‐level. POPULATION STUDIED: 100% sample of FQHCs across the US (N = 1349), serving >28 million low‐income patients. Our analytic sample included 11,169 FQHC‐weeks. PRINCIPAL FINDINGS: From April through June of 2020, 96% of FQHCs across the US were using some telehealth and 47% of all FQHC visits were virtual—from 52% of visits in early April to 37% of visits by the end of June. However, there was significant heterogeneity in these trends. For instance, while urban and rural FQHCs had statistically similar rates of virtual visits in April 2020, over time, rural areas were increasingly less likely to be using telehealth (39% of visits in urban areas vs. 29% of visits in rural areas by late June 2020, p < 0.001). FQHCs serving a high proportion (>25%) of Black patients, Hispanic patients, or non‐English speaking patients experienced a significantly lesser rate of decline in virtual visits over time relative to all other FQHCs (p < 0.001 for all). Finally, telehealth utilization varied widely by state over our study period, including highest rates of use in CT (80%), RI (78%), and MA (76%) and lowest rates of use in SD (14%), KS (18%), GA (21%), AR (23%), TN (24%), ID (26%), and SC (26%). CONCLUSIONS: As FQHCs across the US reach a steady state of integrating telehealth into care delivery, there are significant differences in telehealth utilization that may be mitigating existing inequities in health care access, particularly for FQHCs that disproportionately serve Black, Hispanic, or non‐English speaking patients. However, geographic inequities in telehealth utilization are vast. IMPLICATIONS FOR POLICY OR PRACTICE: Permanently expanding coverage and reimbursement of telehealth services may help to address racial/ethnic and linguistic inequities in access to care. Wide across‐state variation in telehealth highlights the potential importance of state‐level policy, leadership, and investment in telehealth in enabling, or hindering, its implementation and reach. PRIMARY FUNDING SOURCE: The Robert Wood Johnson Foundation.