Digital inequity is leaving safety net hospitals behind

By Dr. David Berger

The COVID-19 pandemic initiated a digital health revolution in the healthcare space, providing a convenient and safe way for patients to receive care outside of the four walls of the hospital or clinic. In droves, nonprofit and for-profit health systems invested in digital health strategies to help increase hospital capacity, divert from the crowded emergency department, ease staff burden, and enable providers to care for their patients from afar. Beyond COVID-19 response, these strategies have helped healthcare entities deliver comprehensive care, increase access, reduce costs, and improve patient convenience.  

Digital health strategies are here to stay, and while they have shown to improve patient care and outcomes, many patients and organizations face barriers to adoption. While “wealthy” systems have been able to invest, others, like safety net hospitals, have largely been left behind. 

Safety net hospitals play an essential role in the US health care ecosystem, as they care for patients regardless of their ability to pay or insurance status. Safety net hospitals serve the nation’s most vulnerable patients and provide comprehensive care that meets the needs of diverse, often complex patient populations. Safety net patients, who frequently are high utilizers of care, can benefit from digital tools that help increase engagement, health literacy, and care coordination.  

Unfortunately, safety net hospitals have fewer resources to invest in these innovative models, making adopting digital health tools nearly impossible. Financial pressures and insufficient resources magnify challenges.   

Safety net hospitals, and their patients, are suffering from the digital divide: “the chasm between those who have technologies and the digital literacy to work them, and those who don’t.”
 

The Safety Net Hospital Patient

By removing barriers like transportation costs or location, digital health tools make care more convenient and accessible. Unfortunately, it’s not that simple. Digital health tools, such as remote patient monitoring, wearables, patient portals, videoconferencing, and mobile applications, all require technology and connectivity, which are not accessible to all patients. Arguably the newest social determinant of health, the digital divide is more likely to affect the patients that safety net hospitals serve.  

The digital divide leads to access disparities that hinder outcomes–if a patient does not have access to the internet or smart devices, they cannot access digital health tools. They cannot use patient-facing practice management software, like online appointment schedulers or messaging tools. Today, 15% of Americans lack a smartphone, and at least 10% lack access to the internet beyond cellular data. Many patients don’t have access to an email address or a computer. For many digital health strategies, the patient and the provider need reliable internet access and a device with video and messaging capabilities.  

If the digital divide is not addressed, digital health could actually exacerbate health disparities, the opposite of its intention of improving access, convenience, and patient engagement. The digital divide threatens to widen existing disparities among at-risk populations, including the population’s safety net hospitals serve. Black and Latinx individuals, patients with public health insurance (Medicaid, Medicare) or no insurance, people with low levels of education and health literacy, and those experiencing food or housing insecurity are especially vulnerable to the digital divide.

Bridging the Digital Divide for the Safety Net

So, what’s the solution? What can be done to ensure that safety net hospitals are not left behind and that they can evaluate, then implement digital health tools? If safety net hospitals can invest in digital health tools, how can they ensure their patients benefit? 

• Increase opportunities for grant funding by offering more grants that support the evaluation and expansion of digital health infrastructure within safety net systems.
• Improve Medicaid reimbursement; since Medicaid reimburses at a far lower rate than private insurance, safety net hospitals operate on razor-thin financial margins. Improving Medicaid reimbursement can lead to increased revenue for the safety net system. 
• Accelerate investment in value-based care models like the hospital at home, chronic disease management models, and other value-based care strategies that reward providers for achieving health equity goals. This can increase revenue for the safety net system, resulting in more resources for digital health strategies.
• Urge private health care systems to contribute resources to safety net systems.
• Consider new payment models that enable safety net systems to take risks and implement innovation that allow them to deliver care that better meets the needs of their vulnerable patients.
• Extend and expand state legislation that ensures cash flow and ties more significant funding to higher Medicaid utilization will increase the safety net’s resources.  

Safety net patients are more likely to suffer from chronic disease and are more likely to have multiple chronic conditions. They also are more likely to lack home broadband or WiFi access and might have limited English skills.  

Safety net patients, including those that struggle with delayed diagnosis and care, suffer from complications from chronic conditions, or experience barriers due to health literacy, could benefit from digital health tools the most. For digital health tools to help the safety net population, they must meet their unique needs and circumstances.  

More than 15% of adults in the US rely on their smartphones exclusively for the internet. These individuals are typically from low-income households (with less than $30,000 annual income) or minority populations. For this population, it is essential that digital health solutions are accessible via a smartphone and don’t require a computer, tablet, or WiFi connectivity.  

Safety net leaders must also consider digital health literacy and factors like motivation and trust when evaluating digital health tools. 

Shifting the Paradigm to Improve Access to Digital Health tools

The safety net hospital’s mission is to serve low-income populations, regardless of a patient’s insurance coverage, ability to pay, or immigration status. At the intersection of health care, public health, and emergency response, safety nets are essential for health equity in this country. 

Digital health offers the opportunity to help safety net hospitals fulfill their mission by increasing access to care for underserved populations and patients in rural areas. Digital health strategies can increase access, improve convenience, promote prevention, influence the provider-patient relationship, and save billions in health care expenditures. But, for digital health strategies to reach their full potential, they must be inclusive. They must be accessible to safety net hospitals and the patients they serve.  

A paradigm shift is needed to address gaps in digital access and improve digital equity nationwide. States and counties must increase funding sources, harness partnerships, and develop resource-sharing opportunities that increase adoption of digital health strategies. 

About David Berger, MD

David H. Berger, MD, MHCM is Chief Executive Officer of University Hospital of Brooklyn, the main teaching affiliate of SUNY Downstate Health Sciences University. Dr. Berger is also Professor in the Department of Surgery at Downstate. He writes about digital solutions to healthcare challenges at davidbergermd.com.