Virtual Care and the Inverse Care Law: Implications for Policy, Practice, Research, Public and Patients

Abstract

Virtual care spread rapidly at the outbreak of the COVID-19 pandemic. Restricting in-person contact contributed to reducing the spread of infection and saved lives. However, the benefits of virtual care were not evenly distributed within and across social groups, and existing inequalities became exacerbated for those unable to fully access to, or benefit from virtual services. This “perspective” paper discusses the extent to which challenges in virtual care access and use in the context of COVID-19 follow the Inverse Care Law. The latter stipulates that the availability and quality of health care is inversely proportionate to the level of population health needs. We highlight the inequalities affecting some disadvantaged populations’ access to, and use of public and private virtual care, and contrast this with a utopian vision of technology as the “solution to everything”. In public and universal health systems, the Inverse Care Law may manifests itself in access issues, capacity, and/or lack of perceived benefit to use digital technologies, as well as in data poverty. For commercial “Direct-To-Consumer” services, all of the above may be encouraged via a consumerist (i.e., profit-oriented) approach, limited and episodic services, or the use of low direct cost platforms. With virtual care rapidly growing, we set out ways forward for policy, practice, and research to ensure virtual care benefits for everyone, which include: (1) pay more attention to “capabilities” supporting access and use of virtual care; (2) consider digital technologies as a basic human right that should be automatically taken into account, not only in health policies, but also in social policies; (3) take more seriously the impact of the digital economy on equity, notably through a greater state involvement in co-constructing “public health value” through innovation; and (4) reconsider the dominant digital innovation research paradigm to better recognize the contexts, factors, and conditions that influence access to and use of virtual care by different groups.

Understanding the integration of artificial intelligence in healthcare organisations and systems through the NASSS framework: a qualitative study in a leading Canadian academic centre

“…Our study provides new insights for decision-making and practice on the conditions required but also on the pitfalls to be avoided to ensure successful integration of AI technologies into healthcare organisations and systems. It shows that the pitfalls of the technocentric vision of digital health of the last thirty years in Quebec (and elsewhere too) could easily be repeated with AI technologies, but this time with more profound repercussions [ 31 – 33 , 35 , 36 , 63 ]. As Matheny et al (2020) highlighted: “Disconnects between reality and expectations have led to prior precipitous declines in use of the technology, termed AI winters, and another such event is possible, especially in health care” [ 64 ].…”

Virtual Visits With Own Family Physician vs Outside Family Physician and Emergency Department Use

“…Furthermore, within-system virtual care has demonstrated the potential for associated increases in JAMA Network Open | Health Policy equity of care 54 via improved access for individuals who struggle to afford higher visit-related costs. [55][56][57] Some health systems in the US and Europe have adopted integrated virtual care models. 49,54,58 However, other insurers, such as US Medicare, the UK National Health Service (NHS), and the Canadian provinces of Nova Scotia and British Columbia, have contracted out publicly insured health care services to corporate virtual clinics.…”

“…In 2 Ontario studies, patients whose regular family physicians provided more virtual care did not have higher rates of emergency department use. Furthermore, within-system virtual care has demonstrated the potential for associated increases in equity of care via improved access for individuals who struggle to afford higher visit-related costs …”

“…Furthermore, within-system virtual care has demonstrated the potential for associated increases in equity of care 54 via improved access for individuals who struggle to afford higher visit-related costs. 55 , 56 , 57 …”

Protocol: How can people with social care needs be supported through processes of digital care navigation to access remote primary care? A multi-site case study in UK general practice of remote care as the ‘new normal’.

“…The expansion of remote care through digital means can be convenient and beneficial for many patients. However, digital inequity can lead to digital health disparities whereby those people who might benefit most are least able to access remote care ( Alami et al , 2022 ). Increasing digital access therefore has the potential to generate further inequities ( Veinot et al 2018 ).…”