**4.2 FACETS outcome research**

FACETS outcome research has been conducted with populations of varied age, ethnicity, socio-economic status, household income, and educational level. Respondents who had been diagnosed with, or demonstrated any symptoms of, any neurocognitive disorder, including Alzheimer's Disease, Neurocognitive Disorder with Lewy Bodies, or Vascular Neurocognitive Disease were screened and excluded from research samples. Among other variables, age groups were used to assess potential differences in IT utilization between age groups. Age groups were established based on age per decade, except those younger than 30 and those older than or equal to 80, each of whom formed their own group. The age groups were defined as 18 to 29, 30 to 39, 40 to 49, 50 to 59, 60 to 69, 70 to 79, and 80 or older. The seven age groups are summarized in **Table 2**.

FACETS outcomes indicate that the strongest effect on IT utilization is for differences in age. Older respondents consistently score lower in each of the five FACETS functional domains, and although almost all respondents report access to a computer (93.3%) and access to the internet (93.5%), the age effect is consistent with previous data indicating lower internet and IT utilization with increasing age [15, 17, 18]. FACETS outcome data also indicate that the decline in IT utilization associated with increasing age advances differently for each domain, suggesting that IT use is not a homogenous category. The frequency of IT utilization in the Home domain showed the weakest correlation with age, while frequency of IT utilization in the Health Care domain showed the highest association with age. **Figure 1** shows the differing patterns of decline in frequency of use for the five domains.

Although the frequency of IT utilization declines with age in all domains, the Health Care domain shows the steepest decline, which also occurs earlier than declines in the other domains. Although previous research indicated that the 20% discrepancy in IT utilization between younger age cohorts and people aged over 65 has not changed since 1985 [16], FACETS data indicate that discrepancies in the frequency of IT utilization continue to increase with greater age beyond the age of


**Table 2.** *FACETS age group cutoff points [18].*

**Figure 1.** *Frequency of IT use for each FACETS domain by age group [18].*


#### **Table 3.**

*% IT utilization of health care by age [18].*

65. This is a significant finding, suggesting that people over 65 years of age are not a homogenous population [18].

Specifically, the frequency of IT utilization for communicating with doctors, clinics and insurers declines most rapidly with age. In comparison with cohorts up to age 40, the frequency of IT utilization for communication with insurers and health care providers declined 28% by age 50, 58% by age 60, 93% by age 70, and 98% by age 80. The demonstrated decline in IT utilization with increasing age is consistent with earlier research [15–17], but importantly provides more detailed information about the age at which the rate of decline is greatest, and about preferences regarding IT utilization for communicating with health care providers at different ages [18].

#### **5. IT and access to health care**

Older adults use IT less than younger age cohorts specifically for accessing health care. While 95–98% of people under the age of 50 prefer to use IT to communicate with health care providers and insurers, only 7% of people over the age of 70 and only 2% of people over the age of 80 do so [18]. These data are shown in **Table 3**.

The decline in the use of IT for accessing health care with increasing age is more dramatically apparent when viewed graphically, as in **Figure 2**.

For example, even though they state that are capable of doing so, adults in age group 4 (50–59) prefer not to use IT to communicate with insurers or doctors. The distinction between the respondent's self-perceived ability to use IT as oppose to their willingness to use it is especially important in the context of health care, and has not previously been addressed. FACETS scores for members of older age groups (aged 70 to 79, and those over 80) whose health care utilization is highest [58, 59]

**Figure 2.** *% frequency of IT use for accessing health care by age group [18].*

indicate that they almost never utilize IT for communication with insurers or doctors [18].

#### **5.1 Insurers and IT**

The FACETS outcome research data demonstrate that the default use of IT media (videoconferencing, websites, MyChart, text messaging) by insurers, health care agencies or providers for communicating with older adult patients is ineffective, making health care least accessible to the population with the greatest health care needs, older adults [58, 59]. The FACETS outcome research data also suggest that the default use of IT by Medicare, private insurers, and providers of health care for communicating with their patient populations might create a barrier to care and communication, which in turn might lead to poor health outcomes and lower satisfaction ratings by patients and providers of care [70, 71].

Despite these data, Medicare and private insurers continue to make increasing use of websites for communication with patients [63–65, 69]. This trend is shared by hospitals, regional health centers, university teaching hospitals, and local medical clinics [66, 67]. This is somewhat alarming, in the absence of any data indicating that the populations they serve have fluency using the internet or with IT [60, 74].

#### **5.2 Looking forward: IT and younger age cohorts**

One of the arguments employed in defense of the increasing use of IT media by Medicare, insurers and health care providers is that younger age cohorts are more IT fluent and in time, those lacking IT fluency will no longer be part of the population. The data demonstrate that this is a flawed premise. For example, the highest internet users in the 1985 U.S. Census Bureau study (age 30–35) are now in the low internet user category in the U.S. Census Bureau 2016 findings (now aged 63–68).

This finding appears paradoxical, and invites investigation and speculation. Data from FACETS outcome research suggest that the high IT users of 1985 did not stop using the internet as they aged, but rather, that adoption of new IT platforms including those for accessing the internet is lower among increasingly older cohorts. The lower rate of new IT adoption with age might reflect reduced neuroplasticity with increasing age [96–98], or detachment from newly introduced technologies after retirement, and/or lack of access to and/or training in the use of novel IT.

#### *COVID-19,Telehealth and Access to Care DOI: http://dx.doi.org/10.5772/intechopen.99300*

Perhaps more importantly, these findings suggests that high IT utilization is tied less to a specific individual consistently over time than it is tied to a person's age at the time novel IT is introduced. Younger people appear to adopt new IT & use it more consistently than older people, even if the older people were high IT users when they were young. This is especially relevant in the context of introducing new or evolving IT for communicating with patient populations. The FACETS outcome research data indicate that older adults continue frequent use of IT that is familiar, likely adopted prior to age 40 or 50, while people over the age of 70 demonstrate much lower utilization of IT introduced after they were in mid-life. Late-life introduction of novel IT appears to dramatically decrease the likelihood that it will be utilized. In the context of access to care, the introduction of novel IT by Medicare and health care providers for patient communication with populations over the age of 70 is likely to represent a future barrier to care even for people who currently belong to younger age cohorts [18].

#### **5.3 Insurers, IT and other age-related issues**

It is important to recall that no symptoms or diagnosis of neurocognitive disorder had been observed in any of the participants in the study, including but not limited to Vascular Neurocognitive Disease, Neurocognitive Disorder with Lewy Bodies, or Alzheimer's Disease. In 2015 the global number of people diagnosed with neurocognitive disease was 46.8 million, and 50 million in 2017. It is expected that by 2030, the number of people with neurocognitive disease will exceed 75 million, and by 2050 it will exceed 131.5 million [99–101]. The progressive organic deterioration characteristic of neurocognitive disease correlates with decreasing episodic memory [102, 103], making it even more challenging for older adults with neurocognitive illness to learn how to utilize new IT in order to communicate with health care providers or insurers. The use of IT for communicating with patients in this population may be neither practical nor realistic, and potentially creates a barrier to access to care [18].

#### **6. COVID-19, CMS, IT and access to care**

Along with people who have serious underlying health conditions, older adults belong to the cohort most at risk for serious illness reactions to COVID-19, for whom shelter in place is most strongly recommended. People over age 70 have been encouraged not to leave their homes to purchase groceries or perform other routine tasks, but only to leave their homes in the case of a physical emergency [104].

In the context of shelter in place measures to reduce exposure to COVID-19, between February and April of 2020 the Center for Medicare and Medicaid Services (CMS) made a number of policy changes intended to make telehealth more accessible to older adults. These include non-enforcement of policies limiting the patient's location to approved rural facilities, and the HIPAA compliance of the audio-visual platforms used for telehealth communications [13, 105]. While these measures increased access to care to Medicare subscribers with IT fluency, they failed to address access to care for Medicare subscribers who lack IT fluency. As the data demonstrate, 93% of people over the age of 70 and 98% of people over the age of 80 lack IT fluency and do not use the internet to communicate with health care providers, but instead rely entirely on face-to-face or telephone interactions with health care providers [18].

## **6.1 Advocacy for access to care for older adults during shelter in place**

Beginning in March 2020, the American Psychological Association (APA) made repeated appeals to CMS to allow reimbursement for the use of telephonic psychotherapy services during shelter in place [106]. On April 30, 2020, after a series of refusals, CMS agreed to provide reimbursement for the use of routine psychotherapy CPT codes for service provided using the telephone [107, 108]. Although the Medicare policy change is temporary, it makes health care accessible to 95.5% of Medicare subscribers over the age of 70. The policy change was intended to expire when the status of COVID-19 was reduced from a national state of emergency, but legislation is being considered that might make the changes partially or wholly permanent [74].

#### **6.2 Advocacy for making CMS changes permanent**

During shelter in place due to COVID-19, the public was encouraged to utilize virtual communications, especially videoconferencing, for access to health care. A growing body of research demonstrates the effectiveness of telemedicine [48, 109–113]. While this is a viable alternative for younger age cohorts, research data demonstrate that older adults make very limited use of, and/or have very limited access to IT for the purpose communicating with health care providers. While the discrepancy in internet and IT use between younger age cohorts and people aged over 65 is generally about 20% [16], mean utilization of IT (internet, web-based interaction) for access to health care by people over the age of 70 is only about 4.5% [18]. In other words, during shelter in place, 95.5% of people over the age of 70 relied exclusively on telephonic contact for access to health care. This finding is of special concern because older adults belong to the cohort most at risk for serious illness reactions to COVID-19 [104]. Limiting reimbursement for telephonic health care represents a barrier to care for older adults [74].

While CMS's decision to reimburse telephonic psychotherapy [108] is an important acknowledgement of the potential barriers to health care IT represents for older adults and makes health care accessible to an average of 95.5% of Medicare subscribers over the age of 70 [18], the change is temporary and will expire when the COVID-19 pandemic has been resolved [114]. Making reimbursement for telephonic psychotherapy services a permanent policy will facilitate better communication with patients, leading to better treatment outcomes [70, 71]. To facilitate better communication between patients and health care providers, routine assessment of IT utilization might be conducted a part of the standardized initial intake evaluation with older adults and other populations, in order to determine the most effective means through which they can access health care. FACETS is a valid and reliable instrument for assessing which media people use for accessing health care [18, 69]. Instruments like FACETS can be employed in order to determine the most effective means through which patients can access health care. Such assessment is especially important for older adults and other populations with limited IT fluency and/or access to IT or high-speed internet.

#### **7. Conclusions**

Although people over the age of 65 account for only 9% of the world's population, they account for 30 to 40 percent of COVID-19 cases and 80 percent of COVID-19 deaths [114]. Despite these statistics, people over the age of 65 have been *COVID-19,Telehealth and Access to Care DOI: http://dx.doi.org/10.5772/intechopen.99300*

excluded from more than half of COVID-19 trials seeking effective treatments, and from all of the vaccine trials [114]. These data speak to the healthcare system's tendency to overlook the needs of older adults. Hospitals, community health clinics, government-funded health agencies and private practices might also conduct similar assessments to build a larger data base that informs decisions about which media are most effective for communicating with older adult patients. A larger broadbased sample might also provide valuable information about the ways in which older adults access social contact, financial management, and other business functions. At the time of this writing, the COVID-19 pandemic remains unresolved. However, it is increasingly apparent that older adults rely heavily upon telephonic access to health care, emphasizing the importance of permanent changes that liberalize CMS telehealth policy.
