As Washington considers which virtual care flexibilities should remain in place post-COVID-19, experts are flagging that paring back telehealth access and affordability will disproportionately affect women, even as a growing share of startups emerge to address women's unique health needs.

While women are more likely than men to visit doctors and consume healthcare services in general, telehealth seems to be uniquely attractive to women.

The time savings and convenience of virtual care are especially helpful for caregivers, a historically female role, and the pandemic has seen a large number of caregivers using virtual care to triage needs for their loved ones — and themselves, experts say.

Startups have cropped up to address this demand, resulting in booming growth in the femtech sector over the past year and a half.

From January through August of this year, women-focused digital health startups raised a whopping $1.3 billion across 26 deals — nearly doubling all of 2020's funding with four months left in the year, according to seed fund Rock Health.

As a result, telemedical offerings have evolved beyond historical norms of fertility and pregnancy tracking to more comprehensive services, from menopause health to primary care to remote consultations for gynecology and telephone-based maternity care coordination.

Mounting patient utilization and investment in women-focused digital health and telemedicine comes as regulators consider how much telemedicine should be allowed post-COVID-19. Yet women say they don't want to lose the convenience of the service — even if it's not a first choice to address their medical needs.

Amber Bigler Newman, a technology marketer located near Sacramento, California, used telehealth for the first time last May and has since used it twice more to be prescribed medication for chronic urinary tract infections. The modality has allowed her to get medication while protecting her immunosuppressed husband from potential COVID-19 exposure in a doctor's office.

Bigler Newman, who characterized digitally delivered care as "ideal," said she will certainly use telehealth again, even after the pandemic wanes.

"It's most definitely a convenience thing," Bigler Newman told Healthcare Dive. But "I just think it’s a valuable tool for everybody. I see it as kind of a big part of how healthcare will be provided in the future."

Women, both doctors and patients, are disproportionately consuming telehealth

Women are currently accounting for significantly more visits than men, data from U.S.-based telehealth vendors shared with Healthcare Dive shows.

Virtual care giant Teladoc said in the first quarter of 2021, women accounted for 64% of general medical visits, while men only accounted for 36%. Women aged 25 to 44 are the most frequent telehealth users, while women aged 45 to 64 are the most frequent users for chronic condition management.

Amwell's provider network saw a surge in male patients around the initial spike of the pandemic last year, but visits have since returned to pre-pandemic gender distribution, the Boston-based vendor said.

Looking at telehealth use holistically across all of Amwell's business lines and therapeutic areas, female patients are "significantly more likely" to use virtual care, Amwell noted.

Similarly, nearly two-thirds of users on telehealth company MDLive's platform are women; more than half of MDLive's annual wellness screenings are for women; and 70% of female wellness screenings are among women aged 25 to 45, suggesting virtual care is playing a valuable role in the overall health needs of that demographic.

MDLive doesn't have any data on why women are more likely to use telehealth, Cynthia Zelis, chief medical officer at the company, told Healthcare Dive. But anecdotally, consumers cite time savings, avoiding waiting in the doctor's office and the convenience to call in from anywhere instead of having to go to the office all as benefits.

And "women have traditionally put off their own care while focusing on the needs of family members and other loved ones," Zelis said. "The COVID pandemic added unique challenges that put into stark relief the need to make access to care simple and hassle-free for women."

The data also suggests female physicians offer virtual care services at higher rates than their male counterparts, likely for the same reasons.

A little over 60% of Doctor on Demand's physicians are female, while 65% of the vendor's users are female. Both figures have remained consistent over the pandemic, the vendor told Healthcare Dive.

And data from telehealth platform Doximity published last year shows that female physicians adopted telemedicine at a significantly higher rate than male physicians during COVID-19. The study, which analyzed physician interest in job opportunities by gender, found that women were 24% more interested in telemedicine jobs relative to men.

That's a significant increase over 2019's data showing female physicians were engaging with telemedicine job ads at a 10% higher rate than their male colleagues.

Facilitating caregiving for US women

Unpaid caregiving and childcare are traditionally burdens that disproportionately fall on women. It's a unique position that, while being emotionally fulfilling for many caregivers, stresses mental and physical health.

Compared to non-caregiving peers, female caregivers are more likely to report poor health, have one or more chronic health conditions and have depression, anxiety or other mental health conditions. One in four caregivers say it's difficult to take care of their own health, while a similar proportion report caregiving has made their own health worse. And the growing shortage of professional caregivers is only likely to increase that burden on American women.

Recently, mothers and caregivers alike have turned to telehealth in droves to triage their own mental and physical wellbeing, along with that of their loved ones, experts say.

MDLive's Zelis said about a fourth of patients on their platform have used virtual care for their child, and the volume of virtual visits for urgent care for children has jumped this year compared to last.

Amwell Senior Medical Director Mia Finkelston told Healthcare Dive the vendor has seen a high number of moms calling with their kids in the summer months. The executive chalked that up to the confluence of school being back in session and difficultly getting in-person pediatric visits as long-deferred care comes to a head.

"Whether it's a child who's male or female, or a mom calling about herself, it's usually mom who's initiating this," Finkelston said. "Normally, if a dad calls, you see the dad yelling questions to mom in the other room."

Courtney Tobin, a communications specialist with health services company Cardinal Health, used telehealth last fall to follow up with hospital staff after her newborn needed double hernia surgery closely after birth. Her baby required multiple trips to the closest children's hospital — a 30 minute drive away — but specialists were able to check his incisions remotely for followup care, an easier option for Tobin now with two children at home.

"My husband and I — I was on maternity leave at the time and he was working, and so it was just super convenient to be able to do that," Tobin said.

Since that visit — Tobin's first experience with telehealth — she's also used virtual care for herself, to check on a potential eye infection while her second child was home sick from school.

"My husband and I work full time remotely and so basically I thought if I'm getting an eye infection right now, and I already have a kid home who can't go to school and is sick, I need to nip this right away," Tobin said. "All my doctor's appointments were booked up to come in in-person and she had an open telehealth spot. So I thought all right, we're going to do this."

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"Whether it's a child who's male or female, or a mom calling about herself, it's usually mom who's initiating this. Normally, if a dad calls, you see the dad yelling questions to mom in the other room."

Mia Finkelston

Amwell Senior Medical Director

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That convenience is also a major draw for female physicians with families. Virtual care allows them to provide easily accessible medical care for their patients, while allowing for more flexibility in their schedules and balancing any caregiving responsibilities.

"As a working mother with three kids, it has been incredibly flexible for me to work full time and raise my family without it being stressful," Finkelston, who has been practicing virtually for nine years, told Healthcare Dive.

Lauren Eberly, a cardiologist at the University of Pennsylvania, also pointed to telehealth's ability to increase access, even in specialty care, as a major draw for her in offering the service.

"It can be really difficult as a specialty physician for patients to make it to us and I always worry about who we're leaving behind," Eberly said. "So for me, I love the idea of, that if this is something that works better for you, and I feel like I can still deliver good care, then absolutely this should be an option."

Shivani Beri, a psychiatrist practicing in San Francisco's Bay Area, started her own practice early last year, right before the pandemic hit. Beri had used telehealth before and had planned to make it a tenet of her practice, but quickly pivoted to 100% virtual as COVID-19 grew.

"I actually thought from the beginning that it would be a part of it, just because I had seen previously how much people liked it and how convenient it was in certain situations," Beri said. "I didn't plan for it obviously to be 100%."

Beri, who signed a lease for a new office in February 2020 that has since gone unused, has yet to decide whether she'll return to an office once COVID-19 abates. Her home has become a quiet workspace now that her children, aged 3 and 6, are back in school, and Beri — who noted telehealth is especially useful for women with kids — appreciates the convenience of working at home, a few-minute drive from her children's school for pickup and drop-off.

"Thus far, I actually haven't had any patients who are asking to come and see me in person," Beri said. "If it continues where people are very content with doing the telemedicine visits, and there isn't a need to actually come and see me in person, I will stay remote. So far, it's actually working pretty well."

Telemental health a specific boon

Gender disparities in telehealth use become significantly more pronounced in mental health, as women are some of the hardest hit by the pandemic's effects and have flocked to telemedicine for support.

Historically, the proportion of female patients has drastically outstripped male users of mental health services. Need is higher among women, who are more likely than men to have certain disorders such as anxiety or depression, and women are less likely to face gender-based stigmas to asking for and receiving mental help.

And telehealth is becoming increasingly used to make services like a visit with a psychiatrist or counselor more widely available, especially in the majority of U.S. counties without a single psychiatrist, and for patient populations with a mental or physical block to accessing in-person care.

"I think it's really helpful, especially with mental health, in terms of access to care," Beri said, noting sometimes depressed patients, for example, find it extremely difficult to get out of bed, much less leave the house and drive to a doctor's appointment.

"But now, because they can pick up their phone or their computer and do a visit remotely, they're actually accessing the care," Beri said.

Rates of depression and anxiety climbed globally by more than 25% last year, a tragic byproduct of the pandemic that hit women and young people particularly hard, according to a study published in the Lancet.

When looking specifically at mental health visits, the share of women using Teladoc's platform skyrockets from 64% to 71%, the vendor said.

For MDLive, 71% of behavioral health visits are for women, and 70% of highly frequent repeat users in behavioral health are women.

The vendor said this makes sense as women tend to seek out behavioral health services at higher rates than men, but also shows that virtual care seems to have a stickiness with women when it comes to behavioral health that isn't shared by their male counterparts.

Meanwhile, Amwell's percentage of female patients using telehealth for urgent care hovers around 63%. That figure hikes to 65% in psychiatry and 72% in therapy.

"There's such an emphasis on wellness lately and that often resonates more with women than men and I think they're being a bit more mindful about their mental health," Amwell's Finkelston said. "I do think there's a little bit of a gender issue with that. Men don't necessarily see the importance of their wellness as much."

Being open with and seeking help for one's mental health needs is not culturally ingrained in the image of a stoic American male. A survey conducted in 2015 found 77% of men reported experiencing anxiety, stress or depression, but 40% said it would take them reaching thoughts of self-harm or suicide before actually seeking help of any kind, much less professional mental health counseling.

But COVID-19 may have tipped the scales. The share of men using telemental health appears to be steadily growing, vendors say.

Women account for most of Teladoc's mental health visits, but male visit growth is outpacing females', Kelly Bliss, president of Teladoc's U.S. Group Health business, told Healthcare Dive.

Men aged 18 to 24 are Teladoc's fastest-growing segment for depression, with 765% growth year over year, while anxiety-related visits are also way up at 915% year over year, the vendor said.

"As stigma around mental health decreases, men are feeling more comfortable seeking care," Bliss said.

As the share of men grows in telemental health, virtual care advocates are also pointing to some specific use cases that are more likely to be used by men as evidence that the number of male users will continue to increase.

A December study published in JAMA found that female sex was correlated with increased telemedicine use overall, and in primary care. But women were less likely to use telehealth to access specialty care, or use video modalities for telehealth.

UPenn cardiologist Eberly, a lead author of that study, said that could be due to women's disproportionate burden of childcare duties, which could restrict the time they have to engage in specialty telemedicine care.

Additionally, women had a bigger increase in unemployment during the pandemic, so probably lost their job-based insurance at higher rates, creating a financial strain due to the higher copayments for specialty care.

"We know that women have the burdens of childcare duties traditionally, but also especially during the COVID pandemic," Eberly said. "That, especially with more at-home schooling and the burden disproportionately being placed on women to be more at home and engaged with our children, might limit time to engage in specialty care but might allow them to be able to engage with their doctors more readily through telehealth."

Losing access would hit women hardest

Patchwork laws and insurance coverage in the U.S. have undermined telehealth access for years, but losing the broader access shepherded in by legislators and regulators during COVID-19 would disproportionately affect women — especially Black and low-income women — while throwing cold water on a red-hot industry, experts said.

"Telemedicine has this great opportunity to really meet the patient where they're at and help them in the way that works the best for them and I think we're learning so much during the pandemic about telehealth in general," Eberly said. "We're learning that there's definitely a great opportunity to use it to really decrease disparities and help people access care that traditionally have barriers. We just have to be really intentional in doing so."

As public health emergency orders continue to lift across the U.S., some states are introducing new legislation to keep virtual care provisions intact, while several others have halted telehealth expansions and allowed restrictions on out-of-state medical licenses to resume. Only a handful of states require payers to cover telehealth visits at the same rate as in-person ones, resulting in considerable coverage and affordability gaps that hit women harder, as they're more likely to consume the service.

And since women are less likely to use video, restricting access to audio-only telehealth is particularly concerning, Eberly said.

Earlier in the pandemic, lower reimbursement for such telephone visits was disproportionately affecting providers that care more for female and minority patients, leading CMS to up reimbursement — but only temporarily. Medicare doesn't plan to offer payment parity for video and telephone visits after the public health emergency expires.

Many providers and telehealth vendors have advocated for more permanent legislative action to guarantee payment parity for telemedicine, including that delivered solely over the phone.

But it's unclear whether Washington will deliver. There are a number of bills introduced to codify greater telehealth access, and broad bipartisan support on the Hill, while politicians seem to agree audio-only telehealth should continue to be allowed post-pandemic.

But legislators have also flagged that it's insufficient to address many health needs. That — along with deep concerns rampant telehealth use could actually inject more cost into the system — makes it unlikely audio-only visits will continue to be paid at parity after COVID-19 is in the rearview.

As the U.S. emerges from COVID-19, the nation needs to entrench policies and practices to build systems to meet the needs of communities — like women — most affected by structural inequality in the past, experts say.

There are obviously limitations with telehealth: You can't do everything over video, and patients have aired concerns about trusting a new physician met only over video. Female patients interviewed for this story stressed they prefer in-person visits for serious or uncertain medical needs, but the convenience and immediacy of telehealth is unparalleled, especially for those with children at home.

Tobin, who first accessed telehealth for her baby, still prefers seeing the doctor in-person if possible, but definitely plans to use telehealth after the pandemic.

"I think, COVID or not, the way I've used it in the last year, I would like to continue being able to use it. Like I said, I think I prefer that face time with a physician," Tobin said. "But when it comes to being more convenient, or getting an appointment when I wouldn't otherwise get one then yes, I still like being able to do telehealth."