Expansion of Telehealth Across the Rural

Abstract

Keywords

telehealth underserved structural inequity digital divide

Rural America faces a health-care crisis due, in part, to mergers in large hospital systems and divestments that threaten the closure of nearly 700 rural hospitals (National Rural Hospital Association 2020). Since 2013, the number of annual rural hospital closures has been in the double digits with 2019 seeing nineteen closures, the highest number to date ( HealthLeaders 2020). More generally, residents of rural areas face significant health disparities due to the lack of access to specialists/subspecialists, low patient volumes that drive up health-care costs, geographic isolation that increases travel times to obtain services, and the demographics of rural residents (i.e., higher percentages of elderly and low-income residents) that increase health-care risks and incidence of chronic conditions (Taylor 2019). Indeed, recent evidence documents higher rates of “deaths of despair” (i.e., deaths associated with suicide, poisonings, drug overdoses, and cirrhosis) within rural areas, which highlight the vulnerabilities rural residents face (Case and Deaton 2015). Expansion of telehealth services in rural areas offers promise for addressing the factors contributing to health vulnerability. This article provides an overview of telehealth implementation in rural areas of the United States, discusses barriers to wide-scale uptake, presents a review of recent policy changes initiated by the SARS-CoV-2 (i.e., COVID-19) pandemic, and offers recommendations for future policy initiatives.

Defining Telehealth

The Health Resources and Services Administration (HRSA) is the federal agency that houses the Office of the National Coordinator for Health Information Technology that oversees telehealth-related policies. Officially, the agency defines telehealth as “the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration” (HealthIT.gov 2017). HRSA recognizes the following four general categories of telehealth modalities: synchronous, asynchronous, remote monitoring, and mobile health (mHealth; HealthIT.gov 2017). Live videoconferencing (i.e., synchronous service) involves real-time videoconferencing between a patient and a health-care provider located at a remote site. Asynchronous technologies involve successive data exchanges between two users. Also known as “store and forward” technologies, these modalities generally involve information exchange between primary and specialty providers (e.g., radiographic images sent from a radiologist’s office to a primary care office). Remote monitoring systems include wearable technology (e.g., heart rate or wireless blood pressure monitors) that can transmit data directly from a patient to the health-care provider. Finally, mHealth technologies include applications and other health-related functions accessible on mobile devices (i.e., smartphones, tablets).

Models of Telehealth Services in Rural Communities

The Rural Health Information Hub (RHIhub 2020), funded by the Federal Office of Rural Health Policy, serves as the national clearinghouse for rural health issues. The site provides comprehensive tools for the development of telehealth solutions in rural areas and describes models for telehealth delivery to manage chronic health conditions, access specialty services, and support patient and provider education (RHIhub 2019b). The following examples, described in greater detail on RHIhub, highlight a number of successful programs addressing a variety of health-care needs.

Avera eCARE^© Emergency

Avera eCARE (2020a), a private company, has supported telehealth solutions across a range of specialty practice settings (e.g., school health, pharmacy, correctional health) in rural areas since 1993. Launched in 2009, Avera eCARE (2020b) Emergency provides rural hospitals and local practitioners access to board-certified emergency department (ED) physicians to consult on complex ED cases, provide ED orders, and assess and facilitate transfers for higher levels of care. Participating health-care systems access high-definition audiovisual support, with ED providers credentialed and licensed as part of the local health-care delivery team. According to the company’s Web site, the service provided more than 7,700 telehealth encounters to rural areas in 2019, which resulted in US$3.5 million in cost savings and the avoidance of more than 700 unnecessary patient transfers (Avera eCARE 2020b).

Skills Training in Affective and Interpersonal Regulation (STAIR)

The STAIR program is an evidence-based therapy originally designed to treat people with post-traumatic stress disorder who were victims of childhood abuse (Cloitre et al. 2010). The program was adapted to provide telemental health services to women veterans living in rural areas who have a history of military-associated sexual and other traumas (Weiss et al. 2018). Participants receive evidenced-based treatment for post-traumatic stress disorder through individual or group teleconferencing available in local outpatient clinics or their own homes. The ten-week program focuses on managing depression symptoms, enhancing mood regulation, and increasing social functioning. Research demonstrated enhanced program participation through the use of teleconferencing (Weiss et al. 2018).

Bridges to Care Transitions-Remote Home Monitoring and Chronic Disease Self-Management

Designed by researchers at Emory University, the Bridges to Care program seeks to address behavioral health issues in patients with poorly managed chronic health conditions (RHIhub 2019a). Patients enroll in this program following preventable hospitalizations or ED visits for chronic health conditions. The program offers in-home monitoring equipment to track vital signs and prompt additional assessments in the context of abnormal readings. With particular focus on the management of comorbid behavioral health conditions, the program is associated with lower rates of hospital readmission and ED visits and high patient satisfaction scores (RHIhub 2019a).

Project Extension for Community Healthcare Outcomes (ECHO^®)

Established in 2003 at the University of New Mexico, Project ECHO^® uses telehealth to train rural primary care providers in specialty care as a way to increase access to these services in local communities (University of New Mexico 2020). Clinicians participate in grand rounds presentations and case studies in weekly teleECHO^™ clinics. Although the program started with training in hepatitis C management, it has expanded to provide training on more than hundred health conditions and operates in thirty-one countries around the world.

Addressing Barriers to Widespread Implementation

Technology’s ability to reach consumers in geographically isolated areas, particularly rural settings, provides promise for telehealth to reduce health disparities, but the evidence of those effects remains unclear (Marcin, Shaikh, and Steinhorn 2016; Gonzalez 2018; Myers 2019; deShazo and Parker 2017). For example, a review conducted prior to the COVID-19 crisis examined the effect of state policies on the use of telehealth in a nationally representative sample (Park et al. 2018). The authors found that providing more access to telehealth services was not associated with greater uptake among underserved populations (i.e., Medicaid beneficiaries, individuals with lower incomes, and rural residents) despite favorable views of telehealth within these groups. A number of technical, financial, health system, and behavioral barriers have contributed to the suboptimal uptake of telehealth solutions (Infosys 2019). Many of these barriers are not geographic-specific but reflect structural vulnerability and isolation that operate across the rural–urban continuum (Bourgois et al. 2017; Doogan et al. 2018).

The current COVID crisis prompted policy makers, business leaders, and service providers to devise solutions to these barriers to enhance health-care delivery during the pandemic. For example, in March 2020, the month when social distancing directives went into effect, 48 percent of physicians reported use of telehealth services up from 18 percent in 2018 (Merritt Hawkins 2020). Similarly, one of the large private health plans operating in Massachusetts reported a 3,600 percent increase in reimbursements for telehealth visits from February to March 2020 (America’s Health Insurance Plans [AHIP] 2020). The following sections highlight some of the more common solutions across the aforementioned categories of barriers; a full accounting is beyond the scope of this article.

Technical Barriers

Solutions to the lack of access to broadband connectivity in rural and underserved urban areas and the digital divide are topics addressed in greater length in the papers by Feld and Gallardo in this issue. However, several recent initiatives speak to these issues specifically as they pertain to telehealth. For example, on April 2, 2020, the Federal Communications Commission (FCC 2020) announced US$200 million in funding available through the COVID-19 Telehealth Program and appropriated by Congress through the Coronavirus Aid, Relief, and Economic Security Act (Pub.L 116–136). The funding allows health-care providers (not health insurance companies) to purchase equipment, services, and devices to support patient care through telehealth. Allowable expenditures include broadband and Internet connectivity services and tablets, smartphones, and wireless instruments to support remote patient monitoring (e.g., pulse oximeters that provide direct feedback to remote systems and not those that require patients to report results). At least one private insurance company made a similar commitment to support increased telehealth capacity with a pledge of US$5 million to assist federally qualified health centers to purchase telehealth equipment and provide training and technical assistance (AHIP 2020).

Broadening of acceptable modes of contact and service delivery has further facilitated more widespread telehealth uptake. Prior to the COVID crisis, Medicare would allow telehealth reimbursements only for visits that included a video component. At least through the end of the current crisis, Medicare now allows reimbursement for regular telephone consultations, a move supported by several state Medicaid programs and private insurance companies (Centers for Medicare and Medicaid Services [CMS] 2020; Center for Connected Health Policy [CCHP] 2020; AHIP 2020). Furthermore, under a recent U.S. Office for Civil Rights Notification of Enforcement Discretion decision, telehealth communication may occur through the use of common, nonpublic facing, digital communications platforms (e.g., Apple FaceTime, Google Hangouts video, Zoom, Skype) and texting applications (e.g., Signal, Jabber, WhatsApp; U.S. Department of Health and Human Services’ [U.S. DHHS] 2020) rather than solely through proprietary telehealth software systems.

Financial Barriers

Costs related to the establishment and support of telehealth services are one of the most commonly cited barriers to program implementation. Recent changes that facilitate reimbursement include the decision by many payers to reimburse telehealth services at the same rate as in-person visits and the elimination of cost-sharing requirements (i.e., co-payments and deductibles) for telehealth visits (CMS 2020; CCHP 2020; AHIP 2020). Massachusetts currently offers free access to the state’s Doctor on Demand program to patients regardless of insurance status, and several third-party insurance providers are temporarily providing complimentary access to telehealth platforms to self-funded employer customers and physician practices with five or fewer providers (mHealth Intelligence 2020). Finally, New Jersey’s Governor, Phil Murphy, expanded the scope of practice for nonphysician health-care providers to allow practice without physician collaboration or oversight (The National Law Review 2020). This allows nurse practitioners to offer telehealth services independently, which saves money since these clinicians receive lower reimbursement rates through most health plans.

Health System Barriers

Privacy concerns and other restrictions in health service delivery can also undermine telehealth delivery. Under the aforementioned Notification of Enforcement Discretion, the U.S. Office of Civil Rights announced that it would not enforce penalties for Health Insurance Portability and Accountability Act (HIPAA; Pub.L 104–191) privacy violations against health-care providers acting in good faith in the provision of telehealth services during the COVID crisis (U.S. DHHS 2020). The policy statement indicates an expectation that telehealth services be conducted in private settings but allows for measures to protect privacy (e.g., lowering voices) should visits take place in more public locations. Furthermore, under this notification, telehealth services are defined broadly to include “all services that a covered healthcare provider, in their professional judgment, believes can be provided in the given circumstances of the current emergency” (U.S. DHHS 2020, 3).

This more permissive approach to telehealth delivery is also reflected in the expansion of the number of Current Procedural Terminology^® codes (i.e., the codes used by health-care providers to bill for health services) covered for telehealth delivery (CMS 2020; CCHP 2020; AHIP 2020). For example, CMS made available more than eighty new telehealth service codes for Medicare reimbursement and expanded telehealth service coverage for any patient, new or established. Under prior policy, clinicians were required to establish a patient–provider relationship through an in-person visit before initiating telehealth services. CMS (2020) also eliminated originating site restrictions for patients covered under traditional Medicare, which allows providers to conduct visits with patients in their homes, rather than requiring them to travel to brick-and-mortar sites to participate in telehealth consultations. Finally, some states suspended out-of-state licensing restrictions to facilitate cross-state telehealth service delivery (Tech Crunch 2020).

Behavioral Barriers

A recent body of research focuses on structural factors within society (e.g., criminal justice policies, economic institutions, urban infrastructure) that may appear unrelated to health policies but which, through their cross-sectoral downstream effects, perpetuate health inequities (Metzl and Hansen 2014; Hansen and Metzl 2019). For example, financial practices that enable homeowners to build credit ratings through timely mortgage payments, but which do not extend the same benefits to renters, perpetuate disparities in the capacity for homeownership and the ability to accumulate wealth. These policies then have downstream effects in terms of housing stability, stress, and management of medical debt, which exacerbate health inequities (Dwyer 2018). Dorsey and Topol (2016) identified such “social factors” as one of the key barriers to full implementation of telehealth in the United States. Initiatives to address these factors are particularly critical in light of the inequities exposed through disproportionate numbers of COVID-related deaths among elderly people, people with low incomes, and members of ethnic minority groups (Artiga, Garfield, and Orgera 2020; Melillo 2020). Although few recent policies address these issues specifically, private insurance companies have shown leadership through establishment of free telebehavioral health services to community members (i.e., not just plan members) and the announcement of US$1 million in funding to support nonprofit organizations in Minnesota to provide telehealth and other supportive services (e.g., child support, shelters, and food security) during the crisis (AHIP 2020).

Policy Recommendations

The COVID crisis forced the health-care system to enact many of the changes that have long been advocated to advance telehealth services. Although the majority of these changes have been described as temporary initiatives, the potential for a resurgence of the virus in the fall of 2020 and later suggests that they may persist as long-term solutions. To ensure that the health-care system remains responsive to the needs of vulnerable populations, policy makers should enact many of these programmatic enhancements into law. Feld and Gallardo (this issue) highlight critical and innovative investments and solutions for broadband infrastructural investments. Beyond that, telephone consultations should remain an option for telehealth reimbursement since approximately 15 percent of Americans continue to lack access to smartphone technology (Pew Research Center 2019). Similarly, insurance should continue to provide coverage for visits conducted with patients in their homes, and telehealth should receive the same reimbursement as in-person visits. Finally, the federal and state governments should enact permanent policies that allow all health-care providers to practice at the full extent of their licenses and training. The Emergency COVID Telehealth Response Act, currently before Congress, would extend the Notification of Enforcement Discretion to allow physical therapists, speech language pathologists, and other health professionals to provide services through telehealth platforms (McDermott Will & Emory 2020). Congress should enact this policy and also seek to extend the Social Security Act’s definition of eligible distant site providers to include all licensed health-care professionals, as described in New Jersey’s Telemedicine and Telehealth Law (P.L. 2017 c.117) passed in July 2017.

Other changes enacted in the early days of social distancing will require modification. For example, health insurance plans may need to reassess some of the temporary service categories allowed during the pandemic to determine whether they are truly suitable for telehealth service delivery. Similarly, to ensure patient privacy, the social media and text service platforms currently allowed for telehealth consultations should remain viable options for the future but will have to develop HIPAA-compliant options to remain eligible as methods for service delivery.

Ideally, implementation of telehealth services follows a systematic approach that first identifies a specific need, studies the issue from a range of perspectives, and then designs a solution and evaluates its impact (American Medical Association 2020). The rapid scale up of telehealth necessitated by the COVID crisis did not allow for this type of thoughtful approach. Therefore, a critical need moving forward is for formal evaluation of the changes enacted and their effects on members of underserved rural and urban communities. CMS should conduct formal evaluations and demonstration projects to ascertain which beneficiaries have benefited from telehealth service expansion and which remain underserved. This will likely require mandates for clinicians and health insurance providers to formally track patient access to digital technology at the site of care and analyze insurance claims to identify disparities in telehealth delivery.

Although discussions of successful telehealth models rarely consider consumers as active participants in system development, federal agencies encourage consumer input. In its guide for the development of accessible health information technology (IT), the U.S. Agency for Healthcare Research and Quality noted, “…most health IT developers have little knowledge of populations with limited literacy and of the technical standards and aspects of accessible health IT design” (Eichner and Dullabh 2007, iii). Researchers echo these conclusions, calling for more community-based technologies and the inclusion of members of underserved groups in technology design (National Opinion Research Center 2013; Parker et al. 2018). As such, federal and state agencies should identify ways to bring consumer voices into telehealth system development. For example, federally qualified health centers provide the critical safety net for members of underserved communities. As part of their mandate, they are required to maintain advisory boards comprised of at least 51 percent consumers. These boards are ideally positioned to assess the impacts of telehealth service delivery on consumers and solicit consumer input into formal policies and regulations.

Conclusions

As critical as it is, access to health care through telehealth and other tools is not sufficient to ensure the basic requirements of human health. Less obvious, but equally important and repeatedly documented by health policy researchers, are the so-called social determinants of health such as access to nutritious food, employment at living wages, affordable housing, and political participation (HealthIT.gov 2020). Underserved rural and urban communities require additional supports to participate fully in telehealth service provision. Consumer education and training would increase the acceptability of telehealth, and the availability of telehealth in social service agencies (e.g., offices to apply for food stamps and medical assistance programs) and community settings (e.g., libraries) would improve access. Policy makers must make improvements here as well as they seek to improve the health-care system.

Telehealth has the potential to transform health service delivery in rural and underserved urban communities in ways that could help to reduce health disparities but barriers to widespread implementation remain. While the COVID crisis has proven a formidable challenge to the health-care system and has exposed the depths of health inequities in American society, recent efforts to enhance telehealth accessibility helped to overcome the inertia to embracing innovation. While some recent policy changes may not be sustainable, many reflect long-standing recommendations by researchers and advocates for the underserved. Health insurance providers, in particular, may find it difficult to return to the pre-COVID status quo. The fact that the pandemic shows no signs of waning during 2020 suggests the need to keep many of these policies in place. Ensuring the promise of technology to deliver a more equitable health-care system across the rural-urban continuum requires careful evaluation of the effects of recent policy changes, including direct consumer engagement in the process (Willen et al. 2017).

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ann D. Bagchi

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Expansion of Telehealth Across the Rural–Urban Continuum