Prescribing a better connection: Telehealth in Rural America

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The internet promises a world where users can instantly access information and services from anywhere, anytime. As policymakers work to address the access crisis in America’s rural health care system, the use of internet-enabled medicine is more appealing than ever. Despite the prospect of telehealth services, the inequitable deployment of broadband limits the power of technological solutions to address health care challenges.

What is telehealth?
Mayo Clinic defines telehealth as the “use of digital information and communication technologies, such as computers and mobile devices, to access health care services remotely.” These online services make it easier for patients to securely access their private medical information or use videoconferencing to see a doctor or nurse remotely. Doctors also benefit, as connectivity facilitates collaboration between health care professionals, provides easier access to patient records, and expands practice areas.

The use of telehealth services is on the rise: from 2012 to 2017, the percent of insurance claims with telehealth usage surged from just above 2% in 2012 to nearly 45% in 2017.

America’s rural health care crisis
In rural America, telehealth offers a solution to the long-developing problem of health care availability. 113 rural hospitals have closed from 2010 to 2019, cutting rural Americans off from essential health services and economic opportunity. These hospital closures have particularly impacted America’s South, where 12 hospitals have closed in Tennessee alone—more than in the entire Pacific seaboard. 

Hospital closures have deadly consequences for rural communities’ health: rural hospital closures are linked to an increase in inpatient mortality of 5.9% while urban closures have no correlated impact on public health. This problem is expected to continue, as 21% of rural hospitals are at high risk of closure. 64% of these facilities are essential to the health and economic wellbeing of their communities, as determined by their trauma status, service to vulnerable populations, geographic isolation, and economic impact. 

As this disparity grows, rural telehealth adoption also lags behind urban adoption. From 2016-2017, telehealth claims increased 55% in urban areas but only 29% in rural areas.

The limits of telehealth
Patients who would most benefit from telemedicine are the least likely to have the technological capacity needed to support it.

To benefit from telehealth services, patients must be able to access broadband speeds of 25 Mbps download and 3 Mbps upload, which the FCC defines as the minimum access speed for broadband connectivity. In urban areas, 98.3% of the population reaches this benchmark, but over 26% of Americans in rural areas and 32% of Americans in Tribal lands lack coverage. Some experts argue that these benchmarks are unnecessarily stringent, but low-bandwidth connections are less reliable and evidence suggests that electronic consultations are less effective when interrupted by technical glitches.

One in five Americans with inadequate access to primary care also lack access to the broadband connectivity speed needed to reliably use telehealth services. These broadband disparities are even more pronounced in the most remote and physician-deprived parts of the country, areas where telehealth could have the largest impact. Over four million Americans live in what CMS calls “counties with extreme access considerations”—where health care access is considered “adequate” if a patient can drive to their primary care physician in 70 minutes or to a psychiatrist in 110 minutes. 

Among those living in extreme access consideration counties, 62% of patients with adequate access to primary and psychiatric care had the broadband access needed to support telemedicine. However, just 39% of those with inadequate access to primary care and 49% of those with inadequate access to psychiatric care have the technological capacity needed to meet with a health care provider remotely.

Working towards a healthier connection
Multiple federal agencies are taking steps to increase telehealth adoption. This summer, the FCC proposed the Connected Care Pilot Telehealth Program. This $100 million dollar program would operate within the Universal Service Fund and would offer an 85% discount on connectivity costs for telehealth services. However, this program is limited to health conditions that take several months to treat, including chronic health conditions, mental health, opioid dependencies, and high-risk pregnancies.

In April, the Centers for Medicare & Medicaid Services finalized a rule allowing Medicare Advantage plans to include additional telehealth benefits, including the option to receive health care services at home rather than going to a health care facility. In rural America, which has high rates of Medicare enrollment, this coverage would lower the cost of telehealth services.

While these programs address the affordability of telehealth services, the question of technological access remains unanswered. Until rural America is able to connect to the internet as easily as their urban and suburban counterparts, the impact of telehealth will not be fully realized.

To learn more about telehealth and the obstacles for rural communities, download National Journal’s Telehealth Overview