Those underserved by our existing healthcare system are all around us. Forty-four million people, or 13% of all Americans, live in a county with a primary care physician shortage, according to a report from one of the largest U.S. insurers, UnitedHealthGroup.
Two things are evident about this shortage. First, no one is going to wave a magic wand tomorrow and make a crop of new primary care physicians appear to solve this shortage.
Second, technology, in some form, offers our best hope to compensate for this shortage, by provisioning virtual care on a scale far beyond today.
“It’s a lot easier to reach large numbers of people if they are online or on mobile,” says Robert Kwok MD, director of Health Informatics at HealthTap. “Sometimes you have to encourage people who maybe don’t have access to insurance to actually try the online services, because they may not know which ones to pick or what’s out there.”
Underserved populations are not limited to these physician-deficient areas of the country. According to a 2018 report by the Pew Research Center, poverty rates in all areas of the U.S. — rural, urban, and suburban counties – rose since 2000. But looking at the share of counties where at least a fifth of the population is poor – a measure known as concentrated poverty – rural areas are at the top. About 3 in 10 rural counties have concentrated poverty, compared with 19% of cities and 15% of suburbs.
It just so happens, however, that the buildout of the internet usually stops, or drastically slows, where the suburbs end. This is making it difficult to fulfill technology’s promise to make up for the physician shortage in those very rural areas.
Reimbursement remains a problem for underserved populations
Topping this all off, reimbursement for telemedicine services across the nation remains uneven. “Each state is different in terms of Medicaid billing and even whether they require private insurers to pay for telemedicine,” says Donald Warne, MD, MPH, director of Indians Into Medicine (INMED). INMED’s goal is to assist one particular minority, American Indian students who wish to be health professionals to meet the needs of tribal communities.
The University of North Dakota, which sponsors INMED and where Warne is associate dean of diversity, equity, and inclusion, is devoting an April 24 fundraiser to support INMED.
Fundraisers aside, Warne says cellular connectivity at these communities remains inadequate to support telemedicine services direct to needy patients, although a local provider, Avera Health, operates a telemedicine hub in Sioux Falls, South Dakota. Overall, the areawide contract for the Indian Health Services to provide telehealth services is held by the original creator of that Sioux Falls hub, the Leona M. and Harry S. Helmsley Charitable Trust, Warne says. But services are far from complete at this point.
“I do see it as an area we need to pursue, because we can solve the telemedicine infrastructure challenges more quickly than we can solve the challenge of getting specialists to all of our communities,” Warne says.
Rural outreach to underserved extending into urban areas
Another university operating a program to bring telemedicine to underserved populations is the University of Arizona, which runs both the Arizona Center for Rural Health and the Arizona Telemedicine Program. Increasingly, programs originally intended to serve only rural populations are now reaching into underserved populations in urban communities as well, says Ronald Weinstein, MD, founding director of the Arizona Telemedicine Program.
The program also runs the Southwest Telehealth Resource Center, one of 12 regional centers supported through HHS’ Health Resources and Services Administration (HRSA). The Southwest Telehealth Resource Center services the “four corners” states of Arizona, New Mexico, Utah, and Colorado, as well as the state of Nevada.
Initially supporting the telemedicine efforts of rural hospitals, the Center has branched out to serving community health centers, and, increasingly, directly to consumers and patients, Weinstein says.
“The distinction between rural and urban really disappears when we talk about direct to consumer,” Weinstein says. The introduction of 4G networks, now being followed by 5G networks, means that the vast majority of rural communities are going to have the kind of broadband services their urban counterparts have enjoyed for years, he adds.
In addition, international telecom services, supported by satellites, have already proven effective in rural areas, he says. “We have areas where daily electronic body weights for patients with congestive heart failure are connected back to a regional node, and in some of those cases, that activity would be via satellite.”
Satellite services remain expansive, but “it’s certainly cost effective for congestive heart failure, where inpatient services are probably the number one billing code in Medicaid and Medicare,” Weinstein says. “Keeping those patients out of the hospital is important, and you can do a lot there without video,” a typically bandwidth-intensive application.
Agriculture Department annual grants for underserved are due soon
Another source of possible infrastructure funding is the United States Department of Agriculture, which provides grants for telemedicine equipment annually, says Earle Rugg, a member of the board of directors of the Association of Clinicians for the Underserved. The next round of applications is due May 15.
“It’s limited, because they only give out so many per year,” Rugg says. “There are other grants, but not specific necessarily to telemedicine. You have to tailor your telemedicine focus to a particular NIH, AHRQ, or HRSA grant.” The USDA also offers low-interest loans in addition to direct grants, he says.
One issue that continues to be debated is the definition of “rurality” – those measures the government considers when they define what a rural area is.
“That’s always a problem,” Weinstein says. “There area some very rural areas that have one major city in the area, and it disqualifies the entire rural community. The way we draw our county lines varies a lot from state to state.”
Technology such as 5G will help governments move beyond rurality as a criteria for funding telemedicine activity, Weinstein says. Another intriguing development: starting in 2019, CMS began reimbursing certain asynchronous services delivered via telemedicine, he says. By not requiring the session to be real-time, communities that are bandwidth constrained, or whose patients have scheduling conflicts with physicians, may still be able to benefit from telemedicine.
Finally, government needs to conduct more research to find out who is using telemedicine services such as HealthTap’s, and to what extent they are benefitting more than if they only had in-person visits, Kwok says.
“I think what will happen is the same thing that happened after the Affordable Care Act,” he says. “People who didn’t have health insurance or access will be better off if you give them access. They’ll get more visits, more medical attention, and probably live more healthily. It will probably cost more money, because more people are going to talk to the doctor. But virtual care reduces overhead such as transportation costs. But you are bringing more people to the doctor virtually, to get better health.”
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