While about 20 percent of Americans live in rural areas, only 9 percent of physicians practice there. That healthcare reality is forcing those areas of the country to consider expanding telehealth services as a potential solution for overcoming provider shortages and the lack of patient access to care.
A House panel heard testimony last week on the current utilization of telemedicine in rural America and how increasing the use of that technology could fill the care gap and benefit those communities.
“For the 62 million Americans living in rural and remote communities, access to quality, affordable healthcare is a major concern,” said David Schmitz, MD, president of the National Rural Health Association.
According to Schmitz, telehealth technology can support rural delivery of care but depends on adequate development of broadband Internet into rural and remote areas of the country. Likewise, he argued that rural providers must invest in necessary technological infrastructure and systems, emphasizing that government grants and private investment in technology “can increase the flow of new dollars into rural economies, empowering local resources to further healthcare infrastructure.”
“Maximizing our utilization of healthcare resources through the use of technology is the only way we can reach all of the Mississippians who need lifesaving healthcare,” claimed Michael Adcock, executive director for the Center for Telehealth at the University of Mississippi Medical Center, which delivers care in more than 200 sites in 68 of the state’s 82 counties, providing access for patients who might otherwise go untreated.
“Access to healthcare services can be challenging for some people, such as those who live in remote areas,” testified Nicole Clowers, managing director of the Health Care Team at the Government Accountability Office. “Telehealth can provide an alternative to healthcare provided in person or at a doctor’s office, for example, by providing clinical care remotely through two-way video.”
According to Clowers, telehealth used in rural areas can save patients the time and money needed to travel long distances to see a provider. As a result, she said it can lead to better adherence to recommended treatments and as well as overall patient satisfaction.
GAO interviewed Medicaid officials in six states and found that those that were more rural than urban said they used telehealth more frequently than more urban states. Given Montana’s limited access to specialists, auditors revealed that it leveraged telemedicine as a tool to help patients see both in-state and out-of-state specialists remotely, while in Illinois—which contains more urban areas—telehealth represented a very small portion of the state’s overall Medicaid budget used primarily to provide psychiatric services.
However, Clowers noted that Medicaid and Medicare are quite different. When it comes to Medicare, she said there are several barriers to the use of telehealth including payment and coverage restrictions that limit the geographic and practice settings in which beneficiaries may receive those services, adding that these policies are more restrictive than those of other payers.
Likewise, Barb Johnston, CEO of telepsychiatry vendor HealthLinkNow, lamented the fact that Medicare is the only health insurance payer that limits access to healthcare via telemedicine related to geography. And, because the Centers for Medicare and Medicaid Services will not reimburse for telehealth unless the location is in a narrowly defined “rural” location, many health facilities refuse any telemedicine programs because of concern over billing problems.
“Medicaid doesn’t have these rules, but Medicare does,” said Johnston. “The limitation of a patient being rural or non-rural doesn’t make sense when you have a neighbor who has Medicaid and they can see a doctor, and their next-door neighbor has Medicare and they can’t.”
Nonetheless, Clowers observed that as of April 2017 CMS was supporting eight models and demonstration projects that have the potential to expand the use of telehealth in Medicare.
“For example, one demonstration aims to develop and test new models of integrated healthcare in sparsely populated rural areas,” she told lawmakers. “Under the demonstration, CMS allows participating providers to receive cost-based payments for telehealth when their location serves as the originating site, rather than the approximately $25 fixed fee that CMS otherwise pays originating sites.”
Johnston credited CMS, through its Center for Medicare Medicaid Innovation (CMMI) Initiative, for funding the development and implementation of a new model of care where a telepsychiatry network was integrated into more than 80 primary care clinics across Montana, Wyoming and Washington.
“The goals were to prove this model would improve access to healthcare, assure patient satisfaction and reduce the per capita cost of care—these goals were achieved,” she said. “Patient satisfaction data collected by an independent third party reported that the 96 percent of patients who had received care via this telepsychiatry program would recommend telepsychiatry to friends and family, and 81 percent preferred telepsychiatry to in-person psychiatry. Significant cost savings were also achieved.”
For his part, Adcock pointed to cost savings from a Mississippi pilot with diabetics as part of public-private partnership between critical access hospital North Sunflower Medical Center, telecommunications provider C Spire, technology partner Care Innovations, the Mississippi Division of Medicaid, the Office of the Governor of Mississippi and University of Mississippi Medical Center.
“The preliminary results through six months of the study showed a marked decrease in blood glucose, early recognition of diabetes-related eye disease, reduced travel to see specialists and no diabetes-related hospitalizations or emergency room visits among our patients,” he added. “This pilot demonstrated a savings of over $300,000 in the first 100 patients over six months.”
Citing data from the Mississippi Division of Medicaid, Adcock contended that if 20 percent of the diabetics on Mississippi Medicaid participated in this pilot program, it would result in savings of more than $180 million annually. With the success of the diabetes pilot, he added that the Center for Telehealth at the University of Mississippi Medical Center has expanded remote patient monitoring to other conditions, including congestive heart failure, hypertension, and bone marrow and kidney transplants.
“Working closely with a patient’s primary care provider, we continue to grow this program both in terms of volume and number of diseases that can be managed,” he concluded. “Most importantly, this program is giving patients the knowledge and tools they need to improve their health and manage their chronic disease.”
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