Telecare for All

Physician shortages, socioeconomic barriers, and high uninsured rates—these challenges perpetuate the lack of access to health care for the 60 million residents of rural communities across the United States.

To combat the scarcity of medical services in rural areas, federal and state governments are implementing regulations that promote the use of telehealth for medically underserved populations.

Patients in rural areas have the lowest quality health care and health outcomes in the United States. On average, rural populations have higher rates of suicide, substance use disorders, chronic health conditions, and infant mortality rates. The ongoing coronavirus pandemic further exposes health disparities for rural Americans. The Centers for Disease Control and Prevention warns that rural Americans who contract COVID-19 may develop more severe sickness from the virus.

Three major factors contribute to disparities in rural health.

First, most rural hospitals do not have specialty care providers and services to help patients with less common health conditions. Although nearly all rural hospitals provide surgery, obstetrical care, and certain outpatient services, they typically lack intensive care units (ICUs), substance use treatment programs, and chemotherapy services, among other specialty care. Amid the COVID-19 pandemic, deficiencies in infrastructure—such as a lack of ICU beds or ventilators—pose challenges for rural providers to deliver necessary and lifesaving care to COVID-19 patients.

Second, a shortage of resources has forced many rural hospitals to shut down. In the first half of 2016, an average of over two hospitals in rural communities across the United States closed every month—leaving many rural residents without access to any health care. Now, 700 hospitals face risk of closure.

Finally, due to the shortage of health resources in their communities, rural residents must travel long distances to access medical care. Many patients, however, cannot afford transportation, so they often forgo needed health services and treatment.

Yet the need for health care in rural communities remains great, especially in light of the disproportionate impact COVID-19 has on patients in these areas.

To try to meet that need, over 60 percent of health care institutions in rural areas now use telehealth technology to deliver medical services to patients in remote locations.

Telehealth is a type of health care delivery tool that uses electronic technology to connect patients to providers in another location. Through the use of broadband networks, high-resolution imaging, and mobile devices, doctors in remote locations can consult with and evaluate patients.

Although live videoconferencing is the most commonly used telehealth tool, telehealth also includes remote patient monitoring and store-and-forward communication—technology that electronically transmits medical information, such as X-rays and videos of examinations. These tools allow providers to collect patient health information, evaluate patients’ treatment progress, and coordinate care with other providers.

In response to telehealth’s growing popularity, federal and state governments have developed laws and regulations that seek to promote the use of this technology, particularly in medically needy communities.

Most recently, the Centers for Medicare and Medicaid Services proposed a rule that would extend the federal government’s temporary changes to telehealth regulations in response to the COVID-19 pandemic. The proposed rule seeks to improve access to health care through telehealth for Medicare beneficiaries in rural areas by, for example, increasing the number of virtual medical appointments that Medicare would cover.

Such efforts also existed before the pandemic. In 2019, the Federal Communications Commission released a final rule that increases funding for telehealth programs under its Rural Health Care Program budget. Through this funding, providers can obtain broadband and videoconferencing technology at discounted rates to connect with patients in the surrounding area who lack transportation.

But most regulation and policy development has occurred at the state-level.

Many states now have formal definitions of telehealth, as well as requirements for and restrictions on services provided through the technology. Regulation of telehealth, however, varies considerably across states.

Most states regulate the delivery of telehealth through Medicaid reimbursement guidelines and private payer laws. All states and the District of Columbia provide reimbursement through Medicaid for telehealth videoconferencing services. Only eight states, however, also offer coverage for other telehealth tools, such as store-and-forward and remote patient monitoring services.

Some states also apply telehealth regulation to private health insurers. These laws typically require private coverage for telehealth to equal in-person reimbursement amounts. Other laws do not impose parity rules on coverage costs, but rather they regulate the types of services that are covered under both policies.

Arkansas is one such state that has expanded coverage of telehealth to private insurers. As almost half of its population lives in rural areas, Arkansas has used telehealth programs to combat barriers in health care access for these communities.

For example, the state’s Medicaid program and two academic medical institutions in Arkansas developed a program to improve obstetrical care for women with high-risk pregnancies in rural areas. Using broadband equipment, providers at these institutions connect with patients for consultations, ultrasounds, and regular appointments. In 2018, these providers conducted over 2,500 telehealth visits.

As a result of its success in bringing obstetrical care to women to rural areas, Arkansas’s Medicaid program expanded its telehealth services to include specialty care for women with diabetes, sickle cell disease, hypertension, and mental health conditions.

Despite the favorable outcomes of telehealth programs, regulations limit the extent to which health practitioners can use this technology since telehealth could pose risks to patients, such as data breaches, provider licensing fraud, and patient misdiagnoses. To combat these potential issues, some states restrict providers from diagnosing patients through telehealth in the absence of a physical examination.

Proponents of telehealth, however, disagree with these constraints and advocate updating state telehealth laws to accommodate the growing need for virtual medicine during the coronavirus pandemic.

Although proponents recognize the need to ensure patient safety and quality telecare, they argue that such restrictions limit access to care for populations that have insufficient medical options for diagnosis and treatment. Telehealth’s proponents support expanded policies that increase insurance coverage as telehealth technology continues to improve and become more popular.

These proponents also encourage greater uniformity in telehealth regulations across states. They contend that current disparities in telehealth laws and policies pose difficulties for providers who operate their practice in multiple states.

Since telehealth programs continue to demonstrate success in addressing health care disparities, states have responded by relaxing current coverage restrictions. In loosening regulations, states seek to expand telehealth’s capacity to tackle pressing public health concerns, such as COVID-19, opioid addiction, and inequality in access to care.

For rural communities disproportionately impacted by these ongoing health crises, telehealth expansion might be one step closer to ending the rural health care gap.