Telehealth delivers crucial rural access to care

The future of health care is starting to look more and more like an episode of “The Jetsons”: mobile, seen on screens and often available at a moment’s notice. As medical providers across Western North Carolina work to expand access, especially in rural communities where it’s notoriously lacking, telehealth has emerged as a promising new solution for patients in areas that lack local resources. Although rudimentary, hospital-based remote medical care has been around since the late 1950s, when a closed-circuit TV link was established between the Nebraska Psychiatric Institute and Norfolk State Hospital, telehealth has seen a dramatic rise in popularity as the technology has evolved and access to specialty health care has diminished.

An estimated 7 million patients in the United States will use telemedicine services this year, a December 2018 article in the Cleveland Clinic Journal of Medicine predicted, and demand will continue to rise. The piece also noted that from 2012-13, the telemedicine market grew by 60%.

“As we become more digital in our daily lives, it makes more sense, from a provider’s perspective, to interact with folks in that realm,” says Shane Lunsford, practice manager at the Asheville-based MAHEC Center for Psychiatry and Mental Wellness. “Often we can reach folks better through technology than we can face to face,” says Lunsford, whose facility — an arm of the Mountain Area Health Education Center — is about to roll out a new telepsychiatry program. “This is a way to make that access to health care happen and treat patients’ conditions before they have to go to the emergency room or call 911.”

Middle of no-care

That kind of tech-driven outreach is critical in a region where, according to the WNC Health Network, 88% of counties are considered rural. The nonprofit corporation has 17 member hospitals. Meanwhile, MAHEC data shows shortages of primary health care providers in all 16 of the westernmost North Carolina counties, and regionwide, the estimated shortfall for those providers plus general surgeons stands at 85. Even Asheville, the home base for most of the area’s primary care providers and specialists, is prone to shortages, the data shows, and beyond that epicenter, access may become painfully sparse.

That’s particularly true for behavioral services. In Jackson, Mitchell, Transylvania and Yancey counties, there are no providers that accept Medicaid and Medicare for patients with mental health or substance abuse disorders, according to a report by the federal Substance Abuse and Mental Health Services Administration. And Cherokee, Clay, Graham, Macon and Madison counties each have only one such provider. In contrast, Buncombe County tops the list with 34, followed by Henderson County with four.

With no easy way to access those services, rural residents have suffered from higher rates of drug and alcohol use, injury, teen births and preventable hospitalizations, according to North Carolina Health News. Additionally, notes MAHEC, an estimated 20% of adults in WNC have a behavioral health diagnosis, opioid-related injuries and deaths in our region are among the highest in the state and nation, and the suicide rate is significantly higher than national benchmarks.

Telehealth to the rescue?

That’s where telehealth could make a world of difference, proponents say. Over the last few years, a number of local providers — including Mission Health, MAHEC, Pardee UNC Health Care and Range Urgent Care — have launched or are in the process of establishing a range of telehealth offerings. Things like live two-way video, online questionnaires, instant messaging platforms and, in some cases, specialized equipment such as digital stethoscopes or heart rate monitors can help patients connect remotely with hard-to-reach specialists. This significantly reduces commuting time for patients and overhead costs for providers.

“Telehealth programs allow patients to stay in their local hospital to receive care they need, providing faster treatment for emergencies such as stroke and neonatology at a lower cost,” says Amy Roberts, executive director of virtual care at Mission Health. “Families can spend less time traveling and more time visiting loved ones.”

Mission’s program covers an impressive amount of ground in terms of both depth and scope. Current services include an emergency stroke consult, behavioral health and telepsychiatry assessments and a virtual clinic, which is basically an online input form that covers common urgent care issues and is available for $25 a session. Mission also provides digital access to specialists in psychiatry, neonatology, infectious disease, nursing wound care, diabetes management, genetics, heart failure, pediatric cardiology and varicose veins.

“Many of these programs are available in regional hospitals or clinics and do require some assistance by a nurse or clinician in the facility,” Roberts explains. “They may require some specialized video or audio equipment, such as a digital stethoscope to hear heart sounds, that’s not readily available at home.” But despite those limitations, she continues, “These programs are at least closer to home for patients in rural parts of the region and can help avoid a costly hospital transfer or drive to and from Asheville.”

Bills, bills, bills

While Mission’s telepsychiatry program focuses exclusively on crisis-level mental health, the pilot program that MAHEC plans to launch in late September will offer more routine behavioral health sessions at a satellite site in Cullowhee. If the pilot is successful, says Felicia Hipp, MAHEC’s director of nursing operations, the organization will add substance abuse treatment and maternal fetal medicine across the region. Once the program proves to be technologically viable from a broadband and programming perspective, says Hipp, the biggest hurdle for success will be finding a way to deal with insurance providers’ low reimbursement rates.

Although rules for reimbursement are evolving, telemedicine still represents only a tiny fraction of overall health care expenditures, the Cleveland Clinic Journal article points out. In 2015, for instance, Medicare spent approximately $14.4 million on such services — less than 0.01% of total health care spending. One reason for the low reimbursement rates is that Medicare requires the telemedicine services to be provided at specific sites such as physicians’ offices, hospitals, rural health centers or skilled nursing facilities.

That helps explain the approach MAHEC is taking with its pilot program. “Right now, we’re starting with current providers who are volunteering their time,” Hipp explains. “That way we can map out what it would look like but we don’t have to worry about whether or not the billing will work. Meanwhile our billing team is digging deep into that component.”

Another hurdle is that because North Carolina is one of the 19 states that haven’t passed a telemedicine parity law, insurance providers aren’t required to reimburse virtual care the same as they would in-person treatment. And though the major private providers — Aetna, Cigna, Blue Cross Blue Shield, Humana and UnitedHealthcare — all offer some form of coverage for telemedicine, the specifics vary.

“Most carriers do have some type of coverage for telemedicine services,” notes Gina Banks, the director of MAHEC’s central business office. But the “requirements, guidelines, reimbursement and claims processing vary from carrier to carrier.”

A new kind of house call

Mathew Trowbridge, who founded Range Urgent Care, has developed a unique health care model that’s managed to sidestep the problem of insurance providers: He just doesn’t use them. Instead, Range gives patients the option to pay either a subscription fee or a flat rate per visit.

For Trowbridge, the decision to offer medical consultations via video chat was a no-brainer. When it comes to diagnosing simple issues such as a rash, allergy or urinary tract infection, a video appointment saves time and money for patient and provider alike, he explains. And unlike the hospital model, which typically requires clients to travel to the facility and have a nurse present during the consultation, Range’s program enables patients to connect directly with a provider from the comfort of their home or wherever else they happen to be. Since its launch in 2017, Range has offered the service at a flat rate of $99 — $50 less than the cost of an in-person appointment.

The system, notes Trowbridge, also reduces congestion in the office and helps patients needing multiple follow-up visits. “Say you came in for a concussion, which is something we like to follow up with at least two times after,” he explains. “It can be burdensome to have you come in that many times. Being able to handle that follow-up virtually helps us stay open for new appointments and saves time for patients.”

But as video appointments grow in popularity, cautions Trowbridge, digital providers might have a tendency to overprescribe antibiotics. “When you’re on a video chat, it’s tempting for providers to put their eyes on you and think it’s strep throat,” he explains. “You’re more prone to do less testing, because you can’t, and therefore might be led to cut more corners in order to meet your patient’s needs.”

Overall, though, Trowbridge couldn’t be more excited about the future of telehealth services. “Our focus is on creating great patient experiences, and this is one way we can provide a hyperconvenient option,” he says. “I think health care will look completely different in 10 years.” Both the technology and providers’ ability to treat different conditions remotely, he believes, “will continue to grow exponentially, and access will continue to grow.”

Finding the bandwidth

Despite telehealth’s considerable promise, however, its biggest hurdle may be the very thing that’s made providing rural health care access so challenging to begin with: the remoteness of the areas needing service. Sara Nichols, a regional planner for the Land of Sky Regional Council, knows this better than most.

Based on the results of a survey she orchestrated recently that targeted residents of Buncombe, Henderson, Madison and Transylvania counties, about 13% of the 8,523 respondents reported not having broadband access. And in more rural areas, Nichols explains, the figure was much higher. In Madison County, for example, it was 22%. But because it’s harder to track down survey participants who lack broadband, she continues, the actual number is probably closer to 30%. The survey identified underserved pockets in rural areas, some of which are now getting attention thanks to this project. Broadband providers, though, are only going to go where it makes business sense, stresses Nichols. This is especially true when it comes to installing fiber optic cable, which requires digging deep trenches.

“Our environment is challenging: The mountains and winding roads get in the way, and the rockiness in the ground can be unpredictable. All the things we love about here are challenges to overcome,” she reflects. “With this project, we’re interested in seeing if we can connect the dots between substance abuse, rural health care and broadband, instead of treating them as separate issues.”

One solution, Nichols suggests, might be installing telehealth clinics in community centers that already have a reliable broadband connection and are gathering places for local residents. Another concept Nichols is considering is a van or bus equipped with a fixed wireless internet setup. Such a vehicle, she notes, could travel around to different locations once a week and, if there were no tall objects blocking the signal, provide really affordable internet access.

“I don’t love the bus idea for those people who might be sick on the wrong day, but in public policy we have to take steps where we can,” she points out.

Nichols, though, isn’t the only one searching for answers. In March, the Appalachian Regional Commission awarded nearly $100,000 in new funding to assess telehealth infrastructure in 20 WNC counties. The grant went to the N.C. Department of Information Technology’s Broadband Infrastructure Office and the state Department of Health and Human Services’ Office of Rural Health, which will partner with local and state organizations to conduct a 12-month study of opportunities, challenges and gaps in broadband and health care infrastructure in those counties.

“Telehealth is so important, and it’s on a lot of people’s radar,” says Nichols. “A combination of creativity, collaboration, policy work and funding will be critical to move the needle on this issue. It’s exciting to see those things come together.”