Biden administration seeks to expand telehealth in rural America

The roughly 15% of the population living in rural America includes some of the oldest and sickest patients in the country — a disparity that has grown more stark during the coronavirus pandemic.

The Biden administration is investing more in telemedicine, whose use has grown sharply during the pandemic, as a way to improve their access to care.

Last month, the Department of Health and Human Services announced that it was distributing nearly $20 million to strengthen telehealth services — usually medical appointments that take place by video or phone — in rural and underserved communities across the country. While the amount is relatively modest, it is part of a broader push to address the long-neglected health care infrastructure in those areas.

The spending includes about $4 million to help bring primary, acute and behavioral health care directly to patients via telehealth in 11 states, including Arkansas, Arizona and Maine.

The money will update technology in rural health care clinics, train doctors and nurses how to conduct telehealth appointments and teach patients how to take advantage of virtual appointments when they cannot see a doctor in person.

An additional $4.3 million will help specialists at academic medical centers provide training and support to primary care providers in rural and other underserved areas via “tele-mentoring,” so that they can treat patients in their communities with complex conditions, such as long COVID or substance use disorders.

“Telehealth expands access to care and is a vital tool for improving health equity,” said Diana Espinosa, the acting administrator of the Health Resources and Services Administration, an agency within the department that is distributing the money. “This funding will help drive the innovation necessary to build clinical networks, educational opportunities and trusted resources to further advance telehealth.”

Rural Americans are at greater risk of dying from heart disease, cancer, accidental injury, chronic respiratory illnesses and strokes than their urban counterparts, according to the Centers for Disease Control and Prevention.

The pandemic, too, has hit them disproportionately: ICU beds have been sparse in rural Idaho during virus surges. Navajo Nation in rural Arizona once had a higher virus death rate than New York City.

In August, the Biden administration provided billions of dollars to rural communities through the American Rescue Plan — separate from the $20 million — to address virus concerns, including by expanding telehealth, and to help rebuild crumbling health care infrastructure.

Other investments in rural health during the pandemic have included improving training for clinicians working at rural Veterans Affairs hospitals; more than $8 billion to help hospitals and doctors’ offices make up for lost revenues and increased expenses during that time; and $350 million to rural communities for food, medical supplies and vaccines.

Even though telehealth has become more mainstream during the pandemic, challenges persist. It remains inaccessible in areas without internet or proper speeds. And there is still a lot of uncertainty about how using telemedicine more would affect insurers’ and hospitals’ bottom lines over time, not to mention patient outcomes.

A large body of research supports the use of telehealth for communication and counselling, and for monitoring patients with chronic conditions, but more evidence is needed on its broader use.

The University of Mississippi Medical Center will receive more than $3.5 million of the $20 million from the Health Resources and Services Administration, through two grant programs to improve health care in rural, medically underserved areas of the state that have widespread chronic disease and high poverty rates.

The coronavirus pandemic increased not only the need for telehealth but also the amount that doctors and nurses get paid to use it. Early in the pandemic, Congress and the Trump administration expanded Medicare’s coverage of telehealth services for the duration of the public health emergency, although it is unclear whether the coverage will continue indefinitely.

“There is now momentum; telehealth is now considered part of the mainstream of health care delivery,” said Dr. Saurabh Chandra, the chief telehealth officer at the Center for Telehealth at the University of Mississippi Medical Center. “There were lots of loosening of regulations that allowed us to expand telehealth and do telehealth in a very short period of time.”

Telehealth is not just for rural areas, Chandra said. It can be used in schools and correctional facilities, as well as in patients’ homes, nursing homes, doctors’ offices and hospitals. Among other things, telehealth technology has been crucial to stabilizing rural COVID-19 patients as they await transfer, through a program commonly called “tele-ICU.”

The University of Mississippi Medical Center plans to start such a program — essentially a two-way video system that connects critically ill patients in rural hospital ICU beds with teams of doctors and nurses who specialize in caring for patients from a distance.

Angela Turner-Ford, a Democratic state senator in Mississippi who is the chairwoman of the state’s legislative Black caucus, said that increasing access to telehealth would also help medical providers combat misinformation that had been circulating among the state’s Black residents and creating high vaccine hesitancy.

If it were easier to connect with doctors regularly, many of the hesitant might change their minds, she said.

“They are left to themselves and what someone may have told them that may not be reliable information,” Turner-Ford said. “If you don’t have that existing relationship with a practitioner, someone in that instance may have known who to call just to have a simple conversation.”

Jennifer Yturriondobeitia, CEO of Cornerstone Whole Healthcare Organization, a nonprofit in Boise, Idaho, focused on improving rural health care, said the $350,000 it received will go toward telehealth for mental and substance abuse disorders. Idaho lacks treatment for these conditions, especially in rural areas, she said.

Yturriondobeitia said her group had used telehealth in Idaho since 2015. Back then, patients drove to doctors’ offices to connect with distant specialized providers. Now the focus is on connecting patients with those providers from their own homes.

In Oregon, the funding will help residents primarily in the Columbia River Gorge region. Five of the six counties that will benefit are in the vast rural area where mountain ranges form the boundary between Oregon and Washington. Poverty levels are high, and for some, a visit to the doctor can be an hour’s drive away. Nearly one-third of the population is Hispanic.

“They don’t have enough primary care doctors, they don’t have enough mental health professionals, they don’t have enough anybody there,” said Dr. Nancy Elder, director of the Oregon Rural Practice-Based Research Network, which received $475,000.

Chronic diabetes is also pervasive in the region. Elder said one way she believed the quality of care could be improved was by increasing the skills of the doctors and nurses already based there.

The region’s award will be used for Project ECHO, a program that allows rural primary care clinicians to learn from specialists by video. The meetings begin with an educational presentation, followed by a discussion of real-life clinical obstacles the providers are facing.

“They get access to expertise that they wouldn’t have,” said Maggie McLain McDonnell, director of the Oregon ECHO Network and Health Education Initiatives, “but they also get support so that they feel less alone in the challenges that they’re facing treating these patients.”