Telehealth May Help Rural America, Where Facilities Are Closing and Providers Are Hard to Find
By Sydne Enlund
Health care in rural America is hurting. Medical facilities are closing and doctors, nurses, physician assistants and other health professionals are in short supply.
At least 100 rural hospitals have closed since 2010 and more than 400 are at risk of financial distress. Meanwhile, physicians between the ages of 55 and 64 make up 27% of the active workforce. As the demand for health care services rises over the next decade, there will not be enough providers to fill the gap left by those retiring. The American Association of Medical Colleges projects a shortfall of between 42,000 and 121,000 physicians by 2030.
Telehealth—the use of electronic information and telecommunications technologies to support long-distance health care—has the potential to address both of these challenges.
Telehealth gives rural patients access to more providers and allows them to receive care in their home communities, instead of traveling sometimes long distances. This can reduce health disparities for aging and underserved populations, as well as lower the costs and burdens for patients who must take time off work and find child care or transportation. Patients can instead stay at home or visit a nearby clinic and have a live video visit with primary care providers for treatment of acute or chronic issues.
Many policymakers, particularly those from states with large rural areas, see telehealth as a key component in the future of health care in their state. But along with the benefits come potential challenges, including a lack of access to broadband, state licensure issues, questions about the quality of telehealth, and the need for in-person follow-up care for patients with certain conditions. Despite these potential difficulties, most states are increasing their investment in telehealth services.
North Dakota uses telehealth because the state lacks providers in its rural counties. According to Senator Judy Lee (R), 36 of the state’s 53 counties are designated “frontier” counties, with six or fewer people per square mile. “Telehealth is one of the tools the state uses to provide follow-up care, particularly in the behavioral health field,” she says.
State legislatures are designing regulations and laws on telehealth to increase patients’access while ensuring their safety. Strategies include licensure compacts and reciprocity agreements, expanded reimbursement, store-and-forward technology, and new rules on patient-provider relationships.
Crossing State Borders
State health care laws usually require providers to be licensed in the state where the patient is receiving care. The remote nature of telehealth, however, lets states break down that traditional licensing barrier. At least nine states have created telehealth-specific licenses that allow out-of-state providers to offer telehealth services in the state, if they abide by certain requirements. Physicians providing telehealth services to patients in Louisiana, Maine and Minnesota, for example, cannot set up physical office locations where the patients are located. Some states grant temporary licenses or have reciprocity agreements with neighboring states.
Licensure compacts are mutual agreement between participating states to accept each state’s licenses. Compacts are formed and become active when a certain number of states enact the same legislation, with specific required language, by a certain date. Joining the compact is voluntary for the providers, however. Among the largest of these agreements is the Nurse Licensure Compact, created nearly 25 years ago by the National Council of State Boards of Nursing. It currently comprises 31 states, including Kansas and Louisiana, which joined on July 1 this year.
Three Modes of Care
Reimbursement from private insurance and Medicaid for telehealth services varies widely across the nation depending on the type of service and how it is delivered. Although states occasionally use similar language in their policies, no two states define and regulate telehealth in exactly the same way.
There are three primary ways (called modalities) that telehealth is delivered: real-time communication, store-and-forward technology and remote patient monitoring. Real-time communication allows patients to connect with providers through a videoconference. Store-and-forward technology lets a practitioner receive stored data, images, sound or video for use in providing care. Remote monitoring involves collecting a patient’s vital signs or other health data while the patient is at home or another site and transferring the information to a remote provider. Mobile health, or mhealth, is also an emerging area for telehealth and state policy.
All 50 states and the District of Columbia offer some type of coverage for live videoconferencing in their Medicaid programs, and most reimburse for live video services under private insurance. Laws and regulations in 23 states and the District of Columbia allow for reimbursement of store-and-forward services. And at least 27 states allow reimbursement for remote patient monitoring, according to the Center for Connected Health Policy and NCSL.
Maintaining Care Standards
States are regulating the ways they provide telehealth services to take full advantage of rapidly accelerating technology while maintaining high-quality care and practice standards for providers.
There are concerns as well. For example, what if care becomes so fragmented among different providers that a patient’s primary care provider is not aware of services received via telehealth? Ideally, telehealth is integrated into the health care delivery system and is coordinated with other providers. Another concern is that remote services are not as safe and comprehensive as in-person care. To ensure patients’ safety, some lawmakers are creating guidelines for establishing patient-provider relationships and mandating certain informed consent requirements.
The Work Continues
State lawmakers continue to develop innovative ways to harness technology to bring health care services to their constituents. A recent example is legislation passed in Hawaii, where almost 94 percent of the total land area is rural.
The bill establishes the Telehealth Advisory Council and a state telehealth coordinator position. The council is charged with developing a comprehensive plan that will establish telehealth as a high-quality, cost-effective and reliable means of receiving health care services.
The telehealth coordinator will ensure that state agencies and private businesses have the infrastructure and policies in place to promote the expansion of telehealth services.
The bill establishes “permanent resources to increase the visibility of telehealth and enable the Department of Health to work with community stakeholders to ensure the state remains on track to achieving its telehealth goals,” says Representative John Mizuno (D).
More than 50 telehealth-related bills have been enacted nationwide this year. Telehealth is a rapidly growing field that has the potential to help states address a shrinking provider workforce, increase access to services and improve public health.
Sydne Enlund is a policy specialist in NCSL’s Health Program.