Rural Tele-Health: Moving toward Innovation, Transformation, and the Triple Aim

Could “dialing up” the use of tele-medicine or telehealth help achieve rural health sustainability?

In a new report dated March 30, 2017, The Rural Broadband Association found that the use of telemedicine has four powerful economic benefits, for rural providers, producing results that Congress, the Centers for Medicare & Medicaid Services (CMS), state policymakers and grant funders should pay attention to going forward. On average, per facility, the following results were achieved:

1. Hospital cost savings = $81,300
2. Increased local revenue for MRIs = $105,600
3. Increased local revenue for CT scans: $144,000
4. Increased local revenue for bloodwork: $156,000

Other studies showed these results, again, on average, per facility:

1. Travel expense savings = $5,718
2. Increased local lab work = $9,200-$49,000 (depending on type of procedure)
3. Increased local pharmacy revenue = $2,319-$6,239 (depending on the specific drug prescribed)
4. Lost wages savings = $3,431

Currently, there are more than 200 telemedicine networks and 3,500 service sites across the nation. Nearly half of all hospitals, including rural facilities, have at least one physician interested in and/or already providing telemedicine in one form or another.

Telehealth/telemedicine is defined as the remote delivery of healthcare services and clinical information using telecommunications technology. It holds great potential to improve quality, cost, and availability of services in rural areas. It can be utilized across a spectrum of settings, including but not limited to hospitals, clinics, physicians, offices, and patients’ homes and workplaces.

Impressively, rural telehealth creates a model for ideal care – a balance of reliability, safety, and patient flow – while delivering the following:

1. Reduces hospital administration rates
2. Delivers better patient experience to retain and attract patients
3. Cuts costs through more preventative outreach
4. Enables more specialists and clinical teams to see patients in a more timely manner, allowing the patients to receive care in a more comfortable setting
5. Helps improve clinical outcomes
6. Provides great benefits in treatment of chronic diseases, especially diabetes management
7. Real-time patient examinations increase the depth and breadth of provider medical knowledge
8. Eliminates transportation issues for patients, as well as providing additional time for the provider to be in outreach settings

Telehealth Reality

Driven by policy, technology, finance, evidence, and consumer demand, recent surveys indicate patient openness to use telehealth: in 2017, 50 million consumers (rural and urban) indicated that they would switch providers to join one that offers such services (compared to 17 million in 2015). Additionally, at least 11 states expanded provider eligibility in 2016 to reduce barriers to access to care, and 28 types of providers were included in at least one state’s eligibility expansion legislation. Providers ranged from optometrists to physical therapists, dentists to social workers. Also, there was an 18-percent increase in usage between 2015 and 2016. Rural healthcare is also advancing in remote specialist consultations, in-home monitoring, and outsourced diagnostic analysis.

VA Telehealth

The Veterans Affairs (VA) health network also has increased its focus on telehealth dramatically. In 2015, the VA provided 2.1 million treatments known as episodes of telehealth care, which included home telehealth, site-to site telehealth, and others. Included in these 2.1 million treatments were 400,000 mental health episodes. Equally impressive, the VA’s financial commitment includes a budget of $1.2 billion for telehealth.  

Challenges Associated with Telehealth

Some potential issues with telehealth can be found in the following areas:

• Malpractice insurance. Currently, some malpractice insurance providers will cover services provided via telehealth, but not all provide coverage.
• Cost of basic equipment can range from $7,000-$30,000. Costs can also rise to $15,000-20,000 for video conferencing and $20,000 to $250,000 for digital radiography or specialty equipment.
• Licensing regulations dictate that while virtually all providers must be licensed in the state in which they are physically practicing, many states also require that providers hold a valid license in the state the patient is located. While national licensure has gained some support, this area is still evolving in terms of discussion and legislation. One certain thing is that eliminating the regulations for various states will make telehealth easier to adapt, adopt, and expand. 
• Patient privacy is vital. All reasonable steps must be taken to ensure that PHI remains protected, including security measures such as password and data protection. A wait-and-see approach will be taken in the area of HIPPA compliance to see if flexibility in telemedicine will be incorporated.

Reimbursement Guidelines

The 2017 Medicare Physician Fee Schedule finalizes the CMS changes for telehealth reimbursement and coverage for 2017. Medicare and Medicaid reimbursement can be complex as it pertains to protocols for services and reimbursements.

As it relates to technology, generally, Medicare requires “interactive technology” for telehealth and doesn’t provide reimbursement for “store-and-forward” delivered services (watch for results in the demonstration projects of Hawaii and Alaska) or for remote patient monitoring. To qualify for reimbursement consideration, the originating site must be located in a designated Health Professional Shortage Area (HSPA) in a rural census tract or other location. As it relates to annual covered service updates, there is an approval process for new services, defined in two categories: Category 1 covers services similar to existing office visit, consultation, and office psychiatry services, similar to the list of already approved telehealth services. Category 2 covers services that require a demonstration substantiating how it will improve the diagnosis or treatment process, citing evidence gleaned from appropriate clinical support studies.

Additionally, there are CPT® codes for advanced care planning (99497 & 99498) and critical care consultations (HCPCS codes GO508 and GO509) and new point of service (POS) codes distinguishing between facility and non-facility sites. As it relates to medical codes, states may choose from a variety of HCPCS codes (T1014 and Q3014; CPT codes and modifiers GT, U1-UD) in order to identify, track, and reimburse for telehealth services.

Adding to the complexity is that each state needs to determine whether specific telehealth services are covered by Medicaid. In 2016, Medicaid provided coverage for live video telehealth in 48 states; 12 states provide some reimbursement for store-and-forward, but there isn’t any standardization. 

Grant availability primarily focuses on the following:

• Computers/laptops/tablets used for video transmission
• Examination devices – cameras, stethoscopes, peripherals, etc.
• Video conferencing unites and associated software
• High-definition video cameras
• Screens
• Telemedicine carts

CMEs – Primary Care Providers/Nursing

More and more sites are offering free educational services to meet the continuing medical education needs of community-based physicians and other healthcare professionals, allowing them to gain knowledge, improve performance, and provide extraordinary patient care while interacting with faculty experts directly. Areas of education include dementia, men’s health, management of thyroid cancer, diabetes complications in the elderly, opioid prescribing, Hepatitis C treatment, common infections, emergency services,, and stroke treatment and prevention. There is also a LERD model providing rural RN-BSN students with learning and demonstration of skills.

Funding Needed

While grants are provided at the federal level and by several organizations across the nation, there still hasn’t been enough money allocated to provide high-quality telehealth services nationwide. 

Telehealth trends include the following:

1. More legislation is being used for reimbursement equality.
2. More than one-third of states have signed the Interstate Licensure Compact.
3. Modalities can include remote patient monitoring.
4. Rules for patient locations are becoming more flexible.
5. New types of services for coverage are being identified, beyond primary care.
6. More store-and-forward reimbursement states are being identified.

Best Success Stories

There are at least 25 examples of highly impressive and evidence-based telehealth programs across the country: these include the University of Arkansas ANGELS program to treat low-birthweight babies and women in rural areas; Project ECHO to provide effective treatment of chronic conditions in rural communities; South Carolina’s Telepsychology Service delivery for depressed elderly veterans; Madison Outreach’s MOST Network, which provides mental health and substance abuse prevention in rural Texas; the New Mexico Mobile Screening Program for Miners for respiratory treatment; Health-COP Obesity prevention for rural children; the STAIR program for telehealth mental care services for female rural veterans; the SD eResidential Facilities Access Project for treatment of rural elderly patients in long-term care; Project ADEPT,  which provides diabetes services to rural southeast Georgia; Lutheran Social Services for rural mental health in North Dakota; and Health-e-Schools, providing healthcare resources to rural children in a classroom setting.

A Rural Lifeline

The bottom line is that rural telehealth equates to innovation, transformation, and the Triple Aim. In order for rural healthcare to meet growing rural health needs, it will depend largely on the future provision of fiber-based broadband infrastructure. Rather than being a medical desert, rural America can be the technology superhighway with telehealth – but it will take long-term investment commitments from Congress, CMS, states, and grants to keep pace with patient need and technology advancements and equipment replacement.

It is a critical need for a critical time – let’s broaden the band of telehealth for rural sustainability and bridge the disparity divide of access to care.