Telemedicine- A Bridge to Access in Rural NC

“I’m excited for the potential it represents for innovation and the potential that it creates for people who have had limited access to have a higher quality of life”

Laura Jane Ward is the Program Manager of the North Carolina Rural Health Leadership Alliance, a program of the Foundation for Health Leadership & Innovation whose work groups address issues of imminent rural health needs in our state. In February of this year, the Alliance convened a telehealth delivery work group whose mission is to provide information and advocacy on select telehealth issues, and to exist as a resource to stakeholders, both internal and external to the Alliance. The need for this group is testament to the buzz of excitement telehealth has catalyzed—on the local, state, national, and global levels. The workgroup has a diverse composition with representation from government organizations to non-profits to philanthropy. Co-chaired by Elizabeth Hudgens (NC Pediatric Society) and Brian Cooper (Office of Rural Health), over the next six months the workgroup plans to deliver a series of briefs and to carefully track the progress of legislation around the topic as the Centers for Medicaid and Medicare Services works on approving North Carolina’s Medicaid 1115 Waiver and broadband infrastructure in the North Carolina General Assembly.

Buzz and legislation aside, telemedicine is of particular interest to the Alliance because it speaks so directly to the concerns and challenges rural communities face. “The goal of NCRHLA is to make sure that North Carolinians in rural areas have a voice, and access to healthcare. Telehealth ties directly into the goal of healthier, longer lives because it has so much potential to fill gaps to access, not only for certain acute care needs, but also in preventative care for chronic, high risk conditions.” Chronic illnesses inevitably disrupt an individual, and a family’s quality of life, so any means of improving preventative care for high risk individuals in rural communities should be high priority. From a purely cost-effective standpoint, patients and hospitals alike stand to benefit from fewer visits to the ER, and lower rates of re-hospitalization.

figure from NC DHHS Report on Telemedicine and Recommendations

While isolation from resources in rural communities is commonly perceived as limited to issues of distance, Laura Jane discussed the potential of telehealth to expand access across several other gaps as well.  The time, transportation barriers, and burden on caregivers to bring patients in can be partially relieved by virtual meetings and check-ins. This type of meeting can also function as a great connector for patients in areas with a shortage of specialized health care providers. As a committed advocate for the better health of older adults, Laura Jane also discussed the huge burden that can be imposed from having to regularly commute from a nursing home or assisted living to the hospital. The appeal of technology is not limited to younger generations—a number of programs successfully engage older adults and help break down barriers and misconceptions about their use of these services. In this sense, telehealth can help promote healthier lifestyles across all ages. She also discussed telepsychiatry as a unique sub-practice for its ability to provide care to individuals who might otherwise remain closeted. For instance, an individual living with anxiety or depression might be able to access support without risking being seen walking out of a care center.

“Telemedicine is not a replacement for a medical home. It’s a supplement, with the opportunity for having impacts across the system”

However, innovation often comes with challenges. “Advancements in technology often outpace the production of peer-reviewed research” (Restrepdo, 2017). The evidence-base for effectiveness of specific policies is still being created. From a logistic standpoint, one of the biggest existing barriers to widespread telemedicine practice is the infrastructure of broadband. HIPAA (the Health Insurance Portability and Accountability Act of 1996) regulations, designed to protect patient information, is as applicable in instances of practice via telehealth as it is in the clinic. Considerations of bandwidth and appropriate videoconferencing applications must be addressed. The Office of Rural Health and the Office of Broadband Access have partnered in an effort to create regional meetings addressing this issue. There is also the issue of how telemedicine services will be considered in regards to insurance policies, reimbursement, and liability issues. Currently, Medicaid does reimburse providers for virtual patient encounters with the caveat that a patient must be a “sufficient distance” from the provider and that pre-approval must be obtained. Medicare also reimburses if the patient has first been seen at a qualified originating site. Most private insurance companies, including Blue Cross Blue Shield in North Carolina, do have some provisions for offering virtual telemedicine services. States are paving the way for addressing these concerns within their own healthcare systems—some have opted for full or partial parity laws. North Carolina does not have one, as of yet and a comparison of other state successes and challenges are addressed in this article published by the John Locke Foundation.

Finally, Laura Jane stresses the importance of remembering the bigger picture: That providing access does not equal overprescribing or under-delivery. When implemented correctly, the cost of innovation should never be quality health treatment. “Telemedicine is not a replacement for a medical home. It’s a supplement, with the opportunity for having impacts across the system”. It is a matter of determining in what ways telemedicine can enhance and amplify the existing system of healthcare delivery. As North Carolina continues to navigate through the ever-evolving healthcare landscape on this issue, the Alliance will continue to serve as a pulse check and resource provider on this issue.