Telehealth creates a lifeline in rural areas
Amid the uncertainty in the early days of the COVID-19 pandemic, the staff at Bamberg Family Practice in South Carolina watched with concern as patients started missing and cancelling appointments.
“There was so much we didn’t know back then and we started seeing this jump in no show rates,” described Alicia Barnes, a licensed practical nurse and the clinical manager at the rural health clinic.
The practice never shut its doors, but had to quickly adjust how it was serving its patients. As people became afraid to leave their homes, the clinic started offering virtual appointments using a video conferencing system.
“This is a very rural area that we serve,” Barnes said. “A lot of our patients have chronic health issues. The worst thing that could have happened would have been for them to fall out of care.”
Telehealth use surges thanks to COVID-19
While telehealth has been available as an alternative to in-person doctor visits across a variety of medical specialties for years, use of this tool has surged during the pandemic.
In the South, telehealth insurance claims increased from .16% to almost 10% between April 2019 to 2020, according to FAIR Health, a nonprofit that collects and manages a database on privately billed health insurance claims. In rural areas in the South, claims for telehealth visits grew from .07% to 6.46% in that same time period.
The technology has become invaluable, especially in rural areas where healthcare access was a challenge even before the pandemic. Some of these areas also have limited broadband access, which historically made it difficult for clinics to offer telehealth as an option.
CARES Act eased restrictions on telehealth use
The federal government has at least temporarily addressed some of these challenges, providing significant support for telehealth during the public health emergency.
In March, Congress relaxed some of the rules around its use as part of the CARES Act, the legislation which addressed the economic fallout from the pandemic.
This allowed patients in areas where broadband access is unavailable to consult with their doctor from a smartphone or computer in their own home. In cases where patients don't have broadband or limited data, some medical consultations can be done through a phone call. The rules also require Medicaid to reimburse providers for virtual visits at the same rate as in-person visits.
Southern states seeing higher usage for rural patients
In Louisiana, the Ochsner Health System saw telehealth visits increase from 58 visits statewide during the week of February 17 to 15,434 visits statewide the week of April 20 — the height of the outbreak in New Orleans. During this time, the hospital system used telemedicine to limit face to face interactions and reduce risk of exposure, said April Radford, the vice-president of telehealth.
“When we are requiring people to stay at home as much as possible, it becomes our responsibility to make sure medical care is absolutely accessible to people regardless of where they are,” she said.
The emergency room staff at Holmes County Hospital in Mississippi is currently seeing a second surge of COVID-19 patients. The nine-bed emergency room is usually staffed with two registered nurses, a nurse practitioner, and when needed, an attending emergency room physician who video conferences in from the University of Mississippi Medical Center in Jackson.
Holmes County Hospital is part of UMMC'S network of hospitals and clinics across the state. Since 2003, this has included the largest hospital-run telemedicine network in Mississippi.
The hospital system began exploring telemedicine in 2003 to link emergency room doctors on their main campus to rural emergency departments only staffed with nurse practitioners.
“It is really hard to recruit providers into rural areas. Getting connected through this tele-emergency hookup with the emergency department at UMMC in Jackson lets us expand the role of the nurse practitioner in our emergency department here,” said Paige Lawrence, the chief nursing officer at Holmes County Hospital.
As of the week of August 3, Holmes County had the second highest incidence of cases per capita (323.3 out of 100,000 residents), according to data from the Mississippi State Department of Health.
Many of the patients seen by Lawrence and her team are considered at high-risk for COVID-19.
“There's a lot of uninsured people, high poverty, it can be a challenge to provide high-quality care,” Lawrence said. “There's also a lack of transportation, food insecurity in the area; there are a lot of issues to address and (then) you throw COVID into the mix.”
Broadband access in the South is a huge hurdle to telehealth’s spread
While this technology has surged during the pandemic, it is unclear how much support it will have in the future. The rules that enabled its expansion are temporary, though there is a push to extend them through the end of 2021, according to Nathan Baugh, the Director of Governmental Affairs for the National Association of Rural Health Clinics.
Additionally, broadband access is an enormous barrier, especially in rural areas where healthcare options are scarce.
“It's a challenge that is almost impossible to overcome,” said Billy Sample, the program manager for the Medical Advocacy and Outreach (MAO) Telehealth Resource Center in Alabama. “While 98% of our patients have a cell phone, we still have a pocket of patients without cell phones or Wifi access.”
MAO serves about 2,000 patients in rural Alabama that are HIV positive or at high-risk for contracting HIV. The organization offers telehealth consultations at 11 satellite clinics across the state. Due to COVID-19, the organization had to close the clinics and move consultations to a video conferencing application patients can use on their phones.
Alabama ranked 38th in the U.S. for state broadband access, according to a survey from the policy group Broadbandnow. About 88.6 % of Alabamians have access to wired broadband 25 Mbps or faster, leaving about 475,000 people in the state without access to connections at the same speed.
The Federal Communications Commission has awarded nearly $200 million in grants since March to help healthcare organizations expand telehealth. Alabama has also awarded nearly $15 million toward expanding broadband access in areas without adequate service this year.
Dr. Cordelia Stearns, the medical director at MAO, said that there is still no clear data on HIV and COVID-19 risk, which is a concern for a lot of her patients.
People were initially afraid to leave their homes, which made a virtual visit indispensable.
Stearns acknowledges that while telehealth has its benefits it will never be an adequate substitute for face to face interactions.
“When you have someone who has recently tested positive for HIV, there is no way to substitute the comfort you are able to give the person when you are with them in person. This is not for everything,” she said. “But patients need to be able to access services.”