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In the Face of Poverty, a Scarcity of Providers, and Geographic Isolation, Rural Westerners Find Promise in Telehealth
A ranch on a stretch of road from the Grand Canyon to Flagstaff, AZ. Many rural Westerners are so geographically isolated that they are hours away from basic health services and suffer from poorer health outcomes. Photo by Prescott Horn on Unsplash.
The Bill Lane Center for the American West and Stanford Medicine have released a new white paper on telehealth in the rural American West to address the region's struggles with poor access to care. The paper builds upon the Lane Center’s earlier work from our Rural West Initiative, as well as ongoing research by our undergraduate teams who have been exploring connections between environment and health in the American West.
Characterized by vast distances, scarcity of care, and even fewer specialist providers, the rural western region challenges health care professionals and policymakers to devise solutions that address an aging and more vulnerable population. Many invidivuals in this region suffer disproportionately from poverty, addiction, obesity, and mental health challenges. The possibility of technological solutions to help them is enticing, but limited by spotty broadband and uneven reimbursement policies.
In May of 2019, we hosted a one-day workshop with Stanford Medicine that examined how telehealth and policy can improve access disparities, and treat the specific population health crises that plague many rural Westerners. Our white paper continues that examination, detailing specific recommendations that decision-makers might consider.
The hurdle of geographic isolation
Some of the stumbling blocks Native Americans on tribal lands face when trying to access proper care mirror the struggles of rural Americans across the West in general: They are just too far away from services to reliably benefit from them. Telehealth can bridge that distance, says David Meyers, director of a telehealth clinic designed to reach tribal members in Northern Wyoming: “We’re so rural,” Meyers says. “If somebody needs surgical care or anything that can’t be provided in our area, we’re two hours away from everything. Sometimes we help transport clients to appointments, but you’re going to Salt Lake City or Billings a lot, and that’s six hours away. We can get patients to the initial appointment, but then you have a lot of 15-minute follow-up appointments. If we could use telehealth services for follow-up care that would eliminate a lot of stress on clients.”
Reducing the amount of stress individuals face when trying to access care is one way to improve health equity. And addressing health disparities is one of the main goals of the Lane Center/Stanford Medicine partnership. How can our health system better serve vulnerable populations in the rural West? Our new telehealth white paper offers guidance on overcoming the obstacles of georaphic isolation and delivering care using new digital tehcnologies.
Low-tech recommendations
The paper provides four specific recommendations: leveraging low-tech telehealth solutions; increasing broadband access; establishing consistent rules for reimbursement; and finding ways to use data (from electronic health records and medical devices for example) to inform public health decision-making.
For example, it turns out that sending text messages to parents to suggest very basic things, such as teaching children colors while shopping at the grocery store, can actually help foster kindergarten-readiness. Lisa Chamberlain, professor of pediatrics at Lucile Packard Children’s Hospital, has found that these kinds of low-tech interventions can be valuable in delivering health care to Spanish-speaking immigrant communities in San Jose. “They’re very basic things that parents can build into their day to day activity,” Chamberlain says. “The mom gets a text in her phone three times a week every week…That’s really leveraging the clinic relationship to help promote the behaviors and give these behavioral nudges for the families and directions so that they can help all their children thrive.”
Chamberlain recently finished a randomized controlled study at Santa Clara Valley Medical Center to evaluate the effectiveness of the program and found that it improved child literacy levels and was well-received by parents. As Chamberlain believes that education is the major social determinant of health, with lower education associated with poorer health, this small gesture can have a rather large impact.
Similarly, connecting patients to providers on a screen can bring much-needed diabetes care, surgical follow-up treatment and mental health services to folks who would otherwise have to drive six hours to see a physician in person, as David Meyers explains above. There are just too few local providers in rural areas. Moreover, many on tribal lands in the West are reluctant to seek out behavioral health services due to historical trauma and fear of stigma, Meyers notes. Allowing individuals to access care from the comfort of their own homes might lower the barrier of entry.
Improving broadband and reimbursement practices
It takes reliable broadband to provide telemedicine services, but unfortunately, in much of the rural West, broadband is lacking. While the Federal Communications Commission (FCC) maintains great progress has been made in improving rural connectivity, findings reported in this paper suggest otherwise: “The trouble with the FCC data is that it’s overly permissive in how it calculates coverage. The FCC gets its data from Form 477 filings by internet service providers. If providers indicate on the form that they can provide broadband to one resident, the FCC considers the entire block to be broadband enabled,” the paper concludes.
Says Carter Boon Casady, a researcher at the Bill Lane Center for the American West, “This is the worst rounding error imaginable. It’s like saying you have one, so let’s round up to 100.” To address broadband inequities, researchers suggest local communities might benefit from taking control of their own data-gathering to counter the narrative offered by the FCC’s overly optimistic broadband assessments.
Reimbursement for telehealth provides yet another set of obstacles, with both government and private insurers offering inconsistent rates and practices across the rural West. For example, programs in Alaska, Arizona, California and some other states reimburse quite generously for video visits. But other western states do not, the white paper points out. North Dakota, Utah and Idaho offer limited reimbursement. In Washington, rural health clinics are not authorized to serve as a distant site for consultations. Only Oregon reimburses for phone and email consultations. This can be remedied, researchers suggest, by mandating consistent rules for reimbursement from Medicare and Medicaid, and requiring the same from private insurers as well.
Leveraging data
Finally, with all the health data being collected by electronic health records (EHRs) and individuals’ own devices, the paper recommends that government and the medical industry better harness this information to inform public policy. AI machine learning analytics, genomic screening, and interoperable EHRs allowing data-sharing between institutions and patients can be leveraged to make sound policy that better serves rural populations in the western U.S.
As our research on telehealth and public policy in the rural West has shown, technology might go a long way toward filling the care gap that patients currently experience on the farm, ranch or reservation. Although data on the impact of telehealth in the rural West is still in short supply, the anecdotal evidence is overwhelming that telehealth has already increased access to health care for millions of rural Westerners.
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