Telemedicine and Health IT as Key Solutions to the Rural Hospital Crisis in the U.S.

In 2017, approximately 81% of Americans lived in urban areas, representing a 2-percentage-point increase from 2000. Meanwhile, vacant land in cities and suburbs (excluding high-density, land-scarce cities like San Francisco) has continued to expand, signaling that the meaning of “rural” is poised to change in the new era. As demographic patterns shift, resources, tax revenues, and services—including healthcare—have been moving away from rural areas.

In fact, we can gain insights into the state of rural healthcare from statistical data associated with the North Carolina Rural Health Research Program: 1) From 2010 to the end of 2016, more than 70 rural hospitals closed, and 673 were highly vulnerable to closure, with 68% of them being critical access hospitals. 2) Distances to hospitals in rural areas of the United States are typically much greater than in urban areas; time and distance often mean the difference between life and death. 3) The number of physicians per 10,000 residents is 13.1 in rural areas compared to 31.2 in urban areas, clearly indicating that access to medical resources and care is more difficult in rural settings. Regarding specialists per 100,000 residents, the average in rural areas is 30, while in urban areas it is 263, reflecting a substantial disparity.

Generally, the rural population in the United States has a longer life expectancy, earns less income, smokes more, suffers from poorer health, and utilizes Medicaid more frequently. All these factors complicate healthcare issues and lead to predictable outcomes. For instance, opioid-related addiction and overdose rates are significantly higher in rural areas than in urban areas. The previous momentum of improvement in mortality rates among rural residents has dissipated; notably, the mortality rate for rural white women has increased by 30% in recent years, marking a striking reversal of prior trends.

The reasons for this situation are complex and deeply entrenched. While the high opportunity cost resulting from underdeveloped economies is one factor, technological disadvantages can make a significant difference in many respects.

In a recent article published on KevinMD, Dr. Leonard Sowah stated, “While urban patients are well aware—and this has been confirmed by most physicians—that opioids carry a high risk of addiction, rural patients lack such awareness. I have encountered patients with clear opioid addiction who continually assert that they are not addicts because they only receive medications from authorized prescribers.”

Clearly, raising awareness and providing better education will help improve this situation, but the ultimate responsibility falls on physicians. Without Prescription Drug Monitoring Programs (PDMPs), this would be an almost impossible task. PDMPs are electronic clinical tools and patient databases for prescribed medications, available in 49 states, that enable physicians to review patients’ prescription histories and identify potential addictive behaviors. New technologies are indeed improving the state of rural healthcare and hold significant promise.

If the National Health Service Corps uses loans as an incentive for physicians to work in high-need, underserved areas, what changes will occur next?

Now, nearly all bets are on telemedicine, which has been proven effective in treating depression and PTSD. Funding for telemedicine is a key component of the recently passed “21st Century Cures Act” by the U.S. Congress, which also requires the Centers for Medicare & Medicaid Services (CMS) to regularly report on the utilization and effectiveness of telemedicine under Medicare.

Telemedicine can also provide cost relief for rural hospitals. According to a 2012 report by the Institute of Medicine, telemedicine has significantly improved care and reduced costs by keeping patients out of emergency departments and reducing hospital readmissions. To make it truly effective and widely adopted, all insurance providers need to cover telemedicine, and all healthcare providers need to implement the technology.

Telemedicine is a solution to avoid hospital closures, but it is not ideal and does not work in every region. After all, only physical hospitals can truly improve patients' health outcomes or save lives.

Electronic Health Records (EHRs), along with Health Information Exchange (HIE) and Accountable Care Organizations (ACOs) that facilitate data sharing between hospitals and external healthcare institutions, offer benefits in streamlining patient care and improving efficiency, ensuring that optimal treatment plans and specialist expertise are readily accessible when patients require referrals.

In the United States, an Accountable Care Organization (ACO) is a collaborative entity voluntarily formed by diverse healthcare providers—including primary care physicians, specialists, and hospitals—that enters into contractual agreements with payers (not limited to Medicare) to deliver healthcare services to a defined population. The ACO model is grounded in the voluntary organization and participation of healthcare providers, adopting a gradual rollout strategy that began with government-led demonstration projects under Medicare and was subsequently adopted by commercial health insurers. This model aims to ensure that healthcare quality meets established standards while keeping medical expenditures below predefined cost benchmarks. The greater the cost savings achieved, the larger the financial incentives the ACO receives from the Centers for Medicare & Medicaid Services (CMS).

CMS Executive Committee Member Andy Slavitt stated, “The ACO Investment Model is designed to help rural communities pave the way forward by establishing better payment channels for improved healthcare. In this rural-focused model, we provide prospective shared savings payments to ACOs in rural areas, leveraging shared savings rates to incentivize cost reduction.”

Although the ACO investment plan is not a technology itself, its implementation would be completely hindered if rural providers fail to adopt technological improvements. A major challenge facing ACOs is upgrading health information systems to enhance proactive care management capabilities. This includes facilitating information sharing across various levels of care to improve efficiency and reduce waste in medical services, such as redundant tests. It also involves adjusting business priorities by analyzing the composition and characteristics of the served population, for instance, by identifying and tracking high-risk patients to prevent minor conditions from progressing into severe diseases. Many ACOs have undertaken the construction or upgrading of electronic medical record (EMR) systems.

Of course, technology alone will not fully resolve the challenges plaguing rural healthcare. Economic factors and public policy will also play a role.

For example, if profit margins are slim, rural hospitals need an affordable EHR system that does not require substantial cash investment for implementation. Most hospitals leverage the Meaningful Use criteria (designed to promote the comprehensive and coordinated development of health information technology in the United States by encouraging hospitals and independent practitioners to use EHRs effectively, thereby improving healthcare quality and efficiency) to help fund these systems. However, the unique financial challenges faced by rural healthcare providers may necessitate participation in the MACRA program, even though the Centers for Medicare & Medicaid Services (CMS) has indicated that the implementation of the MACRA legislation is nearing completion.

Leveraging policies to support rural healthcare providers is a key focus of the newly established CMS Rural Health Council, which has adopted a comprehensive agenda: 1) improving access to care for all Americans in rural areas; 2) supporting the unique economics of delivering healthcare in rural America; and 3) ensuring that the healthcare innovation agenda is well-suited to the rural healthcare market. Solutions that meet all three objectives must be creative, flexible, and effective.

The Future Dynamics of U.S. Healthcare: It will take time to assess the impact of past legislation and whether the current administration’s policies will yield positive outcomes. If not, the U.S. may face an increasingly challenging landscape for rural care. If the economy does not improve and technology fails to deliver significant cost reductions, what alternatives remain for the future? Can large hospital acquisitions successfully revitalize underutilized facilities and lower costs? These questions remain unanswered.

References:

【1】http://hitconsultant.net/2017/01/11/37113/

【2】http://www.beckershospitalreview.com/finance/the-rural-hospital-closure-crisis-15-key-findings-and-trends.html

【3】http://www.healthleadersmedia.com/finance/macra-end-meaningful-use-and-beyond

【4】http://www.bioon.com/3g/id/6678541/