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Published in Health Care
40 percent of Michigan residents live in rural areas that lack high-speed internet access compared to just 3 percent in urban areas, a disparity researchers say must be addressed as telehealth expands. 40 percent of Michigan residents live in rural areas that lack high-speed internet access compared to just 3 percent in urban areas, a disparity researchers say must be addressed as telehealth expands. COURTESY PHOTO

Growing shift to telehealth raises questions about access in rural communities

BY Sunday, August 16, 2020 05:00pm

The COVID-19 pandemic created what Kelly Hirko calls a “massive shift” in health care.

As physicians were unable to see patients in the spring, they urged people to transition to telehealth or virtual visits. Hospitals and health insurers offered similar encouragement. 

That resulted in huge spikes in the use of telehealth services and has generated heightened awareness of disparities in rural health care, including access to broadband internet service that some rural communities lack.

“The rapid implementation of telehealth programs in rural areas in response to the COVID-19 pandemic holds tremendous potential for addressing rural health disparities,” Hirko wrote in a recent commentary published in the Journal of American Medical Informatics Association

“Overcoming issues in broadband access in rural settings, which limit the reach and effectiveness of telehealth initiatives, must be prioritized,” according to Hirko, an assistant professor of epidemiology and biostatistics at Michigan State University’s College of Human Medicine.

The commentary cited how 40 percent of Michigan residents live in rural areas that lack high-speed internet access, versus just 3 percent in urban areas. That’s problematic because rural areas tend to have lower access to care, older populations, and higher incidence rates of chronic illness such as diabetes, hypertension and obesity, Hirko said.

“It’s a double burden. The people in general who have the lowest connectivity have the higher health care needs. So, if anything, it’s just going to exacerbate these disparities if we continue to develop these solutions that are not reaching widespread, especially to these targeted populations that could benefit the most from having that access,” Hirko said.

Hirko’s research focuses on rural health disparities. That led to her interest in rural broadband access, which she considers a “super determinant of health” that also affects education, employment and other factors such as social disconnections that influence health and have been magnified during the pandemic.

Among the conclusions in Hirko’s commentary, written with colleagues at Munson Healthcare in Traverse City, is a need for health systems to craft “a comprehensive strategy to ensure sustainability of telehealth programs following the COVID-19 pandemic.”

“Many lessons will inevitably be learned from the COVID-19 crisis. Already, the pandemic has exposed underlying health disparities while also fostering innovative solutions to address health needs in these trying times,” she and her colleagues wrote in their commentary. “Thus, it is our hope that through this crisis, we may be able to envision and work toward a more equitable world.”

Growing use

Care providers have touted the promise of telehealth to improve access in rural markets, including for primary care, connecting virtually with medical specialists, or monitoring and connecting more with patients who have chronic medical conditions.

When the pandemic hit this spring and stay-at-home orders were issued, they closed medical practices for non-essential in-person patient visits, and care providers moved quickly to direct people to use telehealth platforms. That caused a large spike in the use of telehealth.

Care providers see the rise of telehealth during the pandemic as a permanent sea change for the health care industry.

Prior to the pandemic, 1 percent to 2 percent of Metro Health-University of Michigan Health’s patients had used telehealth to connect with a doctor, Dr. Ronald Grifka, the health system’s chief medical officer, said last week in a panel discussion at the Grand Rapids Area Chamber of Commerce’s annual Health Care Summit.

The use ballooned to 50 percent to 60 percent as stay-home orders were in effect and physicians had to forgo non-essential office visits through mid-June, when offices could reopen for routine patient visits.

Telehealth use by patients has waned since, although at about 30 percent now, it remains much higher than the pre-COVID period, Grifka said.

Patients weren’t the only drivers behind the greater use of telehealth. Many more doctors who were reluctant to do so previously have signed on to see patients virtually.

Prior to the pandemic, about 10 percent of the doctors in Blue Cross Blue Shield of Michigan’s care network offered virtual visits. That quickly grew to 82 percent during the pandemic and as Blue Cross Blue Shield offered up to $5 million in incentives to physician groups to assist in launching or expanding a telehealth service and providing virtual visits.

“COVID really has changed the landscape,” said Dr. George Kipa, deputy chief medical officer at Blue Cross Blue Shield of Michigan, which now is looking at the role the technology plays in future care delivery.

“Telehealth and telemedicine, online visits, virtual visits, whatever you call them, over time were something that very few people utilized. During COVID, it became really a lifeline for patients and for doctors, and going forward it transforms the expectations,” Kipa said. “We’re looking at what the future of telemedicine is going to look like and how best we can assure access to mid-level and chronic care issues along these lines.”

Lacking access

Telehealth’s move into the broader public consciousness and a far larger role in care delivery brings a heightened need to address issues with rural broadband access, said Eric Frederick, Michigan director for Connected Nation, an organization that advocates for great broadband access.

Hospitals and health systems have a role in advocating for greater rural broadband access that accommodates telehealth and in generating awareness and understanding about the issue, Frederick said.

Among the findings, a study Connected Nation Michigan released in March found that many households in five rural counties — Gladwin, Sanilac, Roscommon, Osceola and Dickinson — simply lack broadband connectivity.

Part of the problem is that what makes economic sense for high-speed internet service providers in urban markets does not work for rural areas with low population density, Frederick said.

“Obviously, where household density falls off, so too does broadband connections, and that’s from an availability standpoint,” Frederick said. “It’s going to be tough to get those types of services to rural areas.”

Other barriers that persist include the affordability of broadband in rural areas where it is available, often because of a lack of competition; worries about the safety of medical data online; and concerns that a doctor can actually diagnose a medical condition virtually, he said.

As health care providers step up and look to expand telehealth services for virtual visits at patients’ homes, “We’re going to have trouble rolling those out into rural areas because of the lack of connectivity and affordability of connections, if they’re there,” Frederick said.

Partner up

The gaps in high-speed internet service are primarily in the central northern Lower Peninsula and Upper Peninsula, plus counties in southern Michigan, according to Connected Nation Michigan.

Resolving the barrier requires municipal and local leaders in rural markets who understand the problem to come together with internet service providers “who are willing to come to the table and find a solution, and be honest about why that can’t expand to all of the community. It’s simple economics,” Frederick said.

“And then we start forming partnerships,” he said.

Frederick cites rural Lyndon Township in Washtenaw County where local officials worked with private internet service providers on a plan to provide high-speed service. By a two-to-one margin, voters passed a millage in 2017 to build a fiber optic system a private ISP uses to provide broadband through a partnership with the township.

Other similar partnerships have been formed all over the state, Frederick said. He hopes the growth in telehealth will drive broadband development and “improvements in infrastructure in rural areas that need to happen.”

“It involves bringing the public and the private sector together to really hash out these issues, being honest about what the needs of the community are, being honest about what infrastructure can or can’t be expanded to certain parts of the area, and then working on a solution,” he said. “COVID is really bringing it to the forefront of importance.”

Adding incentives

Health insurers also pushed the growth of telehealth during the pandemic, agreeing to pay doctors the same rate for a virtual visit as they did for an in-person visit. The previous reimbursement rate for virtual visits had been one of the barriers holding back telehealth, Hirko said.

Grand Rapids-based Priority Health will reimburse virtual visits at the same rate as in-person office visits until the end of 2020. As well, the insurer implemented zero member cost share for both medical and behavioral telehealth visits to encourage physician and consumer adoption of the technology.

A decision remains pending on whether to continue those policies beyond 2020, said Curtis Gritters, director of Priority Health’s ancillary provider network.

“At this point, with as much as things are in flux, we’ve not taken any options off the table,” Gritters said.

To illustrate telehealth’s growth during the pandemic, Gritters cited data that show one in 1,000 doctor visits by members in April 2019 occurred virtually. In April 2020, one out of every five visits were via telehealth, Gritters said.

In May and June, telehealth visits waned to 50 to 100 per 1,000 physician visits by members, “but I like to think telehealth is here to stay as a convenient, safe way to access necessary care,” Gritters said.

“Telehealth is a fantastic option for members,” he said.

Despite the large growth in telehealth, Priority Health has not noticed a variance between medical claims for virtual visits in rural markets compared to urban markets, Gritters said. In other words, a lack of access to high-speed internet service in rural markets has not shown up in the health plan’s internal data, based on medical claims.

“It’s Priority Health’s observation based on that internal data that, in general, telehealth is accessed from Michigan’s rural counties at approximately the same rate as from metropolitan counties,” said Gritters, noting that it’s too early to draw any definitive conclusions from the early data about access to broadband and telehealth in rural areas.

“But we have our eye on it, too,” he said.

Priority Health recognizes that reliable internet access “may be a limitation to health care access,” leading to a decision early in the pandemic to pay for telephone access to care, Gritters said. The health plan also has been contracting with more care providers who do telehealth “so that our rural members have access to the depth and breadth of specialty care, for example, that might be physically concentrated in metro areas,” he said.

When Blue Cross Blue Shield added telehealth four years ago, it acknowledged that access to high-speed internet was an issue for some people, so the insurer also paid for telephone-only access, Kipa said.

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