Overcoming the Barriers to Telehealth Use in Urban Settings

Imagine a mother who is juggling two children under the age of five and a full-time hourly wage job.  When her child contracts pink eye or a worsening cold or a sinus infection or asthma, she is forced to choose between giving up wages to see the primary care physician or going to the emergency department that is unable to turn her away, even if she cannot pay, after work hours.  Many choose the latter option but it is costly and risks additional illness. While retail clinics have closed some of the gap in primary care, telehealth visits have the potential to close even more of the gap.  Unfortunately, these visits are rarely covered by private payers and are rarely covered by public payers like Medicare and Medicaid.  So, unless the mother can afford $40-55, the telehealth visit, while saving time, will not be utilized.

Although telehealth traditionally has been used as a tool to extend urban specialists into rural areas, the need for telehealth in the urban areas is growing.  It is no secret that the nation is suffering from a shortage of primary care physicians.  The situation is worse with physician specialists and sub-specialists.  Booking an appointment with a specialty physician can take as long as six months, even in the most urban areas.  And, urban patients can lack transportation, availability of physicians, or even the ability to schedule due to health illiteracy or language issues. 

There are 6359 Primary Care Health Professional Shortage Areas (HPSAs) and 4362 Mental HPSAs in the United States.  Even Rhode Island, the state with the smallest geographic area, has 40 HPSAs.  California and Texas have more than 1100 each.  Practically speaking, surveys and studies show that:

• 79.7% of adults visited the emergency room due to lack of access to other providers.
• 48% went to the emergency room because the doctor’s office was not open.
• 43% of people do not have access to same or next-day PCP appointments.

As the population ages and people live longer, new types of care delivery need to be used.  Telehealth is one of those “new” types of care.   That said, there are many forces that work against telehealth’s implementation, especially in the urban environment. 

1. Reimbursement:  The home is not a qualified “endpoint,” or originating site, for Medicare and rarely for Medicaid. (This varies by state.) Unless a patient is physically located in a physician office, or clinic or hospital, the patient’s telehealth visit will not be covered by Medicare or most state Medicaid programs--and few private payers will cover telehealth services to the patient at home with the exception of UnitedHealthcare, which is a leader in providing reimbursement for telehealth visits regardless of location.
2. Licensure:  Physicians, like nurses, should have the opportunity to practice safely yet fluidly across state borders.  The Federation of State Medical Boards is actively engaging states in a physician licensure compact that will facilitate telehealth.  Yet, each state legislature must approve compact participation, making a 50-state compact a near impossibility.
3. Parity:  Private payers, in some states, do not pay for telemedicine in the urban environments and even pay a reduced rate in the rural areas.  Parity laws work to encourage telehealth use and adoption throughout a state, especially the urban areas.
4. Lifting geography restrictions:  Although the Centers for Medicare and Medicaid Services (CMS) defines “rural” as non-Metropolitan Statistical Areas and Health Professional Shortage Areas, states are allowed to change definitions for private payers and for state-run Medicaid programs.  Lifting the geography restrictions on payment within a state enables telehealth to flourish without the artificial restrictions and complexity that hinders adoption and billing.
5. Communication infrastructure: Urban areas, as well as rural areas, have communication infrastructure access issues.  Whether it is due to a lack of resources to pay for internet access or a lack of availability, the communication infrastructure including broadband and cellular access must continue to be addressed.

As we work to achieve the “Triple Aim” of better healthcare, lower costs and improved population health, telehealth in theory is a valuable tool.  Telehealth in reality is so complex, nuanced and varied that it is challenging, at best, to incorporate into a practical workflow.  By improving reimbursement, licensure, parity, geography restrictions and the communication infrastructure, the likelihood of telehealth being a viable care delivery tool improves and our ability to manage the health of our rapidly aging population progresses.