Despite the wide-ranging expansion of telehealth in the past year, there is still a broad swath of the U.S. population it has largely failed to reach: the 57 million people in rural parts of the country.
Even now, as employers rush to add virtual care to their benefits, many telehealth companies have avoided rural areas. Several acknowledged to STAT that most of their users remain in urban and suburban areas, and they’ve made far less progress than they’d like to in reaching rural patients. The companies recognize they face an uphill battle. Beyond the foundational barrier of broadband access, providers must contend with questions about reimbursement rates, strict rules on interstate licensing, and a hazy road map without clear inroads for reaching rural patients and providers.
“Honestly, as much as our mission statement fits well with rural health care, we haven’t really made enough progress to date around this work,” Brad Younggren, the chief medical officer of telehealth company 98point6, told STAT.
Telemedicine has been heralded as a potential solution for many of the health-related problems facing rural America, including as a way to increase access and reduce health care spending, though the evidence on whether it can do so is far from conclusive. Still, as telehealth has expanded, it has remained largely out of reach for the one in five U.S. residents who live in rural parts of the country. Rural areas trail behind cities when it comes to high-speed internet connectivity, face licensing challenges as a result of spanning multiple states, and lack sufficient numbers of trained clinicians, according to a May report from the American Hospital Association’s 2021 Rural Health Task Force. There are also issues with data sharing, since patients’ medical records are often hard to access during telehealth visits, and with patient-provider engagement, since people on either end of the care spectrum have to be comfortable with telehealth visits.
Experts fear that disparity may stretch existing inequities, ultimately creating an even wider chasm between highly-developed parts of the country and those with less infrastructure and affluence.
“For anyone concerned with ensuring health care for all, it’s areas with significant rural populations that absolutely have to figure this out,” Kaakpema ‘KP’ Yelpaala, the chief executive officer and co-founder of Colorado-based health communications company InOn Health, told STAT. Yelpaala also served as an advisor to the AHA’s Rural Health Task Force.
Company executives and analysts said that permanent policy changes are needed to make the investment in building out their offerings for rural populations not only worthwhile from a strategic standpoint, but also successful in improving access to care. Those changes include increasing access to broadband and reimbursing virtual care at the same rate as in-person treatment.
“Without government intervention, we’re not going to be able to move the needle,” said Yelpaala. “It’s really about infrastructure, and with that in place, the rest can follow.”
The Biden administration recently announced $20 million in new grants for rural telehealth programs, which will go toward helping rural clinics overhaul their technology, train providers in telemedicine, and help health systems reach patients in rural areas.
But in the absence of broader state or federal policy changes that make it easier to serve rural America, telehealth companies face a litany of challenges. In practice, this has meant that only large and legacy telehealth businesses have been able to make real inroads in these parts of the country, where they have the market power and experience to adapt to lengthy legal requirements. For example, because rural regions often span multiple states, telehealth providers must obtain separate licenses to practice in each state in the region.
“You need a strong strategy for going region by region. It’s really almost a market obstacle,” Damon Lanphear, chief technology officer for telehealth company 98point6, told STAT.
Additionally, because rural clinics often lack the robust technology infrastructure required for telehealth visits, virtual care companies must have the capital and time to set up and maintain such tools. They must also make the case to rural providers and patients that their solutions are worthwhile, even as studies on telehealth have come to mixed, albeit hopeful, conclusions about its benefits, potential cost savings, and potential harms.
“Rural programs with low patient volumes struggle to solicit [telehealth] specialists, and for those who do participate, the cost of maintaining telehealth equipment and paying costly connectivity fees may not be worth the squeeze,” said Natalie Schibell, a health tech analyst with Forrester.
As president of health systems at Teladoc, Joe DeVivo is tasked with building and maintaining partnerships with hospitals and clinics in or near rural parts of the country. In his view, Teladoc’s efforts in rural areas function kind of like an electric power grid: They can either serve to stretch the capabilities of understaffed rural clinics — for example, by pre-screening patients before sending them to a crowded facility — or to route excess clinical capacity from large academic medical centers to rural clinics, such as by facilitating telehealth appointments between city-based providers and patients in rural areas. In a way, he sees Teladoc’s efforts in rural areas as a way to balance medical capacity across the U.S.
“We’re the infrastructure behind the grid,” DeVivo said.
Any company that wants to take its telehealth offerings that have largely targeted urban and suburban customers and translate them to rural areas will also have to consider how their comfort levels with technology or unfamiliar providers may differ. As the AHA report notes, rural users may be reasonably accustomed to seeing their primary care provider in person, so transitioning to a telehealth setup will require time and flexibility.
“When you think about rural populations,” said Ruby Gadelrab, founder and chief executive officer of digital health platform MDisrupt and an advisor to health tech companies, “medicine moves at the speed of trust.” For example, she said, some users might “want to see the physician who delivered their children and maybe even delivered them.”
Barriers notwithstanding, some telehealth companies are crafting creative solutions to support rural communities without seeking to overtake or replace their existing practices. Telehealth company Eko, for example, works with rural providers to equip caregivers including nurses and medical assistants with its AI-powered stethoscopes, enabling caregivers without specialty-level expertise to video conference with medical doctors while they perform physical exams.
“We’re putting the ears of a medical doctor in the stethoscope of a nurse or an EMT who may not have that training to understand exactly what they’re hearing,” said Jason Bellet, Eko’s co-founder and chief customer officer.
As part of its work partnering with health systems, Teladoc teamed up with a health system and school district to kickstart a telehealth program based in local schools. The program, which uses existing laptops at school nursing offices to run Teladoc’s platform, grew out of a realization by school leaders that students were missing classes as a result of basic health concerns, like skin and sleep issues. Similarly, Amwell teamed up with Avera Health, a health system serving patients in rural parts of North and South Dakota, Nebraska, Minnesota, and Iowa, to put telehealth kiosks in HyVee grocery stores.
“We took our tools — originally designed for providers to help other providers — and put them in schools, where it’s not just about convenience but also the immediacy of receiving care,” DeVivo said.
Analysts say more telehealth companies should focus on delivering basic forms of care that meet rural patients where they are — even though that may not be on a smartphone or tablet. Even without broadband or remote tools like AI-powered stethoscopes or connected blood pressure monitors, telehealth companies could, for example, focus on text-based communications, or simply phone calls.
“Maybe it’s not video. Maybe it’s just a phone call, maybe it’s texting,” said Gadelrab. “We need to focus more on making technology fit the purpose.”