Telehealth hub addresses lack of care in rural Texas

The Davis Mountain Clinic offers an exam room
for patients. (Photo by Carol Brewer, Daily Yonder)

In the midst of rural West Texas, a shipping container is giving residents of Jeff Davis County access to telehealth through reliable connectivity and a local registered nurse, reports Madeline de Figueiredo for the Daily Yonder.

The Davis Mountain Clinic was created by Texas A&M and Texas Tech universities to bring remote medical and mental health care to the area’s aging population, explains Figueiredo.

One in five residents in this mountainous county don’t have reliable broadband, and the only doctor is semi-retired, causing most of the population to drive 30 minutes for care, Figueiredo reports.

As the county has a median age of 58, the telehealth hub offers not just reliable broadband, but “digital literacy for older residents, trusted community health workers, and practical ways for clinicians to weave virtual visits into everyday care.”

The director and local registered nurse for the clinic, Carol Brewer, can monitor vital signs, execute physical exams and help patients navigate their virtual telehealth appointments. She told the Yonder, "The advantage is, when they come here to see the doctor, I manage the technology on my end, they don’t have to deal with that at all…I’m the hands of the physician via telehealth.” 

This is not the only area of Texas that struggles with internet connectivity and access to nearby health care. Communities in Erath, Hockley and Reeves counties are working on bridging the gap in services by offering private telehealth rooms, medical monitoring equipment and guidance from staff through local libraries, Figueiredo reports.

Tribal lands need broadband to improve health care access, but progress is slow

Shoshone-Bannock tribal lands are vast with a rocky terrain, which poses a challenge in building fiber-optic cable lines for high-speed internet to homes. (Photo by Sarah Jane Tribble, KFF Health News)

The lands of the Shoshone-Bannock Tribes in Idaho span seemingly endless miles. But the beauty of this vast tribal expanse comes with a cost: Profound broadband gaps that limit health care for Native Americans throughout the region. "Tribal members are historically underserved and, on average, live with the highest rates of chronic illnesses and die 6.5 years earlier than the average U.S. resident," reports Sarah Jane Tribble of KFF Health News.

Accessing medical treatment without broadband connectivity presents a range of challenges. Tribal members have to drive to medical appointments because telehealth isn't an option. "Tribal field nurses update charts in paper notebooks at patients’ homes, then drive back to the clinic to pull up records, send orders, or check prescriptions," Tribble writes. Getting care and medicine all takes longer.

All the while, millions in federal dollars have been set aside to address tribal broadband infrastructure. "Three years ago, the Shoshone-Bannock Tribes were awarded more than $22 million during the first round of the federal Tribal Broadband Connectivity Program," Tribble explains. "But tribes that were awarded millions in a second round of funding saw their payments held up under the Trump administration."

Shoshone-Bannock Tribes Broadband Infrastructure Deployment project
(Map by Lydia Zuraw and Sarah Jane Tribble, KFF Health News)

For some tribal members, waiting for fiber isn't an option. Instead, they pay for Starlink, which uses low-earth-orbit satellites and costs between $80 and $120 a month. "For 53-year-old Carol Cervantes Osborne, who lives with constant pain from severe rheumatoid arthritis, having internet is a necessity," Tribble explains. "She signed up for Starlink so that she can connect with doctors remotely through telehealth appointments." 

Despite the wait for broadband and the current lack of care access on their lands, tribal leaders say Starlink is too expensive for most of their members.

This year, the Shoshone-Bannock Tribes started work on their high-speed internet installation, but progress will be slow. "To build fiber-optic cables underground, the tribes must navigate lava rock and work with the Bureau of Indian Affairs to get permits," Tribble explains. "Eventually, the old radio station will be central to operations, with fiber-optic cable lines that web out over about 800 square miles to reach the reservation’s five district lodges."

When this rancher was gored by a bison, ambulance telehealth helped save his life

Video systems on ambulances let medics get help from more
advanced providers. (Photo by Arielle Zionts, KFF HN)

When severe ranch injuries happen, having experienced medical care on hand can mean the difference between life and death. But in many cases, rural medics don't often treat life-threatening wounds. Some ingenious South Dakotans figured out how to overcome that dangerous knowledge gap.

"Rural medics who rescued rancher Jim Lutter after he was gored by a bison didn't have much experience handling such severe wounds," reports Arielle Zionts of KFF Health News. "But the medics did have a doctor looking over their shoulders inside the ambulance as they rushed Lutter to a hospital. The emergency medicine physician sat 140 miles away in a Sioux Falls, South Dakota, office building. She participated in the treatment via a video system recently installed in the ambulance."

Ed Konechne, a volunteer emergency medical technician with the Kimball Ambulance District, told Zionts, "I firmly believe that Jim had the best care anyone has ever received in the back of a basic life support ambulance." Zionts adds, "The ambulance service received its video system through an initiative from the South Dakota Department of Health. The project, Telemedicine in Motion, helps medics across the state, especially in rural areas."

The pandemic years helped Telehealth become more accepted, and the "technology is starting to spread to ambulances. Similar programs recently launched in regions of Texas and Minnesota, but South Dakota officials say their partnership with Avel eCare — a Sioux Falls-based telehealth company — appears to be the nation's only statewide effort," Zionts reports. "Rural medics often have less training and experience than their urban counterparts, Konechne said. Speaking with a more experienced provider via video gives him peace of mind, especially in uncommon situations. Konechne said the Kimball ambulance service sees only about three patients a year with injuries as bad as Jim Lutter's."

Katie DeJong was the emergency medicine physician at Avel eCare's telehealth center "who took the ambulance crew's video call," Zionts writes. "After speaking with the medics and viewing Lutter's injuries, she realized the rancher had life-threatening injuries, especially to his airway. . . . . DeJong called the emergency department at the hospital in Wessington Springs — 25 miles from Gann Valley — to let its staff know how to prepare. DeJong also arranged for a helicopter to fly Lutter from the rural hospital to a Sioux Falls medical center, where trauma specialists could treat his wounds."

To read more about Lutter's rescue or how South Dakota is funding its program, click here.

DEA looks to curb telehealth prescriptions, which advocates say will complicate rural care and addiction treatment

Photo by Ted S. Warren, The Associated Press

The opioid epidemic has become a persistent, brutal feature of American life. "Its despair and suffering echo through cities large and small, from pitched tents . . . to the hamlets and hollows reeling from the opioid epidemic across Appalachia . . . a nation seemingly inured to the startling toll of addiction," wrote Kevin Deutsch of The Rio Grande Sun in Española, New Mexico, long plagued by drugs.

The stories of suffering, death and a medical communities stretched to their limits explain recent push-back against a new Drug Enforcement Administration "plan to resume tighter limits on the prescribing of controlled substances through telehealth," report Stephanie Armour and Liz Essley Whyte of The Wall Street Journal. "Under the proposed rules, other drugs, including Adderall, Ritalin and OxyContin, would require patients to meet in person with prescribers first or be referred by a doctor they met in person. . . . Patient-advocacy groups say the requirements would create barriers to care. . . . The in-person requirement will make it harder for certain patient populations who live in rural areas where there are few doctors or in areas where there are long waits to see a provider, according to organizations opposed to the proposal."

Dr. Bobby Mukkamala, chair of the American Medical Association's Substance Use and Pain Care Task Force, told the Journal, "The DEA proposal requiring an in-person visit within 30 days to get a prescription refill is far too short and unrealistic. For patients being treated for opioid-use disorder, this proposal could result in more overdose deaths. For those who rely on controlled substances, it could result in avoidable emergency visits and hospitalizations." The Journal reports, "Dr. Brian Hurley, new president of the American Society of Addiction Medicine, said adding the requirement risks undermining public safety because the country is in the throes of an overdose crisis."

Why now? "The proposal comes as the Justice Department has been increasing its focus on telehealth companies that prescribe controlled substances [citing] possible violations of the Controlled Substances Act. . . . The Department of Health and Human Services  issued a special alert warning about telehealth fraud and its potential to harm patients . . . . Still, a number of medical groups say the in-person mandate isn't the solution to possible fraud. They say the DEA has rushed through the proposal, which got about 35,000 comments during a 30-day public comment period."

"A Biden official said the in-person requirement is meant to make sure that patients struggling with addiction are also screened for other health problems, such as heart conditions or diabetes," the Journal reports. "Telehealth with medication-assisted treatment for opioid-use disorder was linked with greater patient satisfaction, an overall reduction in healthcare costs, and an increase in the use of buprenorphine, according to a June 2022 study in the journal Telemedicine and e-Health.

Sexual assault victims in some rural areas are now able to get examinations through telemedicine services

Nurse Lindee Miller stands with the cart used for teleSANE exams at
Avera St. Mary’s Hospital in Pierre, S.D. (Photo by Arielle Zionts, KHN)

Until recently, rural sexual assault victims who sought medical care faced multiple hurdles to simply get to a hospital. Through advances in telehealth exams, that reality is changing, reports Arielle Zionts of Kaiser Health News.

Zionts presents the example of a nurse in Eagle County, Colorado: "Amanda Shelley was sitting in her dentist’s waiting room when she received a call from the police. A local teenage girl had been sexually assaulted and needed an exam. . . . She went to her car and called a telehealth company to arrange an appointment with a sexual assault nurse examiner, or SANE. The nurse examiners have extensive training in how to care for assault survivors and collect evidence for possible criminal prosecution. . . . About an hour later, Shelley met the patient at the Colorado Mountain Medical urgent care clinic in the small town of Avon. She used a tablet to connect by video with a SANE about 2,000 miles away, in New Hampshire."

The exam process involves "the remote nurse using the video technology to speak with the patient and guide Shelley through each step of a two-hour exam. One of those steps was a colposcopy," Zionts reports. "The remote nurse saw, in real-time, what Shelley could see, with the help of a video camera attached to the machine."

Zionts writes, "The service, known as 'teleSANE,' is new at Shelley’s hospital. Before, sexual assault patients faced mountains of obstacles — literally — when they had to travel to a hospital in another county for care." Shelley told Zionts, "We’re asking them to drive maybe over snowy passes and then [be there] three to four hours for this exam and then drive back home — it’s disheartening for them. They want to start the healing process and go home and shower.”

TeleSANE services are "expanding across the country in rural, sparsely populated areas," Zionts reports. "Research shows SANE programs encourage psychological healing, provide comprehensive health care, allow for professional evidence collection, and improve the chance of a successful prosecution."

Big bill's rural-health items touch Medicaid money, telehealth rules, mental-health hotline, drug treatment, Native care

Senate Majority Leader Chuck Schumer speaks with reporters as he
walks to a vote at the U.S. Capitol. (Photo by Francis Chung, Politico)

The whopping 4,155-page omnibus spending bill is whipping its way through Congress. The $1.7 trillion measure is crammed with public-policy changes and funding provisions.

Here are some items with rural resonance that made it in, starting with several health-related provisions:

• An earlier end to Covid-era state Medicaid funding and rules. Additional funding will end on April 1, 2023, instead of June 30. The change will end rules that effectively barred any state from dropping people from the rolls if the state wanted to get the 6.2% bonus.
  
• An extension of rules that supported telehealth options through 2024, which "falls far short of a push from some lawmakers who wanted to make that flexibility permanent," Politico notes. The pandemic ushered in telehealth as accepted medical care.
• Almost $502 million, a nearly $400 million increase, for the new 988 national hotline for mental-health services. "The ultimate goal is to be able to dispatch mobile crisis teams immediately to anyone in need, no matter where they live," The Washington Post reports.
• Easier access for health-care providers to prescribe buprenorphine to treat opioid addiction. They would no longer have to get a separate waiver from the Drug Enforcement Administration.
• More stable funding for the Indian Health Service, a result of perhaps the largest effort by Native American groups "to provide more funding certainty to the federal health agency that helps serve roughly 2.6 million American Indians and Alaska Natives," the Post reports.
• A limit for tax breaks on land-conservation purchases: "The provision would automatically disallow any deduction that is 2.5 times more than what investors put into a partnership that is making the deals — an indication that easement organizers artificially inflated the value of conserved land to get more tax savings," reports Benjamin Guggenheim of PoliticoPro.
• "Maine lawmakers successfully included a pause on new regulations they warned would cripple their state’s lobster industry," Politico reports. "The provision delays new rules by six years, which critics argue will allow fisheries to put off actions that would prevent fishing gear from harming and even killing endangered whales."
  
• UPDATE: The bill funds a program that gives poor families $40 per month per child for summer groceries, and "allows schools and nonprofits in rural areas to deliver meals or offer pick-up options to families during those months," The New York Times reports.

The bill would also amend the Electoral Count Act of 1887 to make clear that the vice president, as presiding officer of the Senate, plays only a ministerial or ceremonial role in the counting of electoral votes from the states. The law's vagueness contributed to the violence at the Capitol on Jan. 6, 2021. The bill would also raise the threshold for challenging electoral votes to one-fifth of both the House and Senate, from the current one member of each chamber.

Amid shaky finances in rural health care, Heartland Forward report suggests ways to improve access and services

By Worth Sparkman
Axios NW Arkansas

Affordability, telehealth and a trained, motivated workforce are the keys to keeping the engine of rural health care running smoothly. A Heartland Forward report outlines strategies policymakers and community leaders in rural America can use to improve health care access and services.

Many rural hospitals in the U.S. face a funding crisis. Many small, independent hospitals face possible closure or consolidation through acquisition as they struggle with finances. One in 10 hospitals in Texas and more than half of Mississippi's rural hospitals are at risk of shuttering.

The report analyzes data from Arkansas, Kansas, Kentucky, Missouri, Oklahoma and Tennessee, where Heartland Forward convened focus groups and expert interviews, but researchers see potential applications for its concepts nationwide. Authors found three areas with the most possible impact:

• Increasing price transparency and working to reduce complexity in understanding the health care system can lead to residents using it more often for preventive care rather than acute care.
• Expanding access to telehealth by lowering policy barriers for providers and normalizing the tools for patients.
• Boosting the health care workforce through training, streamlining licensing regulations and providing advancement opportunities for practitioners.

True to its nature as a "think and do tank," Heartland developed three tools for communities in the six-state region to use to guide care-related planning and decision making:

• A policy recommendations document that provides a detailed map of barriers and opportunities to address affordability, telehealth and workforce issues.
• An interactive accessibility dashboard that provides detailed county, congressional district and state-level data on various health and wellness topics.
• An interactive labor market tool with detailed geographic data on 31 health care professions.

The bottom line: Researchers write that as access to health care declines in rural areas, the workforce becomes less productive and slows economic performance, so a focus on health and wellness will also rev up an area's economic vitality.

New FCC broadband map faulted by telehealth advocates; it's easier to challenge, but the deadline is Jan. 13

The Federal Communications Commission's new maps of high-speed internet service in the U.S. may be "a step in the right direction" but it leaves much to be desired, telehealth advocates say.

They told senators Thursday that the maps. which will guide Infrastructure Investment and Jobs Act funding for internet expansion, "need to be significantly revamped -- as some communities are entirely missing from the maps -- to ensure the unserved and underserved are accurately represented," Cara Smith reports for Inside Telehealth. They want the FCC to extend the Jan. 13 deadline for comments.

"A government official told Inside TeleHealth that navigating the FCC maps also were confusing, so individual community members may have significant challenges navigating the data," Smith reports. "Even if the maps are corrected in time, lawmakers and stakeholders still worry about instances of fraud, waste and abuse from contractors receiving funding to construct broadband in unserved or underserved areas."

Smith notes that the Government Accountability Office, the bipartisan auditing arm of Congress, has "called for the White House to synchronize the over 100 federal programs that aim to expand broadband access to rural areas and other locations with limited or no access to internet, and to ask for congressional help if necessary. Without a national plan, GAO said, the federal government could miss the chance to expand internet access and increase access to essential services, like telehealth."

The new map is still based on reports from telecommunications companies, but at a more granular level, Robert Gallardo, director at the Purdue Center for Regional Development, told Kristi Easton of The Daily Yonder. "That’s the same glitch that we had before, which is providers reporting on their own,” he added. “Now you can go in and challenge that availability, but it does require a little bit of prep time, meaning you can see the options you have to challenge the availability piece.”

To challenge the map, "One has to include either a bill from the provider or include a screenshot from the website that shows the package is not available for that address," Eaton reports. "The worry, according to Gallardo, is that challenging the map takes some technology know-how that not everyone may have. And the deadline to challenge for this map is Jan. 13."

A lack of specialized health services takes a toll on rural communities across the country, four-part series concludes

Part of Lanai City, Hawaii (Cory Lum/Honolulu Civil Beat)

A lack of specialists in rural communities as diverse as remote Hawaiian islands to the rugged mountains and forests of far Northern California are straining local health-care resources and forcing local residents to rely on telehealth services or faraway providers. So say the last two stories in a four-part series by The Daily Yonder, the Institute for Nonprofit News, Carolina Public Press, Honolulu Civil Beat and Shasta Scout, with support from the National Institute for Health Care Management Foundation.

The Hawaiian island of Lanai, which has a population of just over 3,000, no longer has in-person psychiatric care, reports Brittany Lyte of Honolulu Civil Beat. In 2020, the state agency that offers mental-health services to uninsured or underinsured adults no longer staffed a professional on the island and switched to telehealth services from a provider in Michigan. A report from a local health-care nonprofit surveyed residents of Lanai and a nearby island found that nearly 70% of the health care that residents of the two islands receive require trips off the island, "which is arduous and expensive," the report said.

California's North State
(California Economic Development Dept.)

A lack of health-care specialists also plagues Shasta County and the other 10 counties that make up California's rural North State, an official economic development region of the state, reports Annelise Pierce for the Shasta Scout. The largely remote area, which has about a fifth of the state's geographic area but relatively little population, has a dearth of doctors who specialize in lung care and only one neonatal intensive care unit, in Redding. But still, the families of babies in need of intensive care may struggle to come up with the gas money necessary to drive from one county in the area to Redding or Sacramento or southern Oregon where the other closest NICUs are. The lack of specialists is due in part to a lack of state central planning, Pierce reports. There's a statewide acknowledgement of a lack of specialists but "no one Shasta Scout spoke with knew exactly which or how many specialist doctors are missing in Shasta County."

Telehealth potential unrealized in places with poor internet; that becomes a bigger issue when telehealth is mandated

Homes in wealthy communities like the Blue Ridge Mountain Club near Boone, North Carolina, have access to high-speed internet. But most parts of the mountainous western region of the state, which has many poor people, have little broadband infrastructure. (Photo by Mark Darrough, Carolina Public Press, via The Daily Yonder)

The pandemic proved the great potential of telehealth for rural Americans, advancing its use years beyond what its advocates had expected. But it remains hamstrung by the lack of reliable, high-speed internet in many rural areas. That problem is explored in a four-part series by The Daily Yonder, the Institute for Nonprofit News, Carolina Public Press, Honolulu Civil Beat and Shasta Scout. with support from the National Institute for Health Care Management Foundation.

"Chronic health conditions and distance to medical services mean rural residents need more health-care specialists and better telehealth. But they are less likely than urban areas to get it," the Yonder says in introducing the first installment, in which Kristi Eaton cites examples from upstate New York, the Hawaiian island of Lanai, northern California and western North Carolina.

From the latter region, Eaton writes: "Lee Berger sat hunched over her laptop trying to complete a routine appointment with her primary-care doctor. But the 73-year-old, who has good hearing, couldn’t fully hear what the doctor was saying. It came down to unreliable internet access, she told Carolina Public Press. In North Carolina, an estimated 4 million residents don’t have access to reliable broadband service. This tends to have a greater effect on rural residents, many of whom live in communities that suffer most from a smaller supply of health professionals."

Fiber-optic service is provides the best broadband. but fewer than one in four households in western North Carolina even has access to fiber, Shelby Harris of CPP reports in the second installment, which reveals another problem: health-care providers who mandate telehealth, "such as Mission Health’s tele-hospitalist and tele-psychiatry programs. . . . Mission Health is the largest medical provider in the region" and is owned by HCA Healthcare, "the largest hospital system in the country."

Maggie Sauer, director of the North Carolina Office of Rural Health, told Eaton, “I’ve been in this business for a while, and I do not believe that without a hybrid telehealth model — in-person and then also telehealth — that we will be able to do what we need to do for our rural citizens.”

Telehealth roundup: HHS says rural Medicare patients were less likely to use it early in the pandemic, and fraud was rare

Medicare beneficiaries in metro areas were more likely than their rural counterparts to use telehealth during the first year of the coronavirus pandemic, according to a new report form the Health and Human Services Department's Office of Inspector General. The report didn't report or speculate on why rural beneficiaries were less likely to use telehealth, but did say that beneficiaries almost always used telehealth from home or in other non-health-care settings. Given widespread rural broadband disparities, it's possible rural patients may not have been able to get a good enough signal to access the tech. And some rural seniors may have lacked the tech savvy to access telehealth, a problem seen with switching them to newer phones during the 3G transition. Read more here.

Another report from the inspector general found that telehealth fraud was rare in the first year of the pandemic. Read more here.

In July, the House overwhelming passed a bill that would extend through 2024 the expanded pandemic-era Medicare benefits and reimbursements for telehealth services. However, the Senate hasn't passed the legislation, and while supporters say they're confident it will happen, there are still some obstacles (mainly a lack of time before the midterms). Read more here.

Expanded telehealth services during the pandemic reduced the risk of overdose for those struggling with opioid use, according to a newly published study by researchers from the Centers for Disease Control and Prevention and the National Institutes of Health. Read more here.

Telehealth brings important services to rural long-term care facilities. Read more here.

Health-care roundup: Providers in N.D. discuss challenges; regulations boosting telehealth expansion will expire soon

Here's a trio of stories about rural health care:

At a roundtable discussion Monday, rural health-care providers in North Dakota spoke to state and federal officials about the difficulties they face. Participants "cited workforce issues, regulations and rising costs as three challenges to provide services in rural areas," Masaki Ova reports for The Jamestown Sun. Officials in attendance included Sen. John Hoeven, R-N.D.; Xochitl Torres Small, the Agriculture Department’s undersecretary for Rural Development; and Erin Oban, her North Dakota director.

Rural hospitals had to adapt to survive during the pandemic, aided by federal funding. Some hospitals hope to keep some of those new capabilities, but may not be able to when the federal public-health emergency order expires—drying up funding with it.

Donald Lloyd, CEO of St. Claire Regional HealthCare system in Morehead, Ky., said the shift to telehealth is likely here to stay. "Before the pandemic, telehealth visits weren’t common at his hospital. Now telehealth visits account for nearly 20% of hospital visits," Liz Carey reports for The Daily Yonder. That goes especially for behavioral health, he said, since more than 80% of such visits to the hospital are via telehealth these days.

Speaking of telehealth: Relaxed regulations during the pandemic allowed health-care providers to more easily prescribe buprenorphine for opioid-abuse disorder. Studies have shown that telehealth prescription visits are at least as effective as in-person visits in keeping patients on their medication, but those regulations will expire along with the federal public-health emergency order. "That could come as soon as October, and the Drug Enforcement Agency, which has sought to clamp down on buprenorphine’s misuse, has already missed deadlines to facilitate virtual access," Krista Mahr and Ben Leonard report for Politico. "The expansion across sectors has been critical in rural areas, where access to licensed clinicians is scarce and social stigma runs high."

Telehealth is the future of rural health care, CEO of the National Rural Health Association says at telehealth meeting

Telehealth could be the key to rural healthcare's future, but stakeholders must figure out how to remove barriers to access, said Alan Morgan, CEO of the National Rural Health Association, at the Department for Health and Human Services' National Telehealth Conference. 

During a panel discussion, Morgan said many rural health-care providers lack consistent, affordable broadband access, and that many don't know that telehealth services are available or how to use them, Katie Adams reports for MedCity News. He called the rural-urban access gap "beyond frustrating" and called on the health-care industry to stop studying whether telehealth helps rural patients. That question is settled, he said; instead, the industry should focus on identifying and removing barriers to access. 

Morgan "and fellow panelist Ann Mond Johnson, CEO of the American Telemedicine Association, said communication about telehealth can be improved through partnerships with local organizations and community leaders, as patients are more likely to trust these messengers and heed their messages," Adams reports. "This need for programs designed to scale rural patients’ telehealth use is especially dire as healthcare’s workforce crisis intensifies . . . NRHA says the patient-to-primary care physician ratio in rural communities is 39.8 physicians per 100,000 people, compared to 53.3 physicians per 100,000 in urban communities, a disparity that is exacerbated by the country’s ongoing shortage of health-care workers."

Despite relaxed pandemic telehealth rules, rural patients still have difficulty getting medication for opioid-use disorder

Experts agree that medication-assisted treatment is the best way to treat opioid-use disorder, but only one in nine people with OUD receive such treatment. Telehealth can increase access to medication-assisted treatments such as buprenorphine, especially since the federal government relaxed telehealth regulations during the pandemic.

However, OUD patients in rural and other under-served areas still face many barriers to access. In an interview with Stateline, emergency medicine physician Elizabeth Samuels discusses those barriers, how pandemic-era policy changes have helped overcome them, and what policymakers must consider to further increase access to underserved areas. Read the interview here.

Rural cancer survivors less likely to have telehealth access, especially older, poorer, and/or minority patients

Telehealth has become increasingly popular in rural America during the pandemic, but rural cancer survivors were less likely to have access to telehealth than their urban counterparts last summer, according to a newly published study in the Journal of Medical Internet Research. 

Here are some of the study's top findings:

• Telehealth access disparities were found among patients who were Black, Hispanic, older, and/or enrolled in Medicare or Medicaid, across rural and urban lines.
• Only 53 percent of rural cancer survivors covered by Medicare reported that their medical provider had telehealth service available, compared to 63% of their urban peers. 
• Those who were enrolled in Medicare and Medicaid were even less likely to be offered telehealth services, the study found. 
• 67% of the rural respondents owned a desktop, laptop, smartphone or tablet, compared to 82% of urban respondents. 
• 58% of rural respondents had internet access, compared to 79% of urban respondents. 
• Only 28% of rural respondents were likely to participate in voice calls or conferencing, compared to 46% of urban respondents. 

The researchers suggested that the health-care industry and lawmakers work on increasing broadband access and find ways to help patients increase their telehealth literacy.

Telehealth popular in rural U.S. during pandemic; states pass laws to continue access and maybe make it permanent

Telehealth has been a boon to rural areas during the pandemic, "but its future depends largely on whether state lawmakers extend emergency measures that made telehealth a viable alternative for patients and providers wary of in-person contact," Michael Ollove reports for Stateline. "The most important changes most states made were to expand Medicaid coverage to different types of virtual appointments and to enact telehealth coverage requirements for private insurers."

Before the pandemic, 43% of providers used telehealth; that jumped to 98% early in the pandemic. Telehealth visits increased by up to 40%, and remain 30% higher than before, Ollove reports.

Telehealth has proved so popular that at least half the states "already have extended temporary telehealth measures that were set to expire with the lifting of public-health emergencies, and other states are considering doing the same," Ollove reports. More than 1,000 telehealth bills are pending in state legislatures, many of which would mandate that insurers cover telehealth and/or expand the number of telehealth services covered. Those bills generally apply only to individual or non-employer-funded plans, since the federal government regulates employer-funded plans.

It's unclear whether patients will continue to prefer telehealth after the pandemic, and broadband connectivity and computer literacy are still significant barriers to use. But providers say the service has helped them stretch staff resources and better care for patients, Ollove reports.

Doctors worry that telehealth makes it more difficult for them to detect drug abuse by patients or the patients' risk for it

Telemedicine, or telehealth, has proven its value in the pandemic, but physicians are concerned that it leaves them less able to detect patients' misuse of drugs, a national poll of doctors found.

Quest Diagnostics found that two-thirds of physicians it surveyed "fear they missed signs of drug misuse during the pandemic, and, given how the global health crisis disrupted medical care, anticipate rising overdose deaths – especially those involving prescribed and non-prescribed (illicit) fentanyl – even as the pandemic subsides," the company said in a news release. For the full report, click here.

Quest noted an increase in drug-overdose deaths in the first year of the pandemic, and big increases in non-prescribed fentanyl and heroin among people whose test results it ran early in the pandemic. The poll found that 94% of primary-care doctors "reported seeing more patients experiencing stress, anxiety or other mental-health issues because of the pandemic and fear a correlation between rising mental health issues and prescription drug misuse."

Three-fourths of the 505 physicians surveyed said they believe telehealth limits their ability to determine if patients are misusing prescription drugs, or are at risk for it. The release said "91% of physicians feel confident they can recognize the signs of prescription drug misuse during in-office interactions with patients, but only 50% report the same confidence via telehealth visits."

Quest said nearly half of tested patients showed signs of drug misuse, and a fourth "engaged in drug combining, a particularly dangerous form of misuse," the release said. But about half of physicians "do not follow up with definitive tests when presumptive tests are positive."

The poll also found that only a third of physicians are "very confident" in their ability to properly prescribe naloxone, which blocks opioid overdose, to patients who may be at risk of overdose.

Better than telemedicine? Program brings specialty training to rural health-care providers to help patients directly

A virtual mentoring program, Project ECHO (which stands for Extension for Community Healthcare Outcomes) aims to equip rural medical providers with more specialized expertise.

University of New Mexico internal-medicine physician Sanjeev Arora has spent "nearly two decades building the program, which now trains far-flung providers across the U.S. and other parts of the world," Erin Brodwin reports for Stat. "Every week, ECHO participants — often rural nurse practitioners or medical assistants — assemble over video conference to present a challenging patient case to a group of their peers and a team of ECHO specialists. It’s a chance to ask questions and get advice on care, including how to address social factors like housing and transportation. The work fills what experts see as a gaping need for specialty care in remote communities, where traditional forms of telehealth have failed to make inroads."

Arora calls the novel approach tele-mentoring, in a nod to its close cousin, telemedicine. "Rather than giving a single specialist a fish by connecting them to a rural patient, ECHO teaches multiple rural providers to fish by giving them the skills they need to treat scores of local patients," Baldwin reports.

Though telehealth has become more common in recent years, especially during the pandemic, it still can't help many rural patients who lack broadband and can't locally access specialists. The tele-mentoring approach is one way around that problem, according to RAND Corp.'s Ryan McBain. In 2019 McBain was the lead author on a systematic review of 52 studies about Project ECHO, Baldwin reports.

Health IT experts urge Senate to make pandemic telehealth regs permanent; FCC vows to update broadband maps

Health-care internet technology experts told a Senate subcommittee Thursday that many rural hospitals won't be able to take advantage of telehealth services if they can't afford or access broadband internet. The Subcommittee on Communications, Media, and Broadband convened the hearing to examine barriers to telehealth access.

Deanna Larson, president of telehealth company Avel eCare, testified that affordability is the biggest barrier to broadband adoption, and urged lawmakers to broaden telehealth regulations so more hospitals can use it. "Larson urged Congress to extend or make permanent their regulatory flexibility toward telehealth especially as it relates to being neutral on the kinds of telemedicine, such as phone-only care, asynchronous care, and remote patient monitoring," Riley Steward reports for Broadband Breakfast, a site that advocates for better broadband access. "An economic benefit of which would be keeping medical commerce local, she said. Patients wouldn’t be required as often to move to a higher level of care out of town."

Widespread telehealth availability could save the health care system an estimated $305 billion a year, Federal Communications Commission member Brendan Carr said at the hearing, Steward reports. He also endorsed several Senate bills that would enhance telehealth access, including the bipartisan Protecting Rural Telehealth Access Act, which was introduced in June by Sens. Joe Manchin (D-W.Va.), Joni Ernst (R-Iowa), Jeanne Shaheen (D-N.H.) and Terry Moran (R-Kan.).

The bill, along with its House companion, the Protecting Telehealth Access Act, focus on specific changes to telehealth that have proven successful during the pandemic, Eric Wicklund reports for mHealth Intelligence. Both bills call on Congress to allow audio-only telehealth appointments to receive the same payments as other appointments, permanently waive Centers for Medicare & Medicaid Services geographic restrictions so patients can be treated in their homes, permanently allow rural health clinics and federally qualified health centers to provide telehealth services, and allow critical access hospitals to bill directly for telehealth services.

However, even if the bills pass, they can only help if hospitals can access affordable broadband. The FCC awards rural broadband buildout contracts to companies based on maps meant to identify who lacks broadband access. But those maps are inaccurate, a problem the commission has vowed to fix. Subcommittee members at the hearing pressed Carr to complete the improved maps so more rural areas can get the broadband access they need, Maria Curi reports for Bloomberg Law.

Quick hits: Missing factory parts slow supply chains; telehealth could help rural prisoners stop smoking...

Here's a roundup of stories with rural resonance; if you do or see similar work that should be shared on The Rural Blog, email heather.chapman@uky.edu.

One reason for the supply-chain issues plaguing the U.S. (and other countries): factories are having a hard time finding replacement mechanical and computer parts, which slows or halts production. Read more here.

The poultry muscle disease called white striping was nearly nonexistent 10 years ago, but today 99% of U.S. store-brand chickens have it, according to a newly published study from an animal welfare group. Meat from afflicted chickens has up to 224% more fat and 9% more protein than others, but doesn't taste any different. Since the stresses of factory farming cause the ailment, its frequency serves as a rough yardstick for the increasing popularity of such methods. Read more here.

The most common type of liver cancer is on the rise in rural America but trending down in cities, according to newly published research. Hepatocellular carcinoma is the most common type of liver cancer and the fastest-growing cause of cancer deaths in the U.S. Diagnoses are increasing at an annual rate of nearly 6%, approaching rates seen in cities. Rural residents most likely to be diagnosed include men aged 60-69, Black people, Alaskan Natives who live in high-poverty areas or Native Americans who live in the South and/or high-poverty areas. Meanwhile, lung, breast and colon cancer rates are falling in rural America. Read more here.

Telehealth may help smokers in rural prisons kick the habit, a study has found. Read more here.

A retired farmer's new book is a touching and often funny account of life on a farm. Read more here.