- Telehealth has huge potential to improve access to care in underserved populations, but a host of challenges stand in the way, a new RAND Corporation analysis finds.
- In a sample of data from Federally Qualified Health Centers, live video telehealth — particularly telebehavioral health — was the most prevalent format used, although store-and-forward telehealth and remote patient monitoring also were seen.
- Barriers to wider telehealth use include reimbursement issues, lack of infrastructure, technology costs and low buy-in by FQHC providers. Credentialing issues, lack of specialists to provide telehealth services and demographic challenges such as homelessness also undermine efforts to expand use.
For patients who are homebound, lack transportation or live in rural areas far from a hospital, telehealth holds real promise of expanding access to care. In a University of Iowa study, patients were seen six times more quickly when rural hospital emergency rooms used telehealth than when they did not. Length of stay also was shorter when patients received telehealth services.
Legislative and regulatory efforts are underway to address issues like bandwidth access and licensing issues, but major barriers prevent telehealth from being used to its full potential.
The RAND researchers talked with representatives of seven state Medicaid programs and 19 urban and rural FQHCs to understand how the safety nets are using telehealth, the challenges and how Medicaid policy impacts implementation.
While some FQHCs served as originating sites for telehealth, the majority offered patients a combination of externally contracted telehealth services and services they provided remotely.
Telehealth policies varied widely across the seven state Medicaid programs. For example, four reimbursed for store-and-forward services, while just two covered RPM. Patient informed consent was needed in four programs, three required that telepresenters be with patients at originating sites and two limited the specialties and services available via telehealth.
Complaints about Medicaid policies ranged from lack of clarity about which services are allowed and confusion over telepresenter requirements to lack of authorization for FQHCs to serve as distant sites in federal and state Medicaid programs and low reimbursement.
Beyond policy and reimbursement, FQHCs faced multiple barriers to telehealth implementation, including insufficient broadband, elderly and homeless patients, technology costs, workflow and logistics.
"Nonetheless, FQHC stakeholders generally believed they could overcome these various barriers to telehealth implementation if reimbursement, and the risk of losing revenue in offering telehealth services, were improved," the report says. Possible facilitators include grant funding, working with payers and appointing someone to serve as the "clinic champion" on telehealth.
While most of the FQHCs hoped to increase telehealth use, a few were considering abandoning their programs due to the numerous challenges.
To spur telehealth use by safety net providers, FQHCs should be authorized to serve as both originating and distant sites, the report says.
The researchers also recommend clarifying telehealth policies and approaching telehealth as part of a broad strategy to address workforce shortages in rural areas. Safety nets could also learn a thing or two by looking at case studies of successful and profitable telehealth programs, they add.