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Sixty-four rural hospitals closed between 2013 and 2017, unable to continue operating as the result of years of repeated financial duress. These closures were disproportionately for-profit hospitals located in the south with a patient population primarily dependent on Medicare and Medicaid. According to the Government Accountability Office (GAO), states with a higher rate of closures saw a decrease in patients seeking inpatient care and “across-the-board reductions in Medicare payments.” Consequently, GAO research and stakeholder interviews found that “rural hospitals located in states that increased Medicaid eligibility and enrollment experienced fewer closures.”
Roughly half of hospitals and 16 percent of inpatient clinics are considered “rural,” about 2,250 hospitals in total. Rural communities in the United States have gone through significant changes in recent years, including significant population decrease and slow employment growth.
While rural economies are starting to recover after the 2008 recession, they still see half of the job growth of cities—approximately 0.8 percent per year in comparison to 1.9 percent in urban areas.
Rural communities are also typically older, have higher rates of chronic health conditions, and lower-income. In fact, almost 20 percent of those living in rural communities are over the age of 65 in contrast to 14 percent in urban areas. Furthermore, 18 percent of community members have chronic or underlying health conditions, as opposed to 13 percent of urban residents.
In response to limited access to healthcare, rural communities are increasingly turning to telehealth to provide primary and mental healthcare services. The U.S. Department of Health and Human Services defines telehealth as the “use of electronic information and telecommunication technologies to extend care when you and the doctor aren’t in the same place at the same time.”
The Role of Medicaid and Medicare in Healthcare Access
Rural hospital and clinic closures are not a new trend; rather they are a symptom of policies that have been in place since the 1980s. In fact, 140 rural hospitals closed between 1985 and 1988 after the Medicare payment system was restructured by Congress in 1982.
The Tax Equity and Fiscal Responsibility Program (TEFRA) went into effect on October 1, 1983, enabling the brand new Medicare Prospective Payment System (PPS). A response to rising medical costs, which has risen 19 percent annually since 1979, this system replaced the existing fee-for-service model that Medicare had to instead pay a fixed amount after patients were discharged.
The GAO states “the intent was to control Medicare costs by giving hospitals financial incentives to deliver services more efficiently and reduce unnecessary use of inpatient services by paying a hospital a predetermined amount.” However, this greatly reduced the availability of payments to hospitals with a large Medicare-reliant patient base, namely small, rural hospitals. For many rural communities, these hospital closures are the culmination of forty years of policy and economic factors. Now, almost 4.5 million rural residents live in a county without access to hospitals or primary care.
The lack of hospitals and primary care providers results in a domino effect for overall health. Primary care providers also help patients with referrals to other specialists, including mental health. The Behavioral Health Workforce Research Center at the University of Michigan School of Public Health reports that “approximately 60 percent of mental health care visits are directed to a primary care physician.” Even if a rural resident is able to receive a referral, there is a significant lack of available mental health services. In fact, over two-thirds of rural communities do not have access to a psychiatrist.
Rural communities also have a higher number of Medicaid recipients; nearly one in four adults under the age of 65 use Medicaid, which provides health insurance to low-income Americans. It also provides health insurance to people with disabilities.
Uneven treatment of mental health reimbursement on the state-level through Medicare—in conjunction with billing restrictions through Medicare and private insurance—greatly exacerbates the ability of rural communities to recruit and retain mental health care providers, as well as the ability of patients to access care.
The largest payer for mental health services is Medicaid, which also plays a large role in financing services related to substance abuse disorder. While the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 significantly expanded access to mental health services, now available to 60 million Americans, this increase in coverage did not come with an increase in workforce.
Furthermore, Medicaid billing practices are different from state-to-state. For example, one state may recognize licensed professional counselors for reimbursement, while another may only reimburse those services if they are provided through a community mental health center. This results in a two-fold dilemma: patients are unable to access key mental health services and providers are unable to get reimbursed. Consequently, reimbursement rates under Medicaid and private insurance for mental health services are typically lower. On the patient-side, this may result in having to pay out-of-pocket for mental health treatment, traveling significant distances to reach a provider within their state who covers the service, or forgoing treatment altogether.
Bringing Mental Health Care to the Home
Telehealth has become a vital lifeline for rural residents, particularly seniors, people with chronic conditions, and those with limited financial or physical means to travel long distances to see providers. Considering the significant lack of nearby providers and limited options for home healthcare, telehealth enables residents to have regular access to services like primary and mental healthcare without leaving their home.
The ability to see a doctor in the home is especially critical for homebound seniors over the age of 65. A study published in theJournal of the American Medical Association (JAMA) Internal Medicine in 2015 by Katherine A. Ornstein, PhD, MPH; Bruce Leff, MD; and Kenneth E. Covinsky, MD showed that “5.6 percent of the elderly, community-dwelling Medicare population (approximately two million people) were completely or mostly homebound in 2011.”
The importance of home-based health services is well-established through research. In fact, Medicare funded 17 home-based healthcare programs to participate in a five-year demonstration project, Independence at Home, which ran until 2017. The program resulted in $33 million in savings and served over 100,000 homebound patients.
Homebound seniors are disproportionately located in rural areas and commonly live 30 miles or more away from providers that support home visits. Telehealth bridges the best of both worlds: the ability to regularly see a doctor or therapist regularly and the option to get quality healthcare at home.
Through telehealth, patients can access their doctor or therapist from the comfort of their home so long as they have a phone or internet access. This may include talking to a healthcare professional via live video conference or phone. It may also include using a text, online chat, or email-based messaging service to ask doctors or nurses questions or send messages back-and-forth. Many of these messaging services also allow patients to share videos, sounds, or images with their medical care team.
Last, telehealth also includes remote patient monitoring, which allows doctors or nurses to check patients’ vitals from home. While less common in mental health settings, this feature allows medical care teams to use at-home devices to monitor certain vitals, such as an ECG (electrocardiogram) or other indicators of health.
A Model for the Expansion Telehealth
The Department of Veteran Affairs (VA) is the largest provider of telemedicine in the country. Roughly 15 percent of veterans receiving care through the VA use telehealth, in large part due to the VA “Anywhere to Anywhere” initiative. Passed by the VA in 2018, this federal rule allows VA doctors, nurses, and other healthcare providers to administer services via telehealth, including across state lines or outside a VA facility.
“By enabling Veterans nationwide to receive care at home, the rule will especially benefit Veterans living in rural areas who would otherwise need to travel a considerable distance or across state lines to receive care,” states the VA. Furthermore, “the rule also will expand Veterans’ access to critical care that can be provided virtually—such as mental health care and suicide prevention—by allowing quicker and easier access to VA mental health providers through telehealth.”
Access to mental health care via telehealth is growing especially critical in the time of COVID-19. I participated in a May 14, 2020 tele-town hall hall by the American Association of Retired People (AARP). Dr. Lynda Davis, the Chief Veterans Experience Officer at the VA Office of Public and Intergovernmental Affairs, spoke to the critical role that telehealth plays in providing mental health services:
“The mental health capabilities of the VA have increased by about 750 percent recently as we’ve undertaken over 100,000 telehealth appointments, many of them for mental and emotional health concerns,” said Dr. Davis.
She continued, “It is often that isolation and the stress leads us to have physical symptoms because we know that our entire wellness is based largely in part on our mental health, and these are very stressful times. We can find ourselves nervous about the safety of our loved ones far away. We can find ourselves stressed with people in a very small confined area, concerned about our ability to get our medications, et cetera.”
According to Dr. Davis, each VA medical facility has the capability to provide tele-mental health services. This includes “veterans who maybe have been seeing a provider in the past or now need to have a provider.”
Services may include real-time telehealth conferences with a licensed provider, store and forward telehealth (sending images, sounds, and videos), and remote patient monitoring.
Telehealth Today: The Long-Term Effects of COVID-19
In a world with COVID-19, many communities, both rural and urban, are turning to telehealth. Companies like Teladoc and ZoomCare provide telehealth services, including primary care and mental health, to patients around the country.
Moreover, more providers and insurance companies are providing greater access to telemedicine, including text and video-based services. The U.S. Department of Health and Human Services has even relaxed the Health Insurance Portability and Accountability Act (commonly referred to by its acronym, “HIPAA”) rules to allow providers to use Facebook messenger, Google Hangouts, Zoom, and Skype to administer care during COVID-19.
While some of these policies may change in the future, they have already shifted the narrative around telehealth and normalized the use of telemedicine. In a post COVID-19 world, there is hope that rural communities will have more options and greater ability to access mental health care.
Bree is an urban planner and freelance writer based in Seattle, WA. She has worked on land use and housing policy issues throughout the Pacific Northwest. She previously led Run Oregon Run, a nonprofit dedicated to helping Oregonians run for office and apply to boards and commissions. When not writing, she is lovingly tending to her cast iron pans.