Rural hospitals may have to cut investments into telehealth and remote patient monitoring programs as they deal with potential changes beyond their control.
The policymaking uncertainty in Washington, D.C., is affecting all of healthcare and is particularly challenging for providers in rural areas. Cuts to Medicaid are on the table and the fate of Medicare telemedicine reimbursement flexibilities is in doubt. A subsidy program for broadband internet could be ruled unconstitutional by the Supreme Court in June after arguments are made at the end of this month.
Read more: Uncertainty in Washington rattles telehealth sector
Changes to any one of those programs could hurt rural hospitals. They typically operate with thin-to-negative margins and have invested in telemedicine, remote patient monitoring and other technologies since the start of the pandemic five years ago to better serve patients. If significant changes are made to all those initiatives, systems said the disruptions would be devastating.
Healthcare executives in these communities have made frequent trips to the nation's capital to plead their case. Penelope Kyte, chief digital care officer at Johnson City, Tennessee-based Ballad Health, said she doesn't want to see telehealth usage return to pre-COVID-19 levels, when it was barely used by providers because it was not widely covered by insurers.
“I’m going to Washington, D.C., next week and I’m really worried,” Kyte said. “I don’t think people understand pre-COVID data points. Pre-COVID data [means] you can’t do telemedicine in your home anymore. Your place of service has to be at a clinic or health facility. How many people are really going to drive to a health facility to do telemedicine?”
Telehealth waiver worries
Providers in rural and underserved areas have come to rely on telehealth to expand access to neurology, behavioral health and other types of specialty care. It also has meant access to care after natural disasters.
Ballad, which has 20 hospitals across rural Tennessee, Virginia, North Carolina and Kentucky, uses telemedicine to connect with low-income patients who otherwise would have to travel nearly three hours to access services, Kyte said.
Because of flexibilities put in place during the pandemic, providers are fully paid for telehealth medical visits regardless of where the care visit originated. Those flexibilities expire at the end of March unless Congress passes a bill to extend them. In the most recent spending bill, which passed the House Tuesday, Republican Congressional leaders proposed a six-month extension to telehealth reimbursement. The bill still needs to pass the Senate before it is sent to the White House.
While there would be some telehealth reimbursement available for rural Medicare beneficiaries without the flexibilities, it won’t be enough and Ballad only would be able to do one-third of the telemedicine visits it currently does, Kyte said. If the flexibilities expire and Medicaid funding is cut, Kyte said most telemedicine services would end.
“You’ll see death rates go up. You’ll see long-term disability go up because people will get disabled from the strokes we have [in this area]," Kyte said. "We use teleneurology at all our hospitals."
The National Rural Health Association, an advocacy group, sent a letter to Congress in December urging the telemedicine reimbursement flexibilities be made permanent.
Deep cuts to Medicaid, of potentially $880 million over 10 years, would be an even harder pill for rural health advocates to swallow. Facilities could close, said Dr. John Graham, president of the North Carolina Telehealth Network Association.
“In North Carolina for rural hospitals and smaller providers, it will be disastrous if we have an $880 billion cut to Medicaid,” Graham said. “I’d say 30% of our rural hospitals are on the edge right now, and a Medicaid cut would just destroy so much of our rural healthcare infrastructure.”
Broadband challenges
Other changes also could have rural health leaders rethinking their technology investments. At the end of March, the Supreme Court will listen to arguments over the constitutionality of the nearly 30-year-old Universal Service Fund.
The $8 billion-a-year fund provides subsidies for wireless broadband services to rural hospitals, remote critical care providers, schools and libraries. Consumer Research, a conservative nonprofit group, is challenging the constitutionality of the fund, arguing that Congress has given too much authority to the Federal Communications Commission in overseeing it. In July, the 5th Circuit of Appeals sided with Consumer Research and the ruling was appealed by the FCC to the high court. and will be heard by the Supreme Court at the end of this month.
If the Supreme Court upholds the appellate decision, it will cause an immediate crisis, said Jeff Mitchell, an attorney at Mitchell Law, who filed an amicus brief supporting the FCC. Congress would have to immediately pass a law updating how the fund is administered to ensure the subsidies are continuously available for rural hospitals, he said.
“The collateral damage would go on for years,” Mitchell said. “In this current political environment, there's a lot of uncertainty, and you just don't know what's going to happen.”
The fund, financed by providers of telecommunications based of an assessment on their revenues, provides a subsidy that in some cases pays for two-thirds of a rural hospital’s broadband bill, according to the North Carolina Telehealth Network Association.
Medical-grade broadband, needed to power electronic health records systems, telehealth and other technologies in rural hospitals, would become unaffordable for many facilities if the fund disappeared, said Rob Jenkins, senior director of broadband services at the Colorado Hospital Association. That in turn would lead to a disruption to telehealth programs connecting rural patients to critical services.
“We have hospitals in Colorado that have less than 10 beds, some less than five, and they're really being utilized for emergency situations only,” Jenkins said. “A community that can only staff a three-bed hospital is not going to have a radiologist or a neurologist that's going to be on staff. Providers use the bandwidth to connect to a specialist provider who can respond in those emergency situations.”
