“Post COVID” is a phrase that seems to be entering the national lexicon to describe the so-called “new normal” in which we find ourselves. To be sure, it has been a slow swinging pendulum. Many “back to work” plans were altered abruptly as resurgent infections were seen, but overall we are getting back to rush hour traffic and long-haul travel. In all of this – changes to work, school, and other habits – healthcare is a sector eyed attentively from both policy and healthcare perspectives. The national health emergency generated rapid and meaningful changes for patient care, including expansive recalibrations of telehealth services that would be eligible for Medicare reimbursement. States waived licensure requirements to allow cross-border treatments, and the insurance industry joined the effort with an renewed look at reimbursement schedules.
So where does that leave us now? Telehealth has new champions, but the data indicate that like so many other things, it will not be a silver bullet that many might desire. Rather, it will be a spray of silver buckshot, finding beneficial use in certain applications but not all. Switching metaphors, it will be a valuable tool in a comprehensive toolbox. To maximize its use, we will need to ensure connectivity, conquer affordability, and educate prospective users. In rural spaces, telehealth will be a game changer.
Overall, telehealth use is increasing. The U.S. Department of Health and Human Services reports substantial Medicare telehealth growth with the highest increases in behavioral telehealth. This is especially encouraging for rural spaces where (a) there may be a provider shortage and (b) the stigma of seeking help can be mitigated by enabling patients to engage therapy from the privacy of their home. NTCA’s own health benefits program counted steady and significant increases in telehealth usage across core care categories.
A separate survey whose results are published by the Journal of American Medical Association Network collected more than 2,000 responses and found that about 66% of surveyed adults prefer some type of video telehealth option, but when given a choice of video and in-person, 53% preferred in-person visits. However, when video visits were paired with lower fees, preferences for video visits increased. Where there was no difference in out-of-pocket expenses, 53% preferred an in-person visit; 20.9% preferred video; and 26.2% expressed no preference. The survey was limited to non-emergency visits, and the scope of telehealth was limited to video interactions (as opposed to telephone, store-and-forward, or remote patient monitoring).
Demographic variables similar to those identified in a Smart Rural Community (SRC) digital inclusion report were also considered in the survey. Black/African American patients stated a higher-than-average preference for in-person visits, while Hispanic/Latino patients preferred video visits at rates higher than other racial and ethnic groups. Educational attainment also indicated differences in preferences, with preferences for video visits higher among survey respondents with bachelor’s degrees, and higher preferences for videos for high-school graduates as compared to those who did not complete high-school. These results align with broadband adoption rates, which tend to increase proportionally with educational attainment.
33.5% of respondents did not see a role for video visits in their health care. These respondents were typically older, had lower income, lower educational attainment, and live in rural areas. And yet these are precisely the demographics that would benefit significantly from services that break the boundaries of distance and offer lower health care costs. Approximately 60% of the 7,200 Federally designated Health Care Provider Shortage Areas (HCPSA) are in rural spaces. Rural Americans are at a greater risk of death from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke. Rural areas have less access to smoking cessation programs than urban counterparts. And rural residents are more likely to be uninsured and face higher incidence of poverty than urban peers.
Telehealth is not limited to video interactions. Virtual reality (VR) is emerging as a formidable telehealth strategy. VR is used to combat anxiety, chronic pain, and cognitive decline. It has found notable use for treatment of PSTD and phobias. VR enables “exposure therapy,” which focuses on exposing people to their phobia, thereby desensitizing the brain to the reaction. Exposure therapy relies on gradual, tiered exposure to that which the patient fears (heights, spiders). VR allows the provider to manage increments effectively and without placing the patient close to the source of the phobia (atop a high ladder or ledge, or close to spiders). Other use-cases include managing grief/loss and substance use disorders.
Recent pilot studies are investigating the use of VR in surgery for both intraoperative and post-surgical recovery. In a trial of 30 patients, VR reduced post-procedure pain more than 2-D intervention. This can translate to reduced reliance on opioids and the risk of addiction. XRHealth, based in Boston, includes pain management among its other VR-based services that include physical, occupational, and speech-language therapy, as well as memory and cognitive training and support groups. For rural spaces that lack access to specialists or whose residents must travel far for care, VR offers an important opportunity for access to healthcare. (For a deeper exploration of travel costs and others savings enabled by telehealth, please see this SRC telehealth report.)
VR should not be entirely foreign to users: Approximately 30% of U.S. adults currently use some type of wearable health technology for a variety of reasons ranging from fitness to monitoring and management of chronic conditions. However, familiarity and understanding of VR is yet growing among doctors and patients, and price points are yet comparatively high. Although all technology prices tend to decrease over time (the lifecycle has been described to follow innovators, early adopters, early majority, late majority, and “laggards”), cost of equipment (for both standard video and VR interactions) and connectivity will require attention.
In all, telehealth continues to offer good news to rural spaces. Telehealth encounters that offer more convenient and affordable opportunities for healthcare promise better health outcomes for rural spaces. And even where the price of equipment may present a barrier during the “innovators” and “early adopters,” phases, shared telehealth facilities like the Virtual Living Room,® a program from the Foundation for Rural Service which offers veterans free telehealth access, can provide an on-ramp for prospective users.
So if rush-hour traffic, return to work, and long-haul travel are not enough to generate post-COVID optimism, the promise of telehealth and its growing applications signal new benefits for rural spaces. Whether virtual or otherwise, telehealth is ready to help create a good new normal.