National Rural Health Day provides an opportunity to reflect on the quality of medical care in rural and medically underserved communities. This year has posed additional challenges to fragile healthcare systems and vulnerable populations. Faced with new barriers, rural communities are adapting and innovating through telehealth.
COVID-19 caught the entire country off balance, highlighting structural problems in the U.S. healthcare system. Financial loses, an increased number of uninsured and existing disparities taxed the rural healthcare system. In response, the federal government implemented policy changes to improve access and support providers. The expansion of telehealth services was essential to addressing gaps in rural communities.
Rural Telehealth Changes During COVID-19
Congress and the Centers for Medicare and Medicaid Services (CMS) acted quickly to provide telehealth flexibility. However, initial modifications did not apply to many 
rural health providers, including certified Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). The primary legislation, the CARES Act (H.R. 748), modified grants for medically underserved populations to adopt telehealth. The legislation also waived certain CMS requirements, required Medicare to pay for certain telehealth services, and allowed for some forms of telehealth expansion.
CMS used the legislative authority to implement a number of changes. In March 2020, the Office for Civil Rights (OCR) and the Department of Health and Human Services (HHS) relaxed some security and privacy rules to permit telehealth visits via more accessible platforms (Zoom, Facetime, Facebook Messenger, etc). The OCR and DHHS also waived certain requirements [pdf] for staffing and physician supervision of advanced practice providers in RHCs and FQHCs.
Challenges to Implementing Rural Telehealth During COVID-19
Initial telehealth flexibilities were for providers reimbursed using the Physician Fee Schedule (PFS). While a common reimbursement structure, it is not widely applicable to most rural primary care provider types. FQHCs and RHCs were still unable to operate as an originating site (i.e., patients were still required to be physically located in the clinic) and confusion arose on appropriate billing codes. Further flexibility and guidance [pdf] for FQHCs and RHCs finally came nearly two months later.
CMS has proposed regulations that will extend some of these general telehealth flexibilities until December 31, 2021. That is the current expiration date for the federal public health emergency. The proposed flexibilities, however, are again tied to the PFS. At the time of congressional recess in August 2020, the Senate (HEALS Act) and House (HEROES Act) had passed legislation but had not reconciled in Conference.
The proposed HEALS Act would extend the telehealth flexibilities in FQHCs and RHCs for five years beyond the end of the public health emergency. Alternatively, the HEROES Act would enhance telehealth access for homeless veterans but makes no change to current Medicare telehealth policy. Since then, the House has introduced another version of the HEROES Act. With the lame-duck session beginning, it is unlikely any bill will gain traction.
Rethinking Telehealth in Rural Primary Care
Telehealth can be an ideal solution for rural and underserved areas with limited access to care. There are, however, many underlying barriers for these communities. The adoption of telehealth in rural America will likely flourish when regulatory limitations are addressed and physical infrastructure is improved. Limited broadband internet access and access to adequate technology make it more difficult for rural healthcare operations to adopt telehealth.
The majority of the regulatory waivers and expansions will eventually expire with the public health emergency. Ensuring these provisions are permanent would allow healthcare providers to build upon these efforts. Without adopting the provisions permanently, many healthcare entities may have to reinvest in new technologies and re-educate vulnerable (and typically older) patients. Resources for digital health literacy, broadband connectivity and provider implementation are all needed to realize the full benefit of telehealth in rural and underserved places.
Innovation to Promote Rural Telehealth
Across rural America, innovative approaches to addressing the challenges of telehealth adoption are taking shape. For providers, health systems, or other rural health stakeholders, the Health Resources and Services Administration’s Federal Office of Rural Health Policy funds a network of Telehealth Resource Centers that provide free technical assistance. Collectively, the centers can offer comprehensive support in implementing a telehealth program. Outside of healthcare, coordinated efforts at addressing America’s digital divide have led to the formation of Connect Americans Now. This multi-sector coalition, funded by Microsoft, works to eliminate the digital divide through education and advocacy efforts.
Today, on the 10th anniversary of National Rural Health Day, we are surrounded by much uncertainty. But we should take a moment to celebrate our rural healthcare providers and systems. They are working tirelessly to implement telehealth initiatives. Their innovation has helped meet the unique needs of their communities, recognizing that rural America is not a monolith. We must continue to support these innovative, value-driven and sustainable programs as a vital part of the future rural health landscape.
Tiffany Johnson
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Chris Salyers
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- Rural Telehealth in the COVID Era and Beyond - November 19, 2020