States Use Technology to Go the Distance for Rural Populations

States with large rural populations face unique challenges in ensuring access to care.  While approximately 16 percent of the U.S. population lives in rural America, only about 11 percent of physicians practice in rural locations. Additionally, individuals in rural areas face long travel distances to see primary care providers and specialists. Many states are using technology to overcome these barriers to accessing care and to improve the health of rural populations.
Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Telehealth allows patients in one location to connect with providers in another location through interactive video conferencing, telephone or another type of technology. States are using these methods to help make care more easily accessible to rural populations and eliminate the long travel or wait times to see providers located in clinics or hospitals far from their home communities.
States have adopted different definitions for telehealth. While there are many similarities in how states have defined telehealth, states have tailored their definitions to meet the needs of the population and healthcare landscape in their state.

• Forty-eight states and the District of Columbia have a definition in law, regulation, or their Medicaid program for telehealth, telemedicine (which is less broad in scope than telehealth and is generally used to describe the delivery of remote clinical services), or both.
• In Alaska, Kentucky, and Nevada the term is explicitly defined in law or policy.
• A number of states such as Hawaii and Louisiana have put restrictions within their definition to exclude the use of specific technology like audio-only telephone, fax machine and/or email.

Forty-six states provide some form of Medicaid reimbursement for telehealth services but there may be limitations on the types of providers or services covered. States may reimburse for telehealth under Medicaid as long as the service satisfies federal requirements of efficiency, economy and quality of care. States have the flexibility to decide how to structure and administer their Medicaid telehealth policy.

• Only physicians can provide and receive reimbursement for telehealth services in Florida while in Georgia a physician, physician assistant, clinical psychologist, nurse practitioner or clinical nurse specialist qualify.
• Nine state Medicaid programs reimburse for “store and forward” technology, which allows for the electronic transmission of digital images, documents and pre-recorded videos through secure email transmission. Arizona’s Medicaid program covers the most extensive list of services including cardiology, dermatology, and surgery follow-ups.
• Fourteen states offer Medicaid reimbursement for remote patient monitoring (RPM) to collect patient clinical data such as vital signs and blood pressure, but many of these states have restrictions associated with its use. For example, in Minnesota, RPM reimbursement is only available for skilled nursing visits and in the Elderly Waiver and Alternative Care programs. InColorado, patients must be receiving services for at least one of the following conditions: congestive heart failure, chronic obstructive pulmonary disease, asthma, or diabetes.

States are using telehealth to provide mental health services to rural populations.Telehealth can allow rural health clinics to expand their expertise to include behavioral health specialists who are not located in the community. The scope of services providers can deliver via telehealth may include mental health assessments, substance abuse treatment, counseling, medication management, and monitoring.

• To address high rates of suicide and substance abuse in remote areas, the Alaska Medicaid program reimburses for critical behavioral health treatment and follow-up services delivered through telehealth.
• Idaho Medicaid will reimburse for a limited number of mental health conditions and developmental disabilities, and only for participants who live in designated rural health professional shortage areas. Maryland Medicaid also reimburses for certain telemental health services in specified rural geographic areas.

States are addressing provider training and licensing issues associated with telehealth. Ten state medical boards issue special licenses or certificates related to telehealth. The licenses may allow an out-of-state provider to deliver services using telehealth in a state where they are not located, or allow a clinician to provide services via telehealth in a state if certain conditions are met. The Federation of State Medical Boards has a model policy state medical boards can use as a guide for regulating the use of telemedicine across state lines.

• New Mexico offers out-of-state providers a special telemedicine license to practice within its borders for up to three years. Providers can renew their license at the end of the three-year period.
• Louisiana can issue a telemedicine license to out-of-state physicians as long as they hold a full, unrestricted license in another state. However, out-of-state telemedicine providers cannot open an office, meet with patients, or receive calls from patients within Louisiana.
• Similarly, in Oregon, out-of-state physicians may receive a license to practice telehealth within Oregon, as long as they are fully licensed in another state and meet certain requirements.

While telehealth is a promising strategy for connecting rural populations to health care services, remaining challenges and limitations may include the speed, quality and availability of Internet connections in rural areas. States with rural populations can consider adopting policies to support telehealth to expand access to necessary health care services as well as improve on existing reimbursement and licensure policies for telehealth services.
For additional information, see the Rural Assistance Center’s page on telehealth use in rural healthcare. Let us know what your state is doing related to telehealth in a comment below.