Eyal Kedar didn’t start out in rural health care. He spent several years working in a big city before eventually realizing he wanted to become a generalized specialist in rheumatology, a branch of medicine that treats inflammatory or infectious conditions of the joints and other parts of the skeletal system.
“I felt that the best way to do that would be in a rural community,” he said.
Kedar is now the sole rheumatologist in St. Lawrence County in New York state. The county is about the size of the state of Delaware and has a widely dispersed population of about 109,000.
“In an ideal world, a rural rheumatologist has a full staff and a team of advanced practice practitioners who help them with taking care of more stable cases in the community,” he said. “[They] really try to make their job as easy as possible because the job is going to be inherently hard. And you let rural rheumatologists, rural specialists focus on the complex cases in their community. And that keeps the job interesting.”
But, as reporters from Carolina Public Press in North Carolina, Honolulu Civil Beat and Shasta Scout in northern California will show over the next few days in a series examining rural health care, it’s not quite so simple.
From mental and behavioral health to maternity care, specialists in rural areas of the United States are in short supply. For the people who live there, that has meant doing without specialized care or traveling long distances to get it. On Lanai in Hawaii, for example, 25 people who receive psychiatric care through the Hawaii Department of Health’s Adult Mental Health Division were left without support on the island when the care was outsourced to the mainland, making a temporary COVID-19-era safety measure permanent, Honolulu Civil Beat reports.
“The lack of access to behavioral health is one of the top-tier issues,” said Alan Morgan, chief executive officer of the National Rural Health Association. “No. 2: maternity care. I’d say that’s a huge issue, because we’re talking about the future of rural. You’ve got to be able to have a community in which young families can move to live there and have access to health care to start their families off.”
In the case of psychiatric treatment on Lanai prior to COVID, AMHD patients had access to a full-time on-island social worker and in-person appointments every two weeks with a Maui-based psychiatrist, Honolulu Civil Beat found. Availability of in-person mental health care of any kind is now sporadic, amounting to a few days per month. Of the 122 psychiatric visits Lanai patients received this year, only nine of them were in person, according to the Hawaii DOH.
Although milder symptoms related to mental health can improve with a variety of treatments, there’s no consensus about whether new virtual tools are effective at helping more severe cases of mental illness, experts say.
One reason for the shortage of mental health specialists on Lanai is that there are too few doctors in Hawaii. The state’s high cost of living and limited medical training opportunities have made it difficult to attract doctors, even before the pandemic. One solution, in Shasta County, California, is a family practice medical residency that annually brings 8 to 10 medical students to the area, according to Shasta Scout. Most doctors end up practicing within 50 miles of where they’ve done their residency, according to one medical official.
Of course, specialists can be even harder to come by. For example, after a rheumatologist in Humboldt County retired, patients have been traveling four hours east to the Shasta Community Health Center on the days a rheumatologist is on site.
According to the National Rural Health Association, there are 30 specialists per 100,000 people in rural America. Compare that to urban areas in which the number of specialists averages 263 per 100,000 people. In mental health, the number of psychologists per 100,000 population in rural U.S. counties (15.8) was less than half that of urban counties (39.5), according to the University of Washington. Meanwhile, the number of psychiatrists per 100,000 population in rural U.S. counties (3.5) was about one-fourth that of urban counties (13.0).
In many cases, rural areas may not be able to sustain a specialist, although that population tends to have higher incidence rates of chronic diseases leading to more health-care needs, Morgan said.
“And so, even though it’s a smaller volume, which doesn’t support, in many cases, full-time specialists living and working in the community, the percentage of the population there is older, sicker, [and] in many cases, [has] less resources.”
Telemedicine may be one way to alleviate the situation. It has helped specialists reach patients in remote, often isolated areas.
“Before the pandemic, it was actually sort of a niche area in the health-care field,” said Mei Kwong, executive director of the Center for Connected Health Policy, the federally designated national telehealth policy resource center. “But when the pandemic hit … telehealth became kind of an ideal tool in a lot of ways to continue to provide this health-care service.”
Telemedicine can help rural residents gain better access to certain doctors who may be far away, allowing the patients to remain in their homes while still seeing a trained medical professional.
Following the outbreak of COVID in the United States, the Centers for Medicare & Medicaid Services removed geographic restrictions and changed reimbursement requirements to allow providers to expand the use of telehealth services. By changing the restrictions, providers were able to continue to offer care despite physical distancing guidelines. In many places, already-existing telehealth services were expanded, but in some locations, new telehealth programs were created and implemented.
A report on trends in telehealth use among Health Resources and Services Administration-funded health centers from the Centers for Disease Control and Prevention found that nearly one-third of weekly health center visits between June 26, 2020, and Nov. 6, 2020, took place through telehealth. In rural North Carolina, some medical services have switched solely to virtual platforms, Carolina Public Press reports.
A survey of health centers completed in July 2020 found that urban health centers were more likely to complete visits using telehealth than rural health centers. The survey showed that 55.1% of urban facilities and 29.9% of rural facilities provided more than 30% of visits via telehealth.
But telemedicine is not the cure for a lack of specialists for all patients, or even an adequate resource to see a primary care doctor. Telemedicine can be prohibitive to some people because of costs to set up or simply because they lack a sufficient internet connection.
In a rural part of North Carolina, Lee Berger sat hunched over her laptop trying to complete a routine appointment with her primary care doctor. But the 73-year-old, who has good hearing, couldn’t fully hear what the doctor was saying. It came down to unreliable internet access, she told Carolina Public Press.
In North Carolina, an estimated 4 million residents don’t have access to reliable broadband service. This tends to have a greater effect on rural residents, many of whom live in communities that suffer most from a smaller supply of health professionals. Despite the state’s acknowledgement that fiber-optic access is the only way to ensure stable internet connectivity, moves to put the infrastructure in places like the rural mountainous areas of North Carolina have been slow-coming, Carolina Public Press reports.
Across the United States, approximately 19 million Americans—6% of the population—still lack access to fixed broadband service. In rural areas, nearly one-fourth of the population, or 14.5 million people, lack access to the service, according to a report from the Federal Communications Commission.
Kwong said that can be one of the limiting factors of telehealth. The other is the equipment needed, such as a smartphone or laptop, to take part in a call at home. Digital literacy is also required.
“For telehealth to work, you need two things: You need that connectivity. But you also need that equipment. By that I mean the technology, which could be something as simple as a smartphone or what we’re doing here: a laptop,” she said, referring to the Zoom meeting where the interview was conducted through two laptops. “But not everybody has access to those types of devices, nor are they comfortable using it.”
There are possible solutions. In Shasta County in northern California, the Shasta Community Health Center provides real-time video calls with physician specialists via a screen rolled into the patient’s room.
Michelle Carlson, who manages psychiatry, specialty care and telemedicine at the health center, said since the pandemic, the use of telemedicine has grown rapidly and has helped reach some patients who may have otherwise fallen through cracks in the health-care system, Shasta Scout reports.
In fact, at least one broadband internet provider is seeking ways to help patients access telehealth services.
Vistabeam, an internet provider in rural parts of Colorado, Nebraska and Wyoming, plans to create “empowerment” centers. The centers will help community members in four ways: assist them with program qualifications and paperwork, along with other digital equity programs; offer digital skills training material and facilities; provide a private telehealth consultation room and a local person with digital navigator skills; and assist Vistabeam customers with billing, sales and basic technical support, said Matt Larsen, CEO of Vistabeam.
“We figured that we could take the fact that we have infrastructure in this community to deliver broadband and kind of make it a little bit more accessible … so people have access to digital resources and services,” Larsen said.
Larsen added that although a lot of people have mastered digital skills over the past few years of the pandemic, there’s still inequity.
“Behind the telehealth portion of it, all we want to do is help facilitate and provide a room and a camera, and a screen, and the ability for them to interact with somebody else,” he said.
Larsen said the first center will open in Torrington, Wyoming, soon.
According to Morgan, while telehealth was in use before the pandemic, it has increased and will remain in place, despite barriers or obstacles some residents may face.
“There really is no path forward for rural health that doesn’t involve telehealth at some significant level,” he said.
This reporting is part of a collaboration with The Daily Yonder, the Institute for Nonprofit News, Carolina Public Press, Honolulu Civil Beat and Shasta Scout. Support from The National Institute for Health Care Management (NIHCM) Foundation made the project possible.