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Commentary: Broadband provides medical access

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The coronavirus pandemic catalyzed a need for telehealth services in Virginia, placing pressure on state lawmakers and health care systems to develop remote options for accessing safe medical care. Unfortunately, barriers to telehealth — inadequate broadband, restrictive payment structures and regulation on technology use — further exacerbated disparities in access to care, particularly specialty services.

Telehealth has been at least partially accessible in Virginia for more than two decades. Sentara Healthcare, a chain of hospitals serving southeastern Virginia, was first in the United States to create an “electronic ICU.” The eICU leveraged technology to allow specialist physicians and nurses to remotely treat critically ill patients at sites where this level of care would not normally be accessed. Goals included reduction in medical errors through continuous monitoring and intervention for at-risk patients, cost reduction through decreased complication rates and patient length of stays, and a solution for the growing shortage of intensive care specialists.

Successful uses of telehealth have been highlighted by the Virginia Commonwealth University Office of Telemedicine, through the provision of more than 15 subspecialty services to incarcerated patients at Virginia Department of Corrections sites. During the pandemic, telehealth utilization has continued to expand in the commonwealth and across the country.

Prior to March 2020, patients in Virginia were required to go to physical locations to receive telehealth services, due to state and federal regulations on the use of such technologies. However, that month, the Centers for Medicare & Medicaid Services (CMS) eased restrictions, allowing patients to access telehealth services in home for the duration of the coronavirus public health emergency.

Gov. Ralph Northam followed suit in November 2020 and signed Executive Order 57, further easing restrictions. Telehealth now is used widely in home, office and hospital-based settings across several subspecialties in Virginia. But without the continuation of eased regulations, this trend could reverse.

The distribution of specialty physicians in the United States is geographically skewed, clustered largely in urban and academic centers. For example, infectious disease physicians account for about 1% of the nation’s physician workforce, with a national average density of 1.76 specialists per 100,000 people.

However, 80% of U.S. counties do not have a single infectious disease physician, making it a high-demand, limited-access specialty. Broadband access and telehealth have the potential to bridge this access gap for infectious disease and other much-needed specialty services, particularly in rural and remote populations.

The Infectious Diseases Society of America supports the use of telehealth, as stated in a 2019 position paper. The publication called for increased services to deliver consultative care across diverse settings; perform outpatient intravenous antimicrobial therapy duties; conduct research; manage antimicrobial stewardship programs; and implement infection prevention and control measures. The goal is to provide timely, up-to-date and cost-effective subspecialty care. Similarly, other professional societies such as the American Medical Association, the American Psychological Association, the American Psychiatric Association and the American Academy of Dermatology are in support of telehealth and advocate for its use.

While progress has been made, barriers to comprehensive telehealth access remain at the local, state and national levels. As outlined in the 2019 Commonwealth Connect Report, Virginia included an estimated 287,000 underserved households and 40,000 underserved businesses, mainly concentrated in rural parts of the state.

Federal CARES Act funding is available at the local level to finance network improvements. But after this funding is depleted, state government will be a deciding force in the allocation of resources for further development of broadband access. In its most recent session, the General Assembly passed several bills that specifically financed broadband access in rural and underserved areas. However, without continued state and local efforts to expand access to high-speed internet, limited abilities for patients to connect to specialty medical care will persist.

Though limitations on telehealth reimbursements largely were relaxed after a CMS ruling in April 2020 (one which was extended through 2023), improved patient access to telehealth will depend on broadband expansion in remote areas; and more flexible reimbursement for telehealth services, including parity for reimbursement and covered technologies. Nationally, CMS guidelines will have a lasting impact on the financial feasibility of telehealth offerings, with smaller rural health networks disproportionately affected by restrictive reimbursements.

To minimize health disparities and address access gaps in care, lawmakers at the local, state and national levels must continue to expand broadband, minimize restrictions on technology use, and support ongoing improvements in payment parity and ease for telehealth services.

Sangeeta Sastry, M.D., is an assistant professor of medicine and infectious diseases at VCU Health. Rebecca Mullin, M.H.A., is an associate administrator of nephrology and infectious diseases at VCU Health. Gonzalo Bearman, M.D., M.P.H., is a professor of medicine and chief of infectious diseases at VCU Health.

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