The coronavirus pandemic has driven a massive expansion of telehealth, both due to loosening of federal and state regulations allowing public and private insurance payers to be reimbursed for a wider range of telehealth services, and an influx of federal funding through the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Telehealth has become a key avenue for individuals to receive medical and behavioral health care while limiting exposure to coronavirus infection. Widespread use of telehealth for services deemed non-emergent or “non-essential” also allowed communities to flatten the curve and preserve supplies and resources needed by hospitals and frontline workers during the early days of the pandemic.

Telehealth is thought to hold particular benefit for rural populations, who may live in medically underserved areas and struggle with transportation or mobility barriers, and are more likely to suffer from chronic conditions such as heart disease that require ongoing monitoring. Direct-to-consumer telehealth services allow patients to receive care in their own homes, thus dismantling some of the barriers rural patients face in accessing the care they need.

Although government expansion of availability and funding for telehealth may make it more widely available, robust direct-to-consumer care requires something that many rural residents of the United States may lack: broadband connectivity.

DATA PROBLEMS OBSCURE BROADBAND ACCESS DEFICITS IN RURAL U.S.

According to the Federal Communication Commission’s (FCC) 2020 Broadband Deployment report, 22% of rural residents and 28% of residents of Tribal lands currently lack access to broadband, compared to less than 2% of urban residents. (The FCC sets a benchmark of 25/3 megabits per second (mbps) as the minimum speed for acceptable broadband, though these speeds are now considered by some to be prohibitively slow.) These percentages are widely acknowledged to vastly overstate the extent to which rural Americans have access to broadband, however, due to the manner in which the FCC collects and reports its data.

As FCC Commissioner Jessica Rosenworcel stated via email, “Regrettably, the FCC does not know with precision where broadband is and is not in rural communities across the country. That makes this a hard problem to fix. But we need to address it, and doing so starts with a nationwide effort to get better data about the state of deployment.”

Currently, if broadband service providers offer internet service to just one customer within a census block, the FCC assumes that the entire block has access. This paints an overly rosy picture of broadband coverage across the country, and the effect is exaggerated in rural areas where census blocks tend to be larger than urban ones and broadband providers have less financial incentive to offer internet services.

The State of Georgia’s Broadband Deployment Initiative (GBDI), partly funded by the FCC’s Rural Digital Opportunity Fund, developed a map showing the contrast between the FCC’s standard for determining block coverage and a more stringent one. By upping the broadband availability benchmark from one to 80% of locations within a census block, the GDBI exposed over a quarter of a million homes and businesses in the state without access to broadband that were not captured by federal data. The map, considered to be the most detailed of its kind in the country, was developed in response to a 2018 bill passed by the Georgia legislature which sought to more accurately identify areas that lack access to broadband and would therefore be eligible for federal subsidies.

Broadband service providers currently self-report their own service data to the FCC, and there is no mechanism to independently verify or challenge these reports. In 2017, one provider in the Northeastern U.S. reported an increase from zero subscribers to 62 million, or the entire population of the eight states it claimed to serve, over a seven month time period. The FCC failed to take notice of this error large enough to significantly skew state averages and released the inaccurate data in its 2019 Broadband Deployment Report. The error was brought to the attention of the FCC by media reform advocacy organization Free Press upon preliminary release of the report, which occurred one year after the data was originally reported.

The Broadband DATA Act, which became law in March 2020, requires internet service providers (ISPs) to begin reporting granular address or location data on broadband availability, instead of using one site as proxy for an entire census block. The Act also requires the FCC to set up a process for verifying ISP-submitted data and for allowing third party challenges, versus relying on the honor system. ISPs are not required to begin reporting data under this new system until spring 2021, to be included in the FCC Broadband Deployment Report of 2023.

In its most recent report, the FCC estimates that 18 million U.S residents lack access to broadband, the vast majority of which reside in rural areas. According to Commissioner Rosenworcel’s statement in this same report, the true number is in fact somewhere between 42 and 162 million.

HOW DOES RURAL BROADBAND AVAILABILITY IMPACT USE OF TELEHEALTH?

Congress loosened regulatory restrictions governing the provision of telehealth with passage of stimulus packages in response to the coronavirus pandemic, allowing much greater flexibility in the logistics of care delivery and authorizing payer reimbursement for a greater range of telehealth services.  This resulted in a large increase in the use of telehealth, especially during the first few months of the pandemic. This has since leveled off, but remains well above pre-pandemic levels.

According to Dr. Joseph Kvedar, President of the American Association of Telehealth (ATA), “we’re very upset about the uneven penetration of broadband. It’s a real barrier” in rural communities, although the impact is somewhat lessened by the current ability of practitioners to use audio-only phones to provide many services, as proposed in the CARES Act.  However, Dr. Kvedar cautions that as a provider “you’re going to feel a bit handicapped if you don’t have the full experience of seeing that individual”.

He notes the ability to visually connect with a patient is particularly important if they’re new and the provider is not familiar with their baseline clinical state. Although providing care in the absence of visual cues is a safer bet with a patient already known to the provider, Dr. Kvedar affirms it’s still not ideal. “It’s not poor quality care, but there’s less information available which may affect clinical decision-making,” he said.

In the absence of broadband, patients with smartphones can use their own mobile data to achieve an audio-visual connection, and “smartphones can do most of what needs to be done” with regard to telehealth, according to Dr. Kvedar. However, not everyone can afford a smartphone, and this may be especially true in rural areas where poverty rates are disproportionately high. Also, there remain “large swaths of the United States where cellular connectivity is nil,” notes Dr Kvedar. These patients would be completely reliant on a landline for direct-to-consumer telehealth, and it is currently unknown if insurance payment for audio-only telehealth will persist once the national declaration of emergency expires.

“It’s not bleak but the current environment is not acceptable,” said Dr. Kvedar.

TELEHEALTH PROJECTS IN RURAL COMMUNITIES WITH UNEVEN BROADBAND ACCESS

Decatur County Memorial Hospital (DCMH) is located in Greensburg, Indiana; a town of about 10,000 residents located 50 miles southeast of Indianapolis. Greensburg is the county seat of Decatur County, home to 25,000 people. DCMH recently received a grant of nearly $700,000 to expand telehealth services, part of three separate funding streams allocated by the CARES Act for healthcare providers to beef up telehealth. Total funds are $325 million, and the grant received by DCMH comes from the FCC’s COVID-19 telehealth program, the largest of three funding streams at $200 million.

According to an FCC spokesperson, the goal of this emergency program is “to rapidly provide eligible health care providers funding for equipment and connected care services in areas hardest hit by the pandemic, to more safely treat COVID patients, as well as remotely treat patients with other conditions” while conserving medical resources and stemming coronavirus spread by keeping patients out of medical facilities as much as possible.

“Broadband capability and access is very inconsistent in our rural community,” DCMH CEO Rex McKinney wrote by email. DCMH plans to use grant funds to enhance in-hospital telehealth infrastructure as well as capabilities for off-site visits and monitoring, including for patients with COVID-19 who can be treated at home. Some of the grant funds will be used to provide tablets and mobile hotspots to patients who may benefit most from direct-to-consumer care.

DCMH plans to target the community of Westport, located 15 miles away from the hospital and home to 1,500 people who are particularly beset by chronic health conditions as well as deprived in terms of both internet and healthcare access, according to Annie Swinney, Staff Development Coordinator who has been overseeing the grant. DCMH currently offers in-person clinic in Westport for a half day each week and hopes to expand this window by offering access to providers located remotely.

DCMH is working with a local internet provider to upgrade broadband connectivity at the Westport library to 100 mbps, so that patients can access virtual visits as well as health information. Ms. Swinney said that by boosting library broadband, DCMH is able “to put in a solid foundation for the community, making it more affordable for other businesses and homes in Westport to connect as well as providing a base point of access.” However, they are aware that funds “will not be a long term fix” to the problem of broadband access in the area, according to Marketing Specialist Ryan Morlan.

Golden Valley Memorial Healthcare (GVMH) is a rural health system based in Clinton, Missouri, which received a telehealth grant of $800,000 from the annual Distance Learning and Telemedicine Grant program funded by the United States Department of Agriculture (USDA). (The CARES Act added $25 million to this funding stream.) According to an email from GVMH CEO Craig Thompson, “this is the largest grant we have ever received and it will significantly help us in expanding our telehealth capabilities and ease the burden placed on patients who must travel to receive the care they need.”

GVMH will use its grant to purchase eleven telehealth robots which will expand access to provider-to-provider specialty care between its hospital campus and clinic locations. Per an email from Director of Marketing and Communications Lea Studer, ”we do not connect with people in their homes.” According to the FCC’s most recent Broadband Deployment Report, less than 50% of the population of Henry County, where Clinton is located, has access to fixed or mobile broadband.

Overall, the $325 million allocated by the CARES Act for telehealth expansion is “pretty small change to accomplish these projects” in rural communities, said ATA’s Dr. Kvedar, adding that broadband access “may not be a large part of providers’ allocation of these funds.”