As in many other rural places, it’s difficult to access health care in Iowa. The state ranks 44th in the country in doctors per capita, and it is unlikely to improve in the future. One hundred and seventy-two physicians in the state were born in countries targeted by President Donald Trump’s travel ban, and another, less noticed change in H-1B visa policy could further reduce the number of foreign-born doctors in Iowa, who account for almost 20 percent of the state’s practicing doctors.
Even under the most favorable immigration policies, though, Iowa’s rural population ― almost half the state ― would be unlikely to see an influx of physicians. In a recent Merritt Hawkins survey of 1,200 final-year medical residents, only 4 percent said they’d consider practicing in a community of 25,000 people or fewer. For a community of 10,000 or fewer, fewer than 1 percent of residents were interested.
The solution, in Iowa and elsewhere, may involve not bringing doctors to patients, but rather bringing patients to doctors using technology.
For rural Americans, telemedicine could mean cheaper and more efficient care
Last month, a partnership of physicians, pharmacists and public health officials concluded the first six months of a pilot program called TelePrEP. During the trial, 30 patients were able to download a special video-conferencing app, log in from wherever they had a reliable internet connection (their home, office, local library — even their car) and then speak with a health care provider about Truvada, a drug that’s up to 99 percent effective at preventing the contraction of HIV, a method known as pre-exposure prophylaxis (PrEP).
While providing PrEP may seem like a niche service, the procedure could easily be applied to other forms of health care. As Dr. Mike Ohl, an infectious disease specialist at the University of Iowa and one of the program’s coordinators, explained, “A lot of chronic illness care and prevention, which is frankly most of what we do in our health care system, is really talking about behavior, counseling on using medicines, educating about risk reduction, and discussing side effects, so I think these visits apply to all sorts of care.”
Ohl is right. High price tags for cancer and complicated surgeries make headlines, but in reality, 86 percent of health care costs — $2.3 trillion a year — stem from mental health conditions and chronic diseases, including smoking, arthritis and diabetes. Half of Americans have some kind of chronic disease, and a quarter have two or more chronic illnesses. Among the elderly, who are more likely to be uninsured, live in a rural area, and be incapable of visiting a doctor in person, the chronic disease rate jumps to 92 percent.
Not only does telemedicine decrease logistical costs (no waiting rooms, no admitting staff, no transportation costs), but it can also streamline medical bureaucracy.
Under the University of Iowa pilot program, Angie Hoth, a pharmacist, was able to work under Ohl’s aegis in what’s called a collaborative practice agreement, which allowed her to order labs, prescribe drugs and monitor patients. ”What we’ve done is take the pharmacist collaborative model and apply it to a virtual model that can scale up across a rural state,” Ohl said.
That partnership even included clinics around the state, which serve as satellite campuses that can offer services like drawing blood, examining the heart or listening to a patient’s bowels.
The barriers to adopting universal telemedicine
Enlisting this breadth of actors also eliminated the biggest potential barriers to the TelePrEP program: the physical exam and access to technology. To virtually visit the doctor, patients had to download a video-conferencing app compliant with the Health Insurance Portability and Accountability Act of 1996, and have access to the internet and a computer, tablet or smartphone. Of the 30 participants, only one lacked the technology, and he was ultimately able to access it through one of the university’s partners. Besides the expected glitches — periodic video freezing, obtrusive updates — Hoth says that the tech side of things ran smoothly: “For people who aren’t used to apps, I’ll actually get on the phone and walk them through how to get the video working.”
In terms of bedside manner, telemedicine has benefits and drawbacks. It can be difficult to read a patient’s body language when he’s discussing sensitive topics, like sexual history and substance use, which is especially important when evaluating things like HIV risk. At the same time, patients were able to see physicians outside of their small towns — and have their Truvada prescriptions arrive by mail instead of being filled by local pharmacists — which, according to the team, allowed them to seek out preventative services they might not have otherwise.
For these reasons, telemedicine is being embraced not just by cities and states, but also by corporations. Microsoft’s five-year plan to deliver broadband internet to 23 million rural Americans lists telemedicine as one of its main benefits, and the New York-based insurance provider Oscar offers its customers a telemedicine option, which it estimates saved members “at least $1 million in out-of-pocket costs and 84,000 hours in travel time” last year.
Telemedicine needs bipartisan support to thrive
For all its promise, universal telemedicine remains a complex prospect. Because medical licensing is done at the state level, Ohl’s team could see a patient in Rock Valley, Iowa (332 miles away), but not in Moline, Illinois (59 miles away). As with everything else in health care, insurance is also a complication. According to a 2017 analysis from the American Telemedicine Association, “patients and health care providers may encounter a patchwork of arbitrary insurance requirements and disparate payment streams that do not allow them to fully take advantage of telemedicine.”
In February 2016, Sen. Brian Schatz (D-Hawaii) introduced a bill to expand the use of telehealth and remote patient monitoring, which would have saved the federal government $1.8 billion over the following 10 years. Of the bill’s 18 co-sponsors, half were Republicans, including Sen. Ron Johnson (Wis.), ranked by National Journal in 2013 as the country’s fifth most conservative senator.
So far, however, Schatz’s CONNECT for Health Act, along with similar proposals, is languishing in committee. According to Jon Linkous, the ATA’s chief executive, “the issue is getting the individual bills tied to something that is not as controversial as the Better Care Reconciliation Act” ― the Republicans Senate’s proposed (and now failed) attempt to repeal and replace the Affordable Care Act.
Which means that for telemedicine to thrive, it will have to amend itself to another, larger piece of health care legislation supported by both parties — a daunting task.
Still, the University of Iowa team is optimistic going into their second six-month trial. They’re fully funded through the Iowa Department of Public Health and hope to help even more patients find reliable health care and peace of mind. As one patient, a man in his mid-20s who has sex with men, said: “Before taking PrEP, I had a constant fear of becoming HIV positive and would stress each time I had sex with a new partner. It’s been about four months since I’ve been on it, and I couldn’t be happier and more relaxed.”