A patient uses a laptop for a virtual health care visit. File art/The Beacon

With the need to help prevent the spread of COVID-19, many medical providers have turned to virtual appointments, known as telehealth, as a solution.

But rolling out telehealth has its challenges, especially in rural areas, where many can’t access broadband internet. Health care clinics and providers had to quickly navigate how to set up telemedicine programs, stay informed on COVID-19 information for different populations they serve and understand laws that changed at both the state and federal level.

“Before COVID, most health care providers did not utilize telemedicine,” said Rachel Mutrux, senior program director for the Missouri Telehealth Network. “And then after COVID hit, people had to use telemedicine for primary care, so the numbers went sky high, and people had to learn really quickly how to do telemedicine programs.”

The Health Care Collaborative of Rural Missouri operates five clinics in Lafayette County, about 40 minutes east of Kansas City. The rural health network provides medical, dental and behavioral health services. In 2020, the collaborative had to shift to providing its services remotely, using creative ways to expand access to broadband for its patient population. HCC found that using a variety of methods worked better — a one-size-fits-all approach wasn’t a good enough solution.

Most of its patient population — between 65% and 75% — is low-insured, uses Medicaid and is low-income, according to Toniann Richard, CEO of HCC. About 10% have a ninth- to 12th-grade education, but no diploma. 

And many are without broadband internet. In Lafayette County, 42.5% of residents don’t have access to broadband, according to Broadband Now. Across Missouri, almost one quarter of residents don’t have broadband coverage.

When HCC had to shift more of its services to telehealth due to the pandemic, it had to get creative. Richard said the collaborative already had all of the equipment its clinicians needed to provide telehealth services, as it has gotten much cheaper over the years. The problem was connecting with patients.

HCC encouraged patients to come into the physical clinic locations where they can go into an isolated room with access to the clinic’s fiber internet. HCC also partnered with churches and community centers that weren’t using their physical space during the pandemic and that have faster internet than patients’ homes. 

The collaborative also received about 300 internet hotspots through a grant from the University of Missouri for patients to use.

HCC is exploring more ways to increase telehealth access, advocating for expanded broadband access and getting more fiber laid in the rural communities of Missouri that it serves. It may also supply smartphones for telehealth visits that patients would send back afterward.

Currently about 80% of behavioral health therapy and psychiatry visits are through telehealth, Richard said. It also has been doing telehealth visits for some primary care and oral health management, as well as pain management.

But while HCC would like to use telehealth for primary care visits, it first would have to meet stricter privacy regulations. 

“Telehealth is going to continue to grow,” Richard said. “We are going to constantly be keeping an eye on it and evolve methods of practice in order to meet those demands.”

Statewide resources

One large challenge of telemedicine so far is that health care providers weren’t taught it in school, Mutrux said. She said that the organization is starting to focus on how to provide more robust training programs on telemedicine for health care providers.

The Missouri Telehealth Network at the University of Missouri School of Medicine works as a telehealth resource center for clinics, using state and federal funding. During the rapid telehealth expansion across the state, the network found partners struggling with needs like patients not having access to broadband and health care providers needing additional training.

The Missouri Telehealth Network has been providing collaborative, virtual training for primary health care providers using Show-Me Extension for Community Healthcare Outcomes since around 2015, but it found a new demand for training providers on topics specific to the pandemic. It now provides continuing education for health care providers on topics like COVID-19 in pregnant women, children with COVID-19 and COVID-19 in nursing homes. The training allows health care providers to treat their patients with specialized conditions, rather than have to refer them to a specialist.

Across the state line, the University of Kansas Center for Telemedicine and Telehealth provides clinics and health care providers with similar services, and hosted an event series focused on topics like implementing telehealth and sustaining telehealth beyond COVID-19.

How states are making telehealth available to patients after the pandemic

Many states, including Kansas and Missouri, have expanded telehealth at least temporarily during the pandemic. 

But in order for telehealth to continue to be an option for patients like the ones at HCC, permanent laws have to be enacted.

Back in March, Kansas Gov. Laura Kelly signed executive orders to allow physicians to prescribe medications without meeting face to face, let out-of-state physicians practice in the state without a Kansas license and permit temporary emergency licenses for health care professionals.

Missouri Gov. Mike Parson also waived requirements that advanced-practice registered nurses had to be within 75 miles of a collaborating physician, and he allowed physicians licensed out of state to provide care in Missouri.

But in both Kansas and Missouri, these measures are only temporary. Missouri’s executive orders are scheduled to terminate at the end of the COVID-19 emergency. And in Kansas, the executive orders will end 30 days after the state emergency. Both COVID-19 state emergencies are currently scheduled to end March 31 unless they are extended.

There aren’t currently any bills in Missouri to extend telehealth services. But in Kansas, a bill was introduced in the House in the Health and Human Services committee that would continue the expanded reimbursement and payment parity through Medicaid in the state. The bill is supported by the Kansas Hospital Association, the Association of Community Mental Health Centers of Kansas and the Behavioral Health Association of Kansas.

“The law and regulations changed more in two months than they had in the previous 20 years,” Mutrux said. “We saw that it was clear that one of the reasons telemedicine never took off as much as we predicted was because of the tight rules and regulations around it.” 

There is a lot of pressure in place for the state and federal government to keep the temporary regulations tied to the pandemic in place, Mutrux said, so that there aren’t regulatory barriers to telemedicine in the future.

Massachusetts is one state ensuring telehealth will be accessible for patients after the pandemic. Gov. Charlie Baker recently signed a bill into law that orders insurers to cover remote visits for behavioral health services at the same rate they would for an in-person visit. It also requires that payment rates stay the same between telehealth and in-person visits for primary care and chronic disease management for the next two years.

In January, New York Gov. Andrew Cuomo proposed legislation to make temporary reforms to telehealth during the pandemic more permanent. The plan included continuing to allow out-of-state licensed medical professions in the northeastern U.S. to practice telehealth in New York, allowing unlicensed staff like credentialed substance abuse counselors to deliver mental health services via telehealth, and requiring Medicaid to cover reimbursement for telehealth services.

Cuomo’s plan also would require commercial health insurers to offer their members telehealth and reimburse for it at rates competitive with in-person rates. 

Health care providers would also have to tell all patients online or in writing if they have telehealth options available. Insurers would have to offer members a virtual emergency platform to help refer patients to providers so they wouldn’t have to go to a clinic in person to receive care, making emergency care more accessible.

“It is time to push telehealth to the next level in New York State and fully integrate it into our existing healthcare system,” Cuomo said. “These proposals will better allocate our health care and technological resources for the 21st century.”

Mutrux said that although Missouri has good telehealth laws in place, it’s questionable whether health systems will continue telemedicine after the pandemic. She said that health systems that weren’t using telemedicine before may have trouble continuing the momentum and could naturally settle back into in-person visits.

“I think time will tell on that.”

This story has been supported by the Solutions Journalism Network, a nonprofit organization dedicated to rigorous and compelling reporting about responses to social problems.

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Brittany Callan covered health and environment at The Beacon, and was a Report for America corps member for 2020-2021. Funding for this reporting was provided in part by the Health Forward Foundation.