One doesn't have to look too hard to find long-standing obstacles to providing rural health care: too few primary care physicians in sparsely resourced areas and limited support for specialty care referrals. And even as new technologies are enabling greater access for patients and enhanced training to improve care coordination, old education and payment standards persist.
Curtis Lowery, M.D., (left) medical director of the ANGELS program at the University of Arkansas for Medical Sciences, and Sanjeev Arora, M.D., executive director of New Mexico-based Project ECHO, explain how technology is being used to care for more patients in rural areas.
Speaking during a Dec. 8 Brookings Institution panel discussion(www.brookings.edu) that focused on ways to improve rural health care access, two advocates for technology in medicine recently called for changes that would reward physicians and health centers that adopt a coordinated care approach.
In 2003 in New Mexico, gastroenterologist Sanjeev Arora, M.D., was treating patients with hepatitis C virus infection -- many of whom faced an eight-month waiting period to see him. Moreover, some had to drive as much as 250 miles each way for their appointments. Patients were dying of liver cancer and other ailments because they could not obtain timely care.
"I knew if we had treated them earlier, we could have cured them," he said.
Ultimately, Arora realized that the best way to manage patients with complex chronic conditions was not simply for the subspecialty physician to see patients around the clock. Rather, an entire network of health care professionals could be trained to provide needed care. The idea of spreading that knowledge gave birth to Project ECHO (Extension for Community Healthcare Outcomes), where Arora serves as executive director.
- According to panelists at a recent Washington briefing, a program in New Mexico is using technology to train health professionals in chronic care management.
- A telemedicine network in Arkansas allows physicians to treat many patients who live in rural areas without ready access to a physician.
- Despite increasing use of technology in medicine, payment models for such care remain outdated.
ECHO is a mentoring network that seeks to teach primary care physicians and other health care professionals how to care for specific chronic conditions. To make this "telementoring" system work, subspecialty physicians provide guided instruction to primary care physicians, nurse practitioners and physician assistants.
"We know that chronic disease management is a team sport," Arora said. "You become a mentor as opposed to a doer."
Such interactive training sessions are a necessity in a changing medical environment, according to Arora, who said he thinks the traditional graduate medical education (GME) curriculum is no longer effective.
"The system of GME where we educate residents and fellows and just send them out there isn't going to work in a knowledge-based workforce," Arora said. "Academic medicine needs to take responsibility for training the entire health care workforce for their entire career."
Arora said funding for such career training efforts should be considered an infrastructure investment similar to the U.S. National Library of Medicine, a publicly funded institution.
Perinatal Care Via Telemedicine
In rural states such as Arkansas, some residents must drive for hours to meet with a physician. Forty-four percent of the state's population resides in rural areas, and the number of obstetricians, in particular, is inadequate to meet population needs. Curtis Lowery Jr., M.D., medical director of the University of Arkansas for Medical Sciences ANGELS (Antenatal and Neonatal Guidelines, Education and Learning System) program, outlined how telemedicine has helped to close the gap in regions without enough physicians to provide care for women with high-risk pregnancies.
"It's very difficult to get physicians to go to the (Mississippi) Delta," said Lowery, who is also chair of the university's department of obstetrics and gynecology. "They feel alone, like they are on an island with no support. So we use technology to support them."
When the ANGELS program started in 2003, there were only three maternal/fetal specialists in a state that saw 45,000 deliveries each year. Initially, a few telemedicine hubs were set up around the state with local government support. Thanks to an infusion of $102 million in federal funding, however, the program soon expanded to cover the entire state.
Instead of expecting rural patients to meet physicians in urban areas, telemedicine enables physicians to connect with those patients by teleconference. A 24-hour call center is available for patients and physicians to coordinate care. And telemedicine efforts that originally focused on management of high-risk pregnancies have expanded to include care protocols for patients with stroke or sickle cell anemia, as well as those in need of surgical consultations.
Much as the influx of patients newly insured under the Patient Protection and Affordable Care Act has initially added to overall health care system expenditures, wider adoption of telemedicine will also likely lead to increased costs in the short term as more patients are seen via this method. But, Lowery predicted, the system will ultimately save costs on travel and the long-term care that becomes necessary when appropriate preventive and management services are unavailable.
Still, for telemedicine to achieve its full potential, Lowery said changes that permit payment for telemedicine consultations are needed.
"The biggest problem with the adoption of telemedicine is the payment," he said. "We need to change the way we pay and need to be able to pay for new systems. In my career, I've done thousands of telephone consultations, but I've never been paid for one."
Effecting this change is particularly difficult, Arora chimed in, when one considers the fact that elderly patients -- those in their 80s and 90s -- consume 10 times more health care than an individual in his 60s. And it's certainly conceivable that these older people would be using telemedicine services frequently.
"The payers are terrified," Lowery said. "When a lot more care is given, a lot more money is spent in fee-for-service. That's where we are in telemedicine."
Related AAFP News Coverage
Project ECHO Trains, Empowers New Mexico FPs to Provide Subspecialty Care