Digital Health funding continues to grow in 2016 after a record-setting 2015. The Top 3 categories in 2015, according to an article by Rock Health, were Consumer Tools for purchasing of healthcare products and services (e.g., ZocDoc), Wearables and Bio sensing (e.g., Jawbone), and Personal Health Tools & Tracking (e.g., 23andMe). The common feature among these top categories is that they are targeted to the healthier, wealthier, and more literate segments of the population. It makes sense from a purely economic perspective – target the easier-to-engage segments that have a higher propensity to pay.
But, what about from the public health perspective – will these investments in digital health help bend the cost curve and improve health outcomes for the population as a whole? I doubt it. Twenty-Five percent of the US population lives in rural areas where the social-economic conditions of the population create a huge demand for healthcare, and at the same time a unique challenge for delivery of healthcare.
What is different about rural health?
Rural hospitals provide essential health care services to nearly 51 million people or about 25% of the U.S. population.
Compared with urban populations, rural residents generally have higher poverty rates, a larger elderly population, tend to be in poorer health, and have higher uninsured rates than urban areas. At the same time, rural areas often have fewer physician practices, hospitals, and other health delivery resources. These socioeconomic and health care challenges place rural populations at a disadvantage for receiving safe, timely, effective, equitable, and patient-centered care. Statistics show that the prevalence of multiple chronic conditions (MCC) is higher among the rural population. Here are some statistics from the National Rural Health Association:
|A National Rural Health Snapshot||Rural||Urban|
|Percentage of USA Population**||nearly 25%||75% +|
|Percentage of USA Physicians**||10%||90%|
|Num. of Specialists per 100,000 population**||40.1||134.1|
|Population aged 65 and older||18%||15%|
|Population below the poverty level||14%||11%|
|Average per capita income||$19K||$26K|
|Population who are non-Hispanic Whites||83%||69%|
|Adults who describe health status as fair/poor||28%||21%|
|Adolescents (Aged 12-17) who smoke||19%||11%|
|Male death rate per 100,000 (Ages 1-24)||80||60|
|Female death rate per 100,000 (Ages 1-24)||40||30|
|Population covered by private insurance||64%||69%|
|Population who are Medicare beneficiaries||23%||20%|
|Medicare beneficiaries without drug coverage||45%||31%|
|Medicare spends per capita compared to USA average||85%||106%|
|Medicare hospital payment-to-cost ratio||90%||100%|
|Percentage of poor covered by Medicaid||45%||49%|
• Economic – On average, per capita income is $7,417 lower than in urban areas, and rural Americans are more likely to live below the poverty level. The disparity in incomes is even greater for minorities living in rural areas. Nearly 24% of rural children live in poverty.
• Access – Only about 10% of physicians practice in rural America despite the fact that nearly 25% of the population lives in these areas. Rural residents are less likely to have employer-provided health care coverage. Rural residents have greater transportation difficulties reaching health care providers, often travelling great distances to reach a doctor or hospital.
• Literacy – Rural residents are at risk for low health literacy because they have lower educational levels as compared to residents of metropolitan areas. Low health literacy is a particular problem for people in poverty and people with limited education or English proficiency. Low health literacy is associated with a lower likelihood of using preventive health services, a greater likelihood of taking medicines incorrectly, and poor health status.
• Social – Abuse of alcohol and use of smokeless tobacco is a significant problem among rural youth. The suicide rate among rural men is significantly higher than in urban areas, particularly among adult men and children. In rural areas there is little anonymity, and social stigma and privacy concerns are more likely to act as barriers to healthcare access. Residents may be concerned about seeking care for issues related to mental health, substance abuse, sexual health, pregnancy, or even common chronic illnesses due to unease or privacy concerns.
• Ethnicity – Several Migratory and seasonal agricultural workers (MSAWs) establish a temporary home in rural areas for the purpose of employment. These worker groups are predominantly Hispanic/Latino and they and their families face unique health challenges due to their hazardous work environment, poverty, inadequate healthcare access, and cultural and language barriers.
These factors conspire to impede the rural population in their struggle to lead a normal, healthy life.
Rural healthcare organizations disproportionately rely on government payments (Medicare and Medicaid) because of their characteristics – lower income, elderly population. Several government and private organizations are working to improve healthcare access for rural communities. Some of these include the National Rural Health Association (NRHA), National Association of Rural Health Clinics (NARHC), and the Federal Office of Rural Health Policy (FORHP).
How can digital health help rural health?
Despite the factors mentioned above that impede the rural population in their struggle to lead a healthy life, there is hope that the emerging digital health solutions will overcome these impediments.
Several digital health solutions are available today that Providers could use to more effectively engage patients for a range of purposes: chronic disease management, preventive care, and wellness. These solutions vary based on what they deliver (information, reminders, medical advice, social services), how they deliver (with/without devices; with/without live human interaction), and through what mode of communication (Text, Email, Phone, Kiosks, Video) they deliver.
However, very few solutions, it seems, understand the unique challenges for delivery of healthcare in a rural setting – specifically, the poverty, literacy, access, and social issues. Most solutions are not low-cost, low-tech, or customized to address the unique social-economic characteristics of the rural population. Here are a few statistics:
• Cellphone Ownership: The Pew Research also showed that cellphone ownership is common across all major demographic groups, though older adults tend to lag behind their younger counterparts. Rural residents are slightly less likely than urban and suburban residents to have cellphones. Still, nearly nine-in-ten rural residents (87%) have them, making text a very practical mode for engaging the rural population.
•Hispanic Population: Rural healthcare organizations need to be able to help the migrant farmworkers, who are primarily Hispanics, access healthcare. Most of this population does not have access to Broadband nor do they own smartphones. In addition, most of them can only be engaged through culturally or linguistically appropriate solutions.
What is needed?
Statistics reveal that the digital divide is a real issue for the delivery of digital health solutions to the rural population – 39% of the rural population does not have broadband access; 48% do not own smartphones. In addition, a large percentage of this population has cultural and linguistic barriers to engagement. Digital health solutions targeted to the rural population need to take these issues in consideration in their design.
The ideal digital health solution for rural healthcare should work with cellphones (text messaging) in addition to the other modes of communication. Statistics show that 90% of text messages are read within 90 seconds of receiving them – this makes text messaging ideal for not just reaching patients with the right message, but making sure that the message is read at the correct time. In addition, the ideal solution should be multi-lingual to be able to adapt to the cultural & linguistic uniqueness of the rural population. Finally, the ideal solution should be cost effective. These requirements make a text-messaging based, multi-lingual communication platform ideal for delivery of digital health solutions to the rural population.
Providers can use using text messaging to serve the rural population in several ways: for Appointment Reminders; Marketing new programs, Care Coordination; Patient Satisfaction; Treatment Plan check-in; and Self-Management Support. In 2015, Montefiore Medical Center conducted a trial to see if text messaging could increase medication adherence among high-cost Medicaid patients. The study found that text messaging increased patient appointment adherence by 40%, and patient medication adherence by 12%. In addition, the study showed that text messaging can also increase motivation, inspire confidence, and raise awareness in patients by making proactive health measures easy to undertake. Numerous other studies have shown that text messaging for healthcare is not only effective, but also cost efficient.
The adoption of cellphones among rural Providers has increased in recent years, according to a recent survey by the Center for Care innovations. However, only one-quarter of the participants in the survey reported using cell phones in care delivery, and most reported using it for appointment reminders only. The study concluded that many community health centers and clinics do not have the necessary resources and skills to adopt mobile health primarily due to funding constraints and lack of reimbursement to support mobile health.
What else is needed?
Besides digital health solutions that can overcome the digital divide, Rural healthcare organizations need financial assistance in the form of value-based reimbursement models and other funding.
Value-based Reimbursement Models
Understandably, VC funding is not necessarily driven by the noble goal of improving population health. However, CMS can align the incentives for the Providers (and by extension for the investors) by accelerating the shift to value-based reimbursement. Outcomes-based reimbursement will shift the Providers’ focus from fixing what’s broken to optimizing wellness. Policy changes are accelerating the shift towards value as indicated in a previous article. Early last year, HHS set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018.
Rural hospitals face factors, such as diseconomies of scale, which could hinder financial performance in comparison to urban and larger hospitals. For these reasons, federal law makers created special payment classifications under the Medicare program, recognizing that many rural hospitals are the only health facility in their community, and their survival is vital to ensure access to health care. One of these classifications was created under the Medicare Rural Hospital Flexibility Program: Critical Access Hospital (CAH). Unlike traditional hospitals that are paid under PPS, Medicare pays CAHs based on each hospital’s reported costs. Financial performance and condition improved after hospitals converted to CAH status, accompanied by a commensurate decrease in the closure rate of small rural hospitals.
However, a series of congressionally mandated Medicare cuts that have happened over the past few years have led to closure of several rural healthcare facilities – which has further exacerbated the negative impact on the access to care in the community. Rural health experts believe that rural hospital closures are likely to continue because many rural hospitals have such a tight operating budget with little room for financial losses. Until the time that rural hospitals transition to a more efficient model of healthcare delivery – one that relies more on digital health for population health management – federal grants should be made available to them to avoid closures. One such stop-gap legislation now in Congress is called the “Save Rural Hospitals” Act, which aims to stabilize the current environment while establishing a path forward.
Besides government funding, non-profit foundations like the Robert Wood Johnson Foundation and The Commonwealth Fund have funded research and pilots for expanding healthcare access and improving quality of care in rural communities.
I hope that rural healthcare organizations are able to survive and thrive by using effective digital health solutions to address the unique challenges for delivery of healthcare to their Patients. Because, effective population health is not possible without addressing 25% of the population.
I am the co-founder of a digital health startup called Patientriciti. Our company’s multi-modal, multi-lingual, patient engagement and care management platform allows Providers to engage with different segments of the population in a personalized way to affect sustained behavior change. We believe that our platform is ideally suited to serve the needs of the rural population – effectively and efficiently. We invite rural health organizations and funding agencies interested in using our platform to reach out to us at firstname.lastname@example.org.