Colorado health officials want to use “remote” health care services, known as telehealth, as a tool to try to slow the spread of the coronavirus. But despite recent regulatory changes intended to make it easier for patients to seek medical advice or treatment without leaving their home, many rural hospitals and clinics lack adequate funding, technology and providers to do so.

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Rural hospitals are especially vulnerable to the outbreak of COVID-19, the disease caused by the coronavirus, and could be some of the first facilities overrun as the outbreak continues to ripple across the state. These facilities are hoping to ramp up telemedicine services as a way to conserve limited supplies of personal protective gear and other equipment while also preventing providers and patients from being exposed to the coronavirus.

“We need to be doing more. And we need to be doing it a lot quicker than we are doing it right now,” said Chip Lyon, director of business development for Banner Health, a nonprofit health system that operates hospitals and clinics in Larimer and Weld counties.

“When you look at telehealth and who it was designed to help, it was those folks that reside in rural communities,” Lyon said. “And I think what this pandemic has done is really highlight the fact that we’ve got a lot of work to do.”

As a result of the COVID-19 coronavirus outbreak, patients are increasingly being asked to conduct telemedicine appointments — like at USCF Venioff Children’s Hospital in San Francisco pictured here on March 18, 2020 — to avoid infecting healthcare workers. (Photo by Smith Collection/Gado/Sipa USA)(Sipa via AP Images)

The practice allows physicians or nurse practitioners to call or video chat patients to do simple exams and provide guidance on self treatment. Telehealth is already well established in highly populated areas, and health officials have said it will be a critical tool for triaging resources and allowing providers to monitor a greater number of patients.

But rural hospitals say they haven’t been able to fully deploy the practice because, prior to the coronavirus outbreak, telehealth services were limited for Medicaid and Medicare patients.

On Wednesday, Colorado expanded telehealth services for the state’s 1.2 million patients on the state’s public health insurance program for low-income individuals. The expansion allows Federally Qualified Health Centers, Rural Health Clinics and Indian Health Services to bill for telemedicine visits.

“In addition, we realize many rural communities cannot support the broadband requirement for telehealth video visit[s], and we are therefore allowing telephonic visits for nearly all provider types during this crisis,” said Marc Williams, a spokesperson for Colorado’s Department of Health Care Policy and Financing, in an email.

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The expansion for telehealth also adds physical therapy, occupational therapy and home health, hospice and pediatric behavioral therapy to the list of telehealth services, and provides guidance on how to bill for reimbursement.

“So the announcement that came out today allows for those virtual services to happen in rural health clinics and federally qualified health centers for the Medicaid population, which is really great,” said Michelle Mills, CEO of the Colorado Rural Health Center, the state’s nonprofit Office of Rural Health.“But what we also need is the federal legislation to allow that to happen for the Medicare population as well,” she said. “So it’s one step among many.”

Earlier in the week, the federal Centers for Medicare and Medicaid Services announced it was broadening access to telehealth services for Medicare, the federal health insurance program for individuals over 65. But it still doesn’t cover Medicare patients who go to federally certified rural health clinics, according to Mills, which would need to be changed by Congress. Colorado has 49 such clinics providing primary and preventative health services to an estimated 130,000 people annually, according to a 2019 report on rural health.

Expanded telehealth services could conserve limited medical supplies, keep providers healthy

Now that the regulations have been temporarily lifted, Colorado’s rural hospitals are scrambling to figure out if they can get the systems in place to help slow the coronavirus spread.

“When you look at critical-access facilities and the limitations that they have from a budgeting perspective, a lot of these facilities can’t afford that technology number one, and number two, not a lot of these facilities have the providers to be able to deliver those services, especially with the demand that we’re seeing with COVID-19,” Lyon said.

He says Colorado has been on the forefront for telehealth reimbursement, and the current focus is helping get the tools out to rural areas.

Colorado Gov. Jared Polis gives an update about the extent of the coronavirus in Colorado during a press conference on March 12, 2020. (Moe Clark, The Colorado Sun)

“Things are evolving on a day-to-day basis. Unfortunately, it takes a pandemic for us to move the needle as it relates to reimbursement and telehealth, and how to leverage it most effectively. So we’re getting there, but we’re not quite there yet,” Lyons said.

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During this public emergency, Mills said she’s concerned about having enough personal protective equipment, such as face masks, and keeping their limited rural health care providers healthy.

“We don’t have enough workforce on a good day. A lot of our rural clinics have two, three, four providers, so if one gets sick, that’s a big deal,” said Mills, whose organization focuses on providing access to health care in Colorado’s 47 rural counties.

“And if all of them get sick that’s catastrophic,” she said. “…It can take upwards of 18 months to recruit a physician.”

If more patients sought medical guidance through remote services, Mills said it could decrease exposure for providers as well as for people who have chronic illnesses and need medical attention. Fewer patients coming into hospitals will also save medical supplies, hospital space and protective gear that would otherwise need to be used for patients coming in for illnesses unrelated to COVID-19.

Colorado has 32 critical-access hospitals that are licensed to have 25 beds or less. To qualify as a critical-access hospital, the small clinics must be 35 miles from the next closest hospital — or 15 miles of mountainous terrain away.

A screenshot from a 2019 report on rural health, conducted by the Colorado Rural Health Center.

“Some are setting up tents outside to triage,” said Mills, adding that critical-access hospitals are funded primarily by Medicare and Medicaid because that’s the largest part of the population they serve. “People in rural communities –– not always, but often –– tend to be older, sicker and poorer.”

Mills said many rural hospitals don’t have the financial flexibility to expand telehealth services, despite the obvious benefits. “We’ve got 18 rural hospitals operating in the red … the coronavirus is definitely gonna make it worse. Hopefully this doesn’t go on for a very long time.”

Melissa Bosworth, executive director of the Eastern Plains Healthcare Consortium, said her hospitals haven’t started using telehealth services, but they are exploring whether they have the capacity.

The benefit of telehealth services would be to allow individuals with chronic illnesses to manage their conditions without having to go into a healthcare facility and risk exposure to COVID-19, said Bosworth, who represents nine critical-access hospitals and one health system on Colorado’s Eastern Plains.

She said her organization recently received a grant from The Colorado Health Foundation to work on behavioral telehealth services, but they are still in the early phases. “We don’t have fancy systems like a lot of other urban systems do for telemedicine or telehealth,” Bosworth said.

She said the coronavirus pandemic is going to stretch the Eastern Plains health care system to its limits and leave lasting economic scars.

“The Eastern Plains are considered where a lot of agriculture happens. And a lot of the ranchers and farmers are older and more susceptible,” Bosworth said.

“So if this does go widescale, it’s going to have long-term implications on our Colorado economy as a whole. We think about the ski resorts and other kinds of industries, but we don’t pay attention to agriculture as much,” she said.

Bosworth is conducting a survey to see how their member clinics, such as Melissa Memorial in Holyoke and Sedgwick County Health Center in Julesburg, are preparing for the coronavirus outbreak and where the supply needs are.

“Just like the urban areas, we’re seeing a lack of masks and a lack of testing kits,” said Bosworth. “One interesting differentiator with the testing kits is some of our hospitals have the tests themselves, they don’t have the medium that’s needed to to run the test.”

Dr. Chris Davis, Medical Director of Virtual Health, works on a patients file in Virtual Surveillance at UCHealth administrative offices on September 25, 2019 in Aurora (Seth McConnell, Special to the Colorado Sun)

To try to slow the spread of the coronavirus, Bosworth said the member hospitals now are screening their employees before and after every shift, as well as all incoming patients. They’ve also postponed elective and non-critical procedures at their hospitals –– a necessary move that adds additional financial strain.

“Most of our hospitals are operating on either negative margins or a flat margin. So having to take out just regular business because of this is pretty scary,” Bosworth said. Many of the consortium hospitals serve as the only primary care providers and nursing home operators in their regions, she said.

But for some rural hospitals, telehealth is still not financially feasible

“You know, we’re doing everything we can to stay alive as a rural health care center,” said Debbie Channel, public relations director for the Spanish Peaks Regional Health Center in Walsenburg. “We’re always exploring ways that we can best serve our patients throughout the entire county.”

She said her critical-access hospital –– which includes four clinics, a 120-bed Veterans Living Center and an extended-care rehabilitation facility –– is exploring ways to use telehealth during the coronavirus outbreak. But Channel said she’s unsure if Spanish Peaks can get systems up and running in time to make a difference.

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“We have to crawl before we run. When we do things we have to make sure they are right, because we can’t afford to get it wrong,” Channel said.

“Telehealth could definitely be an advantage, but the steps taken to make that happen are up in the air for us right now. It really depends on how quickly the funding and the different rules are established. We’re just moving day by day,” she said. “…But right now, we just can’t afford to do it.”

Spanish Peaks Regional Health Center is screening new patients, visitors and employees for coronavirus symptoms. But they are still allowing family members to visit the hospital. Channel said that the hospital is exploring what needs to be done to set up alternative screening sites, but apart from that, operations haven’t changed much.

A ribbon of two-lane road winds through the prairie in Larimer County, Colorado. (Ed Kosmicki, Special to The Colorado Sun)

“People still need to have their health care taken care of. They still have emergency needs. So all of that is continuing to be business as usual,” Channel said. “Looking down the road, we are looking at what we are going to have to do if this thing blows up. Right now, thank goodness, knock on wood, we don’t have any cases of COVID-19 in Huerfano County.”

“Huerfano County is the oldest county per capita, with an average age of 55 or 56,” Channel said. “So that really puts us in a high risk situation. Also our nursing home.”

She said she’s unsure if telehealth would be rolled out right away.

“We’re implementing things as quickly as we’re asked to, and then we’re trying to go just a little bit above and beyond so that we are prepared and ready,” Channel said. “So we are in a proactive position instead of a reactive position.”

Cara Welch, communications director for the Colorado Hospital Association, said that prior to the coronavirus, some rural hospitals partnered with larger health systems on telehealth programs, for things like monitoring patients who suffered from a stroke.

“So hopefully, as we start to find our way around the payment and the regulatory issues with telehealth for this outbreak, they’ll hopefully be able to deploy it in more places,” Welch said.

“Many of them do have telehealth equipment already… The good news is that now that we’re in this state of emergency, a lot of the regulatory and or even payment issues are being resolved quickly. Much quicker than usual because of the state that we’re in.”



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