Telehealth and other remote monitoring tools once promised to ease the nation's biggest rural health challenges and care access barriers.
After all, a lot of what gets in the way of healthcare visits is geography. According to a study from Texas A&M Health, travel distances are becoming more pervasive, with more people from rural areas having to travel 30 minutes to get to a medical appointment than ever before. When the travel distance is too far, patients will often go without care.
Telehealth and other connected health solutions promised to fix that problem by letting patients and providers meet virtually. There's no 30-minute drive when patients can log onto their appointments on their computers, tablets or smartphones.
Indeed, this kind of technology has, frankly, been a boon for rural healthcare, according to Jen Brull, M.D., the newest president of the American Academy of Family Physicians (AAFP) with 20 years of experience practicing medicine in rural Kansas.
When the pandemic struck, it spurred widespread telehealth adoption that has changed the practice of rural medicine even as COVID-19 became endemic, she explained during an interview.
"I often use telehealth with my patients who can't get to my office for distance reasons, or maybe it's because they are an over-the-road truck driver and need to be on the road that day," Brull said.
"Maybe it's because they work in a town 30 minutes away. They can take their 15-minute break to do their doctor's visit on telehealth, but they can't take a couple of hours to drive to my office, wait in my office, be seen and drive back. And so, telehealth is an example of a successful technology that has been helpful in the rural space."
But now that digital innovations, especially telehealth, have reached widespread adoption, rural health providers still face key issues in reaching their patients and ensuring access to care.
If you don't have a primary care physician or if your primary care physician's schedule is full and they can't get you in, it doesn't matter whether you're trying to go into the office or get a telehealth visit.
Jen Brull, M.D.President, American Academy of Family Physicians
"Did telehealth solve everything? No, because you cannot reach out, touch a patient, examine a patient, do testing on a patient," Brull said. "It is not a broad solution, but it is a piece of the solution."
But it's not just a question of telehealth replacing in-person care and exams; the technology is not even reaching every patient in rural areas, Brull pointed out.
Even in light of wide telehealth adoption, people living in rural areas still face greater barriers to either in-person or virtual care than their urban counterparts. According to a 2023 assessment from the Commonwealth Fund, the U.S. is home to the steepest geographic health disparities in the developed world, with the nation leading the world in care access disparities between rural and urban people.
In another report from the AARP Public Policy Institute, researchers wrote that there's still a geographic digital divide. People in rural areas face barriers to accessing telehealth for a host of reasons, including social determinants of health (SDOH) and regional workforce shortages.
Brull said telehealth has been a tool, but not a panacea. While the technology has fueled some improvements in patient care access, rural health providers and the patients they treat are still bogged down by the perennial issues that have always affected rural medicine: too few providers and an overburden of SDOH.
As of September 2024, there were more than 5,000 health professional shortage areas (HPSAs) in rural areas, according to the Health Resources and Services Administration (HRSA). That adds up to 66% of rural areas being an HPSA.
That's a big patient care access problem, even in the age of widespread telehealth adoption.
"When we talk specifically about telehealth and access, the barriers look a lot like the barriers that patients have in general around access, including a lack of visits and not enough primary care doctors in the United States to take care of people," Brull explained. "If you don't have a primary care physician or if your primary care physician's schedule is full and they can't get you in, it doesn't matter whether you're trying to go into the office or get a telehealth visit."
Telehealth isn't completely ineffective at addressing rural healthcare's workforce challenges, Brull pointed out. There are some offices that use the streamlined efficiency of a telehealth visit to their advantage.
Even still, the U.S. needs to address the forces driving the provider shortages that directly affect rural regions.
"The AAFP's role in this is to ensure that there's a family doctor for every person in the United States," Brull asserted. "Until we solve that, any barrier and every challenge you put in the way makes it that much harder to access great primary care."
Getting to the root cause of rural provider shortages
The rural provider shortage conversation isn't all bad news, Brull noted.
"The good news is more people matched into family medicine residencies this year than ever before," she said. "So, despite the challenges, more people are selecting choosing to become family physicians. That's super exciting."
"The challenge we're facing is that there is a very significant generation who are of retirement age, and so the number of physicians retiring each year outweighs the thousands of new family physicians who enter our workforce each year," she added.
AAFP's goal is to make family medicine a more attractive specialty to enter and, importantly, stay in it.
This means ensuring reimbursement and salaries are such that medical students can pay off their loans should they choose to pursue family medicine. Reimaging provider workloads to reduce clinician burden and, ideally, burnout is also paramount, Brull said.
Enabling providers and patients to use telehealth
Even as rural health providers zero in on workforce issues, there's another key barrier to telehealth use around the corner. Simply put, the healthcare landscape is not always amenable to virtual visits, affecting both the patient and provider.
For the patient, key SDOH, such as broadband and technology access, keep telehealth visits out of reach.
"Not everybody has a smartphone or a tablet," Brull pointed out. "If you don't have one of those devices, if you are unhoused and don't have access to Wi-Fi or electricity, again, you may have a transportation barrier to get to your primary care physician, but you may also have a technology barrier because you don't have a device that they can see you with."
Some healthcare organizations are addressing this issue by advocating on the policy level, using their status as anchor institutions and major job creators and calling for better broadband in all areas.
But even on the provider side, healthcare policy is unpredictable at best. The payment question is always top-of-mind for healthcare providers who lean on telehealth to connect to their patients.
"There is a lot of ongoing conversation about the value of those visits and whether they should continue to be paid at the same rate for family medicine," Brull noted. "The cognitive work is the same, and I am still paying for my brick-and-mortar building, and my nurse still gets on the phone with you, so our cost to provide a telehealth visit is not less. It might be more because of the technology and platform that we have to purchase to do so."
With telehealth reimbursement in a state of flux, it is hard to imagine how the technology can meaningfully change the landscape of rural patient care access.
"There's this ongoing conversation about what will get codified permanently into what CMS and, therefore, other payers pay," she concluded. "Right now, we're still watching that every year."
Sara Heath has covered news related to patient engagement and health equity since 2015.
