The Slow Growth of Telemedicine

One of the most hoped-for benefits of rural broadband has been the use of telemedicine to conduct routine doctor visits via a broadband connection rather than requiring rural patients to drive to cities for a doctor’s visit. However, the use of telemedicine hasn’t grown as fast as once predicted.

A recent study was published in JAMA, the Journal of the American Medical Association that looked at telemedicine use from 2005 through 2017. The study gathered records of telemedicine claims that were reimbursed through insurance. In 2005 there were only 206 telemedicine claims. By 2017 that had grown to 202,000 – but that is still only a tiny fraction of total medical visits. When looked at statistically it’s an annual growth rate of over 50% annually, but the overall number of visits are still a tiny blip in the industry.

The analysis showed that 53% of telemedicine visits were for mental health treatment, followed by 39% of telemedicine visits with a primary care physician. The average age of a telemedicine patient was 38. As expected, 83% live n rural areas, although telemedicine is also valuable for patients in cities with limited mobility.

The use of telemedicine has been bolstered by having 32 states pass laws that require insurance companies to treat telemedicine visits on parity with in-person visits. This provides the ability for Health Delivery Organizations (HDOs) like hospitals and clinics to treat patients remotely if the choose to do so.

I don’t want to sound negative because there is also good news in the study statistics. Most of the growth in telemedicine visits have occurred in just the last few years. A recent study was done by Vidyo, a company that provides the telemedicine equipment for hospitals and clinics. Vidyo surveyed 300 HDO organizations and asked about their telemedicine plans. Vidyo reported the following:

  • 75% of HDOs are now using or planning to soon use telemedicine.
  • Of the HDOs already using telemedicine, 47% report a savings for the medical practice; 51% report improved efficiency for the HDO; 58% report that doctors are satisfied with the results from telemedicine; 67% say that telemedicine is easy for staff to use, and 67% say that patients are receptive to telemedicine.
  • HBOs report the primary benefits of telemedicine as: patients get to ask questions which stops little problems into becoming big ones; telemedicine lets patients build a bond with a doctor; cellular video provides the ability for patients to get access to healthcare from anywhere; and video connections allows for collaboration among multiple doctors for complex health issues.
  • One of the holdups of telemedicine deployment has been the need for HDOs to invest in new technology. There are a number of practices waiting to see more proof of the benefits of telemedicine before implementing.

I’m sure that one of the hold-ups for more deployment of telemedicine is that that a lot of rural places don’t yet have the broadband to support it. Telemedicine requires a 2-way video conference, like Skype. It also often requires a good broadband connection for ongoing 24/7 monitoring of devices for outpatients from surgery or other procedures. Homes without a good broadband connection cannot participate in telemedicine. There are rural health clinics that initiate telemedicine visits from their site to specialists in nearby cities – but this still requires the patient to travel.

It looks like telemedicine is poised for rapid growth. This has taken longer to get going than what I would have guessed when looking at the discussion of telemedicine a decade ago. But like many industries it’s taken a while for the technology to get perfected and for doctors to trust using it. Now that many HDOs are starting to  use telemedicine it looks like we are finally poised for gigantic growth of the practice.

Quantifying the Benefits of Broadband

Economic development staff in almost every community I’ve ever worked with want to be able to quantify the benefits of broadband. It’s not hard to list the many benefits such as providing the ability for rural students to do homework, or the ability to start a home-based business after getting broadband. However, there has never been any way to put a dollar value to the community for these benefits.

Three economists from Purdue University have tackled the problem and took a stab at quantifying the benefits of bringing broadband to all of the areas served by Rural Electric Member Cooperatives (REMCs) in the state of Indiana. The work was done by looking in detail at the public benefits that would be generated at the Tipmont Cooperative and then extrapolating those results to the six other REMCs in the state.

The results are eye-catching and the study calculates a net present value of $24,293 to every cooperative household. I think most people’s first reaction is that amount seem too large, but when you look at the assumptions behind each component of that number, each assumption seems to be conservative.

Here are a few of the benefits measured by the study:

Medical. The study relied on recent studies that quantified the benefits of telemedicine. Several studies have shown that there is a significant decrease in Medicare costs once a region begins using telemedicine. The biggest savings comes from significantly reduced hospital stays and emergency room costs that come as a result of using telemedicine for preventive medicine – by checking up on patients regularly, resulting in small problems not escalating to severe ones.

Education. Numerous recent studies have shown that students without access to broadband don’t perform as well as students with broadband. Adults also benefit from online education through the ability to pursue college degrees online or to get training for new careers. It’s challenging to quantify the benefit of more education at the macro level, but it’s really easy to understand at the microlevel. We know that those who complete high school degree earn more over a lifetime than those who don’t. There have been numerous studies that quantify the increased lifetime earnings from various levels of post-high school education.

Economic Development. Recent studies have shown that there is a direct positive correlation between broadband adoption and economic development. The old economic model of communities thriving by attracting large employers is crumbling as the US continues to lose factories and factory jobs. But broadband helps existing businesses do better and can help keep an existing business to flee a market due to lack of broadband.

At the local level, better home broadband allows people to work at home, many of them finding higher-paying jobs than are available in the local economy. Good broadband also let’s some households bolster full-time earnings by engaging in ecommerce such as opening Etsy web stores. Numerous studies over the years have shown that anything that increases local wages benefits the local community with a multiplier effect as those extra earnings are spent on local goods and services.

Shopping. If you read my blog from last Monday, I discussed surveys we’ve done at CCG that listed the ability to shop online as one of the things most wanted in areas that have no broadband.

A recent Price Waterhouse Cooper study in England calculated the advantages of online shopping at US $754 per household annually – a combination of being able to buy goods at lower prices and the savings from not having to drive to buy things. That number has to be conservative when compared to rural areas in the US where households have longer drive times to reach retail shopping.

Farming Benefits. Much of the area covered by the study are agricultural and several studies have shown that good broadband can bolster farm incomes by as much as 6% annually – a number that is bound to increase as the benefits or smart-farming and outdoor IoT sensors improve crops and herd management.

Why the Study is Conservative. There are some obvious economic benefits that aren’t even included in the study. For example, there are several studies that show that lack of broadband depresses housing value. Anecdotally, I’ve been told in the last few years by rural real estate agents that they are starting to have trouble selling houses with no broadband – and it’s hard to put a value on the inability to sell a house.

The study pulls together studies done by others paint an overall picture of broadband benefits. looking at specific benefits of broadband – anybody that wants to understand this more should read the links to other studies. They step that made this study relevant to me was layering these impacts onto the specific area served by the Tipton Cooperative. One only has to travel to rural America these days to be able to see the differences between areas with and without broadband. Areas without broadband are unable to take part in things the rest of us take for granted like online shopping, easy access to do homework or pursue advanced degrees and the ability work from home and start new businesses. This is the first study I’ve seen that has tried to quantify all of these benefits for rural America, and the results are startling.

Broadband and Rural Population

Rural counties in total in the US gained 33,000 people in 2017, the first overall increase in rural population since 2011. But the gains came entirely to rural counties adjacent to metropolitan areas and highlights that remote rural counties continue a long-term trend of losing population. Nationwide, counties not next to metropolitan areas lost 24,000 people in 2017.

Further, within that global number, there is a different by the primary economic drivers in each county. Farming counties lost the most population, rural counties with manufacturing only lost a little population, and counties that rely on recreation and tourism gained population, attributed mostly to in-migration of retirees.

The loss of population is one of the primary reasons that rural counties are looking for better broadband. Rural counties don’t have to peer to far into the future to see a bleak picture. Their counties are often rapidly aging as young people move away to find employment. They are already seeing houses abandoned and foresee a shrinking property tax base. Farm counties continue to see the consolidation of farms and the loss of the family farmer.

Rural counties have different goals from broadband than more urban areas. They foremost hope that better broadband can mean more jobs and more employment. Many rural counties are not naïve enough any more to think they are going to attract factories or other businesses to their county. Some get lucky occasionally, but the country as a whole has lost an astonishing 60,000 factories since 2001. And even when new factories arise, they are largely automated and support far fewer jobs than factories in the past.

Rural counties care more about finding ways for residents to supplement incomes, and better broadband brings the chance to work from home. I was working with a rural county in Minnesota last year where I noticed that almost every farm in the county was operating a non-farming business along with farming as a way to supplement income – and this was in a county where the farms had practically no broadband at all and many homes relies on their cellular data for extremely expensive broadband connections. These counties want broadband so that the people living there can make enough money to stay.

Rural counties also need broadband for education. I rarely visit a rural county where there are not a few places in the county where rural residents drive their kids a few night each week to use WiFi in order to do their homework. It’s disheartening to see a parking lot full of cars at a library after it’s closed sitting and doing homework on the slow WiFi leaking out through the library walls.

Earlier I mentioned counties that rely on recreation for their economy. These counties desperately want broadband because they are finding that urban tourists don’t want to visit places that don’t have good internet connectivity and cellphone coverage. And businesses in these counties who rely on tourism have a hard time making it without broadband. Something as simple as offering on-line reservations requires a decent broadband connection, and lack of broadband puts counties at a disadvantage compared to similar areas with broadband.

Finally, rural counties want broadband to help keep the elderly in their homes longer. As hard as it is to be elderly in an urban area it’s much harder in a rural area where something as simple as seeing a doctor can mean a long trip. Rural areas also have a hard time attracting doctors and as rural clinics and hospitals continue to close it will become even harder to get basic healthcare. So rural counties are relying more and more on telemedicine and providers like the Mayo Clinic are embracing the technology to help rural America – but telemedicine require decent broadband including good upload speeds.

The skeptics of any government push to improve broadband often use the excuse that people just want broadband to watch TV, and that broadband is just for entertainment. And when people get broadband they take advantage of the wonderful world of entertainment now available on the Internet. But I can’t recall ever having seen entertainment on the list of reasons why rural counties want better broadband – they want it so that their counties survive as viable communities.

Telemedicine Needs Big Bandwidth

Medical_Software_Logo,_by_Harry_GouvasThe Federal Government is a big believer in telemedicine and there are several branches of the government that have been vigorously pursuing it as a way to better treat patients. Some of these initiatives include:

  • The Department of Veterans Affairs kicked off their telehealth program in 2011 named Special Care Access Network – Extension for Community Healthcare Outcomes (SCAN-ECHO). This program is aimed at providing care to veterans without requiring them to travel to a VA hospital. In some parts of the country VA hospitals are widely scattered and the VA knows that a lot of doctor visits are routine and can be handed adequately through telemedicine links.
  • The Department of Defense started working on a telemedicine program almost two decades ago for use on the battlefield. Their telemedicine links allow specialists to weigh in on battlefield injuries along with field medics, and they had great results in Iraq and Afghanistan. The DoD has named their system ECHO and has recently licensed it to Kaiser Permanente. The hospital chain sees use of the technology to field triage accident victims and to use for their patients who can’t make it to a hospital.
  • The Air Force has been working on a focused telemedicine program for the last four years. Instead of working on remotely treating patients, which is being pioneered by others, they have been focused on four specific areas within teleimaging: teleradiology, telecardiology, tele-endoscopy and telepathology. In a nutshell they are working with field devices that can create the diagnostic images that telemedicine doctors need to better treat field injuries. This would provide more detailed diagnostics for accident victims and remote patients who can’t easily get to a hospital.

Telemedicine is a priority for the Veterans Administration which reports that they are today treating 380,000 vets who live in rural areas. They have nearly 11,000 veteran patients now using the VA’s tele-audiology system, but they would like to greatly expand their telemedicine capabilities.

What all of these programs have come to realize is that the broadband in rural America is not adequate for what they are trying to do. One thing every one of the above efforts needs is big broadband capacity to connect to patients through video links or to transmit gigantic imaging files.

The military is used to having big broadband on the battlefield. We tend to think of satellite data links as small bandwidth and slow connections, but satellites can download significant bandwidth pipes with the right receivers and at the right price. I would assume (but don’t know) that the military has their own data satellites in orbit to provide bandwidth on the battlefield.

So these agencies are adding their voice to the cry for better rural broadband, which is the primary place where intensive telemedicine technologies are most needed. As these agencies are moving battlefield-tested technology into the civilian world they are bumping up against the same rural bandwidth limits that others have been seeing for years.

Just last week the FCC boldly increased the definition or broadband in the country to 25 Mbps download and 4 Mbps upload. According to the FCC’s numbers this means that 55 million Americans, or 17 percent of the population do not have access to broadband.

If you have followed my blog you know that I think the number is even higher than that since the FCC’s estimate is based upon a very flawed National Broadband Map, which is populated by the carriers. But one can be pretty certain that the vast majority of the people who can’t get the FCC’s newly defined broadband live in rural areas.

I have worked for years with rural communities and the lack of broadband has some real life repercussions for the people living there. There are numerous rural communities without hospitals, without doctors and without universities, and the people who live in these remote places have to undertake long drives to do things the rest of us consider as routine like see a doctor or take a class.

Telemedicine has a huge potential for diagnosing and treating rural patients. It is already being used worldwide to bring modern healthcare into remote communities. But I find it sad that many places in our own country can’t have this great technology due to the lack of broadband infrastructure.