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Published On October 21, 2020

TECHNOLOGY

Where Telemedicine Is a Revolution

In American Indian country—long underfunded and underserved—new rules and payment models for telehealth can vastly improve the delivery of care.

One of Stephanie Sun’s long-time patients in South Dakota has severe diabetic neuropathy, which causes not only pain but also significant weakness. Because he is wheelchair-bound, every journey to the clinic has been a struggle. When COVID-19 descended on the United States, the news came as another blow. If he became infected, his diabetes would put him at particularly high risk of complications.

But steps to protect him from COVID-19 infection may also have improved his overall care. When his usual outpatient clinic began to reduce in-person visits, it offered telehealth instead, with phone and video check-ins. Communicating in that way provided many benefits for him and his providers. For instance, he no longer had to rely on his memory if Sun had a question about one of the medicines on his long, complicated list. “Before he might have said, ‘I’m not sure of what it’s called but it’s the green one.’ Now he can just go find his pills and read the label,” says Sun, who is part of the Rural Health Leadership Fellowship, a partnership between Massachusetts General Hospital and the Indian Health Service (IHS) hospital of the Rosebud Sioux Tribe in South Dakota. “It made it so much easier for us to communicate.”

Indeed, a shift toward telehealth may turn out to be one of the bright spots from the past year for American Indian populations, who have otherwise borne the brunt of the pandemic. The incidence of COVID-19 among American Indians in 23 states was more than three times as high as it was for non-Hispanic white individuals, and for American Indians who are infected, the risk for severe outcomes is higher, according to an August report from the Centers for Disease Control and Prevention. As of September 2020, the Navajo Nation in the southwest United States had a higher per-capita rate of positive cases than any state.

Because American Indian communities are often located far from urban centers—54% of IHS patients live in rural areas—telehealth would seem an intuitive fit. But while there have been attempts to introduce the technology before, uptake has been slow. The IHS began to offer telehealth in 2009, with options for psychiatric and specialty care, but regulations meant that patients still had to go to a clinic physically to get the care from providers at another location. In rural communities, where the cost of gas and the often considerable distance to a clinic were roadblocks to care, people were hard pressed to make the trip every time they needed a screening, a regular visit or follow-up care.

But that changed in March 2020, when the CARES Act became law. Both the Centers for Medicare & Medicaid Services and IHS eased regulations for telehealth, promising to reimburse providers for its use with more patients and in more circumstances. “Because of the loosening of the regulations we were able to do both telephone visits and video visits with patients at home,” explains Janell Simpkins, medical director of the specialty clinic at Avera Health, a provider of both emergency and specialty telemedicine to the Great Plains tribes.

The CARES Act also provided $1 billion to support the IHS during the pandemic, part of which is funding new investments in telehealth. One challenge is to bridge the digital divide. Just more than half of American Indians living on tribal lands have high-speed Internet service, making that the least connected population in the country, according to a 2018 study by the U.S. Census Bureau.

Yet even this new investment won’t be able to remedy the severe shortfall in federal funding for American Indians and Alaska Natives. Per capita federal spending on those populations was about $4,000, compared to $9,207 per capita health spending nationally, according to the latest statistics from IHS.

That disparity is only too apparent for members of the Rosebud Sioux tribe. “The county where we work has the third-lowest life expectancy at birth of any U.S. county,” says Matthew Tobey, an internist and director of the Rural Medicine Programs at Massachusetts General Hospital. The hope is that the recent changes in telehealth regulations, which have been extended through October 22 amid calls for the change to be made permanent, may be making a tangible impact on the community. “We’ve discovered that being able to provide home visits actually dropped our no-show rates for all appointments,” Simpkins says. “They had been about 40% to 45%. But during the pandemic, with more telehealth, that has fallen to about 25% to 30%.”

Simpkins sees opportunity for even greater strides, particularly in specialty care. “There is a huge amount of autoimmune disease in the Native American population, and ordinarily, it’s difficult to connect patients with rheumatologists across the country,” she says. “If we can get people to specialists in rheumatoid arthritis or lupus early on in their disease, before they develop crippling arthritis or kidney disease, it’s a huge win.”

Endocrinology specialists are also greatly needed to help the 14.7% of Native American adults 18 or older who are diagnosed with diabetes—the highest rate of incidence among all U.S. adults. Telemedicine can also help provide home palliative care and hospice services to patients and their families at end of life. Psychiatry, one of the earliest focuses of telemedicine, has also received an unexpected boost from the remote format. “The home environment plays a big role in mental health and psychiatric issues, and telehealth enables the provider to see the home environment and the interactions there,” Simpkins says. “And patients like being able to stay home, too.”

Many obstacles still stand in the way of widespread adoption of telehealth as a way to improve care for this population. For example, regulations still keep many physicians from practicing across state lines. Stephanie Sun says that her patient with neuropathy continues to wrestle with how to monitor and record his blood sugar levels. To help him, she makes sure to revisit that topic whenever they connect for a televisit. In some ways, she says, this hearkens back to that oldest of medical approaches: the house call. “It’s working out for everyone to deliver care that’s needed, on mutually good terms for doctors and patients,” she says. “It has been a welcome help.”