Telemedicine presents new challenges, opportunities for rural health providers during COVID-19 pandemic

An 87-year-old doctor set up a hotspot in a rural eastern North Carolina parking lot to treat patients who don’t have internet access and can’t do virtual visits at home. But only one in four patients at Roanoke Chowan Community Health Centers has reliable transportation — and doctors who want to use recent telemedicine reforms can’t get reimbursed if they treat patients over the phone. 

“That handicaps those of us where only 50% of our patients can do a virtual visit,” said Kim Schwartz, CEO of Roanoke Chowan Community Health Center. “That’s using the assumption that everyone has access to a virtual visit — but the only access they have is a phone visit.”

The COVID-19 pandemic and associated lockdowns have hit federally qualified community health centers hard. They form a safety net that stretches across the state, caring for North Carolina’s uninsured and its poorest residents. Lockdowns shuttered other medical practices, affecting revenue, and leaving many doctor’s offices fighting to survive. Changes to telemedicine rules paid providers more for virtual visits. Providers get more money, letting them reach patients virtually. It extends a lifeline to those who can’t get to the centers.

But many community health centers were left out of those reforms. They treat patients who often can’t access broadband or transportation — effectively cutting off their practices from telemedicine’s economic relief. When payments increased for online visits, they didn’t for telephone visits. 

Schwartz gets less than $30 for a visit that costs roughly $140. 

“No one expected this and the grave effect it’s going to have,” Schwartz said. “This is what we were created for, to be there standing in the gaps. … But not being able to get a telephone paid for like I got an in-person visit paid for a month ago, that’s eventually going to catch up with us. That’s the scary part.”

Congress allocated $35 million to the 39 FQHCs in North Carolina. But the lockdowns hit practices so hard that federal cash won’t replace losses, says Brendan Riley, policy director for North Carolina Community Health Center Association.

Most of the federally qualified centers don’t have enough reserves to stay afloat, leaving them dependent on relief and vulnerable if lockdowns continue for weeks or months, said Riley.

Appalachian Mountain Community Health Centers furloughed workers after the pandemic cut patient visits in half and sent cash flow into a spiral. In the move to telemedicine, providers had to treat patients over the telephone until online virtual visits became available — dealing another “severe” blow to revenues, said Reuben Pettiford, AMCHC president.

“We’re just getting our ceilings over us, so we haven’t had a lot of time to develop a reserve,” Pettiford said. “So when something like this happens, it hits us hard and fast. … “We’ve had to furlough people, no doubt about it.”

Things are still worse for the “look-alike” FQHCS — clinics that meet the same standards as the federally qualified centers and provide affordable care, but don’t receive federal aid. 

“Everybody is struggling, patients aren’t coming to the office,” said Dr. Lee Ann Amann, CEO of Black River Family Practice in Pender County, in late April. “We’re a nonprofit, so we’re OK. We’re getting by, but if we have to keep this up for another couple more weeks, we’ll be in trouble.”

Amann won’t get any of the money set aside for FQHCs. She hopes to get a loan from Congress’ Paycheck Protection Program for small businesses, but the program initially ran out of money in 14 days. Bigger entities took the lion’s share of the cash, including Harvard University and publicly traded companies. Congress has since added money to the program.

Amann hopes to see a raise for telephone visits, but she describes herself as a “lone wolf” who believes full parity would encourage abuse.

“We have no intention of laying anyone off unless we’re not given any loans or help,” Amann said. “The bankers keep telling me we’re in line. Where we are in line, I have no idea. That’s the essential thing: I’m going to need that PPP loan to stay open.”

Health centers say they must stay open to treat a potential flood of uninsured patients as the economic devastation from the pandemic continues. Many operate in rural counties that have access to few health care providers.

“We’re on uncertain ground,” Riley said. “It’s a really big challenge if we lose any of our health care capacity in North Carolina, especially in our rural health care deserts.”

Even the survival of their telehealth programs is uncertain. The telemedicine reforms made to combat the virus are temporary, and providers worry reforms will fade with the pandemic. If reforms expire, only seniors living in rural areas who can drive to designated telehealth locations will qualify for Medicare telemedicine coverage.

“A lot of this is a leap of faith, trusting that our lawmakers will realize that these changes need to be made permanent, not just now during a pandemic,” Riley said. “Of course it’s on people’s minds that they’re making these big changes and investments now without a guarantee that there’s going to be a way to sustain them in the future. That’s not the way we like to do business.”

The General Assembly may temporarily move telephone visits under the umbrella of virtual visits. A draft bill passed in the health care working group of the House Select Committee on COVID-19 would boost reimbursement for telephonic visits to help providers outlast the pandemic.