Some may find it laughable that in 2016, at high tide in the “Internet of Things,” an American nursing home on the edges of frontier lands does a great deal of communicating by fax machine with the outside world.
Others may be similarly shaking their heads to learn one rural visiting nurse association put a trailer with a wireless access point on the side of the road so that nurses can sync their mobile phone apps while traveling. Or that one rural community’s sole broadband internet service provider abruptly closed its doors, leaving everyone there without service for a month.
Eric Graham, chief technology officer and chief information security officer of VCPI, recounts both of those stories. He says he has served a handful of rural provider clients that resorted to using 4G “hotspots” for broadband access as a backup to their primary data circuit.
“We would not recommend this as a secure solution,” he quickly adds. His company offers a variety of technology systems to the long-term care market.
For 22 years, Dan Holdhusen has devoted seemingly every waking minute feverishly sparring with a partisan Federal Communications Commission board while trying to convince stubborn lawmakers to right a 62-year-old wrong: the exclusion of skilled nursing facilities from tapping into a big pot of federal money called the Universal Service Fund (USF). (Every business and American citizen who gets a phone bill in the mail will find a variously named line item collecting taxes to keep the USF fed.)
Holdhusen plied his status and whatever clout he had as Evangelical Lutheran Good Samaritan Society’s government relations director to exploit a window that had opened before passage of the Telecommunications Act of 1996. That act was designed to encourage competition in the nascent days of the internet. His valiant efforts to add the “have-not” SNFs to the “haves” list have consumed yards of shoe leather and tens of thousands of airline miles for endless round-trips from Good Sam’s Sioux Falls, SD, headquarters to the hallowed halls of the nation’s capital.
Holdhusen’s fortunes took a turn for the better in 2014, when he got the attention of his home state’s Sen. John Thune (D-SD), chairman of the Senate’s Commerce Committee. It has jurisdiction over the FCC. A great deal of lobbying ensued as Holdhusen worked feverishly to muster bipartisan support in the House.
On June 22, 2016, the Rural Health Care Connectivity Act (RHCCA) became law, amending the 1934 Communications Act to permit nursing homes to apply for monies from the USF’s Rural Health Care Program (RHCP). The $400 million program provides discounts for telecommunications services so that rural healthcare providers pay rates comparable to their urban counterparts. It also helps expand healthcare provider access to broadband services, according to Rep. Dave Loebsack (D-IA), the bill’s co-sponsor.
Diane Calmus, government affairs and policy manager with the National Rural Health Association, told reporters at that time the bill could potentially help some 1,600 public and nonprofit nursing homes.
A casual observer probably would have missed that seismic funding event because the RHCCA was buried inside a larger bill, the Toxic Substances Control Act, after garnering hard-fought bi-partisan support.
“Access to robust broadband internet in skilled nursing facilities, no matter where they are located, is necessary for both the folks who live there, and for the doctors to more effectively treat patients,” Loebsack said after the bill’s signing.
The head of MatrixCare, one of the largest providers of information technology solutions in long-term care, doesn’t gloss over the complicated issues rural providers face.
“The good and the bad [of rural health] is sort of the good and bad of rural life in general, which means the community, the people, the human side of things tends to be a little more close than if you’re at 176th Street and whatever in Brooklyn,” says CEO John Daamgard. “It’s a different dynamic. Rural is rural.
“We have thousands of clients in the middle of nowhere,” he adds. “It’s a huge part of our business. We have kind of a front row seat to the good and the bad. Not to mention I’m from Iowa, so I’m steeped in the issue to begin with.”
The list of problems isn’t just connectivity, but the whole gamut of information technology access.
“In our industry, we call it the ‘second-cousin syndrome’,” says Holdhusen, whose employer is the largest not-for-profit provider of senior care and services in America. It has more than 150 facilities across 24 states, 70% of which are in rural or frontier areas of the country. “We’ve been invited to the healthcare family reunion, but we still have to sit in the back row.”
Some observers point out that every challenge facing post-acute care providers is only amplified among those that have the misfortune of being so remote.
Remote access — to people and money
One thing all rural nursing homes have in common: sparse populations. They still need to keep the lights on and the rent paid, but thinning populations mean fewer primary care doctors, fewer caregivers and fewer residents. All of that adds up to less money to invest in luxuries such as new computers and servers and the software to run them.
“The low resident volumes make private pay business models and other market forces and opportunities, including those driven by health reform, unsustainable or even feasible at all in rural areas,” observes Majd Alwan, Ph.D., senior vice president of technology for
LeadingAge and executive director of the Center for Aging
In its own 2015 “Justification of Estimates for Appropriations Committees,” the Department of Health & Human Services acknowledges a “concern that [the Centers for Medicare & Medicaid Services] does not sufficiently account for the realities of rural healthcare in rule making. Small and rural hospitals, where medical workforce shortages are most severe, need reasonable flexibility to appropriately staff their facilities so they can continue to provide a full range of services to their communities.”
Daamgard is more blunt: “People don’t always think about unintended consequences, but they survive on these margins with very low-cost labor, and what happens when Walmart pays 15 bucks an hour? Do you want to deal with the mental anguish of being a front line care provider like an aide in a nursing home versus making more money down the street punching the clock? Who knows what that will end up doing to us?”
Martha Abercrombie, vice president of strategy for Vikus, a leading staffing solutions provider, believes the flight from rural areas is becoming perilous.
“Rural providers will be at a hiring disadvantage if they are not able to fully embrace recruiting and hiring technology due to limited internet access or affordability,” she says.
Ironically, sophisticated information technology is needed most by rural facilities with thin staffs and sparse primary care providers. As Holdhusen observes, in many rural communities, a SNF is often the only healthcare provider available for 100 or more miles. Consequently, as Alwan adds, “technology-enabled services like telemedicine, telehealth, health information exchange, remote monitoring, and care coordination have a paramount value proposition, including remotely connecting to specialists, pharmacists, and hospitals/hospitalists, remotely.”
And as Daamgard observes, “The documentation [from technologies such as telehealth and telemedicine] actually ends up being better because all of that streaming video, all of those pictures, all the narrative that’s going on, is being recorded and stored as it happens. It has all kinds of good derivative benefits.”
Even so, outdated licensure rules can prohibit physicians from providing remote consultation for border towns across state lines, observes Randall Kirk, executive vice president and chief scientist at Direct Supply Inc.
Navigating payment rules can sometimes be dicey. Gary Capistrant, chief policy officer of the American Telemedicine Association, says Medicare and Medicaid reimbursement aren’t yet universal across all settings. In many instances, reimbursement favors doctors most.
“Medicare primarily reimburses the distant physician or specialist,” says Alwan. “The rural nursing home, which usually has to invest in the infrastructure and equipment, only gets an extremely low origination fee.”
Capistrant’s group says rural facilities capable of scraping the funds together to implement their own “hybrid” systems could actually recoup the costs quickly by the savings from avoided emergency room and physician visits. Industry-wide, the savings would be as high as $806 million by some projections.
CMS announced in August a new pilot program with a telehealth component that could provide specialized nursing services in rural counties.
The Frontier Community Health Integration Project Demonstration should help determine whether enhancing payments for certain services and additional beds will improve health outcomes and reduce Medicare expenditures in areas where critical access hospitals operate, the agency said. The FCHIP Demonstration will pay participating CAH originating sites at 101% of cost for overhead, salaries, fringe benefits, and the depreciation value of the telehealth equipment instead of the physician fee schedule fixed fee.
While RHCCA frees up money for rural providers to route into internet tech, it isn’t worth the paper it’s printed on if broadband cable isn’t in the ground or on poles. With so much data now residing in the ethereal “cloud,” providers without broadband access are disadvantaged, observes Chris Lisser, manager of network/telecom engineering and IT operations for VCPI.
“Providers are dependent upon the bandwidth capacity and reliability of a network. In rural areas, there may be only one choice for an internet provider and the service may cost more with lower bandwidth than urban areas,” he adds.
Daamgard, who’s proud to be from a state that was a pioneer in laying thousands of miles of fiber optic cable before people knew what the word meant, agrees.
“I remember people scratching their heads, asking, ‘Why do we need 100 megabits of connectivity for the public library in a town of 1,200 people?’” he recalls. “Turns out that was a tremendous asset to providers in Iowa.”
Nonetheless, struggles remain.
“We’ll sign multimillion dollar contracts and the deployments get held up because of intra-building infrastructure issues, and that’s frustrating,” he says.
Daamgard, and most other experts, staunchly agree it’s the federal government’s role and obligation to build the digital highway from sea to shining sea. But that may be years away.
Alwan believes “if and when” broadband access becomes widely available in rural areas, providers will continue to be stymied by many things, including lack of critical mass.
“Because of lower population density, telecom providers have less incentive to offer services in such areas,” he says. “Those that do have services usually charge more to recover their investment in the infrastructure, especially when there is no competition.”
In his 2015 testimony before the House Energy and Commerce Subcommittee on Communications and Technology, Holdhusen told lawmakers, “The cost of broadband connectivity is extraordinary in rural areas, and often the robust speeds necessary to advance the most state-of-the-art health technology services are out of reach to SNFs due to cost and availability.”
Because local access to broadband is charged by “the mile,” it’s more expensive in far-flung rural areas. Ironically, he says, obtaining more woefully needed robust broadband connectivity would result in an even greater price disparity between rural and urban prices.
As if fax machines aren’t bad enough, many rural providers still muddle along with aging IT, most of which profoundly lacks the horsepower needed to play in the high-speed internet world of healthcare data sharing and transmission.
When Kirk attended a HIPAA conference last year sponsored by the American Health Care Association, he remembers being dumbfounded by the number of administrators sheepishly admitting to using Windows 95- and XP-powered personal computers.
“When MDS data was first required to be transmitted electronically in the 1990s, most of them went out and bought a computer and a modem,” says Kirk, who managed Direct Supply’s e-commerce business for many years. “And that’s the same stuff that’s in those facilities today.”
Constant funding concerns
Still, $400 million could go pretty fast if every rural and frontier nursing home knocks on the USF door all at once. In July, the Sparks (NV) Tribune published an article about how the U.S. Department of Agriculture brought broadband service to 27,000 square miles of rural Nevada.
The USDA also provided about $2.5 million in distance learning telemedicine loans and grants for colleges, schools and medical clinics to develop broadband anchor hubs, the newspaper reported.
Some would call that a good start.