Digital Health for Rural Healthcare

Contributor: Sandeep Puri, WG’99
To learn more about Sandeep, click here.


image011.jpgDigital Health funding crossed $8B in 2016, according to a report by Startup Health.  Almost 160 patient/consumer experience-focused companies received funding in 2016 – between 2-3X as many as other subsectors.  Most of the companies in this space are targeted to the healthier, wealthier, and more literate segments of the population.  It makes sense from a purely economic perspective – target the easier-to-engage segments that have a higher propensity to pay. 

But, what about from the public health perspective – will these investments in digital health help bend the cost curve and improve health outcomes for the population as a whole?  I doubt it. Twenty-five percent of the U.S. population lives in rural areas where the socioeconomic conditions of the population create a huge demand for healthcare, and, at the same time, a unique challenge for delivery of healthcare.   

What is different about rural health?

Rural hospitals provide essential healthcare services to nearly 51 million people or about 25% of the U.S. population.

Compared with urban populations, rural residents generally have higher poverty rates, a larger elderly population, tend to be in poorer health, and have higher uninsured rates than urban areas.  At the same time, rural areas often have fewer physician practices, hospitals, and other health delivery resources.  These socioeconomic and healthcare challenges place rural populations at a disadvantage for receiving safe, timely, effective, equitable, and patient-centered care.  Statistics show the prevalence of multiple chronic conditions (MCC) is higher among the rural population.  Here are some statistics from the National Rural Health Association:   


  • Economic - On average, per capita income is $7,417 lower than in urban areas, and rural Americans are more likely to live below the poverty level. The disparity in incomes is even greater for minorities living in rural areas. Nearly 24% of rural children live in poverty. 
  • Access - Only about 10% of physicians practice in rural America, despite the fact that nearly 25% of the population lives in these areas. Rural residents are less likely to have employer-provided healthcare coverage.  Rural residents have greater transportation difficulties reaching healthcare providers, often travelling great distances to reach a doctor or hospital.
  • Literacy - Rural residents are at risk for low health literacy because they have lower educational levels as compared to residents of metropolitan areas. Low health literacy is a particular problem for people in poverty and people with limited education or English proficiency. Low health literacy is associated with a lower likelihood of using preventive health services, a greater likelihood of taking medicines incorrectly, and poor health status.
  • Social - Abuse of alcohol and use of smokeless tobacco are significant problems among rural youth. The suicide rate is significantly higher than in urban areas, particularly among adult men and children. In rural areas there is little anonymity, and social stigma and privacy concerns are more likely to act as barriers to healthcare access. Residents may be concerned about seeking care for issues related to mental health, substance abuse, sexual health, pregnancy, or even common chronic illnesses due to unease or privacy concerns. 
  • Ethnicity – Several migratory and seasonal agricultural workers (MSAWs) establish a temporary home in rural areas for the purpose of employment.  These worker groups are predominantly Hispanic/Latino, and they and their families face unique health challenges due to their hazardous work environment, poverty, inadequate healthcare access, and cultural and language barriers. 

These factors conspire to impede the rural population in their struggle to lead a normal, healthy life. 

Rural healthcare organizations disproportionately rely on government payments (Medicare and Medicaid) because of their characteristics – lower income, elderly population.  Several government and private organizations are working to improve healthcare access for rural communities.  Some of these include the National Rural Health Association (NRHA), National Association of Rural Health Clinics (NARHC), and the Federal Office of Rural Health Policy (FORHP). 

image003.pngHow can digital health help rural health?
Despite the factors mentioned above that impede the rural population in their struggle to lead a healthy life, there is hope the emerging digital health solutions will overcome these impediments.  

Several digital health solutions are available today that providers could use to more effectively engage patients for a range of purposes: chronic disease management, preventive care, and wellness.  These solutions vary based on what they deliver (information, reminders, medical advice, social services), how they deliver (with/without devices; with/without live human interaction), and through what mode of communication (text, email, phone, kiosks, video) they deliver. 

However, it seems very few solutions reflect a true understanding of the unique challenges for delivery of healthcare in a rural setting – specifically, the poverty, low health literacy, access, and social issues.  Most solutions are not low-cost, low-tech, or customized to address the unique socioeconomic characteristics of the rural population.    Here are a few statistics:

  • Broadband Penetration: According to data published by the FCC earlier this year, 39 percent of Americans living in rural areas still lack access to decent broadband service, compared to only 4% of the urban population.  Video-based telehealth solutions are not practical in this environment.
  • Smartphone Ownership: A study by the Pew Research Center conducted in 2015 shows that even though smartphone ownership has increased to about 68% of U.S. adults, there are substantial differences based on age (86% for 18-29 vs. 30% for 65+), household income (87% for $75K+ vs. 52% for <$30K), education level 81% for college+ vs. 41% for less than high school), and community type (72% urban vs. 52% rural).  A solution that relies on only smartphones, for example a solution based on communicating via emails and apps, will not be effective when 48% of the target population cannot be reached.
  • Cellphone Ownership: The Pew Research also showed that cellphone ownership is common across all major demographic groups, though older adults tend to lag behind their younger counterparts.  Cellphones enable text-based communication, and are therefore ideal for overcoming the digital divide and engaging all demographic segments of the population.  Rural residents are slightly less likely than urban and suburban residents to have cellphones. Still, nearly nine-in-ten rural residents (87%) have them, making text a very practical mode for engaging the rural population. 
  • Latino/Hispanic Population: Rural healthcare organizations need to be able to help migrant farmworkers, who are primarily Latino/Hispanic, access healthcare.  Most of this population does not have access to Broadband nor do they own smartphones.  In addition, most can only be engaged through culturally or linguistically appropriate solutions.  

What is needed?
Statistics reveal the digital divide is a real issue for the delivery of digital health solutions to the rural population – 39% of the rural population does not have broadband access; 48% do not own smartphones.  In addition, a large percentage of this population has cultural and linguistic barriers to engagement.   Digital health solutions targeted to the rural population need to take these issues in consideration in their design. 

image001.jpgThe ideal digital health solution for rural healthcare should work with cellphones (text messaging) in addition to the other modes of communication.  Statistics indicate 90% of text messages are read within 90 seconds of receiving them - this makes text messaging ideal for not just reaching patients with the right message, but making sure the message is actually read and more likely at the correct time. In addition, the ideal solution should be multilingual to be able to adapt to the cultural and linguistic attributes of the rural population. Finally, the ideal solution should be cost-effective.  These requirements make a text-messaging based, multilingual communication platform ideal for delivery of digital health solutions to the rural population.         

Providers can use text messaging to serve the rural population in several ways - appointment reminders, marketing new programs, care coordination, patient satisfaction, treatment plan check-in, and self-management support.  In 2015, Montefiore Medical Center conducted a trial to see if text messaging could increase medication adherence among high-cost Medicaid patients.  The study found text messaging increased patient appointment adherence by 40% and patient medication adherence by 12%.  In addition, the study showed that text messaging can also increase motivation, inspire confidence, and raise awareness in patients by making proactive health measures easy to undertake.  Numerous other studies have shown that text messaging for healthcare is not only effective, but also cost-efficient, especially for engaging the demographic segments that define rural America.   

image005.pngThe adoption of cellphones among rural providers has increased in recent years, according to a recent survey by the Center for Care Innovations.  However, only one-quarter of the participants in the survey reported using cell phones in care delivery, and most reported using it for appointment reminders only.  The study concluded that many community health centers and clinics do not have the necessary resources and skills to adopt mobile health primarily due to funding constraints and lack of reimbursement to support mobile health.  

What else is needed?
Besides digital health solutions that can overcome the digital divide, rural healthcare organizations need financial assistance in the form of value-based reimbursement models and other funding.

Value-Based Reimbursement Models
Understandably, VC funding is not necessarily driven by the noble goal of improving population health.  However, as noted in a previous article, CMS can align incentives for providers (and by extension for investors) by accelerating the shift to value-based, outcomes-based reimbursement and thereby  altering the providers’ focus from fixing what’s broken to optimizing wellness.  In January 2015, The U.S. Department of Health and Human Services (HHS) set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. In March 2016, HHS announced the 30% goal had been achieved, well ahead of the goal.

Rural hospitals face factors, such as diseconomies of scale, which could hinder financial performance in comparison to urban and larger hospitals. For these reasons, Federal law makers created special payment classifications under the Medicare program, recognizing that many rural hospitals are the only health facility in their community, and their survival is vital to ensure access to healthcare.  One of these classifications was created under the Medicare Rural Hospital Flexibility Program: Critical Access Hospital (CAH).  Unlike traditional hospitals that are paid under PPS (prospective payment system), Medicare pays CAHs based on each hospital’s reported costs.  Financial performance improved after hospitals converted to CAH status, accompanied by a commensurate decrease in the closure rate of small rural hospitals.

However, a series of congressionally mandated Medicare cuts that have happened over the past few years have led to closure of several rural healthcare facilities – which has further exacerbated the negative impact on access to care in the community.  Rural health experts believe rural hospital closures are likely to continue because many rural hospitals have such a tight operating budget with little room for financial losses.  Until the time rural hospitals transition to a more efficient model of healthcare delivery – one that relies more on digital health for population health management – federal grants should be made available to them to avoid closures.   One such stop-gap legislation now in Congress is called the “Save Rural Hospitals” Act, which aims to stabilize the current environment while establishing a path forward. 

Besides government funding, non-profit foundations like the Robert Wood Johnson Foundation and The Commonwealth Fund have funded research and pilots for expanding healthcare access and improving quality of care in rural communities. 

I hope rural healthcare organizations are able to survive and thrive by using effective digital health solutions to address the unique challenges of delivery of healthcare to their patients.  Effective population health is not possible without addressing 25% of the population. 

As the co-founder of a digital health startup called Patientriciti which provides multi-modal, multi-lingual, patient engagement, virtual care management, and a care coordination platform which enables healthcare stakeholders to engage with different segments of the population in a personalized way to affect sustained behavior change, I invite rural healthcare organizations and funding agencies interested in using our platform to reach me at [email protected].