Christine Thompson, a speech therapist, works Thursday in her office in Asheville. Thompson sees patients both in-person and virtually. Jacob Biba / Carolina Public Press

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Like providers all around the country, Christine Thompson, a speech language pathologist and the clinical supervisor at Asheville Speech Associates, adopted telehealth as a necessity during the pandemic. 

“There was that first week when everything shut down,” the provider said. “I was at home and I was just thinking, ‘I have to see my kids, so I guess I’m just going to do this. I’m going to figure this out as I go.’”

When the pandemic forced health care providers like Thompson to turn online, many in Western North Carolina found telehealth presented a new opportunity to reach new populations, but it also showed them that geography was not the only barrier to access. 

Insurance coverage challenges complicate the telehealth landscape, as does a lack of broadband connection and a shortage of digital literacy. 

Providers getting paid

One of the first big questions among providers in March 2020 was whether health insurance providers would cover appointments as they moved online, Thompson said. 

Medicaid had not covered telehealth services prior to March 2020, but the program quickly got on board to cover most telehealth services during the pandemic. Private providers soon followed the lead. 

However, the extended coverage was intended to be temporary, and many insurers intend to end some telehealth coverage as the pandemic winds down. 

“That’s the big unknown at this point,” Thompson said.

“Blue Cross and other insurance companies are continuing to the end of the year, but we don’t know beyond that.”

Blue Cross Blue Shield of North Carolina announced an extension of its telehealth policy through 2021, a benefit to the majority of North Carolinians who receive insurance through their employers. 

For individuals on governmental plans, such as Medicaid and Medicare, coverage of telehealth benefits rests on a designation of a Public Health Emergency by the U.S. Department of Health and Human Services.

The department extended the status for 90 days on April 21, 2021, and in a letter to governors, indicated it would likely extend the designation through the end of the year.

Based on information from the N.C. Department of Health and Human Services and county population estimates, roughly one-fifth of the population in North Carolina’s 18 westernmost counties rely on Medicaid. 

The extensions may signal a more lasting change. North Carolina lawmakers introduced legislation to require insurance providers to continue to cover telehealth visits permanently. 

Along with establishing some guidelines and definitions as to what exactly constitutes telehealth, HB 149, Improving Access to Care Through Telehealth, “prohibits plans from excluding from coverage services or procedures delivered by a health care professional to an insured through telehealth solely because the service or procedure is not provided in-person.”

The bill passed the House in early May with sweeping bipartisan support of 113 legislators in favor of the bill and a single dissenter. 

“This pandemic propelled us years in the future in such a short time,” said Rep. Larry Potts, R-Davidson, a primary sponsor of the bill. “There are still details to work out regarding copays and reimbursements, but this legislation is starting that conversation and provides guidelines for insurers.”

Under the current language, the regulation would take effect Oct. 1.

With such strong support in the House, Potts said he hopes the bill will reach the Senate Health Committee, but “these things are a real process, even for things that seem like common sense.” 

Getting connected

Insurance requirements are not the only obstacle telehealth faces for long-term adoption. 

Potts said he and other representatives working on telehealth access are in close conversation with representatives working to increase broadband access because “it is impossible to expand telehealth beyond urban and suburban areas without also expanding broadband to rural areas.” 

Broadband access is an important issue across the state, but that expansion has been uniquely difficult to establish throughout North Carolina’s most mountainous counties. 

“In Western North Carolina, with the mountains and the hollers and the rocks, we aren’t talking about 20 straight acres of rural land without Wi-Fi,” said William Sederburg who chairs the WNC Broadband Project. “We have individual pockets that are largely correlated with low-income areas or specific geographic problems. … Those are much harder to reach.

These situations exist, Sederburg said, because of a lack of economic benefits for providers in providing these “last mile” fiber extensions to difficult-to-reach populations. 

Assessment of the current status is another barrier. In short, one knows exactly where internet service exists. One map that estimates broadband connectivity at the census tract level is widely criticized because of the Federal Communications Commission’s methodology. 

“If a single home or business in a census tract has internet, they (the FCC) assume everybody around them has access to the internet,” Sederburg said. “That isn’t the way this works. And we can’t fill gaps that we don’t know exist.”

In response, North Carolina has attempted to crowdsource data through an online survey to create its own map.

In May, the N.C. House unanimously passed a bill to increase spending on broadband infrastructure in the state. 

Sederburg said he was encouraged by this bill because, rather than focus solely on private providers, the measure includes provisions for building public-private partnerships with counties and local governments who know their own areas best. 

“There needs to be a little more cleverness than we’ve had before if we want to connect that last mile,” Sederburg said. 

Understanding use

While broadband access and insurance coverage may be the two largest obstacles for the future of telehealth, other issues hinder the process.

For example, the current legislation regarding insurance coverage defines telehealth as “an encounter conducted through real-time interactive audio and video technology,” while it excludes “the delivery of services solely through email, text chat or audio communication unless additional medical history and clinical information is communicated electronically between the provider and patient.”

This distinction is important because not all patients are comfortable or able to use a synchronous audio/visual device, according to MaryShell Zaffino, chief medical officer and a practicing physician at Blue Ridge Health.

“I still have a lot of patients who say they would just rather do a call over the telephone because the telephone is much easier, or they may not have a smartphone or strong enough internet for a video call,” Zaffino said. 

Marc Czarnecki, who serves as social media coordinator for the WNC Broadband Project and provides digital literacy lessons for adults, said Western North Carolina’s demographics make it particularly susceptible to these issues. 

The average age of Western North Carolinians skews about five years older than the rest of the state, according to data from the U.S. Census Bureau, causing challenges for digital health providers. 

“This is an attractive place to come and retire,” Czarnecki said. “But that means some of this population doesn’t have kids or family members to assist with their digital literacy.”

Zaffino said that, as a federally qualified health center, Blue Ridge Health tends to attract patients who need to travel long distances. But these individuals can often be exactly the same ones who don’t have ready access to broadband connections or who may not feel comfortable videoconferencing. 

Ultimately, she says, telehealth is not going to be any cure-all, but it is useful to have as an additional tool she can utilize to best serve her patients. 

Part of the puzzle

Even when the financial and technological challenges are met, telehealth may offer only part of the solution to an individual’s health needs. 

Barbara de Loache, 75, said her own experiences using telehealth throughout the pandemic were positive, but as a former nurse herself, she says some situations require an in-person visit. 

“My (telehealth) visits were with a doctor who knows me well, and they were general check-ins, mostly answering questions about how I was feeling,” de Loache said. “But I can imagine there are plenty of situations where it works less well, when a doctor needs to see you in person.”

Often, telehealth’s efficacy depends on how it is used. Studies have found that telehealth can be just as effective as in-person care, but that depends on the technology available and the patient’s needs. 

Telehealth appears to work well for regular check-ins on routine issues, such as for patients with diabetes or to check how a patient is handling a new medication. The process lends itself to situations where much of the information can be easily shared verbally or visually. But for other issues, things like respiratory disease or heart problems, it makes more sense to see a doctor in person. 

“It’s just hard to really assess a patient through telehealth,” de Loache said. “When all a doctor can do is ask questions — it might take a dozen questions when, if the visit were in person, they could have just checked your blood pressure and gotten to the issue much quicker.” 

Some studies showed a mix of telehealth and in-person visits results in a better outcome than picking one option. And for some patients, telehealth offers a convenience they appreciate, even beyond the pandemic. 

Linda Hemstreet, 70, visited a physician in person several times during the pandemic, but she recently had her first telehealth consultation. 

“After multiple in-person appointments that required me to go to the doctor, for this one I had no travel time, no sitting in a waiting room, I didn’t feel rushed,” Hemstreet said. “It was one less appointment for me to have to go to.” 

As a provider, Thompson also sees the many benefits.  

“By offering teletherapy, I’ve been able to expand my own caseload and see kids who live hours away that otherwise I wouldn’t be able to see,” she said.

“I just hope that I’m able to continue that because it’s providing a service that these people really need.”

Christian Green

Christian Green is the lead Carolina Public Press contributing writer reporting on healthcare and health policy in North Carolina. He obtained a master’s degree in neuroscience at Wake Forest University’s Graduate School for the Arts and Sciences, where he worked in the Laboratory for Complex Brain Networks. He is based in Raleigh. Contact him at cgreen@carolinapublicpress.org.