Rural America is a Fertile Field for Digital Health

BY ERIC LARSEN and TOMMY IBRAHIM

Our rural health care system has suffered badly during the COVID-19 pandemic. It entered the pandemic with severe structural weaknesses, including magnified health disparities and inequities, lower rates of vaccination in the general population, and high risk of rural hospital closures. Beginning with these challenges, rural providers have been harder hit by the pandemic than just about any other health care sector.

Juxtaposed against this struggle is the optimism for digital health – one of the few bright spots of the pandemic. We have witnessed a veritable digital health revolution – record capital infusions of $37.9 billion to digital health companies in 2021, a proliferation of digital health companies (11,000 by some estimates), a wave of healthtech IPOs (29), and an unprecedented talent migration of Silicon Valley programmers, technologists, and engineers into health care. With this investment and talent boom comes staggering growth in new digital health tools. From telemedicine to remote diagnostics to the delivery of medications directly to a patient’s home, it seems that for every health care access need there is a digital solution.

We – a health care strategist and rural health system CEO – think digital health entrepreneurs and these severely challenged health systems need each other to achieve their respective missions. Put simply, new digital modalities will be key to resolving many of today’s rural health care issues.

Bassett Healthcare Network in central New York state is showing how this can be done.

Why rural providers and rural communities need help

Rural providers are under siege. They face tough demographic challenges. Rural Americans on average are poorer, older, sicker, and less digitally-savvy than urban and suburban Americans. The vast majority of persistently poor counties (defined by having a >20 percent poverty rate over time) are rural. Poverty rates among rural Black and Native American populations almost triple the rate of rural white populations.

These factors lead to corresponding health care and health status disparities. Rural areas perform worse on evaluations of risky lifestyle behaviors such as smoking and excessive drinking, and exceed urban counterparts in mortality rate across each of the ten leading causes of death in the U.S. The largest gaps are seen in mortality due to heart disease (21 percent), cancer (15 percent), and chronic lower respiratory disease (48 percent).

Making matters worse, the nationwide shortage of health care professionals – from nurses and doctors to hospital security staff – is worse in rural markets. Sixty percent of federally designated health professional shortage areas are rural counties; rural areas average 13 primary care providers and 30 specialists per 100,000 people compared to 31.2 and 263 per 100,000, respectively, in non-rural areas.

Between 2010 and 2021, 138 rural hospitals closed their doors altogether, leaving those impacted communities stranded for services and damaging their economic base.

The explosion of telehealth in the past year is a promising way for rural health care providers to bridge workforce-and transportation-related access gaps.

However, a major hurdle to telehealth is that more than 18 million Americans – predominantly rural – lack access to high-speed Internet networks; 26% of rural households and more than 50 percent of tribal lands don’t have access to broadband connections reliable enough to support virtual health care visits.

The dark side of digital health’s success story

In dramatic contrast to rural health care, digital health is a fast-growing sector. The amount of capital flowing into the space is more than 20 times the digital health investments of a decade ago.

A more sober assessment reveals significant structural challenges facing these innovators. We see myriad factors impeding the successful adoption of these solutions. These include a proliferation of overlapping and imitative solutions in spaces like diabetes, musculoskeletal conditions, and behavioral health care; slow adoption of solutions by providers and consumers (the estimated average time for hospitals to deploy and scale a digital solution is 23 months); lack of interoperability between platforms; confusing and quickly-shifting regulatory requirements; and payer and provider technology bureaucracies that are slow to embrace digital solutions. 

Partnering with large, bureaucratic health systems has been a particular challenge for digital health companies. While some health systems like Stanford, Ochsner, and Rush have been more agile, the typical health system has been slow to welcome these breakthroughs.

Bassett shows potential for a win-win partnership

So how do these two narratives come together?

Unlike urban and suburban health systems, rural hospitals aren’t focused on building lavish new facilities. They can be less bureaucratic and faster-moving, with fewer constituencies and stakeholders to get in the way. Thus, they may prove more open to digital health technologies that advance home care and virtual care, enable professionals to practice at the top of their license, and create significant value for patients and providers in these communities. At the same time, they aren’t supported by the same level of funding as their urban and suburban counterparts, so they must take a more discerning approach to innovation. Since they can’t afford to invest in tools they may not use fully, each new digital prospect must be vetted to ensure it’s the right fit for workflows and patient needs. That scrutiny can lead hospitals to the best solutions.

In other words, the perceived weaknesses of rural health care may be strategic opportunities.

Bassett Healthcare Network in central New York illustrates the potential for rural health system partnerships with digital health companies. Founded over a century ago, it serves an eight-county, 5600 square-mile geography roughly the size of Connecticut. It operates five acute care hospitals, a large multispecialty employed medical group, and a full-service post-acute care division comprising two subacute nursing home facilities, home care services, a durable medical equipment company, and a population health services organization. It also offers a medical school program focused on rural health training and research.

While unique in many ways, Bassett’s organizational challenges are starkly similar to those of other rural health systems. Its struggles include a disproportionate share of patients in lower-paying governmental insurance programs, compressed margins, and inflationary cost pressures exacerbated by stagnating population growth and an increasingly aging patient demographic.

The combination of these factors limits Bassett’s ability to invest in workforce, infrastructure, and growth, translating into recruitment difficulties, aging facilities and equipment, and market vulnerabilities relative to regional competitors.

But Bassett has identified digital innovation as a key strategy to improve operations, advance patient quality, access, and the patient experience, create financial stability, maintain independence, and position for future growth.

In mid-2021, Bassett announced a plan to implement a partnership with Optum, a national health services provider, to install state-of-the-art information technology and cybersecurity infrastructure and end-to-end revenue cycle management that will advance a data-driven culture through a full suite of analytics tools and capabilities. Bassett executives worked closely with the provider’s board of directors to complete a thorough analysis of the transaction, and the partnership deal was finalized within a nine-month timeframe. This partnership has freed Bassett leaders to focus more time and energy on the organization’s evolving transformation and essential patient care needs.

Viewing itself as an innovation center, Bassett’s partnerships with technology and digital health start-ups create an opportunity to co-develop solutions that meet the specific needs of rural health care across the country, and to test specific hypotheses through the Bassett Research Institute.

There are countless examples of how digital solutions can and should be expeditiously adopted by rural providers.

Digital and hybrid companies offering “hospital at home,” remote patient monitoring (RPM) and integrated continuous monitoring (ICM), and remote laboratory services could solve the challenges in addressing geographic and access issues. Behavioral telehealth modalities – including synchronous/asynchronous, artificial intelligence-enabled cognitive behavioral therapy, “game-ification,” and other advances in behavioral care provision – could be deployed. Virtual-first primary care could mitigate the shortage of physicians and geographic distance barriers to care. Automation of operational and clinical systems promise to augment staff where shortages exist. Partnerships with providers and technology companies, several of which Bassett is actively pursuing, will be essential for implementing these systemic innovations.

Digital health is an area of innovation and invention that has advanced over the past two years, both in spite of and because of the COVID-19 pandemic. But digital health’s future is not assured, given the pullback in the public and private markets, the reversal of the Federal Reserve’s quantitative easing which was key to providing the liquidity for the digital health surge, and the delays and complexities in deploying digital health solutions.

The convergence of rural health challenges and the digital health care revolution create a prime opportunity for rural communities. Health care leaders, digital innovators, and federal and state policymakers could finally address the critical issue of improving health care and well-being in rural communities across the country. The digital health sector is in need of an agile ally, and the same is true for rural health care providers. We think leaders in the two sectors should chart a collaborative path forward together. 

Eric Larsen is President of The Advisory Board CompanyTommy Ibrahim, MD, MHA is President & CEO of Bassett Healthcare Network