47 CFR Part 54: Promoting Telehealth for Low-Income Consumers

It is my great pleasure to submit a comment to the Federal Communications Commission (FCC) on the proposed pilot program to support connected care for low-income Americans and veterans. I am an associate clinical professor at the UCR School of Medicine and an obstetrician gynecologist who has practiced in Riverside for the past 15 years. I am working with the Mercatus Center as a research scholar. Mercatus is a university-affiliated policy research center dedicated to advancing knowledge important to current policy debates. In pursuit of its mission, Mercatus scholars conduct independent, nonpartisan analyses of agencies’ rules and proposals.

The region in which I serve as a physician is what the Brookings Institution calls the “Third California,” extending from the outer suburbs of Los Angeles to the Northern California foothills. The population tends to be substantially less well educated than that of the coastal regions and has significant health problems linked to challenging socioeconomic and environmental conditions.  This part of California has the worst shortage of physicians in the state, with about 40 primary care doctors and 70 specialists per 100,000 residents, approximately one-half the recommended primary care ratio. Within that challenging environment, I have seen the cost of poor access to healthcare, with primary care doctors’ schedules completely booked out for several weeks. Rural health disparities are significant, with a substantial part of Eastern Riverside being remote with wilderness conditions. Medically fragile residents reside in isolated areas such as Idyllwild, Anza, and the Cahuilla reservation where emergency medical service response times can be more than 60 minutes and roads are unreliable.

Mercatus Center research by Robert Graboyes and other Mercatus scholars positively focuses on the importance of innovation in healthcare provision through foundational work, such as the “Fortress and Frontier in American Healthcare” report and the Healthcare Openness and Access Project. The FCC’s support of technological innovation in healthcare supply through its pilot program that supports patients’ direct connection to healthcare providers through telehealth services is an excellent step forward in aiding underserved populations in rural and urban America. The impact of distance and isolation on health is immense. In some rural areas, long travel times and poor road conditions make driving to see a doctor prohibitive. In the Rural Healthy People National Survey, access to quality health services was the number-one concern for rural stakeholders. The rural population tends to be poorer and less educated, and shortages of healthcare providers are significant. Therefore, innovative healthcare strategies such as telemedicine will be critical in overcoming the tyranny of distance and isolation in caring for this population.

There is a general acceptance among patients, providers, and healthcare administrators that digital healthcare technology and telemedicine is a key part of the solution in achieving the Institute for Healthcare Improvement Triple Aim (population health, experience of care, per capita cost) and will lead to value-based healthcare. My own field of women’s health has seen the impact of digital medicine internationally. Short message service (SMS) text messages to patients’ cellphones throughout Africa remind patients about immunizations, nutrition, basic hygiene, and other important healthcare education topics. The World Health Organization has attributed achieving a 50 percent reduction in infant mortality to this technology in some areas of Africa. Within the Congo, Guatemala, Zambia, Kenya, and Pakistan, obstetric ultrasounds of women who have difficult pregnancies are performed, and the images are sent via Samsung smartphones to a central health facility where they are emailed to radiologists for analysis.

Within the United States, the Mayo Clinic published a study on remote prenatal care. In that study, 300 women deemed to have low-risk pregnancies were randomly assigned either to 12 planned office visits with a physician or midwife or to the Mayo Clinic’s “OB Nest” model of care, consisting of eight planned clinic visits with a physician or midwife, six virtual visits with a nurse by phone or email, home monitoring with an automatic blood pressure cuff and a hand-held fetal Doppler monitor, and access to an online prenatal community. Patient satisfaction was significantly higher in “OB Nest” group, and there were no differences in patient outcomes.

However, there are key public policy challenges in making telemedicine a reality in aiding underserved populations in America. Innovation in healthcare provision is often stymied by the precautionary principle, which is an aversion to assuming the risk inherent in trying new approaches. This leads to a shortage of capital going into funding and supporting healthcare information technology and innovation. The regulatory environment can be unpredictable and punitive, crushing startup companies before they have a chance to become successful. State-level regulations provide a significant barrier as well, with restrictive state-based medical licensing and scope-of-practice laws preventing the free flow of labor to regions in the United States with inadequate healthcare resources. State regulations make it difficult for healthcare providers using telemedicine to care for patients outside their state. At the federal level, digital health startups are regulated in a piecemeal fashion by the FDA, the FTC, and the Health Insurance Portability and Accountability Act, all of which makes it hard to develop a successful business strategy without the help of expensive legal aid.

It is my hope that programs such as that proposed by the FCC will provide the seed money that will enable healthcare providers to reach and serve those most in need through supporting innovation and technology in supplying healthcare.