Differing Views on the Primary Barriers to Telehealth in Rural Counties

Drake and colleagues blamed rural America's poor access of health care on inadequate broadband service; however, Struminger and Arora questioned their theory that deficient Internet availability leads to a reduction in telemedicine in rural areas.

A study by Drake and colleagues, recently published in the Annals of Internal Medicine, has shown that poor broadband access limits the feasibility of telemedicine in rural counties. In response, authors Struminger and Arora pointed out that other factors — including more efficient telemedicine, changes in policy and regulation, and the adaptation of proven solutions — will have a greater effect than simply increasing bandwidth.

Drake and colleagues defined inadequate access to health care according to Medicare Advantage standards. They used Google Maps to calculate drive times from potential patients to each physician in IQVIA, which provides a comprehensive list of all physician offices. The researchers measured broadband access according to the countywide penetration rate, with a standard of ≥25 Mbps.

Related Articles

The study researchers found that broadband penetration ranged from 96% in urban areas to 82.7% in rural areas to 59.9% in Counties with Extreme Access Considerations, with access to primary care physicians following this trend. In particular, broadband penetration rate correlates with healthcare access.

“Inadequacies in broadband infrastructure have broader consequences than limited Internet access. Cost-benefit analyses of broadband and cellphone infrastructure expansions thus should consider the benefits of telemedicine and the pathway to care it provides,” Drake and colleagues stated. “Although telemedicine has the potential to address geographic barriers that result from long drive times to receive care, its potential will not be realized until the telecommunications infrastructure improves and public and commercial insurers develop and expand policies to reimburse telemedicine visits from patients’ homes, particularly in the most rural counties.”

Struminger and Arora responded that broadband access is only part of the equation and that it is nearly sufficient as is (eg, they contested the detriment that speeds for which <25 Mbps are responsible, as “cloud-based high-definition videoconference platforms function fully on a modest bandwidth of just 1.5 Mbps, 6% of the 25-Mbps FCC standard”).

They also distinguished between telemedicine and the broader opportunities of telehealth. They highlighted Project [Extension for Community Healthcare Outcomes (ECHO)], which has created virtual knowledge-sharing communities of physicians and healthcare workers to treat difficult conditions such as chronic pain, addiction, HIV, and hepatitis C. Project ECHO has provided telementoring and videoconferencing in New Mexico, a state with a majority of Counties with Extreme Access Considerations.

In conclusion, Struminger and Arora recommend the following: “We need to establish incentives for academic medical centers to provide continuing tele-education and telementoring… and to create incentives to encourage rural providers to participate. Second, as Drake and colleagues suggest, we should consider changing reimbursement policies that require patients to participate from hospitals or clinics for telemedicine consults. Third, we need to encourage states to liberalize policies that restrict interstate teleconsults and licensing. Finally, for remote areas without providers, we should consider proven models, such as Alaska’s Community Health Aide Program, developed with the express aim of better serving patients in remote communities lacking local physicians or advanced practitioner providers.”


  1. Drake C, Zhang Y, Chaiyachati KH, Polsky D. The limitations of poor broadband internet access for telemedicine use in rural America: an observational study [published online May 21, 2019]. Ann Intern Med. doi:10.7326/M19-0283
  2. Struminger BB, Arora S. Leveraging telehealth to improve health care access in rural America: it takes more than bandwidth [published online May 21, 2019]. Ann Intern Med. doi:10.7326/M19-1200

This article originally appeared on Medical Bag