How Digital Health Can Improve Outcomes for Rural America
This blog post is adapted from an independent study I advised this past semester with MBA student Jon Weiss (CBS ‘24).
Over 63 million Americans (19% of our country's population) are spread across the 97% of land defined as rural. These communities are defined by the US Census Bureau as any population, housing, or territory outside urban areas with under 2,000 homes or under 5,000 residents.
The vast distances and dispersed populations in these rural landscapes pose significant challenges for healthcare delivery. Traditional models of healthcare, reliant on physical proximity to medical facilities and specialists, often fall short in meeting the needs of rural residents. And it shows when you look at health outcomes.
We believe digital health has the potential to offer more equitable healthcare access, personalized care, and improved health outcomes for these often underserved communities. In this article, we’ll share:
The rural care gap
What's killing rural Americans
What’s driving these health disparities in rural America
Four opportunities for digital health startups to shape rural care
A call to action
Resources for founders
The rural care gap
Understanding the unique demographic and economic profiles of rural communities is helpful in addressing their specific healthcare needs. These areas are characterized by several distinct features, setting them apart from their urban counterparts in meaningful ways. Rural communities, on average, are:
10% older and aging faster. The average age of rural residents is 51 years, compared to 46 in urban areas. These communities are not only older, but also aging at a faster rate. Nineteen percent of the rural population is 65 years or older, compared with 15% in urban areas.
More dependent on public insurance and support. The average earning per rural worker is ~$35,000, 30% lower than their urban counterpart. As a result, rural areas have a higher qualifying rate for public coverage— in fact, rural Americans are 32% more likely to be on Medicare or Medicaid. This dependence is especially true for children, as almost half of children in small towns and rural areas are on Medicaid/CHIP.
More static, demographically. More Americans are opting to live in big cities. Over the past decade, a modest (>1%) decrease in the population occurred for the first time in rural communities, compared to a 6.4% increase over a similar time period for urban populations. From a demographics perspective, rural communities have seen less change than their urban counterparts and remain largely non-hispanic white (76%). The largest minority are Hispanics, making up 9% of the rural population.
Losing sites of care, and fast. Most common sites of care within these communities are rural health clinics and rural hospitals, and their fates are largely intertwined, as 40% of these hospitals have a clinic site. Of the ~800 rural hospitals, 190 have closed since 2005 and of those that remain, 600 — nearly one of three — are in danger of closing. Worst of all, this pace is accelerating, there were nine closures in the first 10 months of 2023, almost as many as in 2021 and 2022 combined.
Of the ~800 rural hospitals, 190 have closed since 2005 and of those that remain, 600 — nearly one of three — are in danger of closing.
What's killing rural Americans
Across each of the 10 leading causes of death, rural residents consistently see higher mortality rates compared to their urban counterparts, and these disparities become more pronounced when contextualized within the broader framework of healthcare access and socio-economic factors.
In 1999, the age-adjusted death rate in rural areas was 7% higher than in urban areas. By 2019, the difference jumped to 20%.
Chronic disease is a large driver of this disparity as rural areas see 21% higher age-adjusted death rates due to heart disease, 34% due to diabetes, and 48% for chronic obstructive pulmonary disease (COPD).
From the behavioral lens, unintentional injuries, the third highest cause of death (which includes drug overdoses), is 28% higher and suicide is 43% higher for rural areas.
What’s driving these health disparities in rural America
The disparities we described above are not merely incidental but are driven by a confluence of factors ranging from logistical hurdles to systemic shortages in healthcare resources. As we delve into the specifics, it becomes clear how these elements collectively impact the health and well-being of rural populations.
Delay of care, largely driven by distance
Rural patients on average travel twice the distance as their suburban and urban counterparts, and are more reluctant or unable to take time off of work. As a result, rural patients often delay seeking care, which can lead to a more complex illness and a sicker patient.
Primary care physician (PCP) shortages
As of September 2022, 65.6% of Primary Care Health Professional Shortage Areas (HPSAs) were located in rural areas. These shortages have been shown to lead to longer wait times, decreased quality of care, and potentially higher costs for patients.
Lack of access to specialists
Ironically, with a sicker population, the referral rate – the probability of a PCP visit resulting in a referral is 71% higher in non-rural than rural areas. Rural Health Clinics specifically have documented their issues on the matter; specialty care services were necessary for more than one in five (22%) of all Medicare beneficiary appointments in RHCs surveyed, but nearly two-thirds (64%) of all RHC respondents noted that they had difficulties finding specialists to whom they can refer their patients. This isolation can lead to disease progression, decreased quality of life and increased mortality for patients.
Behavioral health disparities
Behavioral health presents an even more acute challenge in rural areas compared to primary care. In fact, over 70% of rural counties do not have a single psychiatrist, and access to treatments for alcohol and substance use disorders is markedly limited.
Where access does exist, notable structural and quality disparities emerge. Rural treatment centers often face a shortage of highly educated counselors and are more likely to rely on public funding as non-profit entities. Consequently, these centers typically offer a narrower range of wraparound services and have fewer specialized treatment options.
Health literacy
Rural patients have lower health literacy rates (defined by the CDC as the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others). This barrier to communication can erode trust, which in turn decreases patient’s willingness to engage in care and healthy behaviors.
Higher prevalence of chronic conditions due to health-related behaviors
Simply put, the rural population is sicker. Prevalence rates for a range of chronic conditions—including High Cholesterol, High Blood Pressure, Arthritis, Depressive Disorders, Asthma, Diabetes, COPD, and Heart Disease—are notably higher (ranging from 10% to 32% more) in rural areas compared to metropolitan regions.
Much of this can be attributed to health-related behaviors prevalent in these communities. Rural residents are more prone to smoking, have higher rates of overweight and obesity, and tend to lead more sedentary lifestyles. These factors, particularly when they coexist, not only deteriorate the quality of life but also significantly contribute to increased mortality rates.
Four opportunities for digital health startups to shape rural care
So what are the opportunities for digital health founders to improve health outcomes in rural communities? We’ve uncovered four major areas.
1.Increasing PCP capacity and quality
Two major opportunities exist today aimed at increasing capacity for rural PCPs: telemedicine and the extension of the care team. The first driven by changes in regulations seen during COVID, and the second a change in the adoption of value-based care in the Medicare Advantage space.
We can’t talk about improving healthcare access without talking about telemedicine, which allows patients to be seen outside the walls of a practice. One of the pioneers of virtual care for rural practices, Sanford Health headquartered in Sioux Falls, South Dakota (whose patients span across 250,000 square miles) has saved roughly 25 million miles driven by patients by providing over 650,000 virtual visits in the last decade.
Based on the elderly populations and regulatory changes to the Medicare Advantage program, Medicare Advantage enrollment rates have almost doubled in rural areas. Value-based care— both for traditional Medicare (ACOs) and Medicare Advantage— has provided digital health companies an opening to tackle PCP capacity & quality issues. Most companies in this space hire patient navigation staff (either virtual or clinic-based) and use technology to ensure practices complete activities that unlock value based payments.
Companies such as Homeward Health, Main Street Health, and Oasis Health all play in this space with adjustments in their models around digital/physical engagement with patients.
2. Building better diagnostics and tooling to upskill PCPs
In rural areas where access to specialists is so limited, the ability to support PCPs in gathering precise information to aid in the detection, prevention, and monitoring of diseases becomes vital. Diagnostic tools are enabling physicians to get more out of their visits and can be pushed even further.
Telehealth, while very effective in eliminating distance for patients to access care, is limited by diagnostics. Companies like TytoCare aim to bridge the gap by providing tools to the home that can be used by non-clinical staff to help aid in diagnosis such as remote lung, ear, heart sounds, throat, abdomen, and skin. Their Home Smart Clinic tool layers AI to provide diagnostic support and enable better care and tracking of conditions such as asthma, COPD, and post-discharge.
Interconnectivity between physicians, in the form of consults, is also pivotal for helping physicians provide better care for their patients (check out this case study in NEJM). However, the current status of eConsults leaves much to be desired. One study showed 26% of specialists were dissatisfied with unclear clinical questions and the liability associated with providing medical advice for patients they have not examined. This is where the ability for AI eConsults to take a first pass becomes feasible.
3. Increasing access to behavioral health services
Behavioral health access is extremely limited in rural areas. In fact, 65% of rural counties do not have a psychiatrist. So the ability for digital tools to provide telehealth and integrations for their corresponding drug therapies is vital.
Mental health is currently the top funded clinical indication among digital health startups. But are these companies reaching rural communities?
Bicycle Health provides patients medication assisted therapy (MAT) using virtual interactions and a suboxone prescription sent to the closest pharmacy. Workit Health, which has both alcohol and OUD services, has a similar approach (using Naltrexone and Camprosate for treating alcohol dependence.)
The growth of alternative payment models, such as value-based care, will help unlock their full potential (state-funded initiatives such as CalAIM in California are covering the management of these patients.)
4. Better at-home monitoring tools
In January 2018 CMS first began reimbursing for remote patient monitoring (RPM), letting providers track and manage patients between visits using digital medical devices, such as weight scales, blood pressure monitors, pulse oximeters, and blood glucose meters. For the prevalence of chronic disease, these tools provide a very important ability for management of care that didn’t exist prior.
Tools for tracking the progression of chronic diseases aren't new, but their digital connectivity to communicate to a clinical team is very powerful. For example, heart disease is the largest driver of mortality and hospitalization in rural areas, and extremely disproportionate to urban areas. The most prevalent form of heart disease is heart failure; one driver of this mortality and hospitalization is an inadequate use and dose of guideline-directed medical therapy (GDMT). Cadence, a digital health company focused on RPM, was able to help optimize this dosage. Their in-home tools were able to meaningfully improve heart failure specific vitals and rates of GDMT in patients with heart failure.
In the diabetes space, Virta Health is a pioneer in their remote care model to combat diabetes, using a glucometer and a patient app that connects to a care team and provides personalized diet and coaching support. Their results have been overwhelmingly successful, showing a 31 lb weight loss, a 63% reduction in medication, and a 1.3% HbA1c reduction.
A call to action
In light of the profound healthcare disparities afflicting Rural America, the call to action for digital health founders is unequivocal and urgent. The statistics we've shared above are not just data points; they represent a clarion call for founders to help reshape the healthcare landscape in these underserved communities.
Let this be your mission: to ensure that no American, regardless of where they live, is left behind in the pursuit of health and wellness. This is more than a business opportunity; it's a chance to leave an indelible mark on our country by bridging the health divide. Onwards and upwards for all!