[dropcap]A[/dropcap]s dust settles from the Affordable Care Act’s first open enrollment period, one thing is becoming clear: care still isn’t so affordable, or accessible, for rural Coloradans. Lawmakers are working to find out if the ACA has prompted hikes in rural health care costs or simply brought higher rates into clearer view as more rural Coloradans look for coverage, which long has been more expensive than in urban communities.

The immediate problem: pricey insurance

There have always been fewer – and, therefore, often more expensive — insurance options in the state’s rural and mountain areas. Insurance rates for Colorado’s resort communities, most of which fall into what’s referred to as Region 11 by the state’s Commission of Insurance, have skyrocketed. In Summit County, for example, folks seeking health insurance recently encountered rates on the state’s healthcare exchange that exceeded 30 percent of their income.

Vincent Plymell of the Division of Insurance said that while insurance rates have risen in Summit County, comparing rates before and after the ACA rollout isn’t apples to apples. Plans under the ACA are required to be of a certain quality, which can cause them to cost more.

Plymell also pointed to the ACA’s breakdown of each county’s health costs, which shows that in tandem with rising rural insurance rates has been a rise in health care costs overall for rural residents and the privately insured. For example, in 2009 the Total Cost of Care — which combines how much a patient and their insurer pay for treatments — per person in Summit County was 36 percent higher than in Denver. By 2012 those average health care costs were 61 percent higher in Summit than Denver County. The ACA allows insurers to adjust their rates based on geographic region precisely because of underlying cost drivers like this, so at least part of the jump in premiums is tied to that very real increase in the cost of health care.

State Sen. Gail Schwartz of Snowmass is worried about the cost of insurance in her district particularly because the ACA doesn’t require people who can’t find an insurance policy that costs less than 8.5 percent of their income to enroll.

As the legislative session hurtles towards its May conclusion, Schwartz says she’s actively working with Colorado’s Commissioner of Insurance, Marguerite Salazar, to find tax dollars that might help people in high-cost communities get state-funded subsidies for their care even if they make more than 400 percent of the federal poverty line. That benchmark, which is the current cut-off point for both state and federal insurance subsidies, is just over $78,000 a year for a family of three.

Even if state officials are able to find funding for a targeted, state-level subsidy for people who can’t find affordable policies, Schwartz said it would be a short-term fix. The long-term fix would be to find out exactly why rural health care is so expensive and to put in place innovative ways to cut costs while ramping up accessibility.

The big problem: high cost, limited care

A complex constellation of factors contributes to higher healthcare costs in rural areas. Gretchen Hammer, executive director of the Colorado Coalition for the Medically Underserved, said the population in those parts of the state is disproportionately older. That means there’s more often an increased need for more expensive care. She noted that rural areas also have a higher ratio of people employed in physically challenging or even dangerous work — from mining and fracking to farming and forest services — as well as lower-income families and people who don’t get insurance through work. In addition to those cost drivers, there’s little to no competition for rural doctors and hospitals to keep their prices low because they’re very often the only providers in town or even the county

A recent study of Colorado’s primary care workforce by the Colorado Health Institute found that the state needs roughly 250 more doctors to meet the needs of under-served populations — most of which are in rural and mountainous areas.

On the eastern plains, patients outnumber their doctors 5,000 to one. That is about the same ratio at which patients out number doctors in Afghanistan. In Denver that ratio is just over 1,300 to one. The Health Institute estimates that a single primary care doctor working full time can reasonably serve only 1,900 patients.

Acknowledging that recruiting rural primary care doctors is a major priority for the state, Sen. Irene Aguilar, whose is a Denver doctor, carried a rural residencies bill this session to study just what kind of providers are needed in rural areas and to get a recommendation from the Commission on Family Medicine about how to recruit and retain them. On the back end, Aguilar’s rural residency bill is also supported by budgetary allotments that would allow the commission to open up more spots for would-be rural docs.

“There’s great evidence that if you train in a rural area, you’re more likely to stay there,” said Aguilar. She also noted that with medical school class sizes growing far faster than residency opportunities, there’s no shortage of medical students applying for rural residencies. In fact, in last year’s round of matching — the process in which brand new doctors are paired with training hospitals — some 500 medical school graduates nationwide were unable to find a residency at all.

The plan is to train more doctors in rural hospitals, but it’s hard for rural hospitals to afford residents because they can’t recoup much of those costs when many of their patients are on Medicaid or uninsured. To offset some of that burden, Aguilar advocated for a state budget line item this year to direct $1.5 million in funds to rural residencies — dollars that would be matched by the Medicaid program. Aguilar says the combined $3 million dollars would help add as many as six rural residencies in the state this year, bringing the total up to nine.

The problem, however, isn’t just recruiting future doctors to train in rural areas or hiring new doctors to serve there. Though both the national and Colorado Rural Health Service Corps will repay medical school loans in exchange for a newly licensed physician practicing in an underserved rural or urban area, it’s still tough to keep doctors living and working outside of metropolitan areas once they’ve served their time paying off their education.

“We spend a huge amount of money recruiting rural physicians only to have them stay for just 3 to 5 years until their loan repayment is up,” said Melissa Bosworth of the Rural Health Center. “Our average retention rate is 39.7 percent, which is extraordinarily low.”

Part of the reason many doctors don’t want to spend their careers in the countryside is the risk of professional isolation. Sometimes serving an entire county or more, rural doctors are responsible for treating a huge range of patients with diverse needs – without support, experts in specialized areas and comradery to hone their medical skills. Several counties in Colorado have no primary care doctor at all, much less specialists ranging from mental health providers to neurosurgeons.

New tools, just waiting to be used

Fortunately, technological advancements could address both professional isolation and the lack of physicians and specialty care providers in rural Colorado. New means by which to treat patients via telecommunications systems could, in turn, bring down some of the cost of rural healthcare by giving rural residents more options when it comes to picking their doctors and the ability to reduce travel time and mileage. Ultimately, the advances also could eliminate the need to build or maintain some hospitals and medical clinics.

Just last week, the House approved a slew of telecommunications bills aimed at pushing high-speed broadband out to all of Colorado’s rural communities. This coincides with ongoing advancements in “telehealth” — an umbrella term that refers to the increasing digitization of healthcare, enabling doctors to share patient information and knowledge with each other. Colorado also is making advancements in “telemedicine” — direct online doctor-patient care such as diagnoses and follow-ups. Let’s say, for example, a rural patient has psoriasis. With telehealth-enabled healthcare, he or she would be able to videoconference a dermatologist who could then prescribe a topical medicine delivered to the patient by mail. That would be a radical departure from what might currently be a several-hour drive, coupled with the potential for an out of network co-pay.

Last week, members of Colorado’s Telehealth Working Group — which includes tech-heads, hospital administrators and physicians — gathered at Colorado’s sold-out Digital Health Summit to talk about what can be accomplished via telehealth and what’s preventing these new high-efficiency care tools from being used.

Megan Canter, the Director of Telemedicine for Denver’s HealthONE, told the story of an 83-year-old woman in rural Kansas who came into her community’s small critical access hospital unable to speak and with numbness spreading throughout the left side of her body. Within 15 minutes, the nurse on duty used her hospital network’s telehealth resources to videoconference a neurologist in Denver, who identified that the woman was having a stroke and advised the nurse on how to treat her.

“If that neurologist had not been there to administer that life-saving pharmalytic, which busted the clot in her brain, who knows what would have happened. She probably would have gone the rest of her life with out speaking,” Canter said.

Big hospital networks like HealthONE and Colorado Children’s, as well as closed systems such as the Veterans Administration and the Department of Defense, are already wading into the world of telehealth. But they’re not wholly able to synchronize treatment or provide consistent services Coloradans because they lack the regulations to insure patient privacy, allow doctors to provide care over wide areas and make sure that physicians get paid for their work.

“People think technology is the barrier. Let us assure you that it is not the barrier. It’s well defined. We have good tools. … Reimbursement in this country is a barrier,” said Samantha Lippolis, the telehealth manager for Centura Health.

Currently, there are some reimbursement possibilities for doctors who provide telemedicine to patients who live in counties with less than 150,000 people. Even so, not all reimbursement is equal and some insurers apply geographical restrictions while others don’t. All reimbursable care must also be live audio-visual interaction. That can create a technical barrier for patients who don’t have broadband in their homes.

Rural health centers like critical access hospitals and clinics, on the other hand, usually have robust broadband connections. Using federal dollars, the Colorado Telehealth Network went live more than three years ago with 195 secure broadband sites in rural hospitals and clinics. That technology since has established an imaging exchange that saves rural hospitals money on sending x-rays and the like into the city for analysis by currier.

 Despite technological advancements, federal patient privacy requirements hinder rural-urban medical collaborations. Wider use of telehealth and telemedicine nearly grind to halt because of administrative challenges involving how to pay doctors and specialists for the services they provide each other and not directly to patients. In practice, the implementation of the new technology is severely hamstrung by red tape.

“In the grand sense, we’re trying to make telehealth encounters equal to in-person (visits), regardless of whether the patient is on Medicare, Medicaid or private insurance,” Colorado Telehealth Network’s Ryan Westberry said of his working group’s legislative goals. That means developing and advocating legislation that would set up a “super bill” program allowing providers to bill for the administration of telemedicine like they would in-person consultations and for online specialty consultation like they might bill lab work.

That kind of regulation is being discussed, Westberry said, but it’s certainly not an issue state lawmakers will tackle any time soon. Legislation that would make FaceTime with your favorite nurse practitioner private, secure and a regular part of her job may be a year or so off — and would require potentially drawn out federal action, as well. In the meantime, Colorado’s digi-docs want Coloradans to know that telehealth technology is already here and that, as a matter of public policy, it’s time to start using it.

“It’s not different or substandard care,” said Fred Thomas, director of telemedicine at Children’s Hospital Colorado. “The idea for telehealth and telemedicine is to add another tool to the clinician and the educator’s toolbox.”

 [A critical access hospital in Del Norte, Colorado. Photo by The Neenan Company]