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Rural Health Information Hub

Sustainability Strategies for Rural Telehealth Programs

There are several different strategies for sustaining telehealth programs that may be useful for rural healthcare systems and providers. The Rural Community Health Toolkit provides information about general Sustainability Strategies. Additional information about funding for rural telehealth projects and systems can be found in the Telehealth and Health Information Technology in Rural Healthcare topic guide.

Reimbursement for Telehealth Services

The Center for Connected Health Policy monitors the latest policies related to reimbursement rates for telehealth for Medicare, Medicaid, and private insurers.

The Health Resources and Services Administration's Medicare Telehealth Payment Eligibility Analyzer tool can also help communities determine their eligibility for Medicare reimbursements. CMS provides guidance to clarify reimbursement policies for Medicare fee-for-service providers. CMS also developed a booklet called Rural Providers and Suppliers Billing.

When planning for long-term sustainability, rural communities should be aware of the following considerations for reimbursements:

  • Parity laws at the federal and state level determine whether telehealth visits are reimbursed at the same rate as in-person visits.
  • Payers may also limit reimbursements for certain telehealth applications. For example, some payers may only reimburse live-video telehealth consultations, while others may also fund store-and-forward and remote patient monitoring services.
  • Reimbursement restrictions on provider type also vary from state to state. Eligible providers may include physicians, advanced practice clinicians, and other licensed healthcare workers.

Value-Based Payment Mechanisms

Some rural communities are financing telehealth programs through value-based payment mechanisms, such as accountable care organizations (ACOs), that value quality over volume of care. These programs seek to use telehealth to achieve quality, outcome, and cost targets, including reductions in hospital readmissions, lengths of stay, and transfers to larger care centers. For example, Oregon's Coordinated Care Organizations (CCOs) receive global budgets to integrate physical, behavioral, and dental healthcare for members. CCOs have invested in several telehealth initiatives to improve the health of Oregonians, including telemental health services, remote patient monitoring, and telementoring.

During the COVID-19 pandemic, some health care organizations were able to use the flexibility of value-based payment structures to quickly meet the needs of their patient population with telehealth.

Telehealth User Fees

A key feature of telehealth is connecting rural sites to remote providers and specialists. Some rural sites contract directly with a remote provider who can offer telehealth services. Other rural programs pay user fees to subscribe to a telehealth center, which is typically located in a larger hospital or academic medical center. The fees to connect to these telehealth services can strain facilities with limited budgets. Considerations for rural programs seeking to make the case for investing in telehealth user fees include:

  • Staffing flexibility – Telehealth allows some rural facilities to implement less expensive or more feasible staffing models. For example, some Critical Access Hospitals may have difficulty recruiting qualified physicians to staff emergency departments in rural locations. These hospitals may choose to instead recruit advanced practice nurses to staff emergency departments while using telehealth to enable access to remote case consultations and telementoring.
  • Return on investment – Rural communities can consider if the return on investment from telehealth services justifies the cost of paying for consulting fees. Factors that may affect return on investment include increased revenue from keeping patients in the community and billing for encounters. Programs may also consider cost reductions associated with traveling for professional development and conducting recruitment activities.
  • Alignment with mission of the facility or organization – Some rural programs may consider how telehealth allows them to work towards the mission or vision of their organization by improving quality of care, access to care, health outcomes, or patient satisfaction.

Working with Payers and Policymakers

Some rural communities may choose to work directly with policymakers, Medicaid officials, and private insurers to make changes to reimbursement policies and achieve long-term sustainability for their telehealth programs. Rural programs may consider approaching insurers to determine if they can use telehealth to achieve shared goals for improving outcomes and decreasing costs. For example, a private health plan interested in reducing diabetes-related hospitalizations might be willing to fund a remote patient monitoring program to improve patient self-management.

Rural programs may need to build relationships with state medical and pharmacy boards in order to address additional factors that affect telehealth sustainability, including regulations for licensure and certification. Rural programs may also consider joining or establishing coalitions in order to mobilize diverse stakeholders to support telehealth policies.

Resources to Learn More

CCHP Policy Finder
An overview of the status of state telehealth policies in the U.S. Primary topics covered include Medicaid reimbursement, private payer regulations, and professional requirements.
Organization(s): Center for Connected Health Policy (CCHP)

Facilitating Telemedicine Project Sustainability in Medically Underserved Areas: A Healthcare Provider Participant Perspective
Describes factors affecting the long-term sustainability of teleconsultation projects from the perspective of providers, and how project design can address these factors. Data was collected from interviews with clinicians, administrators, and information technology professionals working in fourteen telemedicine projects within two telemedicine networks.
Author(s): Paul, D.L. & McDaniel Jr., R.R.
Citation: BMC Health Services Research, 16, 148
Date: 4/2016

A Review Of Quality Metrics And Reimbursement For Telehealth
Presents an overview of quality metrics and reimbursement strategies supporting the expansion and maintenance of telehealth programs. Identifies methods to design quality metrics, demonstrates how to use quality and revenue data to support telehealth programs, and highlights reimbursement strategies to promote growth.
Author(s): Hager, M.
Organization(s): Upper Midwest Telehealth Resource Center, National Consortium of Telehealth Resource Centers (NCTRC)
Date: 12/2020

State Telehealth Laws & Reimbursement Policies – State Summary Chart
A chart highlighting key telehealth policies by state. Categories include Medicaid reimbursement, private payer reimbursement laws, and professional requirements including interstate compacts and consent.
Organization(s): Center for Connected Health Policy (CCHP)
Date: 5/2022

Telehealth Essentials For FQHCs And RHCs
Provides suggestions for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to maximize their resources to promote remote healthcare delivery. Helps FQHCs and RHCs learn from other telehealth programs and be aware of the important changes needed to support sustainability
Organization(s): Southwest Telehealth Resource Center (SWTRC), National Consortium of Telehealth Resource Centers
Date: 11/2021

Telehealth Service Implementation Model (TSIM™): A Framework for Telehealth Service Development, Implementation, and Sustainability
Describes the Telehealth Service Implementation Model (TSIM), a framework supporting providers and health systems in their development and implementation of telehealth services. Defines a phased approach in four stages: strategy, development, implementation, and operations, and concludes with quality improvement.
Organization(s): Medical University of South Carolina (MUSC) Telehealth Center of Excellence
Date: 2021

A Toolkit for Building and Growing a Sustainable Telehealth Program in Your Practice
Provides a comprehensive approach for family medicine practices as they progress through the telehealth process. Reviews telehealth services and payment options, considerations for achieving sustainability, and offers a variety of scenarios for implementing telehealth into family practice.
Organization(s): American Academy of Family Physicians (AAFP), Manatt Health
Date: 9/2020