5.
Expanding Rural Access
University of Mississippi Medical Center
We use technology in all areas of our life. Think about it—in banking, in retail, or with travel. We are a tech-savvy population. Why don’t we leverage technology to transform health care?
—Dr. Kristi Henderson, UMMC
Five miles into the frantic race to the hospital, fourteen-year-old T. J. Brewer looked up from his stretcher in the back of the ambulance and told his mother and father that they had been great parents. He told them he loved them, and he told them goodbye. Bleeding profusely from a chest wound, T. J. was convinced that he would die from the shooting accident in the fields behind his house in rural Richton, Mississippi.
There was good reason for his fear: Perry County Hospital, where the ambulance was headed, had neither the expertise nor the equipment to treat a gunshot wound to the chest. It had no surgeons—in fact, it had no board-certified physicians of any kind. But the hospital did have something that could give T. J. a fighting chance. It had a live video connection linking its emergency department to some of the best emergency doctors in the state, who were a two-hour drive away at the University of Mississippi Medical Center (UMMC), in Jackson.
As the ambulance arrived at the hospital in Richton, a UMMC emergency team slid in front of a TV monitor in Jackson and began talking and gesturing, showing a Perry County nurse practitioner exactly how to treat the wound until T. J. could be transported, first by ambulance and then by helicopter, to the critical-care unit that would save his life. During the ordeal, T. J. lost thirty-four units of blood and his heart stopped three times, but the boy survived, because Perry County Hospital, in the little town of Richton, population 1,088, was one of several spokes on a hub-and-spoke telemedical network born of the determination of one emergency-care nurse in Jackson.1
The nurse was Dr. Kristi Henderson (her doctorate was in nursing practice), the daughter of a longtime Mississippi family, who saw a life-threatening problem and devised a high-tech solution to fix it.
Henderson led the development of a homegrown hub-and-spoke telemedicine network—a remarkably Indian-like response to a serious problem of American health-care delivery. In Mississippi, the state that consistently scored at the bottom of US health rankings, access to health care was seriously constrained by a shortage of doctors and by poorly distributed resources. As in India, the underlying problem was poverty. As in India, medical resources were scarce. As in India, solutions emerged from the bottom up, in this case led by a “nursepreneur” who would not take no for an answer. And as in India, a hub-and-spoke telehealth network improved access to health care for poor rural communities, while lowering costs and improving quality and patient experience. It was a powerful example of value-based care.
In 2017, UMMC was selected as one of only two Telehealth Centers of Excellence in the United States by the Health Resources and Services Administration (HRSA), an agency of the Department of Health and Human Services. HRSA, as it detailed in its call for applications, expected each Telehealth Center of Excellence to “serve as a national clearinghouse for telehealth research and resources, including technical assistance. To achieve that goal, the Telehealth Center of Excellence should have substantial experience operating a telehealth program that offers a broad range of clinical services and has experience demonstrating how [its] efforts have improved access to care and enhanced health outcomes for [its] patients.”2
Hub-and-Spoke Model
T. J. Brewer’s life was saved on New Year’s Day 2008, when the University of Mississippi Center for Telehealth was just five years old. Since then, the network has expanded far beyond emergency care. In 2017, Mississippi Telehealth connected specialists in thirty-five fields of medicine with medical staff and patients at 225 sites across Mississippi, including not only community hospitals and clinics but also mental-health facilities, schools and colleges, businesses, prisons, mobile health vans, and even some oil rigs in the Gulf of Mexico. It also linked to hundreds of private homes, connecting patients suffering chronic diseases such as diabetes and hypertension with a team of chronic-disease experts. Today, Mississippi Telehealth is widely recognized as a pioneering model for rural telemedicine delivery, ranked in 2015 by the American Telemedicine Association as one of the seven best programs of its kind in the country.3
In 1999, Henderson managed the nonphysician staff in the trauma center at UMMC, the only level-1 trauma center in the state. She handled the budget, oversaw operations, and tracked quality and patient satisfaction. She knew trouble when she saw it, and she saw it every day: emergencies that couldn’t be handled where they happened; local emergency departments staffed by a family physician or nurse practitioner; community hospitals with no imaging equipment; local hospitals on the brink of bankruptcy; bottlenecks, backlogs, and long waits for patients in Jackson when the beds were full.
The underlying problem was obvious. “We needed to get the existing medical resources and expertise out into the rural areas,” Henderson told us. “I thought we could train community-based nurse practitioners and use videoconferencing to comanage the emergency cases. We jumped in with both feet to a 24/7 operation for emergency care, and it just grew from there.”4
Henderson, driven by a strong sense of purpose, built her hub-and-spoke delivery network with UMMC at the center, and leveraged technology to connect the hub with the spokes—similar to what HCG Oncology and Narayana Health did in India. The best doctors, specialists, and equipment were housed in the hub at UMMC, while the spokes in the small towns were staffed by generalists and supplied with basic equipment. And it worked as well in Mississippi as it did in India. Thirteen years in, the telehealth network that Henderson first imagined in 1999 had recorded more than 500,000 patient contacts.5 The telecommunications equipment, which started out as TV sets hooked up to T1 lines, grew to include wireless communication with computer tablets in the homes of the chronically ill. Those tablets recorded health data that aided in the local treatment of more than 100,000 rural patients a year, whose health outcomes rivaled those of patients seen at the UMMC hub in Jackson.
The hub-and-spoke telemedicine network was also a great boon to local hospitals. It reduced the need for patient transfers, increased local hospital admissions by 20 percent, and cut physician staffing costs by 25 percent.6 Several hospitals that had been headed for closure were spared.
Limited Access in the Magnolia State
Mississippi has one of the lowest standards of living in the United States. In the mid-2010s, it had the lowest median household income of any state, and roughly 21 percent of its three million residents lived below the federal poverty line, including 246,000 children. Twenty-one percent of the adult population held a bachelor’s degree, and more than half the people lived in rural communities where resources and opportunities were limited.7
The states of health and health care were especially disheartening. Mississippi had ranked at or near the bottom of United Health Foundation’s state health rankings for twenty-five years. The 2016 rankings reported that Mississippi had the worst infant-mortality and premature-death rates in the nation, the highest rates of diabetes and cardiovascular deaths, the second-highest incidence of cancer deaths, and alarming numbers of people reporting “frequent physical or mental distress.”8
Health-care delivery was long a big part of the problem. In a 2015 Commonwealth Fund ranking that looked at forty-two health-care metrics, Mississippi came in last. That year the state had fewer primary care doctors per capita than any other state and only one top-tier hospital: UMMC. Twenty-two percent of the adult population under sixty-five had no health insurance, and Mississippi had the largest percentage of adults who went without medical care because they could not afford it. On measures of access, prevention and treatment, avoidable hospital use and costs, healthy lives, and equity, Mississippi consistently scored at the bottom of the charts.9
In 1999, when Kristi Henderson began her work, the disparity between medical care at UMMC and care in the rural parts of Mississippi was shocking. Several counties didn’t have a single physician. The entire state had just ninety-nine acute-care hospitals, three-quarters of them in rural areas. Many of those facilities were critical-access hospitals—that is, hospitals with fewer than twenty-five beds, located more than thirty-five miles from another hospital. They had no medical specialists on staff, performed no surgeries or deliveries, and could provide inpatient acute care only on a limited basis by law. In 1999, not one of these critical-access hospitals even had a ventilator.10
Community hospitals, the next level of rural health-care facilities, were better staffed, often with a cardiologist and pediatrician as well as an internist, but not with the kinds of skills and knowledge needed for emergency situations or specialty care. For many rural hospitals, the expertise gap was filled by locum tenens, doctors who would fly in, work for a couple of days, and fly out, often leaving behind as many problems as they solved. It was expensive, inefficient, and it did nothing to build bonds of trust between the hospital and the community. For chronic-disease patients, especially, reliance on locum tenens was unsustainable.
“We were seeing people come in from all over the state who had bad outcomes because of inconsistent care and delays in care,” Henderson says. “The health-care system isn’t easy to navigate and doesn’t make it easy for us to be healthy or manage our own health. That’s magnified in a state like Mississippi, where sixty-five percent of our patients have to drive over forty minutes to see a specialist.”
To us, Mississippi looks a lot like India: the large rural population, the widespread poverty, the shortage of doctors and medical equipment, the prohibitive distances to high-quality hospitals and specialists, the unequal access to care. It’s a system of haves and have-nots, a system working poorly, a system ripe for innovation.
Leveraging Technology
As Henderson looked out over the workings of her busy emergency department, she noticed something different. She noticed that every day, the most highly trained specialists in the state were sharing their valuable medical knowledge with the nurse practitioners in the ER, helping the nurses manage their emergency patients.
She wondered: Why did it have to stop there?
“I felt this need to share what we were doing,” says Henderson. “I thought we could expand it for more people. I had a path and somewhere I wanted to go. I just made a list of what I needed to check off to get there and just kept doing it.”
Henderson also had the vision to see how technology could be used to replicate the live knowledge-sharing she saw every day at UMMC. Instead of sending trauma patients on hours-long trips to Jackson, or sending locum tenens on jitney tours of the countryside, the resources of Jackson would be transmitted to local hospitals on T1 lines, both audio and video, in real time, and handled there by specially trained nurse practitioners. Only those patients who needed extra special care would be brought to UMMC. It was a clever idea, one that delivered quality health care through a hub-and-spoke system of telemedicine.
“The whole thing was based on necessity, really,” Henderson says.
We looked at the challenge: We have only these resources, so how are we going to provide health care? The only way to do that was to use simple videoconferencing technology to connect the resources and bring them there virtually. At the other end, in the rural hospital, we would use the health-care professionals who were in the community. Instead of trying to convince a high-price medical specialist to live in Belzoni, Mississippi, for example, we’d use the family doctors and nurse practitioners who were already there. We would make the best of what we had.
Henderson worked closely with her boss, Dr. Robert Galli, who encouraged her to draft a proposal for a network that would run a T1 line from the emergency department in Jackson to community hospitals, as a proof of concept. She consulted the American Telemedicine Association, which had come into being six years earlier and from which she gained insight from the pioneers in the field. While the association offered many examples of telemedical services, none of those examples had involved emergency care, as Henderson hoped to provide. Moreover, the equipment used by other members of the association was expensive. The monitors and software cost tens of thousands of dollars apiece. Henderson figured she could put together something cheaper, and she knew that technology would get better and less expensive every year.
Henderson and Dr. Galli, along with Greg Hall, the team’s technology wizard, ramped up their knowledge of technology procurement, consulting with medical experts to identify equipment that was reliable, affordable, and easy to use. Henderson then pitched her idea to telecommunications providers AT&T and C Spire, with whom the state had a special rate. Henderson, Galli, and Hall bought television sets off the shelf and connected them to the T1 line. They weren’t fancy TVs, either.
“We literally had those old-fashioned box TVs on carts,” Henderson remembers. “When I look back at pictures it’s pretty comical. I didn’t have any model to go by.” To make sure the system would provide adequate resolution over long distances, university faculty tried connecting it via satellite phone to the most distant place they could think of: a medical outreach location in Kigali, Rwanda. Success.
Henderson was cheered, but she knew technology would not be her biggest challenge. That would be the health-care system itself, and her concern was justified by the caution with which the hospital and medical establishment approached the project. “This wasn’t what they learned how to do,” Henderson explained to us. “The business model was one that brought people to the hospital and to the clinic. It didn’t push it out into the communities and to the homes.”
Skepticism and Pushback
For three years, from 1999 to 2002, Henderson inched her way over that barrier. She met with members of state medical and nursing boards, explaining the potential of telehealth to regulators, many of whom were disinclined to change things despite the obvious deficiencies in the system they oversaw. Some fretted that medical care could never be truly effective without hands-on contact between physician and patient. Others worried about the reliability of the technology, and about the capabilities of nurse practitioners.
At the time, the practice environment for nurse practitioners was limited, and Henderson, herself a nurse practitioner, wasn’t surprised that an attempt to expand their purview would meet with resistance, from both physicians and nurses. But Henderson knew that, working with the academic medical center, she could create a training program that would expand the skill sets of rural nurses and take advantage of their invaluable local knowledge and their hard-earned patient trust.
Other doubters, while enthusiastic about the potential of telemedicine, worried about starting the service with emergency care, an area where there was little room for mistakes. But the most widely voiced concern was that UMMC would steal local practitioners’ patients.
“That was the exact opposite of what we wanted to do,” says Michael Adcock, the administrator who ran the Center for Telehealth at UMMC. “We were trying to keep the patients in the community and keep them close to home. We wanted patients to come to UMMC only if they absolutely had to, and in most cases, they didn’t.”11
“There were just a lot of naysayers,” Henderson remembers.
Henderson designed an extensive program to teach medical generalists and nurse practitioners to better recognize and treat emergency patients. She didn’t cut any corners. The program had a curriculum and a clinical residency provided by the faculty in the department of emergency medicine. It had written exams and clinical check-offs. It required each practitioner to perform certain listed procedures under supervision, with a final check-off in the trauma center. All ER patients were covered.
In 2002, the boards and Henderson finally came to agreement: Henderson and her team could wire up three hospitals with the medical center, if they agreed to send quarterly reports of patient outcomes to the boards. More good news followed. The TelEmergency program, as Henderson’s brainchild was then known, was given a startup grant of $260,000 from the private Bower Foundation. In October 2003, the network went live. Henderson was off and running.
Purpose: Social Heart and Business Brain
Over the next eight years Henderson built a hub-and-spoke telemedicine network on hard work and persuasion. She had no dedicated staff and no hospital budget line, but she had perseverance and a strong sense of purpose. Henderson will say she just did what she had to do, but Adcock says she just refused to take “no” for an answer.
“She is a steamroller,” Adcock says. “She believed it was the right thing to do, and she was going to make it work, and that’s what she did.”
Funding was tough, but once the three-spoke pilot was underway, money started to come in. Not big money from private-equity investors or plum grants from the National Institutes of Health or the National Science Foundation. But money nonetheless. In 2004, the Bower Foundation came through with another $405,000, and in 2006 the United States Department of Agriculture (USDA) made the first of many contributions that over the next several years would add up to $2.4 million. (Why the USDA? Because it is concerned about rural development and gives grants for rural telecommunications.) Henderson also got help from the Federal Communications Commission, through the Rural Health Care Program of the agency’s Universal Service Fund.
The money went into training and to building out the spokes of the network. Henderson met regularly with representatives of AT&T and C Spire, not only to arrange for new T1-line connections but also to learn where the companies’ newer, high-speed lines were being laid. Henderson traced those lines to the nearest critical-access and community hospitals, and then drove across the state to those hospitals to make her pitch.
That pitch included a hybrid payment system that Henderson devised because insurance companies in Mississippi did not, at the time, reimburse providers for telehealth services. The system worked like this: insurers reimbursed the local receiving hospitals for the services provided locally, such as lab tests, use of the facility, and the nurse practitioners’ time, and the local hospitals in turn paid UMMC a monthly “clinic fee,” based on hours of remote consultation, to cover the services of the physicians taking the calls in Jackson. It was a clever solution, and proof that a hub-and-spoke model for health-care delivery could work in parallel with a traditional fee-for-service payment system.
Rural hospitals began to sign up, and the network began to generate both cost savings and revenue. More and more patients treated by the TelEmergency network were discharged directly from the receiving hospital (57 percent by 2013). Others were transferred to better-equipped area hospitals (22 percent in 2013).12 And the rest were admitted to local hospitals, where their stays—instead of costing $10,000 a day, as would have been the case at UMMC—cost $7,500 a day at community hospitals and less than $5,000 at critical-access hospitals.
“It was much cheaper for patients to stay where they were,” says Adcock. “At Jackson, we were constantly full. We’d much rather that patients were taken care of somewhere else. It freed up a bed for someone here who really needed it, like a complex trauma victim or a kidney-transplant patient, and it filled beds in the local hospitals, which often had too few patients to sustain the operation. It was a win-win all the way around.”
In this way, the network was built out in hops and skips, aided by positive reports from participating hospitals. It was also aided by Henderson’s wide-ranging vision of what value meant in value-based health-care delivery. It wasn’t only the lifesaving value of medical care for the trauma patient—although that was the original impulse. It wasn’t just the cost-saving value to the patient, either. It was also the hospital-saving value to Mississippi’s beleaguered health-care system and rural communities.
“We ended up bringing some of those small critical-access hospitals to a different level,” Henderson says. “It became much more than telemedicine consults. It became a relationship where we really supported these hospitals any way we could. It became a system that brought together what typically were competing hospitals to work together to fill each other’s gaps.” As she told Telemedicine magazine in 2015: “When they had to deal with those high-risk but low-frequency patients, the poisoned child or the near-drowning victim or the survivor of a multi-car accident, we were there for them.”13
Expanding the Network beyond Emergency Care
This hospital-saving value was magnified in 2008, when UMMC began to add specialties other than emergency care to the telehealth network. The TelEmergency network now had a modest infrastructure and a dozen participating hospitals. UMMC also had a separate store-and-forward system in place that allowed rural hospitals to send cardiology images to Jackson to be read by specialists there. Why not use all that capacity to deliver other specialty services to the rural hospitals electronically?
Expanding the service offerings would solve another problem that Henderson had noted. Many rural clinics routinely referred their patients to Jackson for specialist care—cardiology checkups, dermatology consultations, and so on. Henderson identified the clinics with the highest such referrals and paid them a visit. “We’d say, ‘Hey, a large number of patients from your town are coming to see our cardiologists,’” she remembers. “‘How about we partner and the patients stay there, and we’ll bring the cardiologist to your clinic virtually?’”
As the network grew laterally, adding clinics and hospitals in town after town, UMMC also expanded the menu of service offerings, starting with telepsychiatry in 2008. Next in were radiology, pathology, and cardiology and, in a later wave, ophthalmology, obstetrics, neonatology, dialysis, dermatology, and pulmonology. In 2011, UMMC officially launched its Center for Telehealth, which rolled the original TelEmergency program in with all the new telemedicine services.
In expanding the services, Henderson was careful not to cannibalize rural specialists’ practices. Before proposing a telelink, she would comb state records and map out where specialists were already practicing. Where there was coverage, she backed off. Where there was a gap, she’d step in.
“We’d find a region of six counties where none of them had a dermatologist,” she told us by example. “Then we’d find a couple of clinics to contract with to provide that service. That way we didn’t have pushback. We were enhancing, not taking away. I wanted to build a model of collaboration.”
As the service offerings diversified, payment arrangements evolved. Mississippi insurers still didn’t pay for telehealth consults, so the spoke hospitals continued their monthly payments to UMMC, but that fee was customized to the particular services for which the hospital or clinic contracted. While all spokes paid an “administrative fee” to cover UMMC’s technology and support costs, each also paid a “clinic fee” based on the number of specialty services and consult hours it would use, with charges calculated at fair market value. And as the network grew, the administrative share of the cost decreased, and the savings were passed on to local hospitals.
“We worked hard to get the costs and benefits right,” Henderson says. “I’m not going to say it was a rose garden. There were plenty of times I thought I would be escorted out of meetings.”
But Henderson had pulled off a kind of health-care trifecta: The community hospitals benefitted from the opportunity to perform the lab or diagnostic tests locally. Their patients benefitted because they didn’t have to travel so far to see a specialist. And the specialists in Jackson benefitted because they received a monthly take from the clinic fee.
The new telehealth business also bolstered the bottom lines of many smaller hospitals, saving some such hospitals from closing, and it made many rural communities more attractive to new businesses, whose CEOs had been reluctant to move their employees to a health-care wasteland. Before long, the state was using UMMC’S telehealth network as a selling point when recruiting new business to Mississippi.
“What Kristi did empowered our community hospitals to provide better care to their local population,” says Ryan Kelly, executive director of the Mississippi Rural Health Association. “That allows more of those patients to stay close to home and to receive lower-cost care with often better outcomes. It’s a win-win for everyone.”14
The Nursepreneur Plunges Ahead
All our value-based exemplars, both Indian and American, were shepherded to prominence by the most powerful person in the organization: founders, CEOs, physicians and surgeons, usually educated at world-class universities—and, not incidentally, all men. For an innovator, Henderson was an outlier: a nurse, a woman, Alabama born and Mississippi bred.
But Henderson had the great advantage of understanding the cultures at both ends of her network: she knew the UMMC hub like the back of her hand, yet she was sympathetic with the plight of nurses and nurse practitioners in the spokes. She also had an open mind. Not having been anointed in the most hallowed halls of medicine, she was unmoved by the objection she often heard in the corridors of power: “That’s not the way we do things here.”
Indeed, Henderson’s hub-and-spoke solution to health-care delivery was at odds with the model that most big-name US hospitals embraced. That delivery model, the build-and-brand solution, involved building out each hospital’s own physical capacity, either by adding beds and clinics at the hub, or by gobbling up community hospitals and duplicating services in those satellite locations. In this way, hospitals hoped to leverage their big-name brand to attract customers and crowd out the competition, maximizing their bargaining power with insurance companies.
The build-and-brand model had its critics, including Ellen Zane, CEO emeritus and vice chair of Tufts Medical Center. “There is a mentality among a lot of old-fashioned hospital CEOs that is very oriented toward ‘bigger is better,’” says Zane. “They like lots of bricks and mortar, and they like being able to pound their chests about their hospital being all things to all people. These hospitals need to understand that not everybody should do everything.”15
Still, UMMC’s hub-and-spoke telehealth system had some challenges that build-and-brand expansions didn’t have to face. One was data sharing—a mission-critical function that not only raised all kinds of HIPAA concerns but also posed many logistical problems. In the early 2000s, electronic record-keeping was new in the United States, and there was no centralized repository for patient information or even a shared billing system. With the exception of two sister hospitals to UMMC, all the partner hospitals in the Mississippi Telehealth system were separate businesses, some run by counties and others by large health systems, each with its own budget and record-keeping system. Henderson felt she needed to keep things simple, so she elected to share only those records that absolutely had to be shared and then wait for a better solution to arise from federal mandates and market pressures.
Over time, improved technology and bandwidth made data transmission more manageable. It also made computers, monitors, and software more affordable. “Everything has gotten smaller, lighter, faster, and cheaper,” says Adcock. “The fifty-five-inch monitor that would have been $10,000 back in the day is now $500 or $600. Resolution is much better, and storage has gone way, way up.” Reliability improved, too. By 2013, network downtime due to technical problems fell to 0.00025 percent across the Mississippi Telehealth network. As the network grew, Henderson saw efficiencies of scale, and the costs of each spoke continued to decline, allowing UMMC to further lower the fees for participating hospitals and clinics.
“One of the things we learned was that to get adoption, it has to be easy,” Henderson says. “It has to be something that proves to have real value, not only in its clinical impact but also in efficiency, and it has to be financially sustainable. There are such cultural barriers to change, but if you make the new process easier, better, and cheaper, there is little reason not to adopt it.”
Adoption was also aided by UMMC’s status as a teaching hospital. In the fourteen years since Henderson launched the network, the hospital has graduated ten classes of physicians for whom Mississippi Telehealth was a mainstay of their medical training, a working system with evident benefits. The hospital also had many fellows and residents rotate through the telehealth programs. These physicians had all gone on to spread the word to other hospitals, serving as emissaries, boosters, and implementers of telehealth delivery in hospitals throughout Mississippi. In this sense, teaching hospitals were perfect replicators for health-care innovations, and facilitators for their dissemination.
The chief roadblocks to widespread acceptance of Mississippi Telehealth were insurance companies and state regulators, who were reluctant to pay for telehealth consults, citing concerns about quality control and fee-for-service payment arrangements. State legislators, in particular, didn’t pull any punches. “We don’t need that,” they told Henderson. “We can’t afford that. That’s not the way we do things here.”
So Henderson did what she always did: she made a list. Then she outlined a strategy and headed to the capitol to win those legislators over.
“Every legislator had an area they were focusing their attention on— maybe it was prisons, or schools, or small-business development,” Henderson remembers. “So before I met with them, I would pull their key agenda items and do some research. Then I told them exactly how telemedicine could impact prisons, or the educational system, or whatever it was. I couldn’t find any area where telehealth did not promise some benefit.”
It took two years of persuasion to get the state legislature to mandate the change. In 2012, legislation passed, and the next year Mississippi governor Phil Bryant signed legislation requiring public and private insurers to cover telehealth services at the same rate as in-person services. The telehealth program could now be subsumed under the fee-for-service system.
“After that,” says Adcock, “the network really took off.”
Ultimately, Kristi Henderson did manage to win over her many critics and doubters. Her most powerful weapon was her perseverance, but her most potent ammunition was data.
The Ultimate Spoke: Home-Based Care
For ten years, the spokes that linked to the UMMC hub were local hospitals, clinics, and health centers in rural Mississippi towns, but after the state passed legislation in 2012 requiring insurers to cover telehealth consults, the doors swung open to a multitude of possibilities. Over the next four years, the spokes multiplied rapidly. The network extended to elementary schools, where it helped school nurses treat student illnesses and injuries; to high-school sidelines, where it helped coaches to recognize concussion injuries in real time; to colleges, where mental-health consultations were made available; and to prisons, where it provided evidence-based care to HIV-positive inmates.
Even as Mississippi Telehealth was reaching out to those institutions, Henderson felt that she and her team were still just scratching the surface of the potential of telemedicine. She was thinking of places like Ruleville.
Ruleville, Mississippi, is a small town in the Mississippi Delta, about a two-hour drive from Jackson, with a population of roughly 3,000 people, 37.7 percent of them living in poverty. African Americans account for more than 80 percent of the town’s population and more than 80 percent of those living in poverty.16 Many of the townspeople do their grocery shopping at the local gas station, where the foods sold are chosen for shelf life, not healthfulness, and are loaded with sugar. In 2014, the town’s extraordinary diabetes rate of 13.2 percent was one of the highest in a state that had one of the highest incidences of diabetes in the country.17
That same year, Ruleville was chosen for a pilot program that extended the spokes of the UMMC telehealth network to the homes of people suffering from chronic diseases, starting with diabetes. The program, backed by Governor Bryant, partnered UMMC with Intel-GE Care Innovations, C Spire, and the critical-access hospital in Ruleville.
Like most chronic diseases, diabetes is expensive to treat. Two years earlier, in 2012, the 12 percent of Mississippi’s population with diabetes cost the state $2.74 billion in diabetes-related medical expenses. And according to the American Diabetes Association, the United States as a whole spends about $176 billion each year on direct medical care for diabetes. The association puts the annual cost of productivity lost to diabetes at $69 billion.18 And worldwide, according to the Harvard T.H. Chan School of Public Health, the cost of diabetes is $825 billion per year, and growing fast.
Because chronic conditions such as diabetes typically require daily monitoring, they are hard to treat in patients who don’t often see their doctor, a cohort that includes most people living in the rural South. Diabetes is particularly hard to treat, because the information patients self-report about their eating and exercise habits is famously unreliable. Sometimes patients misread their numbers. Sometimes they misremember. Sometimes they flat-out lie. The Diabetes Telehealth Program, as the UMMC-driven partnership was known, eliminated that kind of error by giving two hundred diabetics in its pilot program tablet computers connected by the internet to UMMC. Each day, participants entered their glucose levels, blood pressure, and weight into software on the tablet, and the progress of their disease was tracked remotely by specialists. That data didn’t lie.
“When patients checked their glucose levels, it was Bluetoothed up to our team,” says Henderson. “If the numbers caused concern, a diabetes educator or a nurse would call the patient and say, ‘Hey, I see your glucose is low, get something to eat and I’ll call you back in a little bit, and then let’s talk and see how we can make sure this doesn’t happen again.’”
In a move that reminds us of Narayana Health’s training of patients and patient family members to perform tasks normally done by hospital staff, the telemedicine team at UMMC distributed educational materials, including a series of two-minute videos that could be viewed on tablets.
And like Indian exemplars who enlisted the services of community health workers, the team trained other Ruleville residents to serve as counselors to their neighbors. “The local counselors could tell them, ‘Go down to such-and-such grocery where you can get these foods to eat healthy,’” Henderson explained. “This was a pivotal point in our program.”
Each participant was assigned to a nurse, who was supported by a team of diabetes educators, pharmacists, and dieticians. Because most chronic-disease patients have comorbidities, the teams were designed to manage more than diabetes alone.
“So much of the difficulty managing chronic diseases is related to lack of medication adherence, and this really made a huge difference,” says Henderson. “We were able to get incredible compliance by having people answer questions daily and also by doing vital signs daily.”
From our perspective, UMMC’s Diabetes Telehealth Program mirrored Deccan Hospital’s home-based peritoneal dialysis for patients with end-stage renal disease in India. And its results were equally impressive.
The Value of Telehealth Delivery
All ninety-three of the first participants in UMMC’s diabetes program believed that they had their disease under control for the first time. All lost weight, and all reported feeling better. The sponsors had hoped to achieve reductions of hemoglobin A1C levels of 1 percent in 75 percent of patients over the course of one year. After only six months, they found an average reduction of A1C of almost 2 percent. With the exception of one patient, who was hospitalized at the time of enrollment, not a single participant required a hospital visit for diabetes. The compliance rate for medication was an astonishing 96 percent.
Financial results were equally winning, especially considering that 30 percent of participants were uninsured and another 30 percent were underinsured. Even if the services were unpaid and the tablet was never returned, the state still saved money.
“Part of our analysis was to ask, ‘If I give these people this technology, how badly will I lose my shirt?’” says Henderson. “What we found was we saved money because we kept them out of our emergency rooms. These were people who were coming in to the emergency room four to six times a year and using our resources, and they were not able to pay. Now they were supported by a simple kit in their homes.”
Adcock estimates that downstream savings in emergency-room costs in the first six months were $3,300 per patient. An independent study predicted that if just 20 percent of Mississippi’s uncontrolled diabetics on Medicaid were enrolled in such a program, the state would save $189 million a year.19 The pilot program also saved 9,454 miles of driving by patients and uncovered nine new cases of diabetic retinopathy that otherwise might have gone untreated.20 It is in unconventional metrics like these that some of the latent values of value-based health care are revealed.
In 2014, Kristi Henderson was a local hero, the champion architect of a hub-and-spoke, value-based health-care program that was so undeniably effective that it set the stage for national policy changes. Henderson’s success brought her to the attention of Mississippi’s congressional delegation, which that year helped to start the Alliance for Connected Care, a telemedicine lobbying group, and which introduced bills to expand payments for telehealth delivery. In 2015, Henderson was invited to testify before two United States Senate committees considering federal-level policy changes.
“What we did in Mississippi can absolutely be replicated,” says Henderson. “But it is important to understand that it’s not about the technology. It’s about people and process.” It takes nurturing. It takes relationships and partnerships. And you’ve got to have buy-in across the key stakeholders. It’s not an easy journey, but it can be done.
“We have health-care reform that’s forcing our systems to be value-driven,” says Henderson. “We are moving towards capitation payment. We also have consumers getting more involved in their care. In the next five years we will see increased use of wearable devices, ingestibles, dissolvables, robots, artificial intelligence, precision medicine—all of that. Watching to see how it all fits together to transform the health-care system is going to be pretty remarkable. We are on the cusp of that now.”
The Future of Telehealth
In 2017, under the guidance of Michael Adcock, UMMC’s model program continued to grow. The Center for Telehealth adopted a technology to monitor patients coping with chronic obstructive pulmonary disease, hypertension, kidney disease, and a number of other conditions that require chronic-disease management.
Mississippi was one of only seven states to get an A rating from the American Telemedicine Association for its telehealth policy and legislation. UMMC satisfaction surveys showed that 93 percent of patients were comfortable or very comfortable with the system and 85 percent rated the care as good or excellent. Among hospital administrators, 100 percent felt that the level of care had increased or remained the same.21
While access to medical care in the United States has improved since 1999, when Henderson first imagined a telemedicine network that could distribute quality care to underserved populations, there are still many places with too few doctors and too much chronic disease. In Texas, for example, in 2015, thirty-five counties did not have a single physician. And in all of the United States, sixty million people, or one-fifth of the population, live in an area designated by the federal Health Resources and Services Administration as a Health Professional Shortage Area.
All of them could benefit from health-care delivery innovations like those that we observed among the Indian exemplars, and those that Kristi Henderson brought to fruition in the state of Mississippi. There is no need to reinvent the wheel.