Telemedicine Efforts Target Uninsured, Rural Hispanics

Chronic disease care in the U.S. continues to consume the majority of health care expenditures. Diabetes, in particular, cost $174 billion in 2007 — 32% more than in 2002, according to a recent report from the American Diabetes Association. The findings indicate that one out of every five health care dollars in the U.S. is spent caring for someone with diagnosed diabetes.

Experts contend that telemedicine is the future of treating chronic diseases and reducing associated health care costs, but widespread adoption of the technology has remained slow, in part due to physician reluctance.

But that could change with recent legislation (AB 329) signed into law by Gov. Arnold Schwarzenegger (R) that authorizes California’s Medical Board to expand statewide efforts to treat chronic diseases using telemedicine.

Telemedicine not only would benefit patients but also would serve as an educational opportunity for doctors, especially those who practice in rural areas, Linda Whitney, chief of legislation for the medical board, said.

In California, diabetes care is increasingly targeting rural, underserved areas with high numbers of Hispanic residents who lack access to services they need to better manage and treat their illnesses.

Two telemedicine pilot programs in particular have taken advantage of Spanish-speaking resources to provide California’s Hispanic residents with access to preventive measures, thus reducing long-term health care costs.

Retinopathy Screening

In 2005, a team of optometrists at UC-Berkeley launched a pilot telemedicine program to help 13 clinics in California’s Central Valley screen diabetic patients for retinopathy, a condition caused by poorly managed diabetes that leads to blindness in about 24,000 U.S. diabetics annually.

The pilot program was funded by a $630,000 grant from the California HealthCare Foundation through the California Telemedicine and eHealth Center.

During the pilot, more than 12,000 patients received screenings, and half of them were diagnosed with some level of retinopathy.

The early success of the project led CHCF to fund a $1.8 million statewide expansion effort in December 2007, with a goal of serving 100 rural safety-net clinics and 100,000 patients, according to Veenu Aulakh, senior program officer for CHCF.

At least half of the targeted patients will be Hispanic, Jorge Cuadros, an optometrist and director of the project, said.

The program equips clinics with retinal cameras and EyePACS, a Web-based, picture archiving and communication system that stores and transmits retinal images. Specialists at UC-Berkeley interpret and diagnose the images, and, if necessary, refer patients to specialists for further treatment.

Rather than doing in-person visits, Spanish-speaking optometrists — who Cuadros notes are a rarity in the field — at UC-Berkeley can speak with patients over the phone to explain the results of the screening and help coordinate follow-up care.

Cuadros said the program helps patients better manage their diabetes because the illness “becomes much more real” once they see the extent of their eye damage. The program also helps reduce health care costs by “stressing prevention” and helping patients find treatment for retinopathy before it leads to costly complications, including blindness, Cuadros said.

In 2006, the program received a boost from a new law that provided Medi-Cal reimbursement for doctors who review ophthalmology records that have been sent and stored electronically. Previously, Medi-Cal would reimburse only for telemedicine services that involved face-to-face meetings between doctors and patients via Web cameras.

Promotora Telemedicine Project

A telemedicine pilot program in Santa Clara County also used Spanish-speaking interpreters to help patients better manage their diabetes and reduce complications.

The Promotora Telemedicine Project, launched in 2003, treated diabetic patients in safety-net clinics through real-time videoconferencing. The majority of patients were non-English speaking, uninsured Mexican immigrants.

Patients at the clinics received assistance during the videoconferencing session from promotoras, or health outreach workers in Hispanic communities. The workers served as bilingual and bicultural translators during the visit. While the majority had no extensive medical background, each promotora underwent intensive training in diabetes care to help patients comply with treatment regimens and to recognize early signs of complications.

Joseph Prendergast, president of the Pacific Medical Research Foundation and one of the program’s founders, said telemedicine has the greatest effect on minorities when treatment is delivered “linguistically and culturally by someone in their community.”

The use of promotoras ensures that doctors’ advice is “culturally and medically appropriate,” comprehensible and allows for “the best of care that prevents complications, which [are] the most costly part of all chronic disease,” Prendergast said.

The project ended about three years ago due to lack of funds, Prendergast said. He noted, however, that the program successfully “put patients in charge of their health care,” thus preventing costly hospitalizations for treating complications.

Prendergast is now in the planning stages of establishing a similar program.

Future Implications

Cuadros and Prendergast both agree that the use of telemedicine to treat diabetes and other chronic diseases will continue to grow and evolve.

While Cuadros sees telemedicine becoming more “commonplace” in preventive care, he said the market for delivering the technology must be overhauled to ensure faster and greater access to minorities, who are usually “the market of last resort” in health care.

Meanwhile, Prendergast contended that telemedicine “is the future” for treating all chronic diseases, but he also argued that the majority of doctors still are reluctant to use the technology.

During the beginning stages of his telemedicine program, Prendergast said, most of the clinics’ doctors said the technology “just isn’t needed” and maintained that they already took “very good care of all” of their patients.

He noted, however, that as patients began to manage their diabetes better and return for follow-up visits, doctors praised the technology.

CHCF is the publisher of California Healthline.

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