Telemedicine Struggles in Central Valley Amid Hope, Hardship

KERMAN — Just getting to a clinic in the San Joaquin Valley is difficult for patients who come from surrounding far-flung farm towns.  There are no city buses where there are no cities. Agricultural fields stretch far, poverty runs deep and extended families often share one unreliable car.

“So many of our patients struggle with transportation. We send a van out twice a week, but when it comes to getting them to a specialist we’re at a complete loss,” said Jenny Mendez, clinic manager of  United Health Center in Kerman which serves many people who live 40 or 50 miles away.

It’s this kind of need that makes telemedicine a tantalizing hope to the challenged region. But, despite grants, partnerships, and federal and state mandates, the San Joaquin Valley is lagging behind the rest of the state in linking patients to doctors in other locales. In many cases the equipment and the broadband is there, but the nitty-gritty details are foiling healthcare providers.

“The technology is good. We’ve got it. We’re linked,” said Mendez. “But now we’re at the ‘now what?’  How do we find specialists who will see our patients, when 70% are on Medi-cal and 20% have no insurance? What are the insurance codes? What forms do we need? What are our liabilities?  We’re slamming into ‘Who is going to pay for this?’ We know telemedicine is the way we have to go, we’re excited by the promise, but it’s a difficult adventure.”

It’s an adventure the rest of the state and country should keep an eye on, said John Capitman executive director for the Central Valley Health Policy Institute at California State University, Fresno.

“It’s about understanding the nature of the challenge,” Capitman said. In the San Joaquin Valley, about one-third of the population is uninsured. There are more sick people: For instance more than one in five Valley children has asthma — the highest level in the state. In the Valley, one in ten people have diabetes – compared to 1 in 13 statewide.

There are fewer doctors per capita than in any region of California, as well as a shortage of nurses and other skilled health care workers. There is no local, established medical school to provide doctors and leaders in telemedicine.

In other words: a telemedicine program that can make it here, can make it anywhere.

Patients are Waiting; Doctors Aren’t Coming

Telemedicine, firmly parked at the intersection of technology, health care reform and medicine, attracts a lot of attention and a lot of support.

The Federal Communications Commission funded a $22 million grant for the expansion of broadband services to more than 300 rural telemedicine sites in California, including 81 rural hospitals.

The California Telehealth Network will connect hundreds of rural and underserved providers to a state- and nation-wide broadband network dedicated to healthcare.

But once the technology is in place, who will rural patients link to?The state has an overall shortage of doctors. State health officials say that by 2015 there will be 17,000 fewer physicians than needed across California.

In the Valley, the shortage of doctors with specialty training is already severe. There are 43 specialists for every 100,000 Valley residents. The statewide average is 87.

What will entice specialists to take time from their practices to treat patients without private insurance over a video screen, when Medi-cal payments are a fraction of what they could make elsewhere?

“Telemedicine has the razzle-dazzle. It’s the future,” said Capitman. “But it doesn’t overcome the basic problems.”

All In the Details

Not only is telemedicine in the Valley up against socio-economic barriers, the fine print is also getting in the way.

A study co-authored by Capitman, “Telemedicine in the San Joaquin Valley: Opportunities and Barriers in Adoption,” found Valley health care providers  ranked navigating laws and regulations as almost twice the perceived barrier as physical infrastructure or concerns about the quality of care.

Those wading into telemedicine are watching developments such as a proposed rule by CMS that would create a more streamlined credentialing and privileging process for physicians and practitioners providing telemedicine services. The rule was published in the May 26 Federal Register with a 60-day comment period.

Mendez, the Kerman clinic manager, spends her free time reading legislation, trying to figure out what the clinic’s liabilities are for a telemedicine specialist, whether there is a way to use physicians in another state and an avalanche of other questions.

Her clinic is one of six that UC Merced brought together to form Valley Telehealth Partnership. Funded by AT&T, the California Emerging Technology Fund and the California Partnership for the San Joaquin Valley, the six clinics have hi-speed connections, equipment and UC Merced as a “go-to” place for questions. The partnership is the area’s liaison to larger, more established telemedicine networks such as the UC Davis Telehealth Program.

The  partnership members are all in the nascent stages of developing their programs, far behind health clinic efforts in the Northern and Southern parts of the state.

David Hosley, president of the Great Valley Center, which organizes research and data reports, feels eyes should be on the San Joaquin’s dark horse efforts as a gauge for how telemedicine will function in the future. Northern and Southern California led the way in the innovation and technology of telemedicine. The San Joaquin Valley, in the heart of the state, has to figure out how to use those tools within harsh, rural realities.

“There are so many things that retard the progress here: a lack of reimbursement for doctors, no medical school, just to begin with,” Hosley said.

“But it’s also needed in the Valley more than anywhere else: we have poverty, isolated towns, lack of doctors and other healthcare workers, lack of public transit, a large retired population living in the foothills on mountain roads far from hospitals, higher rates of disease.

“We will keep trying and trying until we make telemedicine work – because we have to. Everyone should watch what strategies are adopted in the San Joaquin Valley, because those are the strategies that will work when nothing is easy.”