The Limitations of Poor Broadband Internet Access for Telemedicine Use in Rural America: An Observational Study

Background: Fewer than 10% of U.S. physicians practice in rural communities, where 25% of Americans live (1). Yet, rural Americans may need more health care as they become increasingly older and sicker relative to their urban counterparts (2). Telemedicine has been proposed as a solution to improve access to care (3). Federal and state policymakers have enacted policies to expand telemedicine use among publicly and commercially insured beneficiaries. However, whether Americans with the poorest access to care have the necessary broadband Internet capability to fully benefit from telemedicine is unknown. Objective: To identify whether Americans with inadequate access to primary care physicians and psychiatrists have sufficient broadband Internet access to support video-based telemedicine. Methods and Findings: We defined inadequate access on the basis of Medicare Advantage standards, which require that 90% of a county's population live within specified driving times of physicians. Driving times vary by specialty and are longer in more rural counties. For example, in Counties with Extreme Access Considerations (CEAC) (population densities of <10 persons per square mile) at least 1 psychiatrist should be in practice within a 110-minute drive of patients. Primary care physicians and psychiatrists in the United States were identified in the SK&A office-based physicians file (IQVIA), a comprehensive and accurate list of all office-based physicians (4). We used Google Maps to calculate drive times to each physician's office from the locations of potential patients, approximated by the center of their ZIP code tabulation areas. We aggregated results to the county level with ZIP code tabulation area population weights. We measured broadband Internet access as the county-level fixed broadband penetration rate as defined by the Federal Communications Commission: the percentage of a county's population with Internet access at a download speed of at least 25 megabits per second, which is sufficient to support video-based telehealth visits (5). We examined whether broadband penetration is lower in counties with inadequate physician access and report our findings by county rurality, using the Centers for Medicare & Medicaid Services definitions for urban, rural, and CEAC county types. Broadband penetration rates decrease as counties become more rural, ranging from 96.0% in urban, to 82.7% in rural, to 59.9% in CEAC county types (Table and Figure). Likewise, adequate access to primary care physicians and psychiatrists decreases in CEAC relative to rural counties. Within rurality categories, counties with inadequate access to primary care physicians or psychiatrists generally had poorer broadband penetration rates. For example, the broadband penetration rate in CEAC is 62.4% (95% CI, 59.3% to 65.5%) if primary care physician access is adequate, compared with 38.6% (CI, 29.6% to 47.5%) if it is inadequate. Likewise, CEAC with adequate psychiatrist access have a broadband penetration rate of 62.4% (CI, 59.1% to 65.7%), but the rate is 49.1% (CI, 42.3% to 55.9%) in CEAC with inadequate psychiatrist access. Table. Broadband Penetration Rates and Adequate Access to Primary Care Physicians and Psychiatrists, by County Rurality* Figure. County rurality, broadband penetration, and inadequate access to primary care physicians and psychiatrists. Broadband penetration is the percentage of a county's population with access to Internet download speeds greater than 25 megabits per second. Maps were generated with SAS, version 9.4 (SAS Institute). CEAC= Counties with Extreme Access Considerations (population densities of <10 persons per square mile). Discussion: Although increasing the supply of providers in rural areas has been a major policy goal, it has proved challenging (1). Telemedicine is an alternative solution to rural physician shortages, but effective implementation requires broadband Internet access. We found that broadband penetration rates are substantially lower in the most rural counties (that is, CEAC), where access to primary care physicians and psychiatrists is inadequate. This observation suggests that the inadequate broadband infrastructure in rural areas prevents telemedicine from mitigating the barriers to care associated with physician shortages and may explain the low rates of telemedicine use among rural Medicare enrollees (3). We acknowledge 3 limitations. First, we did not consider the network participation, availability, or density of providers available within drive time limits. Second, we did not capture smartphone ownership. Telemedicine may be delivered via personal phones, but some insurers, including Medicare, require most telemedicine appointments to originate from a rural health care facility; therefore, broadband access at those centers remains relevant. Third, broadband speeds at individual facilities differ from county-level broadband measures. Our findings suggest that inadequacies in broadband infrastructure have broader consequences than limited Internet access. Costbenefit analyses of broadband and cellphone infrastructure expansions thus should consider the benefits of telemedicine and the pathway to care it provides. Although telemedicine has the potential to address geographic barriers that result from long drive times to receive care, its potential will not be realized until the telecommunications infrastructure improves and public and commercial insurers develop and expand policies to reimburse telemedicine visits from patients' homes, particularly in the most rural counties.