Evolution of Technology and Insurance in Rural North Carolina

By Nishitha Karumuri, Sara O’Brien, Jocelyn Miller, and Sharanya Pemmaraju

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Essay

Introduction

Since the introduction of the American healthcare insurance system, the pace, accessibility, and quality of care have been transformed. Aimed to create equity in healthcare access, modern insurance policies hinder the doctors’ and patients’ abilities to maintain an effective doctor-patient relationship. The advancements in medical technology created to bridge the access divide cannot be utilized by the patients who need it most due to the bureaucratic regulations of insurance providers. A series of interviews conducted in rural North Carolina reveal a rapid but divergent evolution of insurance and technology in the American healthcare system. Insurance policies have been unable to match the advancements in technology, taking a toll on the doctor-patient relationship.

Evolution of Insurance

The 2008 Affordable Care Act, or ACA, offered states the opportunity to expand coverage for the underinsured rural population (Moseley). Although Donald Williams reveals that “Most of them have insurance. We have Medicare, and… Blue Cross Blue Shield”, the effects of ACA were not felt by all as two-thirds of uninsured people in rural areas live in a state that is not currently implementing the Medicaid expansion, including North Carolina (0:39:50.6; Newkirk et al).

Most North Carolina counties have a single insurer offering policies on the ACA health insurance marketplace, limiting access for rural residents (Daily Yonder; see Fig. 1). NC resident Cynthia Songs expands upon this idea of systematic limitations as she argues that “there’s a lot of people now that they can’t afford insurance, they don’t meet the requirements for the marketplace insurance,” revealing that residents may go without insurance because the limited number of insurers do not match their needs (20:32.2).

While technology development flourishes at rapid rates, health insurance policies have not adapted these changes, further hindering access to care. North Carolina does not operate using parity laws which require insurance companies to reimburse televisits? at the same rate as in-person care for services provided. The revolutionizing services offered remotely, such as telehealth, are not covered through North Carolina insurers. Although North Carolina did develop the NC Statewide Telepsychiatry Program to provide government oversight for telepsychiatry, this accounts for a small proportion of health care visits (Galvez). This, coupled with the lack of Medicaid expansion, stagnates any progress made towards bridging the divide between rural communities and access to care. Nurse Ana Marie Deaver demonstrates the hardship the insurance system places as “they require for you to have insurance, and if you don’t have it, you got a bill that—no people cannot hardly pay anything now” (0:43:29.3). The limitations of most American health insurance plans prevent patients from accessing newly developed services such as telehealth, significantly impacting the doctor-patient relationship in rural areas where access to care is already limited.

Effects of Insurance on Patient and Doctor-Patient Relationship

As insurance companies continue to gain more control over the American healthcare system, concerns have arisen that the range of services which can be provided is decreasing. Nicholas Stratas, a former psychiatrist at Dorothea Dix Hospital, frames this as massive failure, saying that “Medicine is broken. We are not interested in the person… we’re struggling with the insurance companies about what we did or what we didn’t do or what we might be funded for before we do it” (0:59:09.4). According to a survey of a primary care practice-based research network, physicians are forced to alter their management of cases based upon the patient’s insurance in a quarter of all visits (Meyers et al.). The growth of insurance has resulted in patient care being less personalized and nearly pre-determined by insurance companies. Under the jurisdiction of these companies, treatment is based upon an algorithm which disregards the opinions of both the physician and the patient (Dowling).

In a new wave of medical consumerism, there is an effort to reduce costs and drive efficiency throughout the healthcare system. The spread of insurance plans is pushing patients to seek out cost-effective care and is putting an end to medical paternalism (Gallegos). The stride towards an efficient healthcare system means that physicians like Manuel Versola are leaving general practice because “the government or insurance system is telling us how long the patient should be in the hospital based on whatever diagnosis that you have” (0:54:36). From a patient perspective, this manifests as physicians “shoot[ing] you out of the hospital just as soon as they can,” but many patients recognize that “the insurance won’t let them, you know, stay any longer than you – really than they think you have to” (Fearrington 0:19:40).

The apparent shortened length of stay in hospitals is a trend that patients have observed in regular office visits as well. Nurse Janette Godwin finds visits to be overly structured and states that “they need to be a little bit more patient-centered… patients need a little bit more time” (1:05:49.7). However, a study published in The American Journal of Managed Care found that outpatient office visits actually increased in length from 1993 to 2010 (Shaw et al.). One possible explanation for this contradictory statistic is that physicians now have an increased responsibility to offer preventative services and are expected to do more within a single visit than they were in the past (Mechanic et al.). The sheer pressure of an entirely competition-driven market influences many physicians to attempt to preserve the length of visits. Regardless of whether length of stay is shorter or not, many physicians and patients still find it insufficient for proper care. As the doctor-patient relationship becomes increasingly impersonal, expanding fields such as telemedicine may jeopardize it even more.

Evolution of Technology in the Medical Field

In the modern world, technology proves a major component of our healthcare systems as machines perform a variety of tasks from simply saving information to supporting life, yet technology has also precipitated a disconnect between doctor and patient. Before this contemporary high-tech model, patients often relied on house calls or home remedies. Donald Williams explains, “Our doctor made house calls then. They’d get in touch with him, and we didn’t have phones. We’d have to go get him or something, but he came to the house” (0:23:34.0). Though bulky and stationary appliances have made the house call inaccessible, technology has minimized the error of misdiagnosis and produced more efficient results.

Some patients find the Internet itself useful; Barbara Brayboy, [insert short introduction] explains, “I use the Internet. When I get a medication that I’m not familiar with… I want to find out how it’s going to affect me. I research whatever I can find to keep me abreast of health issues, medications, and whatever” (0:28:07.8). Patients should feel educated on healthcare issues, but sometimes they may misdiagnose themselves or read unreliable sources spreading false and potentially harmful information. Moreover, computers have allowed for the digitization of health records which prove more accessible and mistakes are more noticeable. Yet as a byproduct, one article describes that primary care physicians spend from 25% to 50% of the time attending to the computer rather than the patient; one physician details, “I am no longer a physician but the data manager, data entry clerk and steno girl… ” (Bodenheimer and Sinsky). From the opposing patient’s perspective, Patricia Somerville confronted her doctor: “It feels like you’re totally ignoring me and you’re paying more attention to what you putting on that computer” (1:38:54.9).

Despite some disadvantages to technology, telemedicine, providing healthcare through electronic means, shows promise for the future especially while treating patients in rural areas or homebound patients. A 2016 study reports, “According to the Pew Research Center, 95% of American adults own a cellphone and 77% own a smartphone” (Serper and Volk). These devices could prove useful for remote monitoring of disease progression or sending reminder texts to prompt patients to take a certain medication or to message daily feedback. The study also highlights certain barriers to telehealth: for instance, is the provider licensed in the patient’s location or is the patient-provider relationship being established? Regardless of these bureaucratic barriers, telemedicine means that patients would not have to worry about transportation or missing work for appointments, and patients wouldn’t have to fear outrageous hospital costs for unnecessary visits.

Impact of Technology on Patients and Doctor-Patient Relationship

Improved medical technology allows patients to have better access to healthcare resources. In one interview, Albrea Crowder [intro] explains that when patients live far away, telemedicine can be useful (00:49:0.8). It allows those who do not really have access to resources where they live to be able to get the services they need. It provides face-to-face connection, which is important, especially in rural areas like Raeford (0:49:23.8). Crowder expresses the idea that those in rural areas, who might not have access to insurance to cover a normal hospital visit can still get that facetime with a physician without actually going to see them. This can strengthen the process to diagnosis, leading to more collaboration which can eventually lead to a smoother process overall. Distance should not prevent a person from being able to receive the best care that they can, and telemedicine can help resolve that. For patients who do not have access to local specialized healthcare resources, telemedicine can be a great way for healthcare professionals to collaborate (Gray et al.).

Even healthcare providers approve of telemedicine and its benefits (Morilla et al). For example, consultations through telemedicine can lead psychiatrists and physicians to collaborate better (Yellowlees et al.). This improvement in communication can help healthcare professionals come to treatment plans faster and communicate with patients more effectively.

However, there are some drawbacks to telemedicine. For example, most insurance plans do not cover the cost of telemedicine, and this can lead to many patients not being able to afford using it (Sisk and Sanders). Because of this, telemedicine may not be a viable option for those who cannot afford to pay for it. This advancement in telemedicine is moving too quickly for insurance policies to be able to keep up, which can have financial drawbacks for patients. It is important for insurance and technology to work together to provide patients with both access and a way to afford their healthcare needs, especially in rural areas where there may not be a lot of insurance providers or healthcare resources nearby. Another example is when patients are not able to get all of the information they need from an online call. Stephanie Atkinson [intrp] mentions that physical tests might be needed for a diagnosis, such as for high blood pressure, high blood sugar, and diabetes (0:29:35). This can be an issue for those who live in rural areas, since they might not have specialized doctors to suit their specific needs, they might have to turn to telemedicine. Telemedicine can limit doctors’ ability to fully interact with the patient, leading to an inability to come to a diagnosis or even worse, a misdiagnosis. Despite this, many healthcare professionals and patients alike agree that telemedicine can be a useful tool for the future.

Conclusion

The popularization of American health insurance during the 1950s has molded the health care system into what it is today, dictating physicians’ interactions and treatments of patients. The unprecedented COVID-19 pandemic facing the world today has caused insurance providers to reassess their plan structures. North Carolina Medicaid has implemented several temporary policy changes including eliminating some prior authorization and referrals, expanding types of providers who can utilize telehealth, and payment parity for approved services (“NC Medicaid Increasing Eligible Technology and Provider Types for Telemedicine to Address COVID-19.”). These changes will drastically benefit current rural citizens; however, these policy changes were created out of unforeseen circumstances, only temporarily increasing access to care. Nonetheless, telemedicine has been implemented on an international scale across various insurance systems so its temporary implementation through American health care insurers may serve as a spark for permanent change.

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