Targets: To discover the perceived impacts of a wide range of telehealth providers on hospital funds and assess how hospital directors make selections about adopting telehealth applications.

Research Design: From October 2021 to January 2022, we carried out semistructured interviews with chief monetary officers (CFOs) of rural hospitals.

Strategies: Recruitment occurred in collaboration with 6 rural well being collaboratives and hospital associations that facilitated CFO peer-learning teams. We used inductive and deductive approaches knowledgeable by a well being care innovation adoption mannequin to establish themes within the qualitative knowledge.

Outcomes: Twenty rural hospital CFOs and different hospital directors from 10 states participated in interviews. Seventeen (85%) represented vital entry hospitals and three (15%) represented short-term acute care hospitals. Though CFOs believed telehealth has some monetary benefits (eg, can assist to keep away from affected person transfers), they didn’t consider that telehealth improved their hospitals’ monetary conditions. CFOs, relatively, appear motivated to implement telehealth providers to enhance high quality of care and handle sufferers’ wants. CFOs reported that restricted reimbursement, low volumes, choice for in-person care, and inadequate broadband have been key challenges to telehealth’s monetary viability.

Conclusions: Understanding how CFOs take into consideration the return on funding of telehealth can inform efforts to advertise telehealth utilization in rural communities and to develop coverage options to make telehealth extra sustainable. CFOs could profit from steerage on promising practices and cost-effective implementation methods. Coverage makers might take steps to enhance telehealth’s monetary attractiveness (eg, via cost parity, subsidies to enhance know-how infrastructure).

Am J Manag Care. 2022;28(12):In Press


Takeaway Factors

Telehealth has been promoted as an answer to the monetary challenges dealing with rural hospitals; nonetheless, interviews with chief monetary officers (CFOs) didn’t help that assertion.

  • Though CFOs believed telehealth has some monetary benefits, they didn’t consider that telehealth improved their hospitals’ monetary conditions.
  • CFOs could profit from steerage on promising practices and cost-effective implementation methods.
  • Coverage makers who’re interested by increasing telehealth to extend entry to care might take steps to enhance its monetary attractiveness (eg, via cost parity, subsidies to enhance know-how infrastructure).


Telehealth is promoted as an answer to the monetary challenges dealing with rural hospitals and a way of stopping hospital closure.1 For instance, a Well being Sources and Companies Administration–sponsored Toolkit for Important Entry Hospitals asserted that telehealth decreases staffing prices and will increase hospital income by lowering transfers to different hospitals.2 Regardless of these potential benefits, adoption of various telehealth providers (eg, telestroke, tele–intensive care unit [tele-ICU], telehealth for outpatient specialty consults) varies considerably throughout rural hospitals. A 2019 examine from previous to the COVID-19 pandemic confirmed that 46% of rural emergency departments (EDs) didn’t have telehealth providers and that value was the most important barrier to implementation.3

A hospital’s choice to put money into new medical applied sciences is a fancy one; adoption selections are sometimes made by hospital management together with clinicians and chief monetary officers (CFOs). The extra expensive a proposed innovation, the extra scrutiny it is going to obtain,Four as hospital leaders weigh a wide range of elements, together with the probably return on funding.

Regardless of the vital position of perceived monetary impression on the choice to implement telehealth, no prior analysis has explored the views of rural hospital directors on the enterprise case for telehealth. Analysis on telehealth has traditionally centered on the experiences and attitudes of clinicians and sufferers,5-9 and though these stakeholders are vital, these events don’t sometimes have perception on the monetary impacts or sustainability of telehealth applications in rural areas. Understanding how CFOs take into consideration the return on funding of telehealth can inform efforts to advertise telehealth utilization and to develop coverage options to make telehealth extra sustainable. We carried out interviews with rural hospital CFOs to grasp the perceived impacts of a wide range of telehealth providers on hospital funds and the way hospital directors make selections about adopting telehealth applications.


Conceptual Framework

Our method to knowledge assortment and evaluation was knowledgeable by Flessa and Huebner’s well being care innovation adoption mannequin.10 On this framework, we assume {that a} hospital CFO is able to be an administrative promoter of telehealth adoption. CFO help for a brand new telehealth service is influenced by many elements together with the inclination to innovate (which relies upon partially on tolerance for danger) and the perceived monetary impacts, together with impression on income and prices. Additional, the mannequin means that CFOs will help an innovation provided that they understand system deficiencies. As a result of many rural hospitals face continued monetary losses, we argue that many rural hospital CFOs will agree that change is critical, and this can improve their help of telehealth. Nonetheless, rural hospitals even have quite a lot of traits that lower the chance that they’ll embrace new improvements. For instance, literature means that hospitals with much less competitors and fewer sufferers with non-public insurance coverage are much less more likely to implement improvements.4

Research Pattern

From October 2021 to January 2022, we carried out semistructured interviews with CFOs of rural hospitals. To recruit, we contacted 16 state-level organizations (rural well being collaboratives and hospital associations) that hosted peer-learning networks by which CFOs met usually to share assets. Six agreed to share recruitment supplies and background on the examine with collaborating CFOs by way of e mail and in standing conferences. CFOs have been requested to contact the examine workforce in the event that they have been interested by collaborating. Some organizations marketed the examine to all CFOs of their networks, whereas others chosen a subset. The organizations that chosen a subset have been requested to promote the examine to CFOs who various with respect to rural location (rural vs frontier), hospital kind (vital entry hospital vs short-term acute care hospital), monetary well being, and sorts of telehealth applications. This instruction helped to help most variety sampling. The one inclusion criterion was that every CFO represented a rural hospital.

We invited each CFO who contacted the examine workforce to take part, and we continued to recruit till we reached thematic saturation, outlined as the purpose at which new interviews didn’t uncover new themes.

Knowledge Assortment

Interviews have been carried out by way of videoconference and adopted a semistructured protocol. Matters included (1) fundamental hospital data (eg, location, payer combine); (2) present telehealth applications within the ED, inpatient, and outpatient settings; (3) perceptions concerning the monetary impression of every program; (4) drivers of monetary impacts; (5) the position of telehealth in strategic planning efforts; and (6) coverage and different limitations to the monetary sustainability of telehealth. Two members of the examine workforce (L.U.-P. and J.L.S.) educated in qualitative analysis carried out the 60-minute interviews, and examine workers recorded and transcribed the interviews. Every participant acquired a $150 reward card for his or her time, and so they supplied verbal knowledgeable consent to take part. The RAND Institutional Assessment Board accredited this examine.


We coded interview transcripts utilizing qualitative analysis software program (Dedoose model 9.0.17 [SocioCultural Research Consultants LLC]). We developed a hierarchically organized codebook to summarize themes and establish patterns. We used customary qualitative evaluation methods consisting of each inductive and deductive approaches to establish and characterize cases of themes arising from the domains within the conceptual framework interview information, in addition to unanticipated themes that emerged. The lead writer (L.U.-P.) coded all transcripts, refining the codebook as she labored and including related probes to interviews in progress.

We outlined a theme as an idea famous by no less than 2 contributors. When figuring out themes, we not solely thought-about cohesiveness and prevalence throughout participant responses, but in addition included views that have been inconsistent (ie, unfavorable case evaluation). We achieved consensus concerning the characterization of themes via interactive discussions among the many analysis workforce.

To enhance inner validity and transferability, we carried out respondent validation. We offered preliminary findings to 14 CFOs in a bunch assembly hosted by one of many collaborating organizations. Respondents largely affirmed the findings and supplied further context for sure factors.


Twenty CFOs and different hospital directors from rural hospitals in 10 states participated in interviews. Seventeen (85%) represented vital entry hospitals and three (15%) represented short-term acute care hospitals. Sixteen (80%) represented hospitals with 25 or fewer beds, and 10 (50%) represented hospitals that operated at a monetary loss within the prior Three years (Desk 111).

Most CFOs reported having a number of telehealth applications at their hospitals together with inpatient providers, ED-based providers, and outpatient providers. The commonest inpatient or ED program was telestroke and the commonest outpatient service was tele–behavioral well being. For inpatient or ED telehealth, the agricultural hospital typically served because the internet hosting website and linked sufferers to remotely positioned specialties. For outpatient telehealth, the hospitals generally served because the internet hosting website and at different occasions because the distant website (eg, rural well being clinic suppliers employed by the hospital delivered telehealth visits to sufferers of their properties).

Most CFOs believed that telehealth was a loss chief or had a impartial impression on hospital funds. All however 1 hospital within the pattern operated a number of telehealth applications; nonetheless, CFOs reported that they have been extra motivated to implement telehealth to enhance high quality, and in some circumstances to maintain up with opponents, relatively than to enhance their monetary place.Though contributors supplied a couple of examples of choose telehealth providers that resulted in direct monetary benefits, they supplied extra examples of telehealth applications that didn’t. Additional, though contributors felt that some particular providers might have advantages, when reflecting on telehealth extra broadly throughout a number of inpatient and outpatient providers, CFOs weren’t obsessed with telehealth’s direct monetary benefits. Desk 2 options related quotes. In accordance with a CFO from Iowa, “All these telehealth fashions that we’re speaking about are simply new bills introduced on to the hospital with none form of return on funding in any respect.…Now, all these issues are a bit of more durable…to get your arms across the actual greenback quantity. However [telehealth results in] main, main enhancements within the high quality of our care, the security of our care.” A CFO from Oregon acknowledged, “[Telehealth] might be a bit of little bit of a loss chief, however I believe that we’re a group well being care supplier that’s actually truthfully extra involved about providing providers.”

Additional, telehealth was not featured prominently in strategic planning. Solely a handful of CFOs mentioned their long-term plans for telehealth. A CFO from Washington acknowledged, “We’ve not particularly mentioned telemedicine as a part of our technique plan shifting ahead.…We’re attempting to rework our hospital. So, a variety of our thought course of goes towards that proper now.” A CFO from West Virginia mentioned, “[Telehealth] isn’t a giant focus. I don’t see particular initiatives for subsequent 12 months for that, however…one in all our [priorities], in fact, is decreasing the price of well being care.” A CFO from Wisconsin defined, “In our final strategic planning cycle, we weren’t centered in any respect on telemedicine…; we have been nonetheless actually centered on getting [more patients and providers].” When telehealth was mentioned as a part of a strategic plan, the main focus was on growing specialties by way of telehealth and rising distant affected person monitoring applications.

Regardless of this normal perception that telehealth was not worthwhile, CFOs did establish a number of direct and oblique monetary advantages of choose providers. Desk 3 lists monetary advantages and illustrative quotes. Just below half of interview contributors reported that inpatient and ED-based telehealth applications assist keep away from affected person transfers, permitting the hospital to retain extra sufferers. On condition that hospitalizations usher in a variety of income, some hospitals used telehealth as a method to extend inpatient quantity and, by extension, their monetary place. The following mostly cited monetary profit utilized to outpatient telehealth. Right here, a number of CFOs believed that telehealth visits for major care and specialty care could not generate a lot income on their very own, however they will drive extra worthwhile ancillary providers (eg, laboratory testing). A handful of contributors recognized further advantages. First, if a hospital can forestall transfers via inpatient telehealth and supply extra full providers via outpatient telehealth, it could actually cut back the chance that it’s going to completely lose sufferers to opponents. Second, beginning an inpatient telehealth program (eg, telehospitalist) is cheaper than having a full-time, in-person supplier and may cut back each direct labor prices and prices of recruitment. Third, in the course of the pandemic, telehealth helped to maintain some outpatient practices as a result of in-person go to quantity dramatically declined.

CFOs have been requested to elucidate the disconnect between a normal perception that telehealth is a loss chief and these constructive monetary impacts. First, they clarified that telehealth requires substantial preliminary investments within the know-how, and the downstream monetary advantages are laborious to quantify and will not be all the time realized. A CFO from Iowa defined that some advantages “don’t present up on a spreadsheet.” Additional, CFOs identified that the utilization of the telehealth service is commonly not excessive sufficient to have vital downstream impression. Lastly, a perception that in-person care is usually superior to telehealth and ought to be supplied when doable could have influenced their perceptions about monetary benefits. The identical CFO from Iowa defined, “That private connection has been a cornerstone of how care is supplied [in rural communities]…[it involves] truly touching [the] affected person.”

CFOs talked about a number of elements that prevented telehealth from being extra worthwhile, together with low reimbursement, the truth that providers are sometimes low quantity, and lack of broadband. A number of contributors identified that reimbursement was too low for telehealth, notably for outpatient rural well being clinic visits. Just a few talked about that with telehealth providers, non–vital entry hospitals could forgo the ability payment (ie, a payment that well being care organizations can invoice for a affected person’s use of hospital amenities and tools). Additional, inside rural well being clinics, telehealth visits have further know-how prices and are reimbursed much less. In accordance with a CFO from Maine, “The speed that we get for a telemedicine go to is 1 / 4 to a 3rd of what we receives a commission for an in-person go to…However we nonetheless need to have all of the workers, we nonetheless need to invoice…[and] register the affected person [and]…do every little thing identical to the affected person was coming within the constructing. So, there’s actually not a variety of value financial savings, however they don’t permit us reimbursed value on these visits. We solely get payment schedule reimbursement. And the way in which that the fee reporting works, it truly pulls value away from our different capabilities for these visits.”

Price-based reimbursement from Medicare for vital entry hospitals reduces among the monetary danger related to implementing telehealth as a result of most prices are supported; nonetheless, not all prices associated to telehealth implementation are allowable. A CFO from Maine defined, “Sure issues with telemedicine are allowable. [With our] e-hospitalist [program], one in all [the] costliest telehealth providers that we’re doing…we don’t obtain any help for that because it pertains to cost-based reimbursement.”

Additional, CFOs identified that incessantly, the low fee at which telehealth providers are utilized means they can’t be worthwhile. That is the case due to each the fastened, restricted demand for providers in a small group and rural tradition, by which in-person connection is valued.

Lastly, restricted broadband in rural communities has discouraged hospitals from rising outpatient telehealth applications that serve sufferers of their properties. Additionally, restricted broadband requires that hospitals make investments extra in infrastructure when establishing inpatient applications. A CFO from West Virginia defined, “I believe [outpatient telehealth is] a chance for us to broaden, however I do really feel like we’re going to be restricted due to the placement. We’re on the mercy of somebody having web or having the potential. We’re not projecting elevated volumes due to these limitations.” A CFO from Wisconsin defined how broadband may be difficult for inpatient applications as properly: “If you happen to’re going to offer a tele-ICU resolution, you’re going to need to just be sure you have some vital redundancies in your [information technology] infrastructure…[and] anytime you’re placing in fiber infrastructure, it’s a actually costly enterprise for a small vital entry hospital.…I guess that’s one main danger that I see in rural telemedicine, particularly while you’re speaking [about] extra vital ranges of care: You simply can’t afford to have it go down. Having vital downtime is simply not an possibility. That half is a bit of scary, since you don’t have your specialists right here on website.”

Contributors additionally expressed a wide range of views about how competitors posed challenges for his or her telehealth choices. One CFO from West Virginia identified that her hospital was involved that if it aggressively pursued telehealth for outpatient specialty care, sufferers preferring in-person care would go elsewhere for care. A CFO from Oregon echoed an analogous concern: “If you happen to’re doing telemedicine [for outpatient specialty care], you don’t need to go to our hospital. You’ll be able to go to these tertiary amenities which can be providing the telemedicine.”

CFOs recognized a number of coverage limitations that affected telehealth monetary viability, together with lack of cost parity, uncertainty concerning the reimbursement setting, and the requirement that vital entry hospitals keep a median size of keep of lower than 96 hours. A number of CFOs talked about that lack of cost parity for telehealth and in-person visits, particularly for rural well being clinic visits, was a barrier to the expansion of telehealth applications. As acknowledged earlier, Medicare reimburses much less for rural well being clinic telehealth visits, and as an extra problem, telehealth visits are carved out of cost-based reimbursement, in order that they contain further accounting challenges. An necessary cause why lack of parity is a priority is that there’s fastened demand for outpatient visits in lots of rural communities. As such, changing an in-person go to that generates extra income with a telehealth go to that generates much less income is problematic. A CFO from Washington state defined, “[Telehealth] was a obtrusive concern, as a result of [the reimbursement for] itwas roughly $110 lower than what we usually get reimbursed for an in-person go to. And since we’re form of quantity primarily based, the suppliers…can do fairly a couple of extra telehealth visits, if that’s what they’re doing. However now we have such a small quantity generally that they’re changing all of the in-person visits…[and] there’s not sufficient [patients] to have [providers] double up on whole visits.” A number of CFOs additionally identified that uncertainty concerning the reimbursement setting and the way reimbursement will change because the pandemic evolves has prevented them from optimizing telehealth providers and making them as environment friendly as doable. A CFO from Illinois acknowledged, “We simply haven’t felt snug sufficient to aggressively have a look at that service optimization.”

Lastly, a couple of CFOs talked about that the requirement that vital entry hospitals keep a median size of keep of lower than 96 hours was a barrier to the expansion of their inpatient and ED-based telehealth applications. The priority was that with a program like tele-ICU, hospitals would preserve higher-acuity sufferers with longer inpatient stays. Nonetheless, there was not common settlement on whether or not this rule posed a big risk to the expansion of telehealth. A CFO from California defined, “On the vital entry hospital, the typical size of keep must be lower than 96 hours…So, if we’re doing telehealth, we’re in a position to deal with issues which can be going to [increase] their size of keep.…Ordinarily, for those who didn’t have telehealth, you’ll discharge them.” In distinction, a CFO from Maine identified, “It’s the general common on your total inhabitants. However I don’t assume the one uncommon [telehealth] affected person right here or there would impression my common size of keep.”

When requested about classes realized and recommendation to different rural hospitals, a number of CFOs instructed that rural hospitals pursue grants to cowl know-how prices, select a distant website that isn’t ready to cannibalize your corporation (ie, don’t accomplice with a neighborhood group that might be a supply of competitors for sufferers), and take into account hidden prices when beginning applications (eg, make sure that no matter system you implement captures knowledge components required for exterior reporting in order that further funds will not be wanted to develop options after the very fact).


Telehealth has been promoted as an answer to the monetary challenges dealing with rural hospitals; nonetheless, discussions with CFOs in our examine didn’t help that assertion. Though CFOs believed that some choose telehealth providers had monetary benefits, they didn’t consider that telehealth total improved their hospitals’ monetary conditions. CFOs, relatively, appear motivated to implement telehealth providers to enhance high quality of care and handle sufferers’ wants. Restricted reimbursement, low volumes, choice for in-person care, and inadequate broadband are key challenges to telehealth’s monetary viability. Given CFOs’ lack of enthusiasm for the direct monetary advantages of telehealth, we have been shocked that so many hospitals in our pattern had a number of, sturdy telehealth applications.

CFOs in our pattern recognized lots of the similar monetary benefits that different literature has mentioned, together with elevated native income for ancillary providers, lowered labor prices (eg, from sharing distant website personnel with different amenities), and fewer transfers.1,2,12,13 Our outcomes are in line with these of a examine by Haque et al, which additionally recognized considerably unfavorable views concerning the monetary impression of telehealth. Just like our findings, hospital workers from frontier vital entry hospitals reported that the excessive upfront prices for tools mixed with low use would probably result in a unfavorable impression on monetary efficiency.14


A key limitation is that CFOs who agreed to take part on this examine could have extra curiosity in telehealth and/or extra excessive views of (each in help of and towards) telehealth.


Our examine findings indicate that CFO perceptions concerning monetary impacts will likely be a barrier to the continued development of rural telehealth. Though we explored perceptions of the monetary impression relatively than quantitative knowledge on precise impacts, we argue that CFO attitudes are extremely related to selections to put money into telehealth.

It’s doable that telehealth does have monetary benefits that CFOs haven’t but noticed straight. In that case, they may profit from steerage on promising practices and examples of profitable applications that might in flip affect their perceptions and improve their help for telehealth. This would possibly embrace a concentrate on less expensive implementation methods. A 2015 examine by MacKinney et al confirmed {that a} tele-emergency program can generate a $187,614 revenue in a high-revenue/low-expense state of affairs and a $69,588 loss in a low-revenue/high-expense state of affairs.15

One other chance is that the monetary advantages of telehealth to rural hospitals are exaggerated. If telehealth actually “doesn’t pay” within the majority of circumstances, then coverage makers who’re interested by increasing telehealth to extend entry to care ought to take steps to enhance its monetary attractiveness (eg, via cost parity, subsidies to enhance know-how infrastructure). Additional, coverage makers can work to finalize everlasting, postpandemic telehealth coverage. CFOs could also be reluctant to optimize telehealth providers and thus obtain these providers’ true potential till there’s a clear sign as to what reimbursement for various telehealth providers will appear to be in coming years.


Recruitment for interviews wouldn’t have been doable with out the help of quite a few organizations, together with however not restricted to California Hospital Affiliation; Healthcare Training Basis of West Virginia; Iowa Hospital Affiliation; Mid-Atlantic Telehealth Useful resource Heart; Oregon Affiliation of Hospitals and Well being Programs; Rural Maine Well being Collaborative, LLC; Rural Wisconsin Well being Cooperative; South Central Telehealth Useful resource Heart; and the Washington Rural Well being d/b/a Rural Collaborative.

Creator Affiliations: RAND Company, Arlington, VA (LU-P), and Boston, MA (JLS); Massachusetts Common Hospital (KSZ, LS), Boston, MA; Harvard Medical College (KSZ, LS, AM), Boston, MA; Beth Israel Deaconess Medical Heart (AM), Boston, MA.

Supply of Funding: This analysis was supported by a grant from the Nationwide Institute of Neurological Issues and Stroke (R01NS111952).

Creator Disclosures: Dr Zachrison acquired funding from the Massachusetts Common Hospital Government Committee on Analysis to review adoption of telehealth in and improvements in telehealth use by US emergency departments associated to COVID-19. Dr Schwamm stories the next relationships related to analysis grants or firms that manufacture merchandise for telemedicine, thrombolysis, or thrombectomy: scientific marketing consultant concerning trial design and conduct on late window thrombolysis and member of steering committee for Genentech (TIMELESS NCT03785678); person interface design and usefulness to LifeImage (privately held teleradiology firm); stroke techniques of care to the Massachusetts Division of Public Well being; member of an information security monitoring board for Penumbra (MIND NCT03342664); principal investigator, multicenter trial of stroke prevention for Medtronic (Stroke AF NCT02700945); principal investigator, StrokeNet Community, NINDS (New England Regional Coordinating Heart U24NS107243); coinvestigator, The Influence of Telestroke on Patterns of Care and Lengthy-Time period Outcomes, NINDS (R01NS111952); and coinvestigator, REACH-PC telepalliative care trial, PCORI (NCT03375489). Dr Mehrotra has consulted for NORC, Pew Charitable Belief, Sanofi, and the State of Massachusetts and has acquired grants from the Nationwide Institutes of Well being, The Commonwealth Fund, and Arnold Ventures. The remaining authors report no relationship or monetary curiosity with any entity that may pose a battle of curiosity with the subject material of this text.

Authorship Info: Idea and design (LU-P, JLS, LS); acquisition of knowledge (LU-P, JLS, AM); evaluation and interpretation of knowledge (LU-P, JLS, KSZ, LS, AM); drafting of the manuscript (LU-P, KSZ, JLS); vital revision of the manuscript for necessary mental content material (LU-P, JLS, KSZ, LS); acquiring funding (AM); and administrative, technical, or logistic help (JLS).

Handle Correspondence to: Lori Uscher-Pines, PhD, MSc, RAND Company, 1200 S Hayes St, Arlington, VA 22202. Electronic mail: luscherp@rand.org.


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