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Appalachian health

Telehealth Changes Will Increase Rural Broadband Demand



A licensed practical nurse examines a patient while instantly transmitting the physical assessment back to an off-site nurse practitioner. Photo: U.S. Department of Agriculture

New federal policies will make it easier for Americans to use telehealth. Rural communities should be looking for ways to leverage the new demand into better internet connections at home.

Several policy changes from Washington, D.C., should accelerate urban and rural telehealth deployments. On November 1 the Centers for Medicare and Medicaid Services (CMS), the body that manages these two healthcare programs, finalized new rules that include payment reimbursements for telehealth.  

These changes are good news for communities that want broadband to help expand access to healthcare. They will also be welcomed who hope that expanded use of telehealth will increase the number of broadband subscribers. Currently, telehealth service isn’t covered by Medicare and Medicaid in many rural homes, and they don’t reimburse telehealth at all in urban areas.  

One of the major telehealth benefits is that it enables people to stay at work or home and have electronic doctor “house calls.” Medicaid and Medicare, as a guard against fraud, required patients to get telehealth treatments at a healthcare provider’s facility. Many private-sector insurers take their cues from Medicaid and Medicare as to what healthcare services they reimburse. Altogether, this has stifled telehealth adoption. 

Eric Wicklund, editor of mHealth Intelligence, says that “the CMS changes open the door for more telehealth and remote patient monitoring programs. In turn, this pressures community broadband providers to make sure healthcare providers have the resources to deliver these services.” The FCC has publicly pledged to boost broadband access in rural areas, and hopefully the CMS’ actions will intensify the FCC’s commitment. 

Shifting the Mental Health Battle to the Home Front 

As the CMS policy changes open the doors to increased home use of telehealth, are communities conducting sufficient assessments to determine what kind of demand this will create for broadband service? Particularly important is telehealth targeted to improving mental health treatments. People likely are more comfortable getting treatment at home rather than going to a mental health professional’s office. 

“There are 65 million Americans that have diagnosable mental health illness but we have less than half of the psychiatric providers needed to meet that demand,” says Encounter Telehealth President and CEO Jen Amis. “When you look at many of the rural areas, we may have less than 20% of the number of providers needed.” 

Encounter’s national network of board-certified psychiatrists works with long-term care facilities in rural and underserved areas to provide behavioral and mental health care. They provide severe mental illness treatments and complicated psychiatric care. Solid telehealth apps built on strong community broadband networks are key to the vender’s success. “Our platform works well over cellular,” says Amis. “However, if an area has bad broadband they probably have bad cell phone reception as well.” 

Dr. Edward Kaftarian is chief of telepsychiatry for the California Correctional Health Care System. He believes telepsychiatry requires good video and audio connections with guaranteed security, anywhere between 30 and 100 megabits per second. Dr. Kaftarian says, “Slower speeds may be adequate, but doctors may lack enough bandwidth for simultaneously charting, accessing medical records, or consulting other information sources.” 

Besides attracting broadband subscribers, telehealth can attract psychiatrists to a community who are tired of the administrative grind, but want to continue helping patients. Amis of Encounter Telehealth observes, “Telehealth creates a better quality of life for the provider, gives them better flexibility, and they don’t have to ‘punch the clock.’” It might not reverse the declining number of psychiatrists, but it could help slow it down. 

Telehealth Tackles the Opioid Crisis 

Yes, drug addiction is a mental illness, according to the National Institute on Drug Abuse. “Addiction changes the brain in fundamental ways, disturbing a person’s normal hierarchy of needs and desires, and substituting new priorities connected with procuring and using the drug. The consequences are similar to hallmarks of other mental illnesses.”  

The Centers for Disease Control have been tracking drug addiction for many years. They report over 32 million illicit users of prescription opioids and illegal opioids like heroin. From 1999 to 2016, more than 630,000 people died from a drug overdose, with 63,600 of those deaths just in 2016, five times higher than in 1999.  

“The opioid epidemic is particularly felt in East Tennessee, and where there is street-use of opioids, there is also an increase in hepatitis C and HIV,” says Matt McAdoo, COO of Choice Health. Their goal this year was to do 25% of treatments through telehealth, with a higher goal for mental-health patients. They use Docity telemedicine neighbor hubs for delivering treatment, but plan to deliver telemedicine directly to patients’ homes in the future. 

“Treating opioid use disorders through telemedicine will likely be a driver as the annual cost of the opioid epidemic in the U.S. has soared to half-a-trillion dollars.” says Robert Knight, executive vice president & COO at Harrison Edwards – SASHE Group. In Texas, the cost of opioid addiction and related factors is $21billion. The cost to the state of Michigan is about $20 billion. 

Municipalitiess, co-ops, and local internet service providers in every state may want to consider teaming up with telehealth vendors with proven mental health treatment success. Through those partnerships, they could make states an offer. Observes Knight, “Billions of dollars will be spent on addressing opioid addiction. Because telehealth holds such promise for rural areas, communities may be successful advocating for spending some of that funding on community broadband/telehealth hubs similar to the Choice Health Network.” 

This article was originally published by Daily Yonder.

Appalachian health

Black Lung Benefits Fund in Deepening Debt as Epidemic Surges



A new study from the Government Accountability Office finds that the federal fund supporting coal miners with black lung disease could be in financial trouble without Congressional action. As NPR has reported, the GAO found that the fund’s debt could rise dramatically at the same time that black lung disease is surging.

Disabled former miner Bethel Brock fought years to win federal black lung benefits.
Photo by Benny Becker/OVR.

Most federal benefits for coal miners disabled by back lung are paid from the Department of Labor’s Black Lung Disability Trust Fund, which covers the cost for companies that have gone bankrupt.

The trust fund is mainly supported by a tax on coal, but according to the GAO, those taxes have not covered costs, leaving the trust fund over $4 billion in debt. The GAO says that debt could soon climb to more than three times that amount if Congress doesn’t take action.

Other recent federal studies show that black lung disease is surging both in frequency and severity, especially in central Appalachia.

Bethel Brock, a retired paralegal in Wise, Virginia, is a disabled former coal miner who fought for years to win federal black lung benefits. As Brock explained, more cases of severe black lung could raise costs significantly.

“The cost is on giving a miner a health card for his lungs and heart,” he said. “Cases where a miner might have to have a lung transplant can run into the millions of dollars.”

Decades of Debt

In 1981, Congress approved a temporary tax increase on coal in hopes of getting the trust fund out of debt. The increase was extended in 2008, and is set to expire at the end of this year. That would cut the fund’s income by more than half and the GAO predicts the fund’s debt would more than triple by 2050, reaching over $15 billion. Even if the tax cut is extended, the fund’s debt is expected to continue to grow slightly.

Republican Senate Majority leader Mitch McConnell of Kentucky said he’s aware of the issue, but would not say whether he’d support extending the tax.

“It doesn’t expire until the end of the year,” McConnell said, “and so we’ve got plenty of time to take a look at solving that problem.”

The issue puts McConnell in an uncomfortable position. Many of the affected miners are his constituents but he also enjoys support from the mining industry, which opposes extending the tax.

Who Pays?

The National Mining Association told NPR it hopes that some or all of the debt will be forgiven. That’s what happened in 2008, when taxpayer funds absorbed $6.5 billion of the fund’s debt.

United Mine Workers of America president Cecil Roberts argues against forgiving the debt. In a press release, Roberts said reducing the amount companies pay is “not just wrong, it is rewarding bad corporate behavior.”

Evan Smith, a black lung attorney and blogger at the Appalachian Citizens Law Center, said industry opposition to extending the tax raises some big questions.

“I want coal to make sense. I want there to be coal mines, I want there to be coal miners,” he said. “But if you say that you cannot protect your workers at the current price of coal, then does the entire enterprise make sense?”

Because black lung can be prevented by limiting dust exposure, experts for many years thought the disease would soon be a thing of the past. But central Appalachia is now facing the largest epidemic of severe black lung ever documented.

This article was originally published by Ohio Valley Resource.

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An Epidemic in Appalachia

White House Takes on Opioids on Its Own Turf – the Mass Media



On Thursday, the White House unveiled the first act in its effort to fight the opioid epidemic by harnessing the power of digital media and cable TV.  

A partnership between the White House Office of National Drug Control Policy, the Truth Initiative, a nonprofit previously focused almost exclusively on efforts against the tobacco industry, and the Ad Council created and premiered “The Truth About Opioids” ad campaign. The project aims to “close the knowledge gap” about the dangers of opioids and “empower people with the truth” to help them fight and prevent addiction.

The campaign kicked off with an airing of the first spot early that morning on the Today Show.


Soon after, during a phone briefing, the President’s Counselor, Kellyanne Conway, delivered a carefully crafted speech, in which she reiterated that the Administration understands the multifaceted nature of the opioid crisis and that the campaign is only a part of an effort aimed at “preventing new misuse and new addiction by raising awareness.”

Spearheaded by the Truth Initiative, best known for its aggressive anti-tobacco campaigns, “The Truth About Opioids” will target primarily young people between 18 and 24 years of age, across all digital media platforms.

Four short documentary-style video clips tell the real cautionary tales of four young adults who harm themselves in violent ways in order to gain access to more opioids.

The shock value is there, and so is the production value. The videos provoke that unpleasant sensation one gets from well-executed, naturalistic depictions of pain.

Every spot provides a backstory, probably the most important element of the whole endeavor, trying to show that opioid addiction is not — necessarily — a typical, recreational drug addiction.

The ads point to the systemic issues of over-prescribing and lack of proper medical guidance that leaves young people addicted and desperate.  

The campaign’s website provides a host of additional information with a clear goal of delivering easy to digest, basic knowledge on the issue. It’s hard to say just how successful these efforts will be.

We have written in the past about the potential pitfalls of following in footsteps of failed mass media campaigns, like the infamous Nancy Reagan initiative, “Just Say ‘No.’”

Robin Koval, CEO and President of the Truth Initiative, pushed back against that narrative. During the briefing, she pointed to extensive research conducted prior to the release, as well as Truth Initiative’s previous success in messaging to young adults.

Koval said that the Truth Initiative “tested over 150 different message possibilities, and pretested all of the advertising and the executions themselves.”

She also shared the criteria used to test the proposed messaging. “One, does it decrease intentions to misuse? […] Two, does it impact willingness to share with someone else?  Does it increase risk perceptions? […] do these ads compel you to want to learn more — as we say, ‘Know the truth, spread the truth’ — and do they compel you to want to share them in your peer network? […]” According to Koval, the final ads were the most successful with the targeted age group.

Facebook, Google, YouTube, NBCU, Turner, Amazon, and VICE are among the companies that chose to donate their resources – broadcasting time, research, or online targeting tools – to help disseminate the campaign and reach the desired audiences. These are powerful allies for the cause.

Although the acting director of the ONDCP, Jim Carroll, didn’t put a price tag on the entire project, Lisa Sherman, President and CEO of the Ad Council, revealed that ONDCP “has funded a very small amount of money to support some of the other hard costs of the campaign.”

Carroll did answer other journalists’ question, saying that the campaign did not tap into the $10 million pot dedicated to fighting the opioid crisis that was secured in the Omnibus spending bill.

Koval added that “We [The Truth Initiative] felt very strongly that, because we had the ability to donate this, we want other funds to go to those very, very urgent matters of prevention, of rescue, of recovery, which are the things that are happening on the ground, right now, every day.”

While we can state fairly conclusively that “scare them straight” types of campaigns have historically worked poorly in reducing harm, these new educational efforts combined with relatable messaging could hold some promise.

The funding structure and emphasis on donated resources by some of the biggest tech corporations also holds promise.

For once, the powerful algorithms that seem to be driving so much of today’s online media traffic and economy are said to be targeting one of the nation’s biggest health problems.

Yet, no matter how optimistic the prospects of the campaign, we should remember that there remains a number of unanswered questions. To the people of Appalachia, some are more interesting than others.

How will the modern, 21st century online-based campaign overcome the connectivity problems across Appalachia? Is the knowledge gap the true problem in poverty-stricken communities, where the black market for the opioids serves as a source of supplemental income?

Last, but not least, when asked during the briefing about the choice of the age range of 18-24 as a target audience, Koval said that the choice was driven by Truth Initiative’s experience and pre-built trust among young adults. “We chose to focus on the group that we know […] It’s an audience that trusts us, that we have relevance with, credibility, and where we can create impact.”

That leaves large swaths of affected populations out of the campaign’s reach, often ones that — in sheer numbers — suffer the greatest loss of life due to the crisis.

According to CDC data, death rates due to drug overdoses are the highest among 35-44 and 44-54 age groups.

Here’s data accompanying the graph.

The promised scope of the campaign and the partnerships it managed to secure are impressive. Let’s hope the impact will be equally so.

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Appalachian health

Appalachia’s Suicide Rates Are Startlingly High. For Veterans, They’re Even Higher.



A factor that makes Appalachian veterans especially susceptible is the region’s struggles with addiction. Veterans who were prescribed the highest possible doses of opioids were more than twice as likely to die by suicide compared to individuals receiving the lowest doses.

“You work for someone [in the military] who’s your boss, and you work with other people. Everyone needs something different,” said “Frank,” a veteran originally from Sistersville, West Virginia, who worked in the Navy’s visual communications team on an aircraft carrier. “Sometimes [worry] can follow you your entire life; you wonder, Have I done something wrong?

Military service, whether in combat or not, can lead to mental health complications for veterans. Frank (name has been changed to protect his privacy), now resides in Daytona Beach, Florida, and has been to see two therapists through the U.S. Department of Veteran Affairs (VA) network. In his appointments, he discusses how his work in the military caused him to suffer partial deafness, and he talks about his overall time in the Navy. But whether visiting the VA for physical issues relating to his hearing loss or visiting for mental health, Frank overwhelmingly prefers the services in Florida to those in his former home in Appalachia; he believes the quality of care is better.

In the massive region of Appalachia, which includes parts of 13 states and spans from New York to Mississippi, most forms of care straggle behind the rest of the nation. An August 2017 report from the Foundation for a Healthy Kentucky concluded that, when comparing 41 different major health indicators, Appalachia’s performance falls below standard in 33 categories. The region records some of the lowest numbers relating to life expectancy while rates of deaths relating to drug overdose and poisoning soar 37 percent higher than the rest of the country.

Transportation barriers and availability issues limit Appalachians’ access to mental health care, including potentially life-saving care for veterans. Appalachia’s lack of resources has taken a toll on its population’s mental health. The region reports one of the nation’s highest suicide rates, averaging numbers 17 percent higher than anywhere else in the country.

Appalachia’s lack of resources to combat major health-care issues means that vulnerable populations face the greatest risks. Veterans fall into this classification because, in many circumstances, the conditions they sustained while serving, such as PTSD or anxiety caused by extended absences from home, require them to receive highly specified care. The resources veterans need are often unavailable in Appalachian communities with about 35 percent fewer mental health-care providers than the national average.

Veteran populations in Appalachia have seen suicide rates drastically increase. Nationally, veteran suicide rates rose by nearly a third between 2001 and 2016. And a 2017 study by the VA concluded that veteran suicides occur more often in rural areas with high levels of social isolation. While the data does not imply that simply living in rural communities will make veterans more susceptible to suicidal thoughts and actions, other systemic issues that plague these regions can help explain why these deaths occur more often in rural spaces.

Veteran suicides are most common in the western part of the United States, but states in Appalachia that have strong rural populations, including West Virginia and Kentucky, also have staggeringly high suicide numbers. According to Denver-based magazine 5280, these high levels of suicide could partially be attributed to “rural isolation, high gun ownership and a rugged sense of individualism,” factors that could also be used to describe Appalachia, with its gun culture and long tradition of self-reliance.

Military personnel may be more reluctant to vocalize their mental health struggles or suicidal thoughts because the topics still remain highly stigmatized in Appalachia. According to a study published in 2015 by the Journal of Pediatric Psychology, this stigma surrounding mental health is socialized in Appalachian children at a young age. The study concluded that “greater perceived stigma was related to less willingness to seek services in a mental/behavioral health center or in schools,” but the study also determined that there were some instances where stigma was not a factor at all, or only present in some children. This suggests that the stigma against mental health and treatment begins early in Appalachia: at home with parents and families.

Lauren Winebrenner, who works as a public affairs specialist and community outreach program coordinator at the Martinsburg VA Medical Center in eastern West Virginia, believes this to be a strong factor in why more veterans do not report mental health concerns. “I think the more we talk about it and the more we open up and are kinder, that will help society destigmatize mental health.”

Dr. Mark Mann, chief of mental health services at the Martinsburg VA center and an Air Force veteran, believes suicide prevention should be one of the center’s top priorities. “As a group, suicide prevention in this hospital is everybody’s problem,” he said. “Anyone who talks to a veteran should think, is this veteran in need of better care? Is there something I could do to help them?”

Mann also believes in providing veterans with the tools they need to feel comfortable managing their mental health issues on their own, so that, upon returning to civilian life, they are empowered to regain as much normalcy as possible. “Veterans don’t want to think they’re going to be tethered to the VA for the rest of their life for mental health care,” he said.

But numerous veterans are not receiving the help they need. According to Mikey Allen, a veteran from Wheeling, West Virginia, who served as a broadcast journalist with the National Guard out of his home state’s capital and then as a cameraman and documentarian in Afghanistan, this is because many military members simply do not report their needs to the VA.

Allen said he is more likely to talk with his fellow veterans, and he has never contacted the VA for mental health resources. “We prefer to confide in each other because we aren’t trying to fix each other,” he wrote in an email to Rewire.News.

An additional factor that makes Appalachian veterans especially susceptible to suicidal thoughts and actions is the region’s overall struggles with addiction. A  2016 VA study found a correlation between high-dosage opioid prescriptions and suicide risk. The study reported that veterans who were prescribed the highest possible doses of opioids were more than twice as likely to die by suicide compared to individuals receiving the lowest doses.

Since 2012, VA-authorized opioid prescriptions have decreased. Veterans are being prescribed these drugs at a 41 percent lower rate than earlier this decade. However, with fewer opioid prescriptions being issued to veterans who may have been receiving the drugs for years, severe issues such as opioid withdrawalmay arise. This, in turn, has been linked to increased veteran suicide and overdose, while also inadvertently encouraging veterans to turn to less safe street drugs to self-medicate and manage their pain and symptoms.

Allen, the National Guardsman, stressed the inherent comfort that comes from connecting with fellow veterans who understand: “There is no fixing us,” he said. “There is only dealing moment to moment. And the whole listening, sharing, understanding with people you already know, love, and trust—with no pressure to solve something—is just most comforting.”

Frank, who served in the Navy, believes increasing discussions about mental health among veteran populations is one of the most powerful actions mental health-care professionals and veterans’ friends and family could take. “For veterans, it’s a different situation because they reach out and nobody takes their hand,” he said. “That’s what turns the clock.”

Veterans who would like to have confidential conversations with trained medical professionals may call the Veterans Crisis Line or visit its website. To find local support, veterans may also visit Make the Connection.

This article was originally published by Rewire.News.

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