not lose sight of the rural designations in ensuring that rural areas are served. However, rural providers are reimbursed less than their urban counterparts. If the financial equation for the urban base originating site does not work, telemedicine will remain as a fringe service. Second, the NRHA recommends the elimination of separate billing procedures for telehealth services. Telemedicine is a tool for the clinician; the use of separate, specific codes does not make any sense. The third recommendation is to reimburse care provided by physical therapists, respiratory therapists, speech therapists, and social workers. These services are in high demand in rural areas, but are often not available to rural communities. Finally, the NRHA recommends reimbursement for S&F applications.

Credentialing

We need to look at the cost of credentialing and privileging, as it is very burdensome to rural providers. A telehealth provider can administer health care services to patients anywhere in the country. The NRHA recommends that CMS adopt a policy to allow telehealth providers to receive deemed status (meaning that the providers meet Medicare and Medicaid certification requirements) and to allow for health care facilities receiving telehealth services to perform credentialing by proxy.

Broadband and Infrastructure

Investment in broadband will require the combined will of and collaboration between government regulators and private industry.

Research

Much research on telehealth is already available. However, the NRHA calls for additional quality measures in telehealth treatments to improve the services in rural America. To be clear, the health care delivered in rural America is not of lower quality. This is reflected neither in the 2005 IOM report Quality Through Collaboration (IOM, 2005) nor in CMS Hospital Compare data that compare small critical access hospitals to their urban counterparts. Those sources indicate that rural health care is comparable (and sometimes even better) than the health care that is delivered in urban communities. However, it makes sense to look at some specialties to see if the quality of care has improved with the use of telehealth.

The NRHA also calls for research to aid the telehealth resource centers and regional extension centers to improve the services they provide. The NRHA does not mean to imply these centers are not doing their jobs, but without the outcomes research of how their assistance is helping, they can-



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