Accessing and delivering healthcare in rural areas is a challenge in the U.S. Rural Americans face health disparities compared with their urban counterparts, and must travel further to get to a hospital. Meanwhile, hundreds of rural hospitals are at risk of closure, and nineteen shut their doors in 2020 in the midst of the COVID-19 pandemic. 

Earlier this year, CEO Dr. Jennifer Schneider, alongside other veterans from chronic care management company Livongo, launched Homeward, which aims to provide care in rural markets through a combination of virtual and in-person care delivered through mobile units. The startup recently announced its first partnership with Rite Aid, allowing pharmacists to connect their Medicare-eligible customers with Homeward for care. 

Schneider sat down with MobiHealthNews to discuss the collaboration, how their model works and why value-based care is paramount for rural communities. 

MHN: What made you decide to tackle rural healthcare for your latest venture?

Dr. Jennifer Schneider: I think it's a combination of a couple of things. One is when you look at how broken rural healthcare is. It's not a little broken. It's massively broken. It's in a crisis. And so it's a big problem, and about 20% of all Americans live in rural markets. 

Second is that this is super personal for me. So I grew up in rural Minnesota, and, as I started to read more about the problems and reflect on my own personal journey, and my family's journey, it became increasingly important, both from a personal motivation and from a "tackling a big hard problem" motivation.

MHN: So there are some other startups that are focusing on this hybrid model of virtual combined with in-person care. How did you differentiate that for rural areas?

Schneider: There's a number of people in the healthcare ecosystem today that are doing combo/hybrid. But I think as you design, you have to design for end users. And so the specificity around rural markets is deeply understanding what it is that's broken for people. 

So if you look in rural markets, they don't have the infrastructure that urban markets do. They don't have public transportation. They don't have broadband connectivity, or have limited broadband connectivity. So the design of the solution has to fit the infrastructure in rural markets. Taking a hybrid, 'Oh, you can see a doctor once in a while and do a virtual visit,' in an urban market doesn't actually answer the problems that exist in rural markets. 

We spend a lot of time being obsessed with the end user, or the patient, and really trying to understand why it's broken from their lens and what we can do to fix it. Our announcement of our partnership with Rite Aid is a great example of this.

Access is a big issue. When you need to see a doctor, you have to drive multiple hours for a 15-minute visit. If you're an hourly wage worker, it's not actually an unreasonable decision to not do it. You're giving up a full day of pay to go for a 15-minute visit.

So the partnership with Rite Aid is a great example of being in a place, parking our provider facility in a place where people are in their daily flow, where they go to get their prescriptions, where they go to get some groceries, where they go to fill up with band-aids because they're coaching the soccer team.

It's really deeply understanding what people need and flipping the care delivery system to give it, rather than kind of saying, 'We're going to build a centralized hospital, and you all can come here.' Because that model has not been beneficial in rural markets.

MHN: Was it an intentional choice to pick a pharmacy as your first partner?

Schneider: Yes, it was with intention. So when you look at the touch points in healthcare, pharmacies have the most touch points, somewhere between 20 to 30 per year. Very few of us see or talk with our physician or care team that many times per year. 

The second is that the local pharmacist is a really trusted entity in any given market, particularly in rural markets. I live in a rural market right now in the Napa Valley, and I have Jeff Smith's cell phone number plugged into my cell phone so I can call them at off hours when something comes up. It is both a combination of healthcare access and trust. That is the reason that we started with pharmacies.

MHN: So one of your big points is moving away from fee-for-service payment. Do you think that's particularly important for rural communities? Or does that just reflect how healthcare generally should change? 

Schneider: I think it's paramount for sustainable healthcare delivery in rural markets, period. I also think it's reflective of some of the movement in the overarching healthcare ecosystem. 

The reason I say the former point is, if you think about the type of care that you need to deliver sustainable outcomes, it will require things such as remote patient monitoring. How can you assess and deliver information, or receive information to deliver care, in a world where access is the number one issue?

A lot of virtual care, if you build a business integrating those components in a fee-for-service world, the economics are not sustainable. In order to actually be sustainable and use the care that you need to be successful in care delivery, I think total capitation is really the only path forward in rural markets. 

There is also, as you noted, a shift within healthcare to move toward allowing people who can pull the levers, if you will, and deliver the outcomes to maintain some of that risk or own some of that risk. But it's paramount in rural areas, I don't think it's as paramount in urban areas.