Healthcare provider trust is an essential factor for a good patient-provider relationship. Trust has been traditionally built during face-to-face interactions and it is important to consider whether an in-person component is necessary to establish a relationship. Although the face of healthcare is evolving, prioritizing patient-provider relationships is at the core of what creates quality care and better health outcomes. If TM programs are to be implemented, it is essential for it to be designed using a patient-first and interactive model that will produce the most effective patient-provider relationship.
If implemented, the Governor would need to address any reimbursement issues. Some insurance companies value TM and will reimburse for a wide array of services while may not. Additionally, Medicare and Medicaid reimbursement may restrict the eligible health professionals who can provide TM services.25
While TM offers an innovative approach to addressing the challenges facing the Mississippi Delta, there are several drawbacks to consider. Rural communities not only suffer from physician shortages and a lack of access, but also typically have difficulties with the needed broadband infrastructure to support TM.24 For instance, if using video conference, the benefit of remote consultation for rural patients would amount to nothing if there isn’t the broadband infrastructure to support it. Rural areas are difficult and expensive to serve with broadband due to lower population densities, potential harsh terrain and fewer consumers over which to spread costs.24
Given the similarities in the problems that Mississippi and Iran have faced in terms of the health of their populations, it is critical to appreciate the model implemented by Iran and the successes they have seen. Peoples in both Iran (pre health houses) and the Delta area have limited access to primary care and preventive services as well as a shortage of healthcare providers. The implementation of a similar model of health houses would address Mississippi’s biggest problems.
Health houses hold an advantage over TM in that health houses have the ability to address racial/ethnic characteristics of the Mississippi Delta region. Because the Mississippi Delta region experiences not only geographic disparities but racial/ethnic disparities, in order to ameliorate such disparities it is critical to the construction of effective policies to that there is a clear understanding of the different levels of causation ranging from proximal environmental to behavioral to biological to social and cultural factors.26 The CHWs that would not only serve as public health workers but also as trusted members of the community served who have a deep understanding of it. This relationship enables them to act as a liaison between health, social services, and the community in order to facilitate access to health services and improve the quality and cultural competence of the services delivered. CHWs also add to individual and community capacity by encouraging health knowledge and self-efficacy via outreach, community education, counseling, and advocacy.27 The CHW role as a culturally competent mediator between health providers and community members and the effectiveness of CHWs in promoting the use of primary and preventive services makes for a reasonable solution to Mississippi’s shortcomings.28
The major challenge revolves around the current health policies that are aimed at treatment rather than prevention. The existing U.S. health system is a major structural barriers because upon implementation would attempt to reshape the health houses model to fit into the existing ineffective healthcare system. The issue with implementing a similar program in the U.S. is that in Iran, the primary reason was to improve health and in the U.S., the primary interest is saving money as long it also improves health. For health houses to be established successfully in Mississippi, initial funding would need to be provided by government endowments to set up facilities. Currently, funding revenues are becoming available through the ACA, Medicare and Medicaid services and much of the work of CHWs will be able to be reimbursed through Medicaid and Medicare.29 The sustainability of the health house will be that it fits into the way the evolution of how healthcare is delivered and paid for in the U.S. Initial funding of health houses may appear costly, the high costs and poor health outcomes of Mississippians are driven by the frequent use ERs for conditions that could have been addressed by PHC. Evidence shows that prevention is less expensive and more sustainable than the current system based primarily on high-cost medical care for more advanced and potentially preventable health issues.30
The key takeaway is that communities need to play a more active and participatory role in primary health care and that chronic diseases should be better integrated into PHC. Technology can be a tempting solution but a comprehensive health solution requires a more local approach. That being said, Iran’s successful implementation of health houses was approached in both a top-down and bottom-up manner in which community involvement played a major role and Mississippi would need to do the same. There appears to be strong community support for the implementation of health houses and it is strongly recommended that government support follows suit.31