Mobile Health Care Works, Why Don’t We See More of It? Answers & Opportunities

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Mark Masselli (00:04)
Harvard Medical School reports that over 3,600 mobile healthcare clinics now serve every state. That's an 80%
increase since 2013, but there are still some bumps on the road.

Nicky Goren (00:16)
One of the special and unique things about mobile clinics is that in general, they are really highly tailored to
what the community needs, each community where a mobile clinic is going. So, understanding and delivering
what the community needs and wants is key to a mobile clinic's success.

Margaret Flinter (00:33)
Our guests today are Don Blanchon and Nicky Goren, who serve as the strategic advisors for Driving Health
Forward, a new national effort to ramp up the mobile healthcare sector.

Don Blanchon (00:44)
Mobile is a proven high-quality solution to bringing access directly to people. And we have an over-reliance on
facility-based models because that's the way we've been doing healthcare for decades, if not a century or more.

Margaret (00:58)
This is "Conversations on Health Care."

Mark (01:11)
Well, Nicky and Don, welcome to "Conversations on Health Care."

Nicky (01:13)
Thank you. Thank you for having us.

Don (01:15)
Thanks. Great to be with you.

Mark (01:17)
Absolutely. Let's start with Don. You're also serving as the interim director of the Mobile Healthcare
Association. Let's ensure we have the terms exactly right. What do we mean by mobile healthcare? What does it
look like, and who does it serve?

Don (01:31)
So, it's a great question, and for me it can be simply defined as kind of mobile programs or modalities that are
bringing healthcare services to individuals and families where they live, work, and gather. And so those can be
testing vans in community settings, they can be home visitations to independent living for seniors, they can be
mobile programs that go to schools and do physicals in August and September. They can be a whole host of
things. But largely thinking about programs that come to people rather than people moving to a building.

Margaret (02:08)
Well, Nicky, mobile healthcare can certainly deliver a range of primary care services, as we were just
discussing, certainly play a role in chronic disease management, urgent and follow-up care. But also, I think,
have a strong role to play in behavioral health services, substance use disorder services, maternity services-
we've read quite a bit about. Tell us about that range and maybe the social services that are wrapped around this
area of healthcare delivery.

Nicky (02:38)
Yeah, absolutely. So, one of the special and unique things about mobile clinics is that in general, they are really
highly tailored to what the community needs, each community where a mobile clinic is going. So, understanding
and delivering what the community needs and wants is key to a mobile clinic's success. So mobile clinics are in
a position to deliver so many different services, as you've mentioned, whether it's primary care, preventive
screenings, mammography, dental, maternal and childcare. And yes, they can also include other social services
as the community needs and wants. So, like a great example of that is in Boston, the Family Van is a clinic out
of Harvard University in Boston. In addition to providing preventive screenings and community-based
healthcare, they also provide health education programs. They connect their clients to resources, including

housing, employment, health insurance, food service assistance, and low-cost dental and mental health services.
So, it's happening everywhere. That's just one example, but it is a great way to bring these, kind of, wraparound
services to people and community.

Margaret (03:42)
And does that include behavioral health and substance use disorder services-

Nicky (03:47)
Absolutely.

Margaret (03:47)
… testing for HIV, for instance, all of those? Great.

Nicky (03:50)
Yes. There are some clinics that are exclusively focused on that, on those issues in different communities, and
there are some that bring that in addition to some of the other core services they provide.

Don (03:59)
On a personal note, I led a federally qualified health center in Whitman Walker call- in Washington, DC called
Whitman Walker. And it had a mobile program that did HIV and STI testing throughout the Washington region.

Margaret (04:11)
Great. And we certainly know that organization's-

Mark (04:14)
We know them well

Margaret (04:14)
... work very well. And the Harvard team, so both urban kind of settings, so interesting.

Mark (04:21)
And Margaret, we've been involved in mobile health for a long time. We certainly understand the value. So, I
guess it seems to us to be a no-brainer. So, Nicky, why is there a need for this campaign, Driving Health
Forward? What are the hurdles that you're facing, and how are you trying to overcome them with a campaign?

Nicky (04:39)
Thank you for that question. So, what we found as we began our exploration of this sector is that mobile health
is hyperlocal, structurally isolated, often outside of the traditional healthcare system. The sector is very
fragmented, which undermines collective impact. There are not a lot of lessons learned in collective work in that
regard, and overall, there's been an incremental approach to scaling mobile in this country. There's also been a
lack of recognition and understanding of some of the structural barriers that impede mobile from sustainably
thriving. So this campaign came together as a way to build a big, broad coalition of stakeholders from across all
the sectors, who believe in this idea of expanding access to healthcare via mobile, working with that coalition to
identify the barriers, the structural and practice barriers that have made it difficult for mobile health to grow and
thrive in a sustainable way, and then begin to identify policy and practice changes that can address the barriers
that are out there. So, with extensive research, extensive input from stakeholders, from everyone, from clinics to
payers to manufacturers, hospitals, everyone in between. We launched our initiatives formally in September and
are focused on three key things. One is a systems change-focused, sector-wide brief that makes the policy case
for expanding mobile healthcare as a high-quality, cost-effective, financially sustainable approach for ensuring
access to care. The second is to develop a series of policy briefs, seven at the moment, with proposed solutions
to some of these systemic barriers that mobile clinics face. We've issued four to date. We have one coming this
month and two more in the next two months. And then third, a proof of concept pilot. It's a state learning
collaborative that would demonstrate what it looks like for health access and eventually health outcomes when a
state or a group of states decide to and commit to incorporating mobile at the statewide level. And then we
make-

Mark (06:43)
So, the rub really seems to be at the policy side, at federal and state level. It doesn't seem to be the healthcare
providers or certainly the people who use the mobile vans. So really the dilemma is having policymakers
integrated into ongoing health reform and health investments.

Nicky (07:02)
That's a big, big part of it, and there was definitely a gap in the sector. Nobody was really looking at policy for
mobile. But also, there was a practice gap, too, where organizations were starting clinics and often, they were
closing. They weren't financially sustainable, and it was because they weren't going through the steps-

Mark (07:20)
Following best practices.

Nicky (07:23)
… and figuring out ways to become sustainable. Yeah.

Mark (07:25)
Yeah.

Margaret (07:26)
Well, there's a lot to unpack of that, and like so many things in healthcare, that's not what people's general past
experience has been. If you haven't seen it, if you haven't seen the inside of one of these mobile health units,
haven't met the staff who are on them, it's hard to appreciate the degree to which you might as well be in the best
exam room of the best practice in town with the best services, except it's actually close to where people are. So,
I bet you have your cameras rolling for that campaign to try and make it obvious to people. But I understand
you're also concerned about possibly some threats to mobile healthcare in H.R.1, the One Big Beautiful Bill, as
it's commonly referred to because of Medicaid cutbacks and the law. Is that something specific to mobile
health? There's certainly concern across the board with-

Mark (08:18)
Writ large.

Margaret (08:18)
... Medicaid cutbacks but tell us how it might particularly affect this area of healthcare.

Don (08:24)
Yeah, I'm happy to offer some comments, and Nicky may join me on this. I think on a practical level, the
changes to Medicaid, the two in particular, the work requirements, mostly for adults, as well as the changes in
the state financing options that they have for provider taxes and other vehicles to maximize the amount of
funding they can pull down from the federal government to support their state program. Those two things are
real. They're coming in a year, in 2027, and so you would expect there will be significant pressure on Medicaid
program directors and governors to try to figure out how to square that off. Which means there's going to be
some loss of eligibility for some current Medicaid beneficiaries, and over time, the financing vehicles that states
have used to keep their programs robust, they won't have as much funding flowing from those financing
vehicles. So that's the macro of the macro-environment consideration. It's somewhat counterintuitive, but mobile
actually has an amazing opportunity right now, and that sequences with the availability of the Rural Health
Transformation Program funds that the states have. As well as mobile is a proven high-quality solution to
bringing access directly to people. And we have an over-reliance on facility-based models because that's the
way we've been doing healthcare for decades, if not a century or more. And we're really having to change the
mindset, not so much in community all the time, but with healthcare providers, with government officials, with
public and private payers, and then with consumers within certain communities, because not all people believe
that mobile programs are for them. And that's one of the community realities that we always have to grapple
with. So as much of the big funding changes and eligibility changes are coming from H.R.1, there's also a great
opportunity for mobile right now to position itself closer to people, bringing care directly to where they live,
work, and gather, and quite frankly, helping knock down some of the known access barriers we have right now.

Mark (10:30)
You know, Margaret, we've been having a conversation with many people about the Rural Health Initiative, $50
billion coming back to the states. It's being distributed. It's good to hear that a rural focus is including mobile
units and opportunities for people to deliver care in a different way. There's sort of a worry about how this will
be executed. Are you seeing any best practices so far? I know the states had to go back to CMS for approval
after their initial round. I think some states are hearing about that. Are you tracking any of the states in terms of
saying, hey, one, they have a great model in terms of their narrative, and two, here's how they're executing it, or
is that something you'll be following over a period of time?

Don (11:22)
I want to share the joy of wearing two hats in this conversation on the Driver Health Forward and with the
Mobile Healthcare Association, which is an amazing organization that's been around about 25 years supporting
mobile program operators in the US and Canada, as well as in Mexico. And so, the interesting thing here, Nicky
mentioned some gaps systemically in policy advocacy in other areas. And so, Driving Health Forward stepped
into that gap in August of last year and said, "With this $50 billion in the Rural Health Transformation Program,
there is probably a once in a generation opportunity here- Yeah ... to position mobile health as literally one of
the go-to places for primary and preventive services." In the past, it had been largely seen as a charity care-
model that was oftentimes outside local healthcare delivery. It was literally seen as something that, well, this is
for under/uninsured people that don't access care regularly. And that has both bias and stigma implicitly when
you structure things like that. It also was heavily reliant on initial government or community philanthropy- to
buy a vehicle or outfit a vehicle without, as Nicky mentioned, a path for sustainability. And so, with those
elements, we felt the Rural Health Transformation Program gave us a great opportunity to advocate on behalf of
mobile. We take great pride that we sent letters to 50 governors, and we provided public comments to 38 states.
And we're thrilled that 48 states have some type of mobile initiative in their final award. We, the Mobile
Healthcare Association, and we, Driving Health Forward, are tracking all of these states, and I'd love to just
share a couple of those initiatives so you can see how this is beginning. So, in Georgia, which has some high
breast cancer screening rates and has some high mortality around that, they have a major mobile initiative
around getting mammography units, mobile units out across the entire state. And so that's a great example of
taking a known chronic health, public health, preventive screening risk and putting that action and being able to
fund something where those units will be available to women all across Georgia. So that's a great initiative. In
Nebraska, which has some chronic disease management issues that they want to tackle, they're allowing rural
health clinics and federally qualified health centers with mobile vehicles and mobile programs to participate in
their RFP, their request for proposal, to be able to do chronic disease management over time. And then lastly,
Florida has got a really great initiative. They've set aside in year one, $20 million for up to 20 programs for
preventive screening, prenatal services, and rehabilitation services across the state. And they've defined their
rural areas as many states have. And so, these are just three examples of states knowing their own issues, what
they're facing from a public health or an access to care challenge, and then trying to tailor the funds from Rural
Health Transformation program to have the greatest impact.

Margaret (14:31)
Well, that is great. Thank you for sharing that with us. We're familiar with the Harvard Medical School
mammography study, showing potential lives that were saved because of mammogram screening. But I wonder
if you could talk a little bit about that continuity. Healthcare is not just about what happens, as we all know, with
the provider and the patient at the time of the visit. It's all that follow-up. It's coordinating with specialists. It's
getting those lab results back. It's getting that mammogram result back. Maybe tell us a little bit about the
infrastructure that has developed around this sector. Is it usually associated with a hospital, health center, or
practice so that that continuity is there? What happens when the van goes away and onto its next city or
destination? Tell us a little bit about that.

Don (15:19)
Sure. I'm happy to share, and I know Nicky may have some thoughts on this also. I can use some information
just from the Mobile Healthcare Association, which has about 535 active members right now. And 60, 65% or
more are affiliated with a healthcare group. An academic center, a community hospital, a federally qualified
health center, a community behavioral health center. And so, there are some natural synergies that are built in.
Those programs are, in part, already embedded in a local system. I think the challenge we have in doing this is
really the investment in technology, and the technology needs to be the electronic health record, technology
around remote patient monitoring, telehealth. And those investments are really important to make a mobile
program successful- in keeping people connected and making sure they get to the next specialty appointment if
they need to do that and making sure they take their medications post-discharge. And so, I think the combination
of mobile programs, vehicles, and what have you, that are doing screening and follow-up care coupled with a
technology investment. That technology investment often falls behind the actual purchase of a vehicle for many
of the programs that use a van- a truck. You come up against this competing funding issue of do we buy the
vehicle but not the technology we need to keep people engaged in care? We've got to be able to do both-
because the way this is going to work is we're going to have to connect people if we do more screenings.

Mark (16:48)
You know, I’m - just picking up on your phrase, the next specialty appointment - I'm thinking about the
program we've been working on for about a decade, providing e-consults to safety net hospitals and federally
qualified health centers, rural health centers, so important. So, there's a lot of technology that can be used on

that. But I want to sort of get to some of the barriers that exist, Don, out there. There's a new research paper
from Georgetown Center on health insurance reforms really highlighted the patchwork of state certificate of
need regulations for mobile healthcare. That sort of slipped by us-

Margaret (17:21)
Yeah. Right.

Mark (17:21)
... in terms of an obstacle that would be out there. Tell us if a national fix would be the solution.

Don (17:29)
So again, a great question, and I want to take this from the perspective of Driving Health Forward. This was one
of, I think, the top five issues that came up from our process with mobile healthcare stakeholders. And the
certificate need and other regulatory barriers just were a hurdle to getting programs off the ground. And
certificate of need has both a time and a cost investment for program operators. They're not cheap. In some
states, they can be a percentage of revenue, so they can be pretty expensive- Yeah ... to be able to clear that. And
then they don't neatly fit into the bricks-and-mortar model, where you can produce volume differently,
projections, the kind of financial modeling side. And so, in the policy brief that we put out previously, we
flagged a couple of recommendations that we thought would be really helpful, particularly as it relates to Rural
Health Transformation program. The first was, we think there should be an exemption at the state level for
mobile programs. We think the programs are being vetted carefully under the Rural Health Transformation
program. The funding's going to be really scrutinized, and as a requirement of Rural Health Transformation,
these programs are going to have to be financially sustainable. And so, you've got to be able to kind of look out
of the gate saying, "We want these things to thrive," and not have anything that's going to put it in a position
where we're spending more time and money in areas that's not adding value. Two, I think we believe in the past
that certificate of need processes are used to keep competition or people out of certain markets, and that's a
horrible reality to some of how the facility side of certificate of need had worked, and we want to do the
opposite. We want to make mobile, we want to grow mobile, and we want to get to access to care barriers. And
so, to have this notion of that, a hospital or a community-based provider could argue against a mobile program
improving access in a community seems to be counterintuitive. Mm. And finally, a recommendation that we feel
strongly about is, I think in this day and age, we believe states should have an individual agency or department
that kind of coordinates all of the regulatory and programmatic oversight of mobile health in their state. What
we've learned from multiple mobile programs operating across the US is that they're dealing with three or more
state agencies with complicated legal and regulatory structures, and it's just... Remember what these programs
are. They're oftentimes four to eight people operating- Right ... in a community- Right ... on really tight
resources. They don't have the ability to hire a lot of attorneys to run around and go, "Okay, what do we need to
do across four different agencies?" And so, we think simplification's the answer, and we'd love to see,
obviously, an exemption to certificate of need for mobile as we go forward.

Margaret (20:20)
Starts right at the beginning, recalling the days of our first foray, the second question on the application for
licensure is, "What's the address?" Well… it's a mobile health-

Mark (20:29)
On what day, on what day of the week?

Margaret (20:30)
On what day are we talking? Right. Exactly. I will say, shout out to the state of Connecticut. They've been very
flexible about associating it with different addresses that were already in play. But I want to talk maybe about
telehealth integration. You talked about things like remote patient monitoring, very important, the ability to
communicate with other people on the team. But tell us more about how telehealth is used by those on the unit,
even when they're in a community with the unit to provide services to people who maybe can't even get to the
telehealth unit, or can't get to the mobile health unit, but can be reached by telehealth, or to use it to connect
them to specialists- as Mark was alluding. Tell us about telehealth's role here.

Don (21:15)
So, the experience I have in seeing some of the programs operate to date, really being able to have a strong
telehealth and electronic health record presence, as well as sufficient broadband satellite coverage because many
of these programs are operating in areas where the broadband is just not that great. And what you're really trying
to do is you have an individual in front of you, and they may be in care in a setting 200 to 300 miles away. And

so, the ability to, in that van, in that moment, to be able to dial up someone to be able to do a consult while you
have that person in the mobile exam room, it's invaluable. And so, I think the play has been marrying vehicle
and bringing service with the technology of making sure that you can access a specialty care physician, a
radiologist who has a specialty in cancer screenings. Those types of elements are really important to us. And it's
largely here, it's one of the core elements of how we need to bring mobile closer to the healthcare system, which
is the connectivity is going to be ultimately the technology and how much the programs are trusted by
individuals in their community. Right. Those two elements, in my mind, are kind of secret sauce to how we're
going to be able to keep people in care over time.

Mark (22:36)
Right. You know, you both have impressive backgrounds, but Nicky, talk to us about your previous position
leading philanthropic foundations and the role of philanthropy in supporting mobile healthcare. And also, who's
invested in this area and why have they so far?

Nicky (22:55)
Yeah. So as a general matter, yes, I did have a background in philanthropy, and a lot of my consulting clients are
in philanthropy today. With respect to mobile health, we've seen philanthropy often invest in the upfront cost of
purchasing a mobile van for an organization, which is a very important contribution, but really insufficient given
the barriers that mobile clinics face in terms of long-term sustainability. The Leon Lowenstein Foundation,
which is a family foundation based out of Connecticut, put a stake in the ground around this issue of expanding
mobile healthcare a few years ago and is really one of the only funders who has consistently, in the last few
years, invested in some of the sector infrastructure and advocacy needed to address the structural and practice
barriers that exist, including their hiring of Don and me to devise and launch this campaign. We really believe
more funders need to pay attention to this issue and need to support the backbone infrastructure that is bolstering
the sector, whether it's the Mobile Health Map at Harvard, whether it's the Mobile Health Care Association,
there are other associations connected, or the work of Driving Health Forward, which is expanding the
messaging, research, and policy advocacy work. Investment in that work will help guarantee that their
investments in the vans pay off in the long run. So, we think this has largely been under the radar, and we want
to bring it, you know, under everyone's- into everyone's vision.

Margaret (24:22)
Well, Don, let me go to your background for a moment. You said that you had served previously as executive
director of Walker Whitman. Did I get the name right, correct?

Don (24:31)
Whitman Walker, yes.

Margaret (24:32)
Whitman Walker. I knew I was going to get that wrong. Thank you for correcting me. Hopefully not the first
person to do that.

Don (24:39)
You are not.

Margaret (24:41)
Good. But I think of the incredible work your organization has done and the work in HIV detection and
treatment, but also hepatitis C, substance use disorders. And certainly, SAMHSA has been investing very much
in mobile health units at the federal level to address hepatitis C screening, detection, and treatment. And I
understand that there's research that showed that $18 is returned for every $1 invested in mobile healthcare
clinics. There's a documentary from Minnesota called "We Are Here" about lowering barriers with mobile
health that suggests the same thing. Tell us about that economic argument and how strong it is for the
policymakers as you talk with them, and using, in particular, some of these really challenging healthcare issues
where there's no doubt, you're not just saving lives, you're saving hundreds of thousands of dollars over the
course of somebody's life.

Don (25:38)
Yeah, I mean, I think the return on investment question has been answered and answered multiple times by
mobile program operators across the US, has been documented by some work from our friends at the Mobile
Health Map. I think the challenges, and Nicky mentioned this, we've run into what I would call a legacy issue
around mobile health programs closing across the country for a variety of reasons, but probably primarily

because there wasn't long-term financial sustainability plan. Right. And the initial investment from government
or from philanthropy to get a vehicle and a program up and running is great. But to have four to eight people on
a program running three to five days a week, the vehicle maintenance, the cost of fuel, and all of those elements,
these are not small investments. And they've got to figure out a way to have sustainable cash flow like any other
healthcare group for that matter. And so, what you have is the ROI is there, and the data's there to support it, but
it competes with the reality that some policymakers, some healthcare leaders, some community leaders are like,
"Yeah, but that program in my county closed." And one of the most significant fallouts from the COVID
funding going away is that there were a lot of vans and vehicles used for COVID testing, screening, and
obviously vaccination initiatives. And when that funding ended, some of those programs have not been
converted over into primary prevention or other types of healthcare outreach. And so, you have this legacy issue
in community of things closing, and yet data that says this is a high-quality proven strategy. And so those two
things compete with each other.

Mark (27:26)
And also, really focusing on best practices for efficient, effective, and economical models that have to just
operate the same level across the country. And also, the returns maybe should be measured in a little longer
period of time than the short returns. But I want to ask you both a question about the future of mobile healthcare.
What does it look like? I don't know if Waymo's going to drive up to me and deliver me a primary care provider,
but what about drones, AI, all the things that you've probably been thinking about. But take a few minutes. I
know we're running short. But Nicky, do you want to start about the future?

Nicky (28:05)
You know, I mean, obviously technology is going to play a role. I think how we've approached this from the
beginning is that the current system isn't working. It isn't working for most people actually. Regardless of where
you are, cities, urban, rural, poor, rich, there's a lack of primary care physicians. There's lack of access. And so,
the system in its entirety needs to change, and we believe that this idea of mobile and bringing services to
people, whether that's through technology or through vans or through cars or through street medicine, is the way
of the future. I'm not an expert on AI. I can't speak to those things at all. Maybe Don has more to add on that
aspect.

Don (28:49)
Well, I practically know that there is work underway around the use of drones to deliver medications. Hard to
reach. That's right. That's right. So, I would expect that drones at some point in time would come into play. I
will not speak about any other aspect of technology. It's not my area of expertise. But I think the thing that has
happened over time is the financing model of most of healthcare is about volume. And in the case of mobile,
mobile does a great job of screening individuals in communities, detecting illness burden early. But who
benefits from the savings? Where do the savings revert to? In a hospital when it's in a value-based contract and
it saves money on a length of stay or avoids this or does this efficiently, it keeps the savings. That's right. When
a mammography unit in Georgia screens 50 women and early detection of breast cancer and helps avoid
hundreds of thousands of costs and illness burden for those women, who benefits? The system benefits. But
mobile, the mobile program itself- Right ... it's not financially structured for those gains or savings to be
reinvested in mobile. And I think one of the issues we've got to do is you've got to align the work around value
so that mobile programs are actually funded for the long haul. If there's one lesson Nicky and I've learned in the
18 months we've been together is the system needs to recognize value alignment, and it needs to recognize what
we do now isn't working, so we have to change. We hopefully are just illuminating the fact that mobile could be
a big part of the solution on how bringing care closer to where people live, work, and gather.

Margaret (30:34)
Wonderful. Well, thank you, Nicky and Don, for joining us, and thank you to our audience for being here. Just a
reminder, be sure to subscribe to our videos on YouTube, find us on Facebook and X, and please share your
thoughts and your comments about this program. Take care. Be well.

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Margaret (30:54)
This copyrighted program is produced by Conversations on Healthcare and cannot be reproduced or
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Healthcare or its affiliated entities.

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