Is rural America prepared for Ebola?

By Raymond Christensen, MD
NRHA 2014 president

The National Rural Health Association has long advocated that we are either all prepared to deal with emerging public health crisis, or as a nation, we are simply not prepared at all. Such is the case for the emergence of the Ebola virus. Decades of rural public health underinvestment raise serious concern as to the ability of a rural community to handle an Ebola-positive patient.

Each rural community needs to assess and determine inherent risks and capacities that can be brought to bear in responding to any public health threat. Ebola is no exception.

From a rural perspective, the ability to identify and diagnose, and then the contact tracing role of local public health officials are the great unknown at this point.

Health professionals, volunteers/first responders and the public must be educated to better identify, respond to, and prevent the health consequences that Ebola presents and to promote the visibility and availability of health professionals in the communities they serve.

For far too long, rural public health has been underfunded. As a result, the infrastructure is thin.  Training and the ability to properly diagnose before the infection gains a foothold in a rural community will be key.

As a nation, we must be prepared for the identification of a future Ebola case to present in a small rural community. As such, local, state and federal authorities need to have a plan in place for this potential outcome. The solution will likely involve a local, state and federal response, and how all these parts of our health system interact will be key to a successful outcome.

NRHA will continue to advocate for rural public health, patients and providers.

President Obama signs the Improving Medicare Post-Acute Care Transformation Act of 2014 into law

President Obama signed into law the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). This legislation improves post-acute care for Medicare beneficiaries, and standardizes data for quality, payment and discharge planning for post-acute care providers, including nursing homes and home health agencies.

The bipartisan legislation was introduced by Ways and Means Committee Chairman Dave Camp (R-MI) and Ranking Member Sander Levin (D-MI).

More information on the IMPACT Act can be found here.

NRHA reacts to HHS report on costs for rural patients

The Office of the Inspector General (OIG) of Health and Human Services released a report today on the calculation of patient coinsurance amounts between critical access hospitals (CAH) and PPS hospitals.

First, some background: CAHs receive cost-based reimbursement for inpatient acute, swing-bed and outpatient services delivered to Medicare beneficiaries. Medicare patients at CAHs owe coinsurance on outpatient services on the basis of 20 percent of applicable Part B charges.

Under the outpatient prospective payment system (OPPS), the coinsurance is based on 20 percent of the OPPS price under the fee schedule for ambulatory patient classification (APC) units. Because the fee schedule is generally much lower than charges, an unintended consequence of cost-based reimbursement is that beneficiaries receiving care at a CAH have a higher coinsurance burden than those going to PPS hospitals.

The National Rural Health Association’s response is:

  1. CAHs are billing Medicare and beneficiaries according to Medicare rules and regulations, any deviance from these guidelines would result in fines and penalties resulting from non-compliant billing.
  2. Medicare can correct this policy very simply by holding harmless beneficiaries on coinsurance calculations between CAH and PPS hospitals. This change would increase Medicare payments to CAHs in order ensure that CAHs receive 101 percent of cost.
  3. NRHA disagrees with OIG’s assertion that CAH participation in a possible fix be contingent upon re-certifying their CAH status. All CAHs were designated according to rules and regulations in place at varying points in time historically. The Necessary Provider program allowed for a state’s right to designate hospitals it deemed essential according to an overall rural health plan. These rural health plans were approved, in turn, by CMS. All CAHs should be fully reimbursed at 101 percent of their cost if a coinsurance change is implemented.
  4. NRHA believes that the current CMS policy unfairly penalizes rural patients, which is not the intent of Congress. We ask Congress to direct CMS to not shift the burden to providers or to patients.

This problem was created by Congress and Medicare and can be fixed by them with ease. As the OIG report documents the problem, it’s time to fix this inequity.

Rural hospitals face an uncertain autumn

Autumn is here. The nights are cooler and football is back. Enough to brighten the mood of anyone worn down by a hot, muggy summer, unless your favorite football team lost, that is.

But the season isn’t looking bright for 26 rural hospitals that shuttered operations across the United States since 2013. That’s more closures in just the last 19 months than the total between 2003 and 2012. These communities are struggling to overcome the absence of vital health services and the economic loss of local jobs.

American Public Media’s Marketplace featured a look at this epidemic earlier this year. This poignant story, “When rural hospitals close, towns struggle to stay open,” tracks what happened to Sparta, Ga., when its rural hospital closed 14 years ago.

When Sparta attempts to recruit industry, the first question asked by a company executive is “do you have a hospital?”

A Georgia state senator wept describing the dire situation: “[It] ends up with rural communities, such as Hancock County, Ga., where 39 percent of the folks who have a stroke or have a heart attack die. That’s a lot higher than in counties with hospitals close by.”

It is believed that many more rural hospitals are teetering on the edge of closure. Evidence reveals that 66 percent of the nation’s 2,323 rural hospitals are operating at a financial loss, according to iVantage Health Analytics. A rural hospital in Washington State is seeking a special tax levy to keep its doors open. Another rural hospital in Tennessee is in danger of closing unless it finds another operator.

Imagining a future for these 26 rural communities whose hospitals have closed is difficult. Sparta may offer a glimpse for what awaits. However, legislators and policymakers at the state and federal levels have the tools to alter the forces that have collided to create this reality. NRHA suggests a two-pronged approach to reversing these dismal trends.

The first prescription is to do no harm. Congress should not make any further cuts to rural hospital and practitioner reimbursements. The uncertainty around rural provider reimbursement programs causes rural providers to focus on the short term at the expense of their long-range planning. This means settling the Sustainable Growth Rate formula permanently, extending the Medicare-dependent hospital and low-volume hospital programs, making no changes to the critical access hospital program as well as other payment structures that help keep rural hospitals solvent.

Once providers are assured of several years of constancy with reimbursement programs, we can then focus on NRHA’s second objective, transforming rural delivery systems based on community need. This requires a creative and dynamic process that focuses on population health and alters the trajectory of current trends in rural communities.

NRHA is actively engaged in this important two-pronged approach to solving the seemingly intractable problems of hospital closures. It is our hope and expectation that legislators and policymakers will work with us toward achieving these important goals.

Join us Sept. 1-Oct. 3 for NRHA’s 13th annual Critical Access Hospital Conference to learn more about the closure crisis and how you can help prevent more rural hospitals from closing their doors.

New Study Looks at Rural Children’s Health Issues

First Focus released a new report today reviewing children’s health throughout the country, and specifically, the number of children covered by Medicaid or CHIP.  Using data compiled in every congressional district in the nation, the report “focuses on differences between rural and urban children in terms of recent trends in health insurance coverage and type of health insurance.” The report concludes that rural children are generally more reliant on CHIP than kids in urban areas.  This conclusion is of great concern to rural health advocates as CHIP authorization is set to expire in September 2015.

NRHA strongly supports CHIP re-authorization and will continue to advocate for its renewal.  Those interested in the report may access it at First Focus’s website.

Members of Congress head home for August recess

Members of Congress are back home for their five-week district work period. The National Rural Health Association encourages rural health leaders across the country to visit the district offices, attend town halls and invite members of Congress to tour rural facilities.

The rural health care safety net is in jeopardy.  More rural hospitals have closed in the last year than over the past decade and they are continuing to face more challenges with Medicare reductions, failure to expand state Medicaid, and regulatory changes imposed by CMS.

Rural hospitals are critical to rural American and provide great value to the rural patient, rural community and taxpayer. Urge your members of Congress to stand up for rural and protect the rural health safety net.

NRHA has outlined concerns with the Affordable Care Act, sequestration and the attacks on rural hospitals here.

VA bill passes Senate and House, heads to White House

On Thursday, the Senate approved 91-3 a compromise bill to overhaul the Department of Veterans Affairs. The House passed the bill Wednesday and it will now go to President Barack Obama for his signature.

The legislation allows veterans who experience long wait times or live far from VA facilities to receive non-VA care. The bill also allows the VA to hire new doctors and nurses.

Continue monitoring NRHA’s blog for the latest VA news. For more information on the health needs of rural veterans, please view NRHA’s recent policy paper:  Rural Veterans: A Special Concern for Rural Health Advocates

Veterans’ Access Bill Falls Short for Rural Veterans

NRHA is disappointed that final language of the Veterans’ Access, Choice and Accountability Act does not do more to improve access for rural veterans across the nation.

Our nation’s veterans are disproportionately from rural America. The legislation had an opportunity to remove significant barriers and allow rural veterans the choice to access quality health care close to their home, yet fell short.

A significant barrier for many rural veterans is that there will be no ability to choose a local rural provider, even if they live well over 40 miles from a Veterans Health Administration hospital. This is due to the inclusion of Community-based Outpatient Clinics (CBOCs) in the definition of VA medical facility within the Act. There are over 800 CBOCs scattered across the county. These outpatient-only facilities offer varying degrees of limited primary care during limited operating hours.  Including these facilities within the bill virtually negates the intent of providing rural veterans true choice in their health care.

NRHA is also disappointed that language was not included to ensure appropriate rural representation on the Commission on Access to Care established within the Act. Rural veterans, like rural Americans in general, are older, poorer and sicker than their urban counterparts and have unique challenges accessing care. Both workforce shortages and sheer geography make the health care delivery in rural areas extremely challenging. Like other health commissions currently charged with reporting to Congress, there should be proper rural representation on the Commission in addition to a representative from the VA Office of Rural Health.

For more information on the health needs of rural veterans, please view NRHA’s recent policy paper:  Rural Veterans: A Special Concern for Rural Health Advocates

CMS issued final rule to reform burdensome regulations for providers

The Centers for Medicare & Medicaid Services (CMS) issued a final rule to reform Medicare regulations identified as “unnecessary, obsolete, or excessively burdensome on health care providers and suppliers.” Revisions include eliminating the requirement that a physician must be onsite at a Critical Access Hospital (CAH), Rural Health Clinic (RHC) and a Federally Qualified Health Center (FQHC) for at least once every two weeks. These facilities will still require a physician to be onsite for a sufficient amount of time, but it will depend on the needs of the facility and the patients.  The rule also provides revisions and clarifications for transplant centers, long-term care, clinical laboratories and Ambulatory Surgery Centers (ASCs). Most of the changes will go into effect tomorrow, July 11.

NRHA applauds CMS for working to reduce burdens for rural providers and facilities.

Tell Congress to protect rural hospitals during this week’s recess

This week, Congress will be back in their districts for the Independence Day holiday to meet with constituents.  Contact your member of Congress today. Invite them to your facility, attend town halls and visit their district offices. Tell your Senators and Representatives to protect rural hospitals:

Rural Hospitals are important health care access points for rural patients across the country.

Rural Hospitals are critical to the rural economy.  Rural Hospitals are often the largest or second largest employer in a rural community. If a rural hospital closes, severe economic decline in the rural community is the result.  Soon after, physicians, nurses, pharmacists and other health care providers in the community will be forced to leave.  Patients will have to travel farther distances for care or will delay receiving care, resulting in poorer health outcomes. Businesses, families, and retirees will not relocate to a rural area if quality health care is not available.

Investments in rural hospitals save tax payer dollars. Rural Hospitals provide cost-effective care.  In fact, in comparing identical Medicare services in a rural setting to an urban setting, the cost of care in a rural setting is on-average 3.7 % less expensive.

For additional information on the importance of rural hospitals, visit our Congressional Action Kit.