[Senate Hearing 118-628]
[From the U.S. Government Publishing Office]
S. Hrg. 118-628
IMPROVING HEALTH CARE
ACCESS IN RURAL COMMUNITIES:
OBSTACLES AND OPPORTUNITIES
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH CARE
OF THE
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
MAY 17, 2023
__________
Printed for the use of the Committee on Finance
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
__________
U.S. GOVERNMENT PUBLISHING OFFICE
60-137 PDF WASHINGTON : 2025
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COMMITTEE ON FINANCE
RON WYDEN, Oregon, Chairman
DEBBIE STABENOW, Michigan MIKE CRAPO, Idaho
MARIA CANTWELL, Washington CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland TIM SCOTT, South Carolina
SHERROD BROWN, Ohio BILL CASSIDY, Louisiana
MICHAEL F. BENNET, Colorado JAMES LANKFORD, Oklahoma
ROBERT P. CASEY, Jr., Pennsylvania STEVE DAINES, Montana
MARK R. WARNER, Virginia TODD YOUNG, Indiana
SHELDON WHITEHOUSE, Rhode Island JOHN BARRASSO, Wyoming
MAGGIE HASSAN, New Hampshire RON JOHNSON, Wisconsin
CATHERINE CORTEZ MASTO, Nevada THOM TILLIS, North Carolina
ELIZABETH WARREN, Massachusetts MARSHA BLACKBURN, Tennessee
Joshua Sheinkman, Staff Director
Gregg Richard, Republican Staff Director
______
Subcommittee on Health Care
BENJAMIN L. CARDIN, Maryland, Chairman
RON WYDEN, Oregon STEVE DAINES, Montana
DEBBIE STABENOW, Michigan CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey JOHN THUNE, South Dakota
THOMAS R. CARPER, Delaware TIM SCOTT, South Carolina
ROBERT P. CASEY, Jr., Pennsylvania BILL CASSIDY, Louisiana
MARK R. WARNER, Virginia JAMES LANKFORD, Oklahoma
SHELDON WHITEHOUSE, Rhode Island TODD YOUNG, Indiana
MAGGIE HASSAN, New Hampshire JOHN BARRASSO, Wyoming
CATHERINE CORTEZ MASTO, Nevada RON JOHNSON, Wisconsin
ELIZABETH WARREN, Massachusetts MARSHA BLACKBURN, Tennessee
(II)
C O N T E N T S
----------
OPENING STATEMENTS
Page
Cardin, Hon. Benjamin L., a U.S. Senator from Maryland, chairman,
Subcommittee on Health Care, Committee on Finance.............. 1
Daines, Hon. Steve, a U.S. Senator from Montana.................. 3
WITNESSES
Aune, Erin, MBA, CRHCP, vice president of strategic programs,
Frances Mahon Deaconess Hospital, Glasgow, MT; and board of
directors member, National Association of Rural Health Clinics,
Fremont, MI.................................................... 5
Rich, Sara K., MPA, president and CEO, Choptank Community Health
System, Denton, MD............................................. 7
Herman, David C., M.D., CEO, Essentia Health, Duluth, MN......... 9
Holmes, Mark, Ph.D., director, Cecil G. Sheps Center for Health
Services Research; director, North Carolina Rural Health
Research Center; and professor, health policy and management,
Gillings School of Global Public Health, University of North
Carolina, Chapel Hill, NC...................................... 11
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Aune, Erin, MBA, CRHCP:
Testimony.................................................... 5
Prepared statement........................................... 39
Responses to questions from subcommittee members............. 41
Cardin, Hon. Benjamin L.:
Opening statement............................................ 1
Daines, Hon. Steve:
Opening statement............................................ 3
Prepared statement........................................... 42
Herman, David C., M.D.:
Testimony.................................................... 9
Prepared statement........................................... 43
Responses to questions from subcommittee members............. 54
Holmes, Mark, Ph.D.:
Testimony.................................................... 11
Prepared statement........................................... 59
Responses to questions from subcommittee members............. 63
Rich, Sara K., MPA:
Testimony.................................................... 7
Prepared statement........................................... 66
Responses to questions from subcommittee members............. 72
Communications
Alliance for Rural Hospital Access............................... 75
Alzheimer's Association and Alzheimer's Impact Movement.......... 81
American Academy of Family Physicians............................ 84
American Association of Colleges of Osteopathic Medicine......... 89
American Association of Nurse Anesthesiology..................... 92
American College of Surgeons..................................... 95
American Dental Association...................................... 97
American Hospital Association.................................... 100
Berglund, Emily, M.S............................................. 106
Bowman, Robert Charles, M.D...................................... 106
Center for Fiscal Equity......................................... 111
Digital Therapeutics Alliance.................................... 114
Federation of American Hospitals................................. 115
Freespira, Inc................................................... 120
MedRhythms, Inc.................................................. 121
National Association of ACOs..................................... 122
National Association of Rural Health Clinics..................... 124
Renalis.......................................................... 127
IMPROVING HEALTH CARE
ACCESS IN RURAL COMMUNITIES:
OBSTACLES AND OPPORTUNITIES
----------
WEDNESDAY, MAY 17, 2023
U.S. Senate,
Subcommittee on Health Care,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 2:36 p.m.,
in Room SD-215, Dirksen Senate Office Building, Hon. Benjamin
L. Cardin (chairman of the subcommittee) presiding.
Present: Senators Wyden, Stabenow, Carper, Casey,
Whitehouse, Cortez Masto, Grassley, Thune, Lankford, Daines,
Barrasso, and Blackburn.
Also present: Democratic staff: Martha P. Cramer, Staff
Director for the Subcommittee on Health Care of the Senate
Committee on Finance, and Health Policy Advisor for Senator
Cardin; Michelle Galdamez, Legislative Aide for Senator Cardin;
and Carolyn A. Perlmutter, Legislative Aide for Senator Cardin.
Republican staff: Grace Bruno, Health Policy Advisor for
Senator Daines; and Mathew May, Legislative Correspondent for
Senator Daines.
OPENING STATEMENT OF HON. BENJAMIN L. CARDIN, A U.S. SENATOR
FROM MARYLAND, CHAIRMAN, SUBCOMMITTEE ON HEALTH CARE, COMMITTEE
ON FINANCE
Senator Cardin. The Subcommittee on Health Care of the
Senate Finance Committee will come to order. First, I want to
thank Senator Daines and Senators Wyden and Crapo for their
help in allowing us to arrange this hearing. This hearing will
deal with ``Improving Health Care Access in Rural Communities:
Obstacles and Opportunities.''
I think this is one of our more important hearings. We
recognize that we have, in the United States of America--and
certainly in my State of Maryland--some of the most outstanding
health-care facilities in the world. We are proud of the
quality of health care that we have in our community. But if
you do not have access to that care, that high quality is not
going to help you very much. We know in rural America, there
are challenges that we need to confront, but there are also
opportunities that allow us to make advancements in those
areas.
Maryland, as many people think, is an urban State, with
Baltimore and the Baltimore suburbs and the Washington suburban
counties around the Nation's Capitol. But Maryland has a large
rural population in the western part of our State, the eastern
part of our State, southern part of our State, northern part of
our State. Central Maryland is more urban; the rest is pretty
rural. So this is an issue that is important to Maryland. It is
important to every State in our Nation.
Rural communities have challenges today. One out of every
five older Americans live in rural communities. It is an older
population. It is a population that has less access to health-
care providers.
When you take a look at the recent statistics from the
Health Resources and Services Administration, they estimate
that nearly 13 million adult citizens in rural communities have
behavioral health issues that need health-care attention. And
yes, they are about half as likely to have a health-care
provider to provide those services. These are gaps in our
health-care system that we need to take a look at and find ways
to improve.
We know the workforce challenges. We have a workforce
challenge generally in health care today. We recognize that,
and COVID made it more challenging, because they are front-line
workers. So, in rural communities, it is even more difficult to
be able to attract the workforce that you need. These are areas
that we need to take a look at as a committee, as to what we
can do to help.
One of the areas that I have concentrated on since my days
in the Senate has been oral health care. Oral health care is a
general indication of general health care. We know that we have
had challenges in access to oral health care in all of our
communities, but in rural America, it is even more challenging
to get the health-care professionals that are needed for
regular oral health-care needs.
So, these are some of the areas that we want to take a look
at. When the Affordable Care Act was passed, I was proud to be
the sponsor of the amendment that established the National
Institute for Minority Health and Health Disparities. Well,
many people think that concentrates solely on racial minorities
or ethnic minorities, but it also deals with underserved
communities. And rural America is certainly an underserved
community.
So, it is one of the areas of attention that we need to
deal with in the United States Senate. There have been a lot of
innovative approaches. I have seen, in my own State of
Maryland, really excellent opportunities to try to close the
gap. Several years ago, I was in Pocomoke City, MD, a pretty
rural part of our State located all the way down on the lower
Eastern Shore. They were using telehealth well before it had
become a more popular option, in order to provide access to
care that otherwise would not be there.
I have seen creative alliances. In Maryland, we had the
Garrett Regional Medical Center located in Oakland, MD. That is
as far west as you can go in our State. They have an alliance
with the West Virginia University Health System, which has
allowed them to get the sophisticated care at their hospital
that otherwise would not be able to be given. And the use of
our qualified health centers has also helped us bridge some of
the gaps.
So today at this hearing, we have a distinguished panel of
witnesses that will help us sort through what we can do as far
as policies in the U.S. Senate, to help provide greater access
to health care in the rural communities.
Before turning to our witnesses, let me turn to our
distinguished ranking member, Senator Daines.
OPENING STATEMENT OF HON. STEVE DAINES,
A U.S. SENATOR FROM MONTANA
Senator Daines. Chairman Cardin, thank you, and thanks for
your tireless efforts in health care over the years, and in
oral health care, as well as just for being the champion for
the rural parts of our States. It is also a pleasure to be
joined today by Ms. Erin Aune from Glasgow, MT. There is rural,
and then you get out to eastern Montana--that is rural.
We will have a more formal introduction soon, but, Erin,
thanks for making the trip here to represent our State and
rural health clinics. We are very glad you have made the long
journey. There is no easy way to get from Glasgow, MT to
Washington, DC.
Rural health is a key component of America's health care.
It is a greatly important issue in my home State of Montana, as
more than 720,000 Montanans live in designated rural areas.
That is about three-quarters of the population of the entire
State.
Almost every State in the Nation, as the chairman indicated
is true in Maryland, has some semblance of a rural population,
and in frontier States like Montana, we are all too familiar
with the challenges that come with living where we do,
including the challenge of accessing health care.
When we consider health care in a rural setting, one of the
defining characteristics of access to care is distance as well
as logistics, which more specifically means transportation. The
majority of people in rural America live great distances from
their nearest health-care provider.
A trip to a hospital or a doctor's office often requires
traveling several hours, sometimes a full day one way. Not only
is this highly inconvenient and straining, but also very
dangerous in emergencies. Extreme weather--that is where it
could take a full day sometimes in States like Montana--and
unpredictable terrain only add to the challenges that our folks
in rural areas face.
Other threats to access we see disproportionately affecting
rural communities are the increasing number of hospital
closures and service line erosions. As our witness Dr. Holmes
can attest, we have seen nearly 150 rural hospital closures in
the past 13 years.
While closures briefly stalled in 2021, this can largely be
attributed to provider relief funds and other assistance to
keep providers afloat during COVID-19. Now, as we move beyond
that pandemic, the number sadly is on the rise again. I also
hear too often about the erosion of service lines in rural
America.
In these areas, one of the first services to be eliminated
is obstetric and maternity care. GAO in fact issued a report
just last year that found access to these services has been in
a steady decline, and more than half of rural counties do not
have these services available at all. In fact, we just heard
the story about a fellow Montanan, a woman who traveled from
her home several hours away from Billings, in the weeks leading
up to her due date. She moved into a hotel so that when she
went into labor, she would be able to get to the hospital for
her delivery. Preparing for labor and delivery of newborns is
difficult enough. No expectant mom should feel the need to go
to these drastic lengths to receive routine prenatal and
delivery care.
This is just one example of how service line erosion
impacts rural residents, but it is illustrative of the
challenge we need to help address, and this hearing will help
us in that regard today. We must find sustainable ways to keep
health care accessible in our rural communities. To that end, I
am looking forward to discussion today from our colleagues and
witnesses and hearing their perspectives. The last time, by the
way, the Finance Committee had a robust conversation about
rural health was 5 years ago, in 2018. I am glad we are
revisiting the conversation today. Again, I want to thank the
chairman for his leadership here. We are doing it post-
pandemic, to examine the difficulties in progress over the past
5 years.
We are proud of Senator Grassley's leadership. In January
of this year, the first new Medicare rural provider designation
went into effect since the Critical Access Hospital designation
was created all the way back in 1997. We are proud of the
Montana leadership, which led to this designation. I think
about my boy State speaker in Montana. It was a guy named Max
Baucus. He spearheaded this, and now it is great to see Senator
Grassley and others working to implement new and creative ways
to serve the changing needs of our rural hospitals today.
So, thanks to the witnesses who, if you are from rural
parts of our country, it was not easy to get here. We
appreciate your expertise on this subject.
Mr. Chairman, I will turn it back to you.
[The prepared statement of Senator Daines appears in the
appendix.]
Senator Cardin. Thank you, Senator Daines. Senator Daines,
I am going to yield to you for the introduction of your
Montanan who is here.
Senator Daines. Thank you. You even said ``Montanan''
correctly. [Laughter.] You know, there are not a lot of us out
there. You stuck the landing there. Thank you.
Mr. Chairman, I am very glad to introduce Ms. Erin Aune
this afternoon. Ms. Aune serves as the vice president of
strategic programs at Frances Mahon Deaconess Hospital in her
hometown of Glasgow, MT.
Previously, she served as the director of Glasgow Clinic
Specialty Care Division at FMDH, overseeing orthopedics,
general surgery, OB/GYN, and the operations and marketing of
Hi-Line Med Spa, which she helped launched, bringing a new
service line to that community. She has been with FMDH for 8
years. She serves on the hospital's senior leadership team, and
also serves on the board of directors for the National
Association of Rural Health Clinics.
Ms. Aune is very active in volunteering and participating
in community events. She has served on the Glasgow Chamber of
Commerce board of directors for the past 10 years.
I am just getting tired reading your background, Erin. Ms.
Aune has also been married for almost 14 years to her husband
Jake, a mom of two boys, aged 10 and 12, who keep her busy with
sports. Her older son had a stellar wrestling season this year,
securing his spot on Team Montana and helping lead the team to
the National Tournament in Des Moines, IA. When you are in Iowa
and you are wrestling, it is big time. I know that. She also
serves on the board of directors for the Glasgow Wrestling Club
that her children are active participants in.
Ms. Aune, we are truly grateful. You took time out of your
busy schedule to be with us here today, and I look forward to
hearing your unique Montana perspective on the challenges as
well as opportunities we face in rural health care.
Mr. Chairman, thank you.
Senator Cardin. Well, welcome. It is wonderful to have you
here, Ms. Aune.
The next person I will introduce is a Marylander. Ms. Sara
Rich is president and CEO of the Choptank Community Health
System. She has a master's in public administration from
Western Michigan University and over 25 years' experience in
local, State, and national health-care settings.
She joined Choptank in 2007 as the vice president of
community programs. Ms. Rich was named the senior vice
president and chief operating officer at Choptank in June of
2015, and in January 2017 she was appointed by the Choptank
Community Health Systems board of directors as their CEO.
Our third witness will be David Herman. Dr. Herman serves
as chief executive officer for Essentia Health, an integrated
health system headquartered in Duluth, MN. Dr. Herman oversees
77 clinics, 14 hospitals, and 15,000 employees who care for
patients in rural Minnesota, Wisconsin, and North Dakota.
Dr. Herman is a native of International Falls, MN. He
received his medical degree from Mayo Medical School in
Rochester, MN, and completed his residency in ophthalmology at
Mayo School of Graduate Medical Education.
And our fourth witness is Mark Holmes. Dr. Holmes is the
director of the Cecil G. Sheps Center for Health Services
Research in the North Carolina Rural Health Research Center at
the University of North Carolina at Chapel Hill, where he
specializes in rural health, including hospital finances and
Federal payment policies. You can explain all that to us. We
can use your help.
He is also a professor of health policy and management at
the Gillings School of Global Public Health. He grew up in
rural Michigan--another person from Michigan. I am telling you,
Senator Stabenow has a great deal of influence on our selection
of witnesses.
We will start with Ms. Aune.
Ms. Aune. Good afternoon, Chairman----
Senator Cardin. By the way, your full statements will be
made part of the record. You may proceed as you wish.
STATEMENT OF ERIN AUNE, MBA, CRHCP, VICE PRESIDENT OF STRATEGIC
PROGRAMS, FRANCES MAHON DEACONESS HOSPITAL, GLASGOW, MT; AND
BOARD OF DIRECTORS MEMBER, NATIONAL ASSOCIATION OF RURAL HEALTH
CLINICS, FREMONT, MI
Ms. Aune. Okay. Good afternoon, Chairman Cardin, Ranking
Member Daines, and members of the subcommittee. Thank you for
the opportunity to discuss the obstacles and opportunities in
rural health.
My name is Erin Aune, and I am the vice president of
strategic programs at Frances Mahon Deaconess Hospital in
Glasgow, MT. I also serve on the board of directors for the
National Association of Rural Health Clinics, which represents
over 5,300 CMS-certified Rural Health Clinics in 45 States
across the country.
During my testimony, I hope to take you on a journey of
what it is like to access and help to provide health care while
living in the heart of rural America. The Rural Health Clinics
program was created in 1977 and remains the oldest Federal
program aimed at improving access to outpatient care in rural,
medically underserved areas.
The RHC program as a whole serves approximately 37.7
million patients per year, more than 11 percent of the entire
population, and approximately 62 percent of the 60.8 million
Americans who live in rural areas. The RHC program is a
separate facility type from the Federally Qualified Health
Center program, also represented on today's panel. Those serve
a critical role in our country's health-care safety net.
I feel fortunate to represent one of those Rural Health
Clinics located in Glasgow, MT. Now, if you are picturing
mountains, we are not that side of the State. Glasgow lies in
the northeast corner of Montana, and is an agricultural
community with big skies and wheat fields as far as the eye can
see.
Glasgow has been deemed ``the middle of nowhere'' by The
Washington Post, as it is the most geographically isolated
area, taking 4\1/2\ hours in any direction to get to a city. As
a provider-based RHC attached to a critical access hospital, we
have no choice but to be very strategic on how we can best
serve our community and the surrounding areas.
Glasgow has a population of about 3,500 residents; 7,600
people live in the county and about 15,000 in the two
neighboring counties. Fort Peck Indian Reservation is also
located 15 miles to the east of us. With the closest major
hospital over 300 miles away, we work very hard to provide our
service area with as many service lines as possible, to relieve
some burdens for our patients.
Our RHC provides a wide range of services, including
primary care, behavioral health, general surgery, orthopedics,
and OB/GYN. We are especially proud that we recently achieved
24-7 coverage in general surgery, OB/GYN, and orthopedics. My
testimony today will focus on specific challenges and solutions
in the workforce, as well as access to care barriers like
transportation. I encourage you to read my full testimony
submitted to the record for further details.
As is the case for other rural areas, recruitment
challenges are significant in the middle of nowhere. After
years of provider turnover and unfilled openings, we
strategically found a staffing model which would allow us to
provide specialty services locally. In 2020, we contracted with
a company that provides 24-7 orthopedic coverage. The providers
are a team of three full-time employees covering the month on a
rotating basis. This model worked so well that we expanded to
general surgery and OB/GYN, and are now considering it for
radiology. Being able to offer these services locally provides
better patient outcomes, continuity of care, a better work/life
balance, and helps prevent provider burnout.
Further, we have sought to inspire our youth to pursue
careers in health care, based on the quality of care they
receive from our organization. This year, we will be hosting
the first Med Camp for kids in grades 6 through 8, introducing
them to multiple areas of the hospital and clinic. For other
service lines, including behavioral health and maternal/fetal
medicine, we are exploring the use of telehealth services and
outreach.
While partnerships to offer telecrisis services through our
emergency room are working well to address some of these needs,
offering telehealth services presents challenges as well. A
great deal of our patient population does not have access to a
computer, the Internet, or a phone.
These services may seem like a great solution to help bring
care to the patient, but when they cannot access the care, it
becomes more of a burden and frustration to those we are
seeking to help. Many of our patients travel 50 to 100 miles
one way to attend an appointment at our facility, which leads
me to one of the biggest barriers our community is facing:
transportation.
I can share many stories with you, but one that stands out
is from this winter, when a patient presented to the ER by
ambulance, a non-emergency ride, which was denied by Medicaid.
After the patient was discharged, they were planning to walk 30
miles home to Frazier in a temperature of negative 35 below,
with wind chills.
We need more systemic solutions to address the impacts of
transportation barriers. Canceled appointments lead to lapses
in care, and this is only heightened when they need a higher
level of care at a facility hours away. My clinic is just one
of the 5,300 RHCs across the country, providing critical
services in innovative ways to serve the needs of our patients.
Issues, such as outdated conditions of participation for
the RHC program, reimbursement disparities in health coverage,
and a drastic increase in Medicare Advantage enrollment without
a protection for RHC reimbursement, challenge an already
overwhelmed workforce and threaten the delivery of quality and
outpatient care in rural America.
I want to thank you for inviting me to share these unique
perspectives as part of today's hearing. I am proud to be a
voice and advocate for this population. I look forward to
seeing the work we can do together for the over 60 million
individuals across rural America.
Thank you.
[The prepared statement of Ms. Aune appears in the
appendix.]
Senator Cardin. Thank you for your testimony.
Ms. Rich?
STATEMENT OF SARA K. RICH, MPA, PRESIDENT AND CEO, CHOPTANK
COMMUNITY HEALTH SYSTEM, DENTON, MD
Ms. Rich. Good afternoon, Chairman Cardin, Ranking Member
Daines, and members of the subcommittee. Thank you so much for
the opportunity to testify today. As president and CEO at
Choptank Community Health, I am honored to represent the more
than 1,400 health centers that are across this country.
In 2021, health centers provided services to more than 30
million people. Health centers deliver primary health care to
the Nation's underserved individuals and families, including
one in three people living in poverty, and one in five people
living in rural areas.
Choptank Community Health System's mission is to provide
access. We want to provide access to exceptional,
comprehensive, and integrated health care for all. Since 1980,
we have been providing access to quality health care through
the delivery of medical, dental, and behavioral health
services, now in five counties representing seven locations on
Maryland's Eastern Shore. In 2022, we saw more than 30,000
patients, representing 99,000 visits.
In my written testimony, I share several obstacles that
rural communities face in accessing health care, and how
community health centers are working to overcome those
obstacles. This afternoon, I am going to focus on two of these
obstacles, workforce and access points for care, and certainly
how Choptank is working to overcome those in an innovative way.
So Choptank, along with other rural health centers--and
really health-care systems all over the country--is
experiencing unprecedented shortages in attracting and
maintaining a qualified workforce. At this time, we are
recruiting 43 open positions at our health center. Fifteen of
those are providers, and those represent medical, dental, and
behavioral health, and we have 28 positions open for clinical
and support staff throughout Choptank.
So, what do we do? Well, at Choptank we know we need to
work on having a robust recruiting effort. We are always
working on how we can improve it, tweak it, and make it better.
At the same time, we have recognized that we have to have a
pipeline of providers and clinical staff. We need to be looking
at ``grow your own'' programs.
And so we are working on that. Some of our efforts include
a collaboration with the University of Maryland School of
Medicine and the University of Maryland Shore Regional Health
to design a rural family medicine training experience for
graduate and new physicians.
We know that physicians who train in a health center are
nearly twice as likely to begin their careers in a similar
setting, providing significant benefits in the rural
communities that they serve. We also have expanded a
longstanding partnership with NYU/Langone for advanced
education and general dentistry. This program is really
critical in providing access to oral health care and our health
centers, and it does serve as a recruiting resource.
We have hired many of the dental residents that came to
Choptank and hired them when they did complete their training.
We also have plans in the works to add a pediatric dental
residency as well, in partnership with NYU/Langone. We have
also partnered with the local community college to address the
shortage of clinical support staff. So we have developed a
scholarship program to support the certification for medical
assistants and dental assistants.
So, meeting people where they are to provide access to care
is vital to meeting the mission of health centers, and Choptank
is no different. We reach the communities that we serve in a
variety of ways, and one of those is through school-based
health centers. We started school-based health centers at
Choptank back in 1999, and at this point in time we have 30
health centers that are providing not only medical, but dental,
behavioral health, and nutrition services.
Often, these centers are the only method of health care
that these students are receiving. We have also had three
mobile units that we have added to our access delivery model,
that have helped us reach the communities we serve. Outfitted
for medical and dental services, the units travel across the
Midshore to community events, and they are providing really
important health screenings.
Choptank's presence at these events helps to build
credibility and increase trust as well. So, new access point
funding for new health centers, including funding for mobile
health units and school-based health centers, is needed. We
certainly recognize that there are budgetary restrictions, but
we do know that investing in health centers saves the health
system an estimated $24 billion annually in reduced medical
expenditures.
Not only that, but expanding our reach as health centers
will positively impact America's health outcomes. We know how
to provide the access to care. We need funds to continue to do
this work, especially with many of the obstacles that we are
hearing about this afternoon.
So, thank you for your time today. I really have only
scratched the surface of obstacles and opportunities. But I do
want to leave you with this: community health centers like
Choptank are passionately committed to people. They are very
committed to providing quality health care, and we are part of
the solution in providing access to medical, dental, and
behavioral health services, especially in rural areas.
Health centers are innovative in putting together new
programs and services and partnerships, which are really key,
and all of this will impact America's health outcomes.
So again, thank you, Chairman Cardin, Ranking Member
Daines, and members of the subcommittee. I look forward to your
questions.
[The prepared statement of Ms. Rich appears in the
appendix.]
Senator Cardin. Thank you very much for your testimony.
Dr. Herman?
STATEMENT OF DAVID C. HERMAN, M.D.,
CEO, ESSENTIA HEALTH, DULUTH, MN
Dr. Herman. Chairman Cardin, Ranking Member Daines, and
members of the Senate Finance Subcommittee on Health Care,
thank you for the opportunity to testify at today's hearing on
improving health-care access in rural communities. We deeply
appreciate your invitation to speak with you today on behalf of
Essentia, and about our commitment to value-based care, which
has demonstrated significant benefit for our patients.
Essentia Health is an integrated health-care system serving
predominantly rural communities in North Dakota, Minnesota, and
Wisconsin. We are all too familiar, as my colleagues are, with
the unique combination of health-care challenges facing rural
residents across the country. It has been said that value-based
care cannot be implemented in rural America, that it just does
not work.
In our experience, we have found it is the only thing that
really does work. This approach to care focuses on improving
overall patient health, with an emphasis on wellness and
prevention. It is about connecting patients with the
appropriate care at the right time, and providing coordinated
care throughout the patient's journey. Through the tools and
infrastructure built to support this work, we better manage
chronic conditions, reduce avoidable hospital admissions and
emergency department visits, and improve the quality of our
care. We know that our patients' goal is not to consume health
care. It is to be healthy and lead better lives.
Value-based care allows us to provide care in thoughtfully
planned ways that result in excellent health outcomes and lower
cost. Simply put, value-based care is the best model for rural
patients and for all patients. It is neither practical or
proper to differentiate the way we care for patients based upon
their enrollment in a value-based program. Stratifying patients
by their clinical and social needs, rather than by payer, is
the most effectable and most equitable. Our approach creates a
model of care delivery that is as standard as possible and
unique as necessary to meet the needs of our patients and their
communities.
Recognizing that this is the best model for all patients,
Essentia Health began a shift to value in 2005, when we entered
our first value-based contract. This led us to be an early
adopter of dual-sided risk models and Medicare Shared Savings
Programs, and Minnesota's Medicaid initiative called Integrated
Health Partnerships.
Today, we have 23 value-based care programs with both
government and commercial payers, with more than 200,000
attributed members. In fact, nearly 40 percent of our health
system revenue flows through value-based programs, and we
continue to work to grow that number.
So, how did we do this as a health system that serves so
many rural communities? Our success starts with a strong
clinical and information technology infrastructure made
possible by the scale of our integrated health system. Our
robust electronic medical record allows us to better understand
our patient populations, and to screen for the social
determinants of health.
In 2022, more than 144,000 Essentia health patients
completed our health-related social needs screening, and more
than 20,000 of those patients identified at least one social
need related to food insecurity, transportation, or financial
difficulties. Informed by that data on our patients, our care
teams work together to address needs and care gaps. Yet we
realize we cannot do this all on our own. We have implemented
an online platform called ``Resourceful'' that links our
patients with a host of community resources. Providers can make
referrals right from the electronic health record and then
learn through a feedback mechanism if that referral has been
completed.
Through this work, we are helping real patients and saving
real dollars. From 2018 through 2021, Essentia Health saved the
Federal Government more than $42 million, thanks to our
Medicare Shared Savings Program participation. We saved $28
million for the Minnesota Medicaid program. Collectively across
all programs, governmental and commercial, Essentia Health has
removed over $102 million from the cost of care through our
value-based programs. At the same time, the quality of our care
continues to improve. In 2021, our providers earned 98 percent
of the Shared Savings Program quality targets. In the latest
quality report from Minnesota Community Measurement, we were
one of two organizations attaining the high-performing status
in 13 measures, which is the highest performance in a State
with a primarily rural population.
The move to value-based care requires a commitment to a new
approach and continuous quality improvement. A shared IT
infrastructure to support rural providers in this journey is
the key, along with partnerships with community resources.
Lawmakers can support this work by aligning financial
incentives with value-based care, and protecting critical
safety net programs that help rural hospitals.
Thank you once again for the opportunity to share our
success with value-based programs in the rural communities we
are privileged to serve. I sincerely hope that this can become
a premier care model for sustainable health care in rural
America.
[The prepared statement of Dr. Herman appears in the
appendix.]
Senator Cardin. Thank you, Dr. Herman.
We will now go to Dr. Holmes.
STATEMENT OF MARK HOLMES, Ph.D., DIRECTOR, CECIL G. SHEPS
CENTER FOR HEALTH SERVICES RESEARCH; DIRECTOR, NORTH CAROLINA
RURAL HEALTH RESEARCH CENTER; AND PROFESSOR, HEALTH POLICY AND
MANAGEMENT, GILLINGS SCHOOL OF GLOBAL PUBLIC HEALTH, UNIVERSITY
OF NORTH CAROLINA, CHAPEL HILL, NC
Dr. Holmes. Good afternoon, Chairman Cardin, Ranking Member
Daines, and members of the subcommittee. Thank you for the
invitation to appear here today. My bio was read earlier, but I
think more importantly, I would mention that having grown up in
Caro in Michigan's rural thumb, with family members still
there, that I have a deep personal connection to rural health.
I am unable to cover all of the salient issues in rural
health today, so I will focus my comments on three main points.
First, the rural health-care infrastructure continues to erode,
threatening the health and well-being of 60 million rural
Americans. Second, Congress can address some specific policy
issues in the rural health workforce. Third, rural communities
have shown remarkable innovation, and recent policy initiatives
have been successful.
Rural-urban health disparities are well known. In the last
2 decades, the rural-urban mortality gap has more than tripled.
Rural COVID-19 death rates surpassed urban rates as early as
September 2020.
We also need to think about less visible disparities: my
family members who had to drive an hour each way or stay
overnight to get radiation treatment, facing the expense and
the fatigue of long car travel while in the midst of fighting
cancer; pregnant people who live in a rural community where the
hospital OB services closed will worry about whether they will
be able to reach a provider in time for the birth or go to a
hotel and make sure that they are there in time; the
frustration and exhaustion of rural residents with opioid
problems or issues who must wait in an emergency room for hours
or days before a transfer to a mental health facility. Fatigue,
worry, and frustration do not show up in official statistics.
Since 2005, nearly 200 rural communities have lost their
hospital. Although roughly half of these hospitals have
continued to provide some kind of health care to their
community, the remainder do not. Because hospitals are
typically one of the largest employers in a rural community,
closures can have large economic effects.
Hospitals are typically one of the most important health-
care providers in a rural community, and many have had weak and
declining finances for years. In 2018, roughly half of rural
hospitals were unprofitable, and financial distress is one of
the leading causes of rural hospital closure.
As hospitals close, residents face a decrease in health-
care access. Congress, the Medicare Payment Advisory
Commission, and others have long proposed new models of care
that focus on a hospital's emergency department services.
Senator Grassley's dedication to this issue manifested in the
Rural Emergency Hospital provision in the Consolidated
Appropriations Act of 2021.
I applaud Congress for acting innovatively to address rural
health needs. Continued monitoring of this provider type will
be necessary to ensure it is meeting the needs Congress
intended.
Rural places have long faced persistent workforce
shortages. Many proposed policy solutions to address these
workforce challenges focus on one profession, for example,
nurses, or one stage of the career, such as graduate medical
education. To shore up and grow the rural health workforce, it
is critical that we look to solutions that are not siloed in
this fashion, and support health-care workers across their
entire career trajectory. Health professionals that train in
rural areas are five times as likely to remain and practice in
rural areas.
Evidence-based investments that increase the number of
health professionals training in rural areas, increase the
number of preceptors and faculty, provide support to early-
career health-care workers, address workplace violence, and
focus on retaining mid- to late-career health-care
professionals, have been shown to work and could be expanded.
By growing the number of rural training opportunities and then
ensuring that resources are available to retain that workforce
across their careers, we can ensure that the workforce needed
to meet the needs of rural areas is there for decades to come.
We commonly hear about rural America being sicker, poorer,
and older. These are accurate descriptions of a population that
provides much of America's food, fun, and fuel. As much as it
describes the health challenges in rural communities, I worry
it suggests government is powerless to improve rural health. In
fact, when Congress and other policymakers have developed
policy to address rural needs, it has improved health in rural
communities. There are many examples of rural health-care
innovation.
Telehealth, community health workers, expanded scope of
practice and task-shifting, drones, new payment models, and
leveraging strong trust in community leaders are all examples
where lessons from rural innovation have helped fuel
transformation throughout the health-care system. My written
testimony provides more examples of creative local-based
solutions. This kind of innovation that is responsive to the
needs and assets of the community should be fostered and
supported.
History has shown that thoughtful legislation designed to
address rural-specific challenges and leverage the assets of
rural America has been successful in improving the lives of the
60 million rural Americans. Rural health-care systems are
different from urban systems, but they can produce similar or
better health outcomes when given the opportunity.
The pandemic exposed the fragility of our rural health-care
system. Fortunately, Congress has a number of policy
opportunities to make real improvements in the health of rural
America.
Thank you.
[The prepared statement of Dr. Holmes appears in the
appendix.]
Senator Cardin. Well, thank all four of you for your
contribution to this hearing. Each of you have initiated plans
in your own community to try to fill the gaps on access to
care. So, one of the questions I will be asking you, if we have
time during this first round, is what tools at the Federal
level have helped you to implement that, and what additional
tools would you like to see?
Ms. Rich, you talked about the--and I have been to Choptank
many times. The services you are providing are incredible, and
you are right: your people are really dedicated to their
mission. You talked about mobile facilities or school-based
facilities. Senator Stabenow and I worked in regards to the
lack of access for oral health care, and we used mobile and
school-based as a way to fill that gap, and it worked pretty
effectively.
So, what additional incentives do we need in order to
provide that type of service in rural communities? As one of
you mentioned, some of your community does not have access to
the Internet or even telephone service. How do we expand
telehealth to rural America? Perhaps broadband is part of that,
but how do we make that more effective, and what tools can we
provide to make that work in your community?
Dr. Herman, you talked about value-based care. In Maryland,
we have a total cost of care model, which is, I think, the
ultimate in value-based. What other incentives do we need in
order to allow you to move forward in those initiatives?
So, I guess my question to the panel is, what would you
like to see us do in order to help you fill--we cannot fill in
the rural community. You do not want us to do that, so the
population is going to be sparse. What can we do to help
preserve your unique way of life?
When you deal with preventive health care and you deal with
wellness, it is so difficult if you cannot have more of a
presence in a community, particularly with an older population
that has more and more challenges.
So, just go down the line, if you have programs that you
think we can help you with at the national level to meet your
needs locally.
Ms. Aune. Yes. So as far as telehealth goes, our community,
a lot of them are aging populations. So they do not have the
Internet, phone, or computer. So that was part of our social
determinants of health, that one of the markers that was high
was connectivity. So, a lot of cellphone service we do not even
have in the area, if they are up north.
So our patients are actually traveling down to our hospital
to use our computer to access their telehealth in Billings. So
maybe getting them computers or something. And then our
telehealth in the Rural Health Clinic is capped at a rate of, I
believe, $98.24, around there.
So those appointments are not generating as much income
either for us. But the connectivity issue, I think, would be
something to address.
Senator Cardin. And we did some of that in the bipartisan
infrastructure bill. But we can look at how we can perhaps
build that up more.
Ms. Rich?
Ms. Rich. Well, thank you, Senator Cardin. So, school-based
health centers are a powerful tool, and when we think about how
we can improve health outcomes in rural areas, it is again, how
can we reach people in different ways? And so, we have a lot of
tools in our toolbox to do that. The school-based health
centers are very powerful, and in fact, one of the things that
we have recently done was converted two of our school-based
health centers--and I should not say ``converted,'' but
expanded their reach.
So, two of them are now open to the community residents as
a whole. So not just the school community, but the community
around, because they are located a far distance from some of
the other health care access points. So additional support,
funding for school-based health centers; mobile health units as
well.
There was a bill that recently passed to include mobile
units as part of the new access point funding if there is some
available for health centers. So, moving that forward is great,
but we have not had new access point funding to bring more of
those mobile health units to life.
And then the other piece regarding telehealth--it was a
lifeline. It still is a lifeline, but preserving the
reimbursement for that, not only for the virtual visits as we
like to call them, but also the audio-only visits, because back
to my colleagues' point, having access to Internet, broadband,
et cetera does provide some big obstacles for the communities
that we serve. So sometimes that phone call, and being able to
talk to the patient and connect with the patient that way,
makes a huge difference.
Senator Cardin. And we have bipartisan legislation that
would do that.
Dr. Herman?
Ms. Rich. Thank you.
Dr. Herman. We believe that our patients really pay us in
three types of currency. They pay us with their trust, they pay
us with their time and attention, and they pay us, certainly,
with money. The challenges of the distances across rural
America--we find it necessary rather than to have them come to
us, we come to them.
So we have community paramedic programs that actually help
people with chronic management of their chronic diseases, post-
acute care, and other things that really make a huge
difference. Funding for those types of programs, as well as the
training for the workforce that can support those types of
programs, allows those patients to stay within their community
and get their care. It does not need to be always with a doctor
or with a nurse.
And when you think about the economic costs that some of my
colleagues have mentioned, about having your son or your
daughter take a day off work to drive you from Ely, MN to
Duluth, MN for a 20-minute visit and then drive back, that
could be better served by a community paramedic. It is
certainly a challenge for the family and a waste of America's
economic vitality.
So, funding those programs where we can actually go to
patients, whether it is through telehealth or the community
paramedic program, can make a huge difference.
Senator Cardin. Dr. Holmes?
Dr. Holmes. I am going to build on Dr. Herman's comment
there, which I think is really astute, and extend it to
maternal home visits and child home visits as well. But the
appeal of all of these is that you are seeing how the
population live in their own home, and understanding they need
a railing here, for example, if community paramedics can go
there, to avoid a fall. And so really understanding more about
treating health just beyond health care and the whole complete
package.
Senator Cardin. Thank you.
Senator Daines?
Senator Daines. Mr. Chairman, thank you.
Ms. Aune, it is good to have somebody officially from the
middle of nowhere. That was, by the way, determined by The
Washington Post, and they had a criterion. It had to be 1,000
residents or more, furthest away from a metro area, and the top
three in the Nation were all in northeast Montana. And by the
way, number four went to Nevada, some small place.
So you are literally from the middle of nowhere and have
the gold medal. So we are glad you are there. I think you bring
a very unique perspective. I know your colleagues here, who
have shared some testimony, have similar challenges.
In your testimony, you mentioned some of the notable
characteristics of providing health care in these very rural
and remote areas of the country. And I know when people are
sitting in gridlocked traffic, that they are yearning to move
to the middle of nowhere sometimes. That is why we are seeing a
lot of growth in a lot of parts of Montana.
But we are seeing health professional workforce shortages
across the board. Ms. Rich spoke about the acute challenges,
the numbers you are facing right now in your facility. But
these shortages have outsized effects when you are talking
about rural communities where populations, the pool that you
can hire from, are limited, small to begin with.
Could you speak a bit more to the rotating provider model
that you implemented at your clinic, as well as your recent
partnership with Intermountain to facilitate the behavioral
health responses in the emergency room?
Ms. Aune. Yes. So, our rotating providers, that was an
organization that we found, luckily found, because we lost our
orthopedic surgeon, and if we do not have that, patients have
to drive 300 miles to have a hip or knee replaced. So we felt
that was a critical need.
So it is 24-7 coverage. We have three full-time providers
that rotate in. They live elsewhere in the United States and
they fly in for their rotation. They do a 10- to 12-day
rotation, and they are on call 24-7. They run a clinic and then
they do surgery, and that model worked so well that we achieved
that for general surgery, and then OB/GYN as well.
And then we just--unfortunately, our radiologist is moving,
so we are possibly looking for that model for radiology.
Senator Daines. Dr. Herman, thanks for your testimony and
highlighting Essentia Health's work serving rural communities.
My ancestors who came from Norway stopped in Minnesota for a
while, and they heard the mosquitos were smaller out west, so I
think they kept going.
You have had some of the most successes in Minnesota, but
there are others who are interested, I know, in adopting
similar approaches as well.
So maybe for us here as Senators, and for those of us
listening to this hearing, what are some observations and best
practices that you see that have worked to drive your success?
What are some of the barriers you have had in the process of
trying to implement value-based care, as you mentioned in your
testimony, in more rural areas?
Dr. Herman. The challenge that small providers have is the
challenge of scale. It is hard to build the infrastructure to
support a value-based program when you have two or three
providers in a small community. Essentia Health is a
conglomeration of more than 30 different practices across
northern Minnesota, Wisconsin, and North Dakota, that got
together because we have a common mission, and that is to serve
our patients better.
I think the Federal Government can provide support just
like--when we live in rural areas, we are very familiar with
the cooperative model. There is no particular farmer in a small
community who can own his or her own silo. But if you can get
together and provide that infrastructure, whether it is the IT
infrastructure or the care infrastructure, you are much better
able to do that.
I also think that some value-based programs are rightly
very concerned about the outcomes. But when you are in a small
community, you are a slave to the law of small numbers. For
many of those communities, the process is more important than
the outcomes.
So, if you are measuring the cost of care in a small
community, one patient with breast cancer can certainly raise
the cost of care, and you end up missing your targets. So how
do you get the right process measures to support that
particular type of care, and pulling it together with the
infrastructure that can support not just a large health-care
system, but could support many small health-care systems?
Senator Daines. So here is a question. Do you get--is there
sympathy to your argument in terms of, since the pool is so
much smaller, where one particular patient could drive means
and so forth out of whack? How do you deal with that?
Dr. Herman. Measurement matters. So what are the things
that you are doing that get your average patient healthier? The
advantage of those small numbers is, you can take a look at
almost every patient, particularly if you have an electronic
health record supporting that.
It also allows you to get a fine view of the social
determinants of health, and what does the community need other
than a health-care provider, to support some of the care of the
members of their community? If you are living in a food desert
and people are eating high-salt foods, the chance of them being
hospitalized for congestive heart failure is very, very high.
So, rather than just taking a look at the patient's path
from illness to wellness, what is the patient's path to sustain
themselves after they get that? And that is building the
community.
Senator Daines. Thanks, Mr. Chairman.
Senator Cardin. Senator Stabenow?
Senator Stabenow. Well, thank you very much, Mr. Chairman
and Ranking Member. This is such an important hearing, and
thank you to all of you for coming.
I specifically have to cite Ms. Rich, coming from Western
Michigan University in Kalamazoo. It is so great that you went
to school there, and I understand that, Dr. Holmes, you went to
school at Michigan State, is that right? Go Green; okay. That
is great. And Caro, MI I know well. Very beautiful place, so
tell your family ``hello.''
All of these issues resonate. I grew up in Clare, in the
middle of the State, northern Michigan, and my mom was director
of nursing at a small hospital. My first job was at the
hospital. This is how old I am. My job was cleaning the test
tubes in the lab in the basement after school. They just throw
them away now so, I know. But that was a long time ago. That
was a long time ago.
But I grew up around health care, and rural health care, so
I very much appreciate this. There are so many pieces to this,
both physical health care, behavioral health care. We have done
a lot together to increase community behavioral health clinic
access, and I know representing States that include that now
through Medicaid funding and others that are applying, in
Montana and North Carolina, and so on, to be able to move
forward.
But I wanted to zero in for a minute on school-based health
centers for a stretch, and talk a little bit more about that.
Because so many times children are getting access to health
care or behavioral health care through school. That is where it
is, and so this becomes so important.
I am leading an effort with Senator Capito, a bipartisan
effort, on school-based health care, both funding--we got
first-time funding, a line item in the budget last year, but we
have Hallways to Health Care, where we are trying to, as I am
sure you are aware, increase both children's health insurance
funding and Medicaid funding, working with our health centers,
working with behavioral health centers, to get into schools.
And we also made some good progress with significant
funding, as a part of the gun safety legislation, on school-
based health clinic grants, and behavioral health, and so on.
Could you talk a little bit more--you mentioned that your
school-based health-care program cares for thousands of
patients. Could you talk a little bit more about how accessing
comprehensive care right at school expands access both for
children and for families?
Ms. Rich. Well, thank you so much for the question, Senator
Stabenow. And also, I wanted to add I also went to Michigan
State.
Senator Stabenow. Oh, you did go to Michigan State?
Ms. Rich. I just wanted to add that.
Senator Stabenow. You went to two schools in Michigan? Oh,
good.
Ms. Rich. Yes, so my apologies. You cannot let that go as a
Spartan.
Senator Stabenow. That is right.
Ms. Rich. But you know, school-based health centers are
such a wonderful way to provide access to care for our
children. When children are in pain, whether it is from a
dental infection or they have strep throat, or they are just
not feeling well because maybe something happened with some
friends and they are feeling down, having that access in the
school makes all the difference, and especially for those of us
who live in rural areas.
I have used our school-based health centers, and you know,
often parents work out of county, for example. They may work 30
or 40 miles away from where their child goes to school. And so,
having that peace of mind and knowing that there is a trusted
health-care provider, whether it is dental, behavioral health,
or medical, is such a relief for families, that they are going
to get what they need while they are in school.
We can do lab testing in school. We can take care of acute
needs. We can help with chronic conditions such as asthma in
school, with dental infections and abscesses, connecting those
children with additional services and care that they need. So,
it is just a lifeline for many of these children and
communities and, if you are not healthy, you cannot pay
attention in your math class, you know. You are not going to be
able to write an essay.
And so, having that access is a huge relief for the
students, for the school team as well, because they want to
have healthy students, so they can be healthy learners, and
then certainly for families in the community. So I am excited
to hear about the work that you are doing to enhance and expand
school-based health centers across the country. It is a great
tool for accessing health care in rural areas--and certainly
beyond.
Senator Stabenow. Great; thank you very much.
Ms. Rich. Thank you.
Senator Stabenow. And one more question for you----
Ms. Rich. Yes.
Senator Stabenow [continuing]. Which is--Senator Daines and
I have led a bipartisan working group in the Finance Committee
on workforce related to behavioral health. We were able to have
some things happen, some additional GME slots for psychiatrists
specifically, to be able to do some things around Medicare
coverage last time, which was helpful.
But one of the things that did not happen that we had put
in our recommendations was talking about how to increase the
workforce by adding a physician bonus payment in shortage
areas, and allowing non-physician providers to also receive a
bonus payment if they are going into underserved areas.
We do have some of that in school loan forgiveness and so
on, but if we were to add a physician bonus payment for rural
areas or for other non-physician providers--you mentioned that
your clinic is in a mental health shortage area, and so I am
wondering how a bonus payment could help clinics like yours
attract and retain more providers?
Ms. Rich. Well, thank you for the question. I think that
anything that we can do to help and retain providers in our
rural areas, especially for behavioral health, is something we
need to take very seriously. We do have a lot of National
Health Service Corps providers in our organization, and it is a
wonderful recruiting tool.
We need to work hard when providers come to our area, to
connect them, to help them be part of the community, because
once they come, we want them to stay. And so, how do we do
that? And that might be a way in terms of that bonus payment.
When your service is done with National Health Service Corps,
maybe there is an additional payment to continue that service.
So, I look forward to hearing more about that. Thank you.
Senator Stabenow. Thank you, Mr. Chairman. I am over time.
Thank you.
Senator Cardin. Senator Blackburn?
Senator Blackburn. Thank you, Mr. Chairman, and thank you
to each of you for being here. I represent Tennessee, and as
you all know, Nashville is the center of much of health care in
this country, managing hospitals, and of course many of our
companies and our citizens are employed by companies that
manage rural hospitals.
In Tennessee, 50 percent of Tennesseans are in a rural
area. So we pay quite a bit of attention to what is happening
with access to rural health care, and we do what we can to
increase that access. And in my work as cochair of the Rural
Health Caucus here in the Senate, we spend a good bit of time
looking at that.
When I was in the House, I came up with legislation for
telehealth, and nobody was interested in telehealth until COVID
hit. And then all of a sudden, everybody was saying, ``Let us
get that bill and pass that bill,'' and of course it went in
under the emergency health order. I have worked with Senator
Crapo to try to decouple that, so that we can continue with
telehealth.
In the behavioral health arena, it makes a tremendous
difference. When I am talking to our community health centers,
it makes a tremendous difference. We have one county in
Tennessee, Hardeman County Community Health Center, which has
access to a cardiologist through e-consults and ConferMED. Now,
they have never had that access in this county, but now they
do, and it is showing tremendous gains and benefit into this
service area.
So, Ms. Rich, let me just stay with you. If you would talk
about, very quickly, how you all have used telehealth, and then
why parity in that payment is important for telehealth?
Ms. Rich. Well, thank you for the question, Senator
Blackburn. And certainly, telehealth was something we knew that
we needed to implement, and certainly with the COVID pandemic,
we implemented it basically overnight--and needed to do so if
we wanted to provide care to our patients. So telehealth has
allowed us to reach our patients when they could not come into
our health centers during the pandemic, but certainly now it is
another tool in the toolbox to be able to provide access to
care.
It is wonderful, because we have patients who have
transportation issues. They live long distances from the health
center, and again, it is another way for them to access care.
In terms of reimbursement parity, I think that is going to
be really critical as we move forward. It has become integrated
into service delivery models at our health center, at other
health centers, and patients need it. Patients want it.
Senator Blackburn. Yes, they do need it. I have a rural
health-care agenda that I have worked on for the last 3 years.
Senator Durbin and I have a bill that focuses on workforce and
would incent, even further than the National Health Corps,
getting people into rural areas, health-care professionals.
Also, a component of it is on innovation in delivery of care.
And the third component is something Senator Warner and I are
working on for an appropriate national minimum to address the
area wage index. We think that that is important. You are not
going to get innovation in rural health care without these
things, and we think that it is so important.
We are concerned about the closure of rural hospitals. Dr.
Herman, I would like to ask you about that, if you all are
looking at this, and then the way the community health centers
are coming in and helping fill that void, because we are facing
closures.
Dr. Herman. We believe that no rural hospital should have
to stand by itself. I think many of the ones that are closing
are hospitals that have had to stand by themselves. So we have
hospitals within our system that, if they were not part of a
system, would not be able to stand by themselves.
But providing that integrated care that surrounds it,
whether it is a health system or another entity, taking
responsibility for the care in the area, not just a particular
community, I think makes a tremendous difference. From a
telehealth standpoint, one of the challenges that we have is,
we certainly do not want anyone to practice fraud from a
telehealth standpoint.
But I use the bird feeder analogy. Sometimes you are so
concerned about keeping the squirrels out of the bird feeder
that the birds cannot get in either. I think when we start
looking at some of the regulations we are building around
telehealth, sometimes it really impedes the provider's ability
to care for a particular patient.
Senator Blackburn. And thank you for that.
I know I am over time, but I am working on community
health-care access for veterans, and one of the components that
we're working on right now is allowing these veterans to
immediately access care in their local community.
And just a thumbs-up or thumbs-down, would your facilities
be able to handle veterans coming in, showing their card,
getting that health care? And then our responsibility would be
making certain that there is a way for you to bill that back
quickly, and of course be quickly paid. Not 180 days out,
right? Absolutely. Thank you.
Senator Cardin. Senator Cortez Masto?
Senator Cortez Masto. Thank you.
Coming from Nevada, telehealth is key for our rural
communities as well. I am curious if anybody is opposed to
audio-only visits as well?
Ms. Rich. I am very much in favor of audio-only visits.
Dr. Herman. Right, because a lot of the areas do not have
the broadband capability to have anything other than an audio
visit.
Senator Cortez Masto. That is right, and that is why we
really should be pushing both of those together. And we can
address the fraud concerns always.
Let me jump to another issue I am hearing about from our
providers in Nevada. They are experiencing challenges
contracting with Medicare Advantage, and clearly we have more
and more beneficiaries choosing to enroll in Medicare
Advantage.
We want to make sure that we take a look at this
relationship between the plan coverage and the patient access.
So, Ms. Aune, let me ask you this. How do Medicare Advantage
payments for Rural Health Clinics differ from traditional
Medicare, and do these payment differentials, if they do occur,
really create access issues in rural areas?
Ms. Aune. Yes. So, at our facility, we are not a contractor
with Medicare Advantage. But for our other Rural Health
Clinics, there has been a drastic increase in the Medicare
Advantage enrollment, and it threatens the rural health safety
net.
So, while Rural Health Clinics receive enhanced traditional
Medicare payments in comparison with their fee-for-service,
their counterpart, says Congress, ``recognizes the increased
costs of providing care in rural America, and the high value of
care in these communities.'' So there is no statutory
requirement around RHC Medicare Advantage reimbursement. With
that, oftentimes there is less negotiating power as one of the
providers in a rural area. So many RHCs across the country are
facing the financial stability concerns due to the low Medicare
Advantage reimbursement rates; reimbursements differ.
Senator Cortez Masto. Is that what you guys are seeing?
Thank you. And is everybody else seeing the same thing?
Dr. Herman. Yes, and prior authorization becomes a
challenge with some Medicare Advantage plans as well.
If you drive some 200 miles and you are at the clinic and
you can get that service right now, and then your Medicare
Advantage plan says, ``Well, we need to take another 2 weeks to
take a look at this,'' even though when they do say ``yes,''
you have gone back 200 miles and you have got to come back
another 200 miles and go back another 200 miles.
Senator Cortez Masto. Right, right. Yes, and let me just
add to this, because I appreciate Senator Daines's and your
comments. In northeastern Montana, Elko, NV, it takes 4 hours
to get to a medical facility, either in Salt Lake or into Reno,
NV. And so we see these similar concerns about how we address
health care and bring that health care to our communities.
So, Dr. Herman, I am really interested in this tri-state
cooperative that you have, and you talked about it, obviously
the value-based payment strategy. But you also talked about
shared IT and community partnership programs. How did you get
that up and going? How did that start?
Dr. Herman. First of all, you have to build the
relationships, and you have to build the trust. But we are on
the Epic platform, and we have our Epic platform in hospitals
that are not our hospitals. But we have the clinic within that
community. If we have a different health-care record, we do not
know enough about our patients to be able to take good care of
them.
So literally, putting that health-care record within
hospitals that we do not own, or within clinics that we do not
own, helps the population that we are all privileged to serve
by coordinating that care.
Senator Cortez Masto. And let me ask you this: just in
2020, Congress created a new designation for rural hospitals,
the Rural Emergency Hospitals, and it went into effect in
January of this year. I know it is still being rolled out. But
what is unique about the Rural Emergency Hospital designation
that makes it an attractive option? Is it an attractive option
for rural providers?
Dr. Herman. We are still taking a look at that. We would
like to thank Senator Grassley and the rest of the Senate for
the great work that they did on that. One of the advantages of
that program is, you do not have to have an inpatient part of
your hospital. You can move it to an outpatient and still be
able to qualify for funding that supports the hospital within
that. We are fortunate enough within our thing that our--those
beds are really needed, even with the 96-hour rule, which we
could talk about some other time as well, because we have seen
an expansion of the ability for these hospitals to care for
patients through the pandemic.
But for a place that does not have the need for that
inpatient care, but needs something within the community, we
think it is a very constructive model.
Senator Cortez Masto. Thank you.
And then finally, we talked a little bit about the mobile
health units. The Mobile Health Care Act was passed; are there
any impediments that you are seeing that we need to address
after the implementation of this law?
Ms. Rich. Well, I know it is a fairly new law.
Senator Cortez Masto. Right.
Ms. Rich. Thank you for the question. I think it has a lot
of opportunity for community health centers to expand that
access and take mobile health units on the road. I think the
challenge with it is, it goes along with new access point
funding that would be available to health centers, and there
has not been new access point funding in a number of years.
Senator Cortez Masto. Okay; thank you.
Ms. Rich. Yes, thank you.
Senator Cardin. Senator Grassley?
Senator Grassley. Yes. I am going to ask Dr. Holmes--but
let me lead in with this. I have helped pass the voluntary
Rural Emergency Hospital program, and I thank the Senator from
Nevada for bringing this up. Since January, several hospitals
have become Rural Emergency Hospitals. An article from St.
Mark's Medical Center in Lagrange, TX was titled, quote,
``Texas Hospital to Keep Doors Open With Rural Emergency
Hospital Designation.''
Another article about the Holly Springs, MS hospital quoted
a hospital official saying, ``We expect the new designation to
improve both the financial and the outpatient capability for
citizens of Marshall County.'' There are several more examples.
So, Dr. Holmes, what hospitals are prime candidates to
become Rural Emergency Hospitals, and what would be the
alternative for hospitals if a Rural Emergency Hospital did not
exist?
Dr. Holmes. Well, the alternative is, for many of them,
closure. And so, at least the REH program offers them an
opportunity to provide emergency department care to their
community. That is usually one of the first instances that we
notice when a hospital closes, is someone needs an ED service
and, within 3 to 4 days, it is not there during a closure.
Dr. Herman, I think, touched on the main points for which
hospitals would be strong candidates for REH conversion. These
would be places that have low inpatient use, probably a low ED
volume as well, and have been financially struggling.
Senator Grassley. For you and Dr. Herman: I support the
Rural Community Hospital Demonstration program. It is a key
tool to support rural hospitals and maintain access. Currently,
the Centers for Medicare and Medicaid Services are
underutilizing the program by leaving five of its 30 spots
open. So do you two, do you think that we should be
underutilizing a cost-effective rural hospital program like the
Rural Community Hospital Demonstration?
Dr. Herman. Certainly not. Certainly, the need is there. I
think what we would need to do is go back and take a look and
say, ``Why haven't five other hospitals been put into that?''
Sometimes the regulatory hurdles are so complex that they are
either hard to understand or, if there are 20, you can meet 19
of the 20 requirements, and you cannot meet that last one.
My suggestion would be to have an outreach program from CMS
to many of these rural hospitals, and try to facilitate the
application, rather than just sending it out.
Senator Grassley. Do you have anything to add, Doctor?
Dr. Holmes. I do not. That was a great answer.
Senator Grassley. Okay. Then let me go to you two again. I
have championed efforts to ensure Iowa physicians get paid
fairly for the health-care services that they do. Iowans pay
the same amount of money on Medicare as everyone else in the
country.
Yet rural States like Iowa get shortchanged when Medicare
pays Iowa physicians less than a lot of other States, and I
will use New York and California as examples. Lower
reimbursement has several impacts, influencing physicians
practicing in our State. The labor shortage of physicians is
not local but national, especially in the age of telehealth.
There are many unforeseen costs physicians face by working
in rural areas, namely travel time, transportation costs, and
broadband. Congress has established this Geographic Practice
Cost Index that we call around this town the GPCI. That floor
is to ensure rural State physicians receive fair reimbursement.
At the end of 2023, this is going to sunset. How does the
GPCI floor protect access to physicians in rural areas?
Dr. Holmes. I will take that one first, I guess, and you
can build on it. I think an important thing to remember about
where the GPCI comes from is, it is based on historical and
longstanding patterns prior to its introduction. So a State
that has low wages gets a lower GPCI, which means lower
revenue, which means they pay lower wages.
So, there is a cycle there that is sort of self-fulfilling,
and I think we have seen some examples where CMS in particular
has tried to up some of those price indexes, and it will be
interesting to see what kind of impact that has had.
Senator Grassley. Do you have anything to add to that?
Dr. Herman. Yes. I would say that it used to be, in the
1960s, when you evaluated a physician's standard of care, it
was based upon the community. Now a physician's standard of
care is based upon the broader community of the United States.
The health-care costs to run a practice are much more
reflective of the broader health-care costs across the United
States than something that happens in Osage, IA. So I think
there needs to be something done with that.
Senator Grassley. Thank you, Mr. Chairman.
Senator Cardin. Thank you.
When Senator Lankford came in, he actually bumped Senator
Grassley, but I did not know that. So let me defer now to
Senator Lankford, and then I will pick up after him.
Senator Lankford. No one on our side of the aisle bumps
Senator Grassley, so just for the record on that.
Let me add one other comment here about what Senator
Grassley was talking about on the GPCI issues and the
reimbursement for physicians. When Oklahoma is competing with
New York City for rates on cardiologists, the devices cost the
same no matter where you are. Costs of everything are the same.
So, this process of punishing doctors if they practice in
rural America, or even just not in the largest cities in
America, has got to be resolved long-term. Shockingly to some
folks outside this building, there are some areas where we can
work together.
Last week, Senator Durbin and I actually dropped a bill on
the Rural Hospital Closure Relief Act. It is the same bill that
we actually had in the last session that we felt we were very
close to dealing with, and this deals with the Critical Access
Hospital designation.
The rural emergency designation does not work for every
location, and we are trying to fix this 35-mile perimeter. We
literally have hospitals in Oklahoma that are 34\1/2\ miles,
and trying to be able to work through the process has become a
pain on it.
So there are areas where we are trying to work together
practically to be able to resolve some of these in very
practical ways on this. Oklahoma State University has had a
process for a while of trying to attract people out of rural
Oklahoma, so that they would return to rural Oklahoma to be
able to practice medicine. OU has been very aggressive in
trying to be able to train physicians as well, nurses, other
practitioners. So there is some practical work that is ongoing
on this, but clearly, we have a long way to go in several areas
on this. I do want to talk about some of the workforce issues,
because this is a significant issue in attracting workforce
into rural hospitals.
Duncan Regional Hospital in my State has done a lot of work
in partnering with local universities, even reaching into high
schools, doing programs there and then helping them through
their education to be able to then return back to Duncan
Regional on that.
Have you seen success--and any of you can answer this--have
you seen success like that in other areas, because that has
been very successful for Duncan Regional? Anyone else seen
success in recruiting workforce long-term?
Ms. Rich. Yes. Thank you for the question, Senator. I would
say that partnering with universities' academic medical centers
has helped us a great deal in providing greater access to
health care in rural areas. We have a partnership with NYU/
Langone for general dentistry residents. We are working to
establish another residency for pediatric dental care, and we
are working with the University of Maryland School of Medicine
to establish a rural training track for physicians in the area.
I think what the challenge is, is that some of these
initiatives that we have taken on, they take time and you have
to be proactive to plan and to get them into place. And I think
right now, in terms of workforce, we are in two stages. We are
in reactive and proactive, and so, how do we bring all those
together so we can address these challenges?
Senator Lankford. Yes. It takes a while to be able to raise
it up. The Federally Qualified Health Centers in my State--we
have a phenomenal group of leaders and groups that are doing
it, almost 200 in my State, scattered around the State. They
are the primary caretaker for a very large percentage of so
many folks in our State, and it has been a very, very
successful model now for several decades.
So, very grateful for them. They have raised the issue to
me about 340B, and I know that is not in our committee. But for
contract pharmacies, are you dealing with the contract pharmacy
issues, Ms. Rich, at the Federally Qualified Health Centers in
trying to be able to deal with that pricing model? Is that
something you are dealing with right now?
Ms. Rich. Yes. Many community health centers across the
country are 340B participants, and it certainly is an important
tool that we have to assist our patients and provide additional
care in rural areas.
Senator Lankford. That has been a big issue on the pharmacy
side of this as well. This has been one of my frustrations, and
I know none of you are pharmacists in that sense, but you are
interacting with those folks in a lot of our rural settings.
That local pharmacy in many areas is the only really health-
care professional that is in that area.
I have a lot of concerns. Our committee has talked about
this quite a bit. I am going to continue to be able to raise
the issue of the DIR fees, especially for our rural pharmacists
and those independent pharmacists.
Literally, PBMs are driving our rural pharmacies out of
business for their benefit, but not to the benefit of health-
care advice for many of these folks in rural areas, to be able
to come to someone and just say, ``Hey, just mail order this,
and it is going to be fine.''
But that is not fine for a lot of folks who just need some
counsel, who have multiple medications and need just somebody
to be able to talk to. Are any of you all dealing with
individual pharmacies and the DIR fees in particular?
Dr. Herman. One of the things that concerns us,
particularly for rural health care, is white bagging, where as
an example, chemotherapy is provided in a small community, but
the insurance company makes sure they get the medication from
the insurance company, rather than from the local care
provider.
What people do not understand is that some of the money
that comes from getting that medication in that particular area
pays for the care and the infusion center where the patient is
getting it, particularly in a rural area like Deer River, MN.
When that goes away and white bagging goes away, that site goes
away because there is no way to fund the site.
Senator Lankford. Yes. Mr. Chairman, I appreciate your
holding this hearing and going through this. It is an
incredibly important issue for us. I would love to be able to
spend more time, but I am out of time on this. But the issue
about Medicare Advantage--we have quite a few Medicare
Advantage carriers that are advertising to rural America to get
Medicare Advantage.
People are signing up for it and finding out that there are
not actually providers in their area, and they have to travel
very long distances. That is a different conversation for a
different day, but that is definitely affecting rural America
as well.
Senator Cardin. It is a conversation we need to have,
because we have also had Medicare Advantage plans leave some of
our rural areas without much notice.
Senator Whitehouse?
Senator Whitehouse. Thanks very much, Mr. Chairman, and
thank you to this panel. We do not have as much rural going on
in Rhode Island as many of these States, but I very much
appreciate the work that you all have done.
I am particularly interested in what, Dr. Herman, you think
about the ACO model. I worked very hard to get that into the
Obamacare bill. I have been a harasser and shepherd of it, as
CMS people have tried various--I thought not particularly
helpful--things to strip revenues out of ACOs as soon as they
get them, and set the new standard low so that you are
competing against yourself in ways that are ultimately
fruitless.
I would love to hear from you if there is anything that you
think is immediate, that would help advance the ACO program.
And to the extent you want to reflect on it, if you could take
that as a question for the record. Because I am eager to spread
ACO incentives as broadly as possible, and to try to make sure
that----
In Rhode Island, we had two spectacular ACOs, I mean,
killer. They were just fabulous. They made a ton of money for
Medicare. Their patients just loved them. So I have seen it at
its best, and I want to make sure that that gets----
Dr. Herman. We are strong proponents and strong
practitioners of value-based care and the ACO model. We are
probably one of the only Level 3 ACOs in rural America. We
believe it is the best way to care for patients. I agree that
when you look at the Medicare Shared Savings Program--my
colleague, Dr. Holmes, is a mathematician. But if you integrate
that over time with the model of the Shared Savings Program,
somewhere along the line you are giving perfect care free.
So the question becomes, what is the floor on that, and
what is a reasonable amount to do that? There are many
different ways to set up these programs. I think a lot of the
programs are set up without the knowledge of the people that
they serve, particularly from the regulatory side.
And what I would suggest is that you partner with people
who want to do it, have a commitment to do it, and do it well,
and see how they do it. And then work with colleagues like Dr.
Holmes, Ms. Rich, and Ms. Aune, who are really committed to
providing great care for their patients, because it is a great
model, not just in rural America, but anyplace in America,
because it takes really three things. You know who your
patients are, you know what they need, and then you can get it
to them before they really need it. That promotes health,
wellness, and well-being, and it also decreases the cost of
care.
Senator Whitehouse. Well, I still have scars from years of
engagement with CMS on this subject, and I hope they have a few
too. I think we have learned to respect one another, and I
would love to work with you going forward. So let us stay on
this.
Dr. Herman. Perfect; thank you.
Senator Whitehouse. And, Ms. Rich, you are in the Maryland
Primary Care Program, which is a statewide program that we do
not have. I think it is unique to Maryland?
Ms. Rich. Yes, it is.
Senator Whitehouse. So I would really like to get your take
on how that works. One of the things that I think bedevils the
health-care system--we have talked about it--is the burden of
prior authorizations, claims denials, payment delays, the
payment warfare that takes place between payers and providers,
which at the end of the day, I think, is a net loss to the
system.
It does not actually add value. If it does, it is
negligible. But I think it is actually negative. It just eats
up costs and time and effort. Once you go to the Maryland model
and you get away from fee-for-service, which I think encourages
those kinds of behavior, have you seen that architecture of
obstruction diminish in your company or in the State generally?
Ms. Rich. Well, so I want to start out by saying the
Maryland Primary Care Program certainly is under the Maryland
Total Cost of Care Model that really focused in on hospitals.
And so, primary care components came in in about 2019, and
following the community health centers. Choptank just joined
the Maryland Primary Care Program in January, so I do not have
a lot of----
Senator Whitehouse. So you are still in the beginning
process?
Ms. Rich. We are. So I do not have a lot of experience to
speak to it, but I am very excited about the transformation
that it will be doing in our health center, to provide greater
access to service to wrap around our patients, and work on
healthier outcomes as a whole.
Senator Whitehouse. Well, to me it stands to reason--and I
have 30 seconds left, so let me make this a question for the
record to any of you who care to engage. It strikes me that
this whole claims denial measure, claims pursuit
countermeasures, that whole back and forth, is completely
unhelpful and very expensive, and ultimately, I think, bad for
patients.
To the extent that we can get off of the fee-for-service
model that encourages it, I think that is likely to diminish,
which will be good for the costs in the system, good for
patients, good for providers, good for everybody. So, if
anybody has observations on that point, in addition to what we
should do to help ACOs, I am all ears and, I look forward to
hearing from you.
Thank you.
Senator Cardin. Senator Whitehouse, let me just point out
that the Maryland Total Cost of Care Model is really very much
what you want to see. You reward the overall health-care costs
of an individual, rather than stove-piping the different types
of needs.
It is also an all-payer rate structure, so that you are not
rewarded by having private pay versus Medicare or Medicaid.
They all pay the same rates at the hospitals. So it is a system
that is rather pure in that regard.
Senator Casey, you get the total 5 minutes. Those 29
seconds are not going to be held against you.
Senator Casey. Mr. Chairman, thanks very much. Thanks for
having this hearing. I just have one question, in the interest
of time, for Dr. Holmes, but I wanted to start by just laying a
little bit of the groundwork for the question.
I live in a State that has 67 counties, and 48 are rural.
And the primacy of rural hospitals in so many counties cannot
be, cannot be overstated in terms of health-care access, the
good quality of care they provide, as well as the job base that
they provide.
And, Dr. Holmes, you said in your testimony that since
2005, I guess it is a little more than 190 rural hospitals have
closed, about 193 I guess it is, and I am told that 150 of
those are just since 2010. It is hard to comprehend the scale
of that. I guess some continue to provide health-care services,
but roughly half of them do not provide health-care services.
These closures lead to a decrease in the labor force in the
population living in the community. I have seen that in
Pennsylvania, and as I said, they are so important to the
stability of a community. I pushed for a 2-year extension of
the enhanced payments for the Medicare-Dependent and Low-Volume
Hospital adjustment payments in the so-called omnibus, the
appropriations bill last December.
I am proud to reintroduce a bill with Senator Grassley to
make both of these payment adjustments permanent, in order to
provide certainty surrounding the funding for these hospitals,
including 27 of which are in the State of Pennsylvania.
Dr. Holmes, can you speak to how permanent funding such as
the Medicare-Dependent Hospital program and the enhanced low-
volume Medicare adjustment payments would provide predictable
funding and help protect the financial solvency of rural
hospitals?
Dr. Holmes. Yes; thank you for the question. I think this
kind of goes back to the question that Senator Grassley asked
as well about RCHs, in that you are asking hospitals to move to
a new program or to make decisions about investments on
something that might be here in 2 years, might not. And you
know, let's face it, MDH and SCH have been continuously
extended.
And so, while it is fair to believe that they probably will
keep being extended, you are asking executives and
administrators to make decisions on something that looks like
it will end. So I think a permanent extension of these programs
will be beneficial.
It will allow them to have certainty and make investments,
rather than looking at, well, we cannot do too much because we
do not know what it is going to look like in the next year or
two; to really say, ``All right, we think this program is
permanent. We can make decisions planning on having a certain
revenue flow.''
Senator Casey. Doctor, thanks, and I want to thank the
panel as well. I have to run, but thank you, Mr. Chairman.
Senator Cardin. Thank you.
Senator Carper?
Senator Carper. How many counties do you have?
Senator Casey. Sixty-seven.
Senator Carper. And how many are rural?
Senator Casey. Forty-eight.
Senator Carper. We only have three counties, and two out of
the three are rural, and the other aspires to be, but probably
without success. [Laughter.]
Senator Casey. And those three used to be in Pennsylvania.
Senator Carper. And they used to be in Pennsylvania. And so
we know who the first State is. It is Delaware.
So, I have a question I want to start off with you, Miss
Rich, if I may--we are grateful that you are all here--dealing
with federally qualified community health centers with respect
to increasing access to behavioral health care. I am a huge
proponent, have been ever since I was Governor, even before I
was Governor, a huge supporter of federally qualified community
health centers.
We have one in each of our counties, and they do wonderful
work in a variety of ways. But I call them federally qualified
community health centers--I do not even use the acronym--I
always have. But they play a critical role in our State in
increasing access to care. My notes say here ``to everyone.''
Not to everyone, but to a whole lot of people.
And that is particularly in rural communities, but not
entirely; not entirely. There are many rural communities in the
State of Delaware, and I am proud to serve as cochair of
something we call the Senate Community Health Centers Caucus
that you may have heard of, along with my fellow cochairs--
listen to this: Senator Cardin, Senator Cornyn, Senator
Cassidy, and Senator Carper. What is similar to all those
people is the letter C--the letter C; there you go.
I would like to say the letter C defines, I tell other
people, the secrets to a happy marriage: communicate and
compromise. But also, the letter C can be used to apply to
getting things done here in the Senate, and the four names that
I have just mentioned are people who like each other,
bipartisan, bicameral, and we get a lot done.
But the services that are provided by federally qualified
community health centers go beyond one's physical health. They
also provide crucial services, as you know, for mental health
care and treatment, not only in Delaware but in the other 49
States as well.
I oftentimes say, as Senator Cardin will attest, ``find out
what works and do more of that.'' I said that just this morning
in the hearing on the permitting processes. But find out what
works; do more of that. In that spirit, Ms. Rich, could you
just share with us some of the best practices from centers that
are doing an especially good job providing mental health
services and addressing behavioral health needs of rural
communities, so that the rest of us can learn from their
success? Find out what works; do more of that. Go ahead.
Ms. Rich. Well, thank you so much for the question, and
thank you for your support of community health centers. So we
have just implemented behavioral health at our health center
about 2 years ago.
Senator Carper. Again, tell me a bit more. Where is your
health center?
Ms. Rich. Eastern Shore, Maryland. So Caroline County is
our headquarters.
Senator Carper. Okay.
Ms. Rich. And you know, when we think about our mission,
providing that access to the comprehensive care that is
integrated, not providing that behavioral health service was a
barrier for our patients. So bringing behavioral health into
the health center was very important because we ensured that it
was integrated with primary care.
And so, through the course of the patient care day, if one
of our medical providers was treating a patient and did some of
the screening tools that we use--the SBIRT screening for
substance abuse disorder, depression screenings, et cetera--we
connect the patient with a behavioral health therapist, right
then and there, through a warm transfer.
And so what we have found with that warm transfer process
is the patient is in a place where they are ready to get into
treatment. They likely show up for their appointments, and they
are getting better. That is what we want to do, and also take
away some of the stigma too, that the behavioral health is
right there co-located with our medical, with our dental as
well.
So I think that integration is really key, and then
ensuring that we do those warm transfers as well during the
course of the visit. So those are some of our lessons learned
as we have moved forward with behavioral health care at
Choptank.
Senator Carper. Well, that is good.
I have about 30 more seconds. That is probably not enough
time to ask another question, so I will just sit back and
listen to Senator Barrasso, Dr. Barrasso's questions.
Senator Cardin. Do you have any Delaware patients who come
into your facilities?
Ms. Rich. Yes.
Senator Cardin. I thought Senator Carper would like to know
that.
Senator Carper. I would like to know that.
Senator Cardin. Senator Barrasso?
Senator Barrasso. Thanks very much, Mr. Chairman.
Dr. Holmes, if I could, for over 20 years I practiced as an
orthopedic surgeon in Wyoming, a State where we are always
trying to recruit and retain physicians in rural areas--
sometimes pretty remote--to just get the health care that we
need. I think we are running more and more into the fact of
recruitment being a challenge, especially since so many
residency programs for training are done in the big cities. You
know the correlation where people are more likely to then set
up a household, where they decide to live and practice, based
on where they trained, or within a radius of 50 miles from
there. So I see that as a disadvantage to rural communities,
because the training is from a distance.
So, Senator Tester and I have a bipartisan bill called the
Rural Physician Workforce Production Act of 2023. It addresses
the current Medicare-funded residency program problem for
entire States. The bill would solve some problems by lifting
resident caps and removing Medicare limits on rural resident
training growth; providing equal funding to rural hospitals for
residency training, because so much of that funding is
disproportionate; increasing Medicare reimbursements for urban
hospitals that send residents to rural health-care facilities;
and creating an elective per-resident payment initiative to
ensure rural hospitals have the resources to bring on
additional residents.
So, the approach to solving workforce shortages to empower
rural health-care providers, I think, is something we should
try to implement. So, can you explain how legislation geared
toward rural physician workforce development could impact
health outcomes and access in rural America?
Dr. Holmes. Great. Thank you for the question. I am glad
you brought this up. As you mentioned, we know that two of the
strongest predictors for rural practice are being from a rural
area and being trained in a rural area. And so, addressing the
paucity of physician training--but also more generally,
workforce training--in rural areas is critical.
Rural areas have shortages of just about every workforce,
and so an initiative to boost training in rural areas has a
twofold effect. The first is, in the short run, you have
trainees out there providing more care. But also, in the long
run, you are going to generate a workforce that is more rural-
aware and likely to continue to practice there.
Senator Barrasso. And then, Dr. Herman, in terms of the
local community hospitals, nursing homes in a place like
Wyoming, if there is a loss of one facility, the impact on the
entire community can be devastating. Not only do closures
impact the services and the care provided; they impose
additional challenges in terms of attracting teachers to the
community, attracting small businesses to the community, all of
those sorts of things.
Recently, the Wyoming Hospital Association conducted a
statewide study to determine the economic impacts of hospitals
and nursing homes, and it is very significant, the number of
jobs that are supported.
Do you see Federal policies that you think are most needed
to protect against closures of these critical facilities in
rural areas? Because I think, over the last 15 years, whether
it's a Republican administration, a Democrat administration,
the great number of hospital facilities that have closed are
rural.
Dr. Herman. That is right, and I think you said ``one
facility.'' It can be one person that causes one facility to
close. So I think Dr. Holmes addressed a lot of that. One thing
that we found successful in recruiting providers to rural
communities and retaining them is, it is not the health system
that recruits and retains the providers; it is the community
that recruits and retains the providers.
So we get our communities very involved in the recruitment,
the retention. When you are part of a community and you
recognize that you are a very critical part of the community, I
think it is very gratifying as a provider. I think you are much
more likely to come, and you are much more likely to stay.
Senator Barrasso. Yes.
So, Ms. Aune, following that, we had a community in Wyoming
a number of years ago when I first started to practice, where
we had a physician and a physician assistant, and at the time
they were tied together, where the physician had to observe and
be in the same facility.
So the physician was tragically killed in a wreck, in an
accident. He was the only physician in the community, and at
that point there was no way for the physician assistant--the
community tried to recruit a physician to then supervise the
physician assistant, because they were going to lose
everything.
But we actually were able to change the law in Wyoming to
then have the physician assistant report and work under a
physician at a remote location in an emergency room 100 miles
down the road. Not as ideal, but it reflected a need that was
going to be met, and legislatively we stepped in.
Have you seen similar things like that, where legislation
has to be done at a local level or statewide to try to help put
health care in communities?
Ms. Aune. I do not have anything to answer towards that. We
do have PAs and nurse practitioners in our facility, which is
great. But I do not have anything legislatively.
Senator Barrasso. Because I know that, Dr. Herman, Dr.
Holmes, you have seen a change in how physicians and physician
assistants, nurse practitioners, additional care providers,
have evolved since kind of our days in medical school, if you
will.
Dr. Herman. We have advanced providers that actually staff
some of the emergency rooms in our smaller hospitals, supported
by the physicians in our Level 1 trauma center, and also
transportation from the people there. So I think it is a very
good model that can be done.
I think it does have some limitations. You are probably not
going to get an emergency-trained physician in every small
community. But we have a lot of resources that regulations
sometimes get in the way of. What we can certainly do is get
back to you on that, because we can look at the regulations and
say where the barriers are.
Senator Barrasso. Okay, because what we are seeing--yes,
Dr. Holmes?
Dr. Holmes. They are recognized as team-based health care,
which I think is where we need to be headed.
Senator Barrasso. Thank you, Mr. Chairman.
Senator Cardin. Ms. Aune, you mentioned transportation as
being one of the challenges. Do you have transportation
available for those who need it in your community, and if you
do, how is it financed? If you do not, what are your
recommendations for filling this void?
Ms. Aune. So currently, we are working on a transportation
project within the hospital and the community. We do not have
hospital-based transportation that we have at our hospital to
bring patients to their appointments.
But we do have a county transit, and so we are working
together with the transit on marketing them and helping patient
awareness, and then asking patients when they do call to make
an appointment if they have transportation needs, and then
hooking them up with that transportation service so they are
aware of it.
Because I think a lot of people are not aware of it. We do
have huge transportation needs. So also, collaborating with the
Tribes on how to get those patients over to our community,
because we do have a lot of people in our area who do not have
a ride, either to their appointments or to outpatient
surgeries, or even like I had mentioned before, when they come
to the ER, they do not have a ride home.
So we are working on our transportation efforts and trying
to come up with a system so we have different phased approaches
to that, how we are going to come up with that.
Senator Cardin. And, Ms. Rich, I know some of our local
governments are providing some of the needs, I know on the
Eastern Shore, on transportation. Let me ask you about patients
who have chronic conditions, and the regular follow-up care. If
they live far away from a provider, how do you deal with
someone who is in that position?
Ms. Rich. Well, that is a wonderful question. Thank you,
Senator Cardin--and it is a challenge. Certainly,
transportation continues to impact us all in rural areas. There
is, you know--the counties contribute to that. We have public
transportation, but again, there is often not enough of it.
We are grateful for the Medicaid coverage for
transportation, and my understanding is there is some movement
to also provide coverage for transportation for dental patients
as well, which is very important. But you know, for the chronic
care management piece, patients come in, they see their
provider multiple times a year, depending on what the condition
is and what their health looks like.
But this is where some of the efforts of the Maryland
Primary Care Program come in and what we term population
health, where we wrap around the patient and we work with the
patient and their family to ensure that they are taking the
medication correctly, that they understand how to do that, that
they understand their care plan.
So, going over a lot of those health factors and assessing
health literacy, looking at the social determinants of health,
all of those pieces are critical, especially in rural areas
when we are looking at getting people back in for care.
Senator Cardin. As you can see by the number of Senators
who have participated in this hearing, there is a great deal of
interest on our committee in regards to rural health care.
There have been lots of initiatives, and we have tried to
include them in some of the major bills around here. I think
this hearing has been very helpful for us to focus in on the
areas where we really still need to make progress, and
providing the right incentives at the Federal level, in
partnership with the other stakeholders we have, in order to
fill the needs that are out there.
I really congratulate each of you for innovative ways to
deal with rural health care in your service areas, because you
have all come up with ways to help fill the void, knowing full
well there are areas that you just are going to be frustrated
about: getting enough providers in your community, getting
enough training facilities in your community, knowing that that
is where people like to stay.
But it is encouraging to see what you are able to provide
for your communities. So I congratulate each one of you for
your commitment to the health care of your communities.
Senator Carper. Mr. Chairman?
Senator Cardin. Senator Carper?
Senator Carper. Before we adjourn, I want to touch on
workforce one more time, if I may.
Senator Cardin. Certainly.
Senator Carper. If I could. I asked my staff if this
question has been asked already and was told that it has not,
so I want to go ahead and ask it. We have a major health-care
provider in our State. It is called Christiana Care, and it is
huge for a little State. And we have any number of smaller
hospitals and federally qualified community health centers.
I stay in close touch with almost all of them, my staff
does, and one of the things I recently discussed with the
people who run Christiana Health Care, a large health-care
provider--among their challenges is workforce. It is not just
the federally qualified community health centers; it is just
about everybody.
And we find that almost every employer that we talk to--I
do a lot of customer calls with businesses large and small
throughout my State, and we hear this all the time. Let me
just--if I can, Dr. Holmes, based on your research background,
could you just give me some idea of ways in which expanding
provider training at rural health facilities has demonstrated
success in increasing the rural health workforce?
Again, I like to say ``find what works; do more of that.''
Just give us some examples of that.
Dr. Holmes. Yes, sure. Thank you for the question. So, I
think the first one I will come up with is the Rural Residency
Planning and Development Program, which was rolled out by HRSA,
I think 3 years ago, to help spur physician residency programs
in rural areas and give them the technical assistance to launch
them.
There have been more rural residency slots created in the
last 3\1/2\ years than in the prior 6 years, I think it was. So
it really shows that intentional and Federal investments in
expanding that can really pay a dividend. We have talked a few
times about this notion that having training in rural areas is
more likely to keep you practicing there subsequently, so there
is a through line between those two that really directly
connects that.
Senator Carper. Good; thanks for that. Anyone else want to
comment on this? Please.
Dr. Herman. One quick comment----
Senator Carper. Yes, Dr. Herman.
Dr. Herman [continuing]. Is that we built this health-care
system on the largest group of high school students and college
students that ever went through in America. And that workforce
is not available anymore. Unless we get a disproportionate
share to go into health care, we will never be able to staff
health care like we have before.
So it will require a lot of different innovations for us to
not only treat people more efficiently and more effectively,
but to find ways to keep people well to reduce the burden on
the health-care system, and more importantly, reduce their
burden of illness.
Senator Carper. Say that again: find ways to help people.
Could you say that again, to keep them well? Go ahead and say
that again. I am a big believer in that. Go ahead. Just repeat
it.
Dr. Herman. What I just said?
Senator Carper. Yes, just the last part of what you said.
It was a great truth.
Dr. Herman. In order for us to really meet the needs of the
population, the population has to be well. And making the
investments up front to keep people healthy and to decrease the
burden of their disease, decrease our need for health-care
providers, decrease the cost for health care most importantly,
keeps people well. People do not want to be consumers of health
care. People want to be well.
Senator Carper. Where does obesity fit in that, if at all?
Dr. Herman. Obesity is huge. We have just done a study of
our health-care system--largely rural. When we look at the
number of the patients who are hospitalized, more than 40
percent of the patients who are hospitalized at any given time
in the 14 hospitals across our system have a diagnosis of
diabetes.
That may not be why they were admitted to the hospital, but
the comorbidities associated with diabetes are likely the thing
that brought them in for a hospital admission.
Senator Carper. All right. Thank you very much. Thank you
all very much. Great to see you.
Senator Cardin. We know that Senator Thune was tied up in
another committee. He was planning to come by, so we are going
to keep the--right on cue. He has been out there for 15 minutes
waiting for me.
Senator Thune, the floor is yours.
Senator Thune. Mr. Chairman, thank you. Thank you for
making it possible for me to get here, and to Senator Daines
for having a very important hearing to discuss access to health
care in rural communities, which is critical in, certainly, my
home State of South Dakota. And I want to thank our panelists
for joining us today and for the work that you are doing in
your communities to improve access to health care.
We had a lot of strains put on rural health-care providers
by the pandemic, and in some very difficult circumstances. The
challenge of attracting and retaining workforce has become even
a more significant issue that they have to deal with.
Providers in South Dakota worked really hard to find
innovative solutions on how to reach patients, but there are
still barriers. I look forward to working with my colleagues on
this committee to advance solutions that will meet some of
those challenges.
Let me just say, I have heard from many of the hospitals in
South Dakota about the impact the workforce shortage has on
their ability to discharge patients from the hospital. Often,
even though a patient is ready to be discharged to a long-term
care facility, because the long-term care facility has a
shortage of staff, they are not able to take these patients.
In South Dakota, these patients are waiting as much as 45
days in the hospital to be discharged. In one recent case, a
patient waited 150 days before being placed in a facility, and
then it was to a facility in a different State, far from his
family.
Further, I am concerned this issue could be exacerbated by
a potential requirement from CMS that would mandate staffing
ratios in nursing homes, something we have heard a lot about.
So, we need to ensure that burdensome regulations do not get in
the way of providing high-quality care for patients, and
instead we need to work on tailored solutions for our rural
communities.
So, Dr. Holmes, you mentioned that in order to grow the
rural health workforce, we need to support health-care workers
across their entire career. At the Federal level, there are
grants to support training and loan relief to recruit providers
to certain areas. What other ways can we help support providers
to both train and remain in rural areas?
Dr. Holmes. We talked about the bonus program earlier. So
that would be another option to continue to make it more
financially sustainable to practice in rural areas. It is not
just getting them there, but keeping them there to that point.
We know that workplace violence has been on the uprise for
a while in terms of, I guess really, anger at many health-care
workers. And what can be done in that space?
Senator Thune. We have--and I am sure you guys have covered
this already--but this mandated staffing nursing ratio issue.
You have talked about that, exhausted that at some length, if
you have already talked about that. If you have not talked
about that, I would love to get your reaction to that.
Senator Cardin. That is the first time that has been
raised.
Senator Thune. Okay.
Dr. Herman. I believe it is about the care of the patient
rather than mandating a particular ratio. It depends upon the
acuity of the patient, the illness of the patient, and what the
patient needs at that particular time. I think it is a very
coarse tool that is unlikely to be completely successful.
We have nursing professionals within each one of our
facilities who know what it takes to care for a patient. I do
think that if you are not caring for patients well, there are
certainly regulations that allow for that to be addressed. But
to mandate a ratio, I think, is a blunt tool that will, number
one, inhibit hospitals from being able to provide the care they
need to provide, and will not have the intended outcome of
patient safety.
Senator Thune. And I hope they will take that into
consideration and relook at that. Unfortunately, increasing the
pipeline of providers in rural areas is not going to happen
overnight, and telehealth has been as good a bridge as we have
for getting there.
I continue to work with my colleagues on the CONNECT for
Health Act, which would eliminate barriers to telehealth in
Medicare, including allowing Rural Health Clinics to provide
access to services through telehealth.
Ms. Aune, during the pandemic, Rural Health Clinics were
able to act as distant sites for telehealth services, enabling
many patients to have access to health services. Could you tell
us more about your experience using this flexibility during the
pandemic, and how making this permanent could benefit patients?
Ms. Aune. Yes. So it was very beneficial to patients. Like
everyone else on the panel has said, we use a lot of audio-only
because our community may not have a computer or Internet. So,
if we could integrate that some way within the payment system,
that would be great. We have a lot of providers that will just
call the patient because the patient will call day of
appointment and say they cannot make it because they do not
have a ride to the appointment; they may be 60 miles away.
And so, the provider will actually just do a telephone
visit with them, and a lot of times those are not even billed
because a provider does not bill them for their call with their
results.
Senator Thune. Yes. And the CONNECT for Health Act does
permanently add Rural Health Clinics as a distant site, and we
have 58 Rural Health Clinics in South Dakota.
Do I have time for one more, Mr. Chairman? Sorry, I know
you are--so anyway.
We have 39 Critical Access Hospitals across the State of
South Dakota, and these hospitals serve as essential health-
care providers in areas where there may not be another health-
care facility. Dr. Herman, you highlighted the challenges that
Essentia's Critical Access Hospitals face with arbitrary
regulatory requirements like the 96-hour rule.
As you know, this rule was waived during the pandemic
health emergency. Could you describe how the waiver of this
rule during the health emergency helped Critical Access
Hospitals better serve patients, and what challenges are those
hospitals now going to face if the rule is back in place?
Dr. Herman. We firmly believe that the best care a patient
can get is the care that they can get closest to home. You have
the support of your family, and you have the support of your
community, and we know that those are incredibly important in
promoting the wellness and the healing of the patient.
What we saw during the pandemic is that waiver of the 96-
hour rule did several different things. First of all, it
allowed those Critical Access Hospitals to retain their staff.
When you have a widely fluctuating census, it is hard to keep
the staff because people work Monday and Tuesday, and then they
do not work for the rest of the week.
Number two, it allowed them to really build their
capabilities to take care of sicker patients. They became more
confident in their ability to do that, and it allowed them to
keep those patients closer to home. Our concern is, and the
other part of it was that we did not have the capability in the
larger hospitals to take care of those patients.
A lot right now towards the post-acute care--there are
about 2,000 patients every day in Minnesota hospitals who are
waiting to get to a skilled nursing facility or post-acute
care. Where do those patients go? If we can stabilize the staff
and build the capabilities of those Critical Access Hospitals,
I believe it will go a long way to their success in the future.
Senator Thune. Okay. Well, we look forward to working with
you on that.
And, Mr. Chairman, I thank you again for giving me the
time.
Senator Cardin. Sure.
Senator Thune. Thank you.
Senator Cardin. Thank you, Senator Thune.
Senator Thune. Thank you all very much.
Senator Cardin. We want to thank the entire panel. These
have been extremely helpful presentations that will be used by
our committee dealing with these issues.
The record will remain open until next Wednesday for
members to ask questions for the record. And again, with our
thanks to our witnesses, this hearing will now be adjourned.
Thanks.
[Whereupon, at 4:28 p.m., the hearing was concluded.]
A P P E N D I X
Additional Material Submitted for the Record
----------
Prepared Statement of Erin Aune, MBA, CRHCP, Vice President of
Strategic Programs, Frances Mahon Deaconess Hospital; and Board of
Directors Member, National Association of Rural Health Clinics
On behalf of my roles with both Frances Mahon Deaconess Hospital
(FMDH) \1\ and the National Association of Rural Health Clinics
(NARHC),\2\ I thank the subcommittee for their attention to the
obstacles and opportunities facing rural health. During my testimony, I
hope to take you on a journey of what it is like to access and help to
provide health care while living in the heart of rural America.
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\1\ https://www.fmdh.org/.
\2\ https://www.narhc.org/narhc/default.asp.
The Rural Health Clinics program \3\ was created in 1977, and
remains the oldest Federal program aimed at improving access to
outpatient care in rural, medically underserved areas. The RHC program,
as a whole, serves approximately 37.7 million patients per year--more
than 11 percent of the entire population and approximately 62 percent
\4\ of the 60.8 million Americans who live in rural areas. Rural Health
Clinics are a separate and distinct program from the Federally
Qualified Health Center program, also represented on today's panel, and
both serve a critical role in our country's health-care safety net.
RHCs receive enhanced Medicare and Medicaid reimbursement but are not
grant-funded.
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\3\ https://www.cms.gov/center/provider-type/rural-health-clinics-
center.
\4\ https://www.narhc.org/News/29910/Sixty-Percent-of-Rural-
Americans-Served-by-Rural-Health-Clinics.
I feel fortunate to represent one of those Rural Health Clinics,
located in Glasgow, MT. If you are picturing mountains, we are not that
side of the State! Glasgow lies in the northeast corner of Montana and
is an agricultural community with big skies and wheat fields as far as
the eye can see. Glasgow has been deemed the ``middle of nowhere'' \5\
by The Washington Post, as it the most geographically isolated area,
taking 4.5 hours in any direction to get to a city.
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\5\ https://www.washingtonpost.com/news/wonk/wp/2018/02/20/using-
the-best-data-possible-we-set-out-to-find-the-middle-of-nowhere/.
As a provider-based RHC attached to a Critical Access Hospital, we
have no choice but to be very strategic on how we can best serve our
community and the surrounding areas. Glasgow has a population of about
3,500 residents, 7,600 people live in the county, and about 15,000 in
the two neighboring counties. Fort Peck Indian Reservation is also
located 15 miles to the East of us. With the closest larger hospital
over 300 miles away, we work very hard to provide our service area with
as many service lines as possible to relieve some burdens for our
patients. Our RHC provides a wide range of services including primary
care, behavioral health, general surgery, orthopedics, and OBGYN. We
are especially proud that we recently achieved 24/7 coverage in general
surgery, OBGYN, and orthopedics. Our RHC serves approximately 8,600
patients annually, roughly 33 percent Medicare, 22 percent Medicaid,
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and 37 percent commercial pay.
My testimony today will focus on specific challenges and solutions
in workforce, telehealth, access to care barriers, and the educational
pipeline. Through my role as a board member with the National
Association of Rural Health Clinics, I will also share insights into
other opportunities and obstacles facing my colleagues in the over
5,300 other RHCs across the country.
workforce
As is the case for many other rural areas, recruitment challenges
are significant in the ``middle of nowhere.'' After years of provider
turnover and unfilled openings, we strategically found a staffing model
which would allow us to provide specialty services locally. In 2020, we
contracted with a company that provides 24/7 orthopedic coverage. The
providers are a team of three, full-time employees, and the same team
covers the entire month on a rotating basis. This model worked so well
we explored the idea for general surgery and OBGYN as well and are
considering it for radiology, another specialty where we are facing
recruitment challenges. Being able to offer these services locally
provides better patients outcomes, continuity of care, a better work
life balance and helps prevent provider burn out. This model has worked
well for those specialties, but we struggle with accommodating the
behavioral health needs of the community. We currently staff one
psychologist and one Licensed Clinical Social Worker Candidate. Our
LCSWC is a local resident who was interested in furthering her career
in the field, and we were able to support her in this. This still does
not meet the needs of our communities, and access to behavioral health
services remains a nationwide crisis in need of significant attention.
Our staffing plan shows a shortage of three behavioral health
providers, but a recent study shows there is a need for 60 in our
region alone. To help bridge many of these gaps in access, we have
pursued telehealth options for behavioral health, pain management, and
maternal fetal medicine. We recently partnered with Intermountain
Health to provide immediate tele-crisis services through our emergency
room to our patients that are having a behavioral health crisis. While
new, this service has been working well.
The ability to serve as a distant site telehealth provider has much
potential for Rural Health Clinics and other providers, as shown
throughout the COVID-19 pandemic, and I thank Congress for seeing the
value in telehealth. Offering telehealth services, particularly in
rural communities, does present challenges of its own, however. The
majority of our patient population does not have access to a computer,
the Internet, or a phone according to the Social Determinants of Health
Index, we were provided with from Cynosure for our pilot project. The
connectivity measure for the area was listed as high in many of the
communities we serve at FMDH. Telehealth services may seem like a great
solution to help bring care to the patient, but when they cannot access
the care, it becomes more of a burden and frustration to those we're
seeking to help. Many of our patients travel 50-100 miles one way to
attend an appointment at our facility and do not have the ability to
utilize telehealth services. Further, RHCs and FQHCs are reimbursed for
telehealth services through a ``special payment rule'' at $98.27 per
visit. While traditional outpatient offices that bill fee-for-service
Medicare receive reimbursement parity between in person and telehealth
services, safety net providers like us are paid significantly less for
telehealth visits than our in-person encounters, disincentivizing
investments in telehealth technologies and obscuring the claims data as
to exactly which services are offered through telehealth. I ask that as
the committee considers long-term Medicare telehealth policy, it takes
into account rural provider perspectives, including the value of
adequate reimbursement and audio-only flexibilities to reach patients
with connectivity challenges.
education pipeline
FDMH seeks to inspire our youth to follow a career in health care
based on the quality of care they receive from our organization. From
my generation alone we currently have seven providers and multiple
nurses on our staff that were born and raised in Glasgow and have moved
back to provide care in rural America. My 12-year-old son wants to
pursue a career in medicine because of the care he has received here.
We strive to introduce our youth to the health-care field, this year we
will be hosting the first Med Camp for kids in grades 6-8, introducing
them to multiple areas of the hospital and clinic. With many clinics
and hospitals being at staffing crisis levels, we need to be proactive
with our youth and getting them to think about the future. We are also
proud participants and supporters of the WWAMI education program \6\
through the University of Washington School of Medicine, through which
Washington, Wyoming, Alaska, Montana, and Idaho expose medical students
to an increased variety of clinical settings throughout their training,
including RHCs like ours. Many of our local students have participated.
Investing in our youth now helps both our present and our future.
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\6\ https://www.uwmedicine.org/school-of-medicine/md-program/wwami.
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transportation
The greatest barrier that our community is facing is
transportation. We strive to provide our community and surrounding
communities with as much access to health services as we can provide
locally, whether we provide them in house, provide outreach to other
facilities, bring in specialty outreach clinics, or provide telehealth
services. The services we cannot provide are 300 miles away and can
cause patients stress and financial burdens. Impacts of no-shows and
canceled appointments, resulting from high gas prices, lack of a
reliable vehicle or a vehicle entirely, inability to take time off work
or have a friend or family member transport them, include lapses in or
delayed care, poor adherence to provider recommendations, lack of
surgical follow-ups, and much more, all resulting in negative health
outcomes and more expensive, higher-level care needs. This is only
exacerbated when patients need higher-level care at a facility hours
away. When patients are transferred to a larger facility for this care,
they are at least 300 miles away from home. Many families struggle to
get to their loved ones as well as how to get them back home after
discharge. I can share many stories with you, but one that stands out
is from this winter when a patient presented to the ER by ambulance, a
non-emergency ride which was denied by Medicaid. After the patient was
discharged, they were planning to walk/hitchhike 30 miles home to
Frazer, in a temperature of -17 below and -35 windchill. While staff
were able to help this individual and consistently seek partnerships
and other solutions to address these significant barriers, we need more
comprehensive solutions.
My clinic is just one of 5,300 RHCs across the country, providing
critical services in innovative ways to serve the needs of their
patients. The unique structure of the RHC program comes with
significant regulatory requirements and oversight, intended to protect
the integrity of the RHC benefits. However, many provisions of the RHC
statute written in 1977 have never been updated. For example, RHCs are
required to have lab equipment within the square footage of the clinic
for specific laboratory services. At FMDH, our patients go across the
hall to our full-service lab for these services, meaning that our
expensive equipment is unused for all purposes except meeting survey
and certification requirements. Requirements like these increase cost
and administrative burden, challenging an already overwhelmed workforce
and threatening the delivery of quality, outpatient care in rural
communities. Finally, the drastic increase in Medicare Advantage
enrollment across the country, including in rural communities,
threatens the rural safety net. While RHCs receive enhanced traditional
Medicare payments in comparison with their fee-for-service counterparts
as Congress recognizes the increased costs of providing care in rural
America and the high value of care in these communities, there is no
statutory requirement around RHC Medicare Advantage reimbursement. With
oftentimes lessened negotiating power as one of few providers in a
rural area, many RHCs across the country are facing financial stability
concerns due to low Medicare Advantage reimbursement.
In conclusion, I want to thank you for inviting me to share these
unique perspectives as part of today's hearing. We often forget our
``why,'' and this experience has reminded me of why I do what I do. I
am proud to be a voice and advocate for this population. I thank the
subcommittee for their continued leadership on these critical issues,
and I look forward to seeing the work that we can do together for the
over 60 million individuals across rural America. Thank you.
______
Questions Submitted for the Record to Erin Aune, MBA, CRHCP
Question Submitted by Hon. Chuck Grassley
Question. Our Nation's maternal mortality rate is too high and has
increased 47 percent since 2018. At the same time, over 80 percent of
pregnancy-related deaths are preventable. These challenges impact women
of color and women living in rural areas the most. There's a lot we can
do, but aren't. My bipartisan Healthy Moms and Babies Act would help
address these maternal health challenges. It takes best practices from
across the country to improve care, including care coordination,
telehealth, and supporting community-led efforts. What actions should
we take to improve the maternal mortality rate, especially among women
of color and women living in rural America? Do you have a best practice
you can share that is helping address these challenges?
Answer. Many patients in our rural area have to travel 300 miles to
receive a higher level of obstetrical care. Not only is it 300 miles,
there is very limited cell phone coverage and little to nothing in
between, making it very risky for our patients. We are very proud that
we have achieved our goal of providing our area with 24/7 OBGYN
coverage. We have achieved this with a rotating provider schedule as I
mentioned in my written testimony. We are also setting up an outreach
clinic with maternal fetal medicine, so our high-risk patients don't
have to travel as much or as far for care. Many of our patients travel
the 300 miles and then will stay there for multiple weeks before
delivery. This causes the patient and their families a lot of stress as
it is a huge financial burden. As a facility we are very proactive with
this issue but it still could be greatly improved, we can only do so
much with the resources that are available. Many other rural areas
struggle as they don't have access to resources or education. Providing
rural areas access to resources will help with improving care.
Question Submitted by Hon. Sheldon Whitehouse
Question. The burden of prior authorization and disputes between
providers and payers about claims and payment denials are time-
consuming, expensive, and ultimately bad for patients. Can you discuss
the extent that transitioning from the fee-for-service (FFS) model to
value-based care could help diminish these administrative disputes?
Answer. Value-based care pushes clinical documentation improvement
to indicate the complexity of the patient, therefore eliminating the
need for peer to peer, only if documentation doesn't support medical
necessity. In my opinion, I believe it would still pose administrative
burdens, not diminish them. There could potentially be a shift in the
administrative burden, more on the providers documentation and coding
and less on the AR follow-up staff. However, high-deductible health
plans will cause a shift from insurance reps to self-pay collectors.
The same problems can be foreseen that we have now with payers having
their own set of guidelines. Standardization will be key in EMRs, by
payers, etc. before we see diminished administrative disputes.
______
Prepared Statement of Hon. Steve Daines,
a U.S. Senator From Montana
Thank you, Mr. Chairman. It's great to be here this afternoon to
discuss rural health care. It's also a pleasure to be joined by Ms.
Erin Aune from Glasgow, MT. We'll have a more formal introduction soon,
but thank you for making the trip to be here representing our State and
Rural Health Clinics. We're glad to have you.
Rural health is a key component of America's health-care
conversation and greatly important to my State of Montana, as more than
720,000 Montanans live in designated rural areas. Most every State in
the Nation has some semblance of a rural population, and in frontier
States like mine, we are all too familiar with the challenges that come
with living where we do--including the challenge of accessing health
care.
When we consider health care in a rural setting, one of the
defining characteristics of access to care is distance and
transportation. The majority of people in rural America live great
distances from their nearest health-care provider. A trip to a hospital
or doctor's office often requires traveling several hours one way.
Not only is this highly inconvenient and straining, but also very
dangerous in emergencies. Extreme weather and unpredictable terrain
only add to the challenges rural folks face.
Other threats to access that we see disproportionately affecting
rural communities are the increasing number of hospital closures and
service line erosions. As our witness Dr. Holmes can attest, we've seen
nearly 150 rural hospital closures over the past 13 years.
While closures briefly stalled in 2021, this can largely be
attributed to Provider Relief Funds and other assistance to keep
providers afloat during COVID-19. As we move beyond the pandemic, the
number is sadly on the rise again.
I also hear too often about the erosion of service lines in rural
America. In these areas, one of the first services to be eliminated is
obstetric and maternity care. GAO issued a report last year which found
that access to these services has been in steady decline, and more than
half of rural counties do not have these services available at all.
I recently learned of a woman in Montana who traveled from her home
several hours away to Billings in the weeks leading up to her due date.
She moved into a hotel so that when she went into labor, she would be
able to get to the hospital for her delivery. Preparing for labor,
delivery, and a newborn is difficult enough. No expectant mother should
feel the need to go to such drastic lengths to receive routine prenatal
and delivery care.
This is just one example of how service line erosion impacts rural
residents, but it is illustrative of the challenges we need to help
address. We must find sustainable ways to keep health care accessible
in our rural communities. To that end, I am looking forward to the
discussion today with our colleagues and witnesses, and hearing their
perspectives.
The last time the Finance Committee had a robust conversation about
rural health was in 2018. I'm glad we are revisiting the conversation
today--post pandemic--to examine the difficulties and progress over the
past 5 years.
The difficulties often receive more attention than the successes,
and I'd like to acknowledge the recent efforts of my colleague, Senator
Grassley, who has long been a champion for rural health issues. Thanks
to Senator Grassley's leadership, in January of this year, the first
new Medicare rural provider designation went into effect since the
Critical Access Hospital designation was created in 1997.
We're very proud of the Montana leadership which led to this
designation--a designation spearheaded by Senator Max Baucus--but it's
great to see Senator Grassley and others working to implement new and
creative ways to serve the changing needs of our rural hospitals today.
Rural health care has long enjoyed robust bipartisan collaboration
and support, and I look forward to continuing that tradition.
Thank you to our witnesses for being here today. We appreciate your
expertise on this subject and all the work you are doing to promote
rural health and access to care.
Thank you, Mr. Chairman.
______
Prepared Statement of David C. Herman, M.D.,
CEO, Essentia Health
introduction and background
Chairman Cardin, Ranking Member Daines, and members of the Senate
Committee on Finance, Subcommittee on Health Care, thank you for the
opportunity to testify at today's hearing: ``Improving Health Care
Access in Rural Communities: Obstacles and Opportunities.'' We are
pleased the subcommittee is interested in learning more on how to
improve health care across rural communities and appreciate the
invitation to tell you about our journey to value-based care.
Essentia Health is an integrated health system serving patients
primarily in rural communities throughout Minnesota, Wisconsin, and
North Dakota. Headquartered in Duluth, MN, Essentia Health combines the
strengths and talents of 15,000 employees, including 2,200 physicians
and advanced practitioners, who serve our patients and communities
through the mission of being called to make a healthy difference in
people's lives. The organization lives out this mission with a patient-
centered focus at 14 hospitals, 77 clinics, six long-term care
facilities, six assisted and independent living facilities, seven
ambulance services, 25 retail pharmacies, and a rural health research
institute.
On behalf of Essentia Health, we are pleased to highlight our
ongoing efforts to serve our patients and rural communities through
value-based care models. Our experience has shown that delivering care
through these models can be successful in rural communities. Our
remarks will focus on:
The unique challenges providing care in our rural
communities.
How we embarked on value-based care models.
What we've learned along the way.
How these models serve as a pathway for the future of rural
health care.
serving rural communities
Addressing the Needs of Our Rural Communities and the Social
Determinants of Health
Providing access to health-care services across rural communities
presents unique challenges in addressing the social determinants of
health. Our rural patients across Minnesota, North Dakota, and
Wisconsin tend to be older, bear greater burdens of chronic disease,
experience higher levels of poverty and substance abuse, and have lower
rates of education and insurance coverage compared to urban
areas.\1\, \2\, \3\ In these rural States,
financial insecurity further perpetuates these challenges, as many of
the counties we serve fall below statewide median income \4\ (Appendix
A).
---------------------------------------------------------------------------
\1\ Minnesota Department of Health, Division of Health Policy.
Rural Health Care in Minnesota: Data Highlights, 2022, https://
www.health.state.mn.us/facilities/ruralhealth/docs/summaries/
ruralhealthcb2022.pdf (accessed May 12, 2023).
\2\ University of North Dakota School of Medicine and Health
Sciences Advisory Council. Health Issues for the State of North Dakota,
Seventh Biennial Report, 2023, https://med.und.edu/about/publications/
biennial-report/_files/docs/seventh-biennial-report.pdf (accessed May
10, 2023).
\3\ Sarina Schrager, ``Rural Health in Wisconsin--Looking to the
Future,'' Wisconsin Medical Journal, 117, no. 5 (2019), 192-193,
https://wmjonline.org/117no5/schrager/ (accessed May 13, 2023).
\4\ Minnesota Department of Health, Division of Health Policy.
Rural Health Care in Minnesota: Data Highlights, 2022, https://
www.health.state.mn.us/facilities/ruralhealth/docs/summaries/
ruralhealthcb2022.pdf (accessed May 12, 2023).
Access to care is the largest, most complex issue currently facing
rural health. Patients with access to a primary care physician spend
less time in the hospital, have fewer visits to the emergency
department, achieve better outcomes and have lower health-care
costs.\5\, \6\ But rural residents face significant barriers
in simply accessing care. Patients across rural Minnesota face more
challenges in securing appointments and establishing a patient-doctor
relationship with primary care providers.\7\ Rural counties are more
likely to face shortages of primary care doctors and mental health-care
providers.\8\ Over 40 percent of rural counties are underserved in
primary care and over 80 percent of rural counties in America lack
local access to behavioral health services.\9\
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\5\ David P. Glass, Michael H. Kanter, Steven J. Jacobsen, and Paul
M. Minardi, ``The impact of improving access to primary care,'' Journal
of Evaluation in Clinical Practice, 23, no. 6 (2017), 1451-1458,
https://doi.org/10.1111%2Fjep.12821 (accessed May 12, 2023).
\6\ Barbara Starfield, Leiua Shi, and James Macinko, ``Contribution
of Primary Care to Health Systems and Health,'' Milbank Quarterly, 83,
no. 3 (2005), 457-502, https://doi.org/10.1111%2Fj.1468-
0009.2005.00409.x (accessed May 12, 2023).
\7\ Minnesota Department of Health, Rural Health Care in Minnesota.
\8\ Elizabeth A. Dobis and Jessica E. Todd. 2022. ``The Most Rural
Counties Have the Fewest Health Care Services Available.'' Amber Waves,
The Economics of Food, Farming, Natural Resources, and Rural America,
Economic Research Service, U.S. Department of Agriculture, August 1,
2022, https://www.ers.usda.gov/amber-waves/2022/august/the-most-rural-
counties-have-the-fewest-health-care-services-available/.
\9\ Dobis and Todd, ``The Most Rural Counties Have Fewest Health
Care Services Available.''
Residents in rural Minnesota need to travel greater distances to
access inpatient services, particularly mental health and
obstetrics.\10\ Furthermore, over 25 percent in Wisconsin \11\ and
almost 20 percent in rural Minnesota \12\ lack reliable broadband
Internet for use in video visits, a barrier to accessing virtual
services that were critical during the COVID-19 pandemic.
---------------------------------------------------------------------------
\10\ Minnesota Department of Health, Division of Health Policy.
Rural Health Care in Minnesota: Data Highlights, 2022, https://
www.health.state.mn.us/facilities/ruralhealth/docs/summaries/
ruralhealthcb2022.pdf (accessed May 12, 2023).
\11\ Danielle Kaeding, ``Report: Rural Areas of Wisconsin Suffer
From Major Gaps in Broadband Access,'' Wisconsin Public Radio, January
4, 2021, https://www.wpr.org/report-rural-areas-wisconsin-suffer-major-
gaps-broadband-access (accessed May 12, 2023).
\12\ Minnesota Department of Health, Division of Health Policy.
Rural Health Care in Minnesota: Data Highlights, 2022, https://
www.health.state.mn.us/facilities/ruralhealth/docs/summaries/
ruralhealthcb2022.pdf (accessed May 12, 2023).
Rural hospitals and health-care systems significantly impact their
local communities, both on health and economic sustainability.\13\ As
anchor institutions, rural hospitals and clinics play critical roles in
the economic and social vitality of their communities.\14\ In 2022,
Essentia Health invested $430.3 million in community contributions \15\
across our organization's geographic footprint.
---------------------------------------------------------------------------
\13\ University of North Dakota School of Medicine and Health
Sciences Advisory Council. Health Issues for the State of North Dakota,
Seventh Biennial Report, 2023, https://med.und.edu/about/publications/
biennial-report/_files/docs/seventh-biennial-report.pdf (accessed May
10, 2023).
\14\ ``Leveraging Position as an Economic Anchor to Improve Health
Equity,'' Rural Health Information Hub, accessed May 13, 2023, https://
www.ruralhealthinfo.org/toolkits/health-equity/2/organizational-
capacity/economic-anchor.
\15\ https://www.essentiahealth.org/about/facts-figures/.
Organizational Commitment from Volume to Value
Building an Organizational Culture and Infrastructure to Embrace Value-
Based Care
Nationwide, health-care spending grew to $4.3 trillion in 2021,
accounting for 18.3 percent of the gross domestic product.\16\ This
spending growth was fueled by the
status-quo approach of paying for medical services based upon volume--
an approach that is simply unsustainable. Traditional fee-for-service
(FFS) models pay for specific, itemized care delivered by clinicians.
Adverse effects of the FFS approach include:
---------------------------------------------------------------------------
\16\ ``NHE Fact Sheet, Historical HE, 2021,'' Centers for Medicare
and Medicaid Services, National Health Expenditure Data, accessed May
15, 2023, https://www.cms.gov/research-statistics-data-and-systems/
statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.
Rewarding the volume rather than the quality of care and
outcomes.
An emphasis on treatment at the expense of prevention and
wellness.
Providing no incentives for integrating and coordinating
care.
Discouraging practice transformation and clinician-driven
innovation.
Recognizing the failure of volume-based reimbursement to meet the
needs of patients, Essentia Health committed to transforming our care
model to prioritize patient outcomes and overall value. Our volume-to-
value journey started with the shared understanding of the need for
strategic change, which helped create an environment and forward-
thinking culture that embraces continuous improvement and innovation.
Effective care transformation relies upon leadership support and
engagement from physicians and providers, all aligned in agreement that
a new model is required to best care for our patients and communities.
At its core, value-based health care emphasizes prevention and
wellness, in addition to treatment. This approach focuses on:
Improving overall patient health.
Connecting patients with the appropriate care at right time.
Providing access to integrated care through the entire
patient journey.
Investing in practice transformation and quality
improvement.
Value-based care is cost-effective and improves care for all
patients, particularly those with chronic illnesses, by improving
patient outcomes, experience, and quality of life by:
Limiting duplicative testing.
Avoiding medication mistakes and overuse.
Reducing avoidable emergency department visits and hospital
admissions.
Increasing patient engagement and adherence to care plans
and medication.
As we face significant workforce challenges, value-based care
supports our clinicians and care teams. Provider wellness has been at
risk in our Nation's health-care system, and the pandemic heightened
these challenges further. Implementing value-based care programs
enhances the care clinicians can provide through care coordination and
other services that connect patients with the resources they need to be
healthy. A team-based approach to care allows clinicians to spend
valuable time with their patients and to contribute their own
innovations. Value-based care provides opportunities to make the
delivery of health care more rewarding and fulfilling.
The model of care developed to improve outcomes in value-based
programs leads to the implementation of best practices for all
patients. Because it is neither practical nor proper to differentiate
the way we care for patients based on whether they are enrolled in a
value-based program, we are creating a best practice standard for all
patients. It is the right thing to do for our communities to ensure
that health care is sustainable. Simply put: value-based care delivery
is the best care model for all patients.
Essentia Health's commitment to engage in value-based programs and
contracts has the added benefit of improving health care for our rural
populations. That is why our organization entered into our first value-
based payment contract in 2005, paving the way to make a substantial
leap into value as an early adopter in the Accountable Care
Organization (ACO) Medicare Shared Savings Program (MSSP). Embarking on
a new way of measuring and providing care in partnership with the
Federal Government was a challenging decision for our organization, yet
it was a necessary step in moving away from a fee-for-service model. We
advanced these efforts when the Minnesota Department of Human Services
(DHS) launched a managed Medicaid program called Integrated Health
Partnerships (IHPs) in 2013. In the IHP program, Minnesota DHS
contracts with ACOs to achieve cost and quality targets. Essentia
Health has remained in both of these programs, moving to dual-sided
risk-bearing models in 2016 for MSSP and 2018 for the IHP program.
Today, we participate in 23 value-based care programs with more than
200,000 attributed members. Nearly 40 percent of our revenue flows
through value-based programs.
how we did it: analytics, action, and accountability
Create a Model of Care Delivery That Is as Standard as Possible and as
Unique as Necessary to Meet the Needs of our Patients and
Communities
Our strategy for success focused on three ``As'': Analytics,
Action, and Accountability. Each of these helps to support a value-
based care system with an emphasis on continuous improvement.
Strategies for value-based care success include:
Identifying the patients.
Determining patients' care needs.
Managing chronic illness.
Providing care needs in a proactive and coordinated way.
Driving appropriate utilization--lower health-care spending.
Addressing social determinants of health.
Partnerships with government, private payers, and community
organizations.
Analytics
Clinical and information technology infrastructure is a fundamental
building block to invest in and maintain value-based care programs.
Robust electronic health record (EHR) functionality and data collection
systems are necessary to understanding patient populations and
screening for the social determinants of health. Payer partnerships are
also critical to the success of value-based programs. Payer and EMR
data are integrated into clinical data registries to stratify the
populations. The results of the analysis support the development of
population-specific and actionable cost containment and health
improvement strategies, such as:
Risk stratification.
The evaluation of utilization patterns.
Care gap identification.
Referral management.
Health is created through social, economic, and environmental
factors in addition to health-care access and individual health
behaviors, and Essentia Health's social needs screening data collected
over the past several years highlights the widespread barriers that
have impacted inequities across the region. For example, in 2022,
144,000 Essentia Health patients completed a health-related social
needs screening, with more than 20,000 (14 percent) patients
identifying at least one social need related to food, housing, or
transportation. The percentage of patients with social needs varies by
clinic locations, with the highest-need communities having more than
half (53 percent) of patients identifying at least one need. However,
this need is not evenly distributed across race and ethnicity. We found
that 22 percent of American Indian/Alaskan Native patients and 17
percent of Black or African American patients reported food insecurity
compared to 7 percent of White patients and were also more likely to
report financial strain and transportation barriers than white
patients.
Actions: Implementation of the Strategies
Informed by data on our populations, nurses, physicians,
pharmacists, and community care associates work together to develop
programs that address the needs of our patients. Clinical data
registries are created to integrate EHR and payer data. The registries
stratify the population, identifying those with the highest level of
needs. Using this information, the team can engage with the patient to
develop an individualized care management plan. As an example, through
pharmacy care management, pharmacists review medications with patients
to ensure they have the information needed to manage their medications
and work with prescribers to identify the most cost-effective
medication options. These efforts result in improved health outcomes,
better patient experience, and lower overall utilization and cost.
The approaches used to serve patients have evolved along our
journey. Changes in the population require new strategies, including:
Use of alternative care delivery models, such as virtual
care and remote monitoring.
Improving transitions of care, such as after hospital
discharge or when leaving the emergency department.
Addressing social factors influencing health and well-being.
Closing care gaps.
Chronic illness management.
Patient-centered primary care encompasses strategies and services
oriented around the patient to achieve their best health. Clinical and
non-clinical experts support the care needs of the population working
together in team-based care. Community care associates in rural areas
are critically important to improve care outcomes by facilitating
access, adding value to the health-care team, and enriching the quality
of life for their patients, including those who are poor, underserved,
and in racial and ethnic minority communities.
At the core of patient-centered care is connection via the EHR.
This critical tool allows providers to facilitate care with closed loop
referral processes to ensure patients receive timely access to
specialists and that the primary care provider remains involved in the
patient's care throughout their journey. Several tools connected to the
EHR support timely, efficient communication between patients and
providers, including Essentia's online patient portal, our Nurse Care
Line program, and Virtual Visits on Demand. This improves the patient's
journey and engages them in the continuum of care. Care coordination
identifies and supports patients with high-risk conditions by helping
to arrange services and communicate with multiple providers while
transitional care management services help patients transition between
hospitalization and community setting.
While collecting data on social determinants of health helps to
establish intervention plans, creating connections to community-based
organizations is critical in addressing the social factors influencing
health. Essentia Health has implemented the FindHelp platform, branded
as Resourceful across our service area, and launched a campaign to
encourage community organizations to input data and enable referrals.
Having the information in a centralized location improves access for
all patients and stakeholders. By building relationships with key
community partners through outreach and engagement, we are facilitating
stronger coordination between agencies and building a network of social
care providers ready to help people in need across the region. Essentia
Health has embedded access to the Resourceful platform in our EHR to
enable providers, care managers, and community care associates to make
direct referrals to community-based organizations. Additionally, we
also have the ability to determine if the patients received help from
the community-based organization. In the two years since launching the
program, there have been more than 10,000 referrals with 30 percent
patients verified to have received services they need to support their
health and well-being.\17\
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\17\ Anthony Matt, ``Essentia Health-supported program reaches
10,000 referrals for vital programs, services,'' Essentia Health
Newsroom, April 12, 2023, https://www.essentiahealth.org/about/
essentia-health-newsroom/essentia-supported-program-reaches-10000-
referrals/ (accessed May 12, 2023).
Expansion to New Partners and Payers
Much like health-care providers, government and commercial health
plans are at varying levels of maturity in the value-based care
journey. While through the years our government payer programs have
been primarily in Medicare and Minnesota Medicaid, we are pleased that
the North Dakota Department of Health and Human Services (ND HHS) has
embarked on the journey to implement a value-based model to replace
fee-for-service Medicaid. Being in full support of advancing value-
based care, Essentia Health has engaged with ND HHS and the governor's
office to promote the benefits of outcomes-based models. This new
program starts out rewarding for process and engagement (pay for
reporting) and ramps up over time toward rewarding health outcomes (pay
for performance). We appreciate the partnership and willingness to seek
input from providers to create a model with short-term and long-term
goals.
While the government remains a key part of value-based payment
strategy, private payer partnerships are just as fundamental to
success. Essentia Health has established criteria to evaluate payer
programs and determine alignment with system strategy through
financial, systematic, and joint accountabilities. From a financial
perspective, models with a glide path to increased risk/reward allow
the payer and provider to create a long-term program together. Payer
models that offer providers options on levels of risk allow the
necessary time for providers to build the infrastructure needed to be
successful. Access to timely data is part of the foundation of value-
based care. Payers that are engaged in advancing value-based care
provide detailed membership and claims data to providers to support the
analytics and care interventions needed. Finally, agreeing to fair
terms and joint accountabilities will help ensure success with
government programs and private payer plans as well.
Accountability
Oversight and accountability are key to advancing the journey from
volume to value. We have developed a governance model with oversight
committees with clinical and administrative leaders within Essentia
Health and also with key payer partners to monitor performance. Through
this governance structure we establish goals and provide oversight on
performance.
Transparency on performance brings everyone together to identify
improvement strategies that support the achievement of standard work
through process and care design. We set targets for achievement that
can measurably improve outcomes, and we have developed the tools needed
to track progress. Examples include dashboards to monitor clinical
quality metrics, surgical outcomes, and hospital inpatient length of
stay.
success in value-based care
From 2018 to 2021, Essentia Health Removed Over $102 Million From the
Cost of Care Across All Value-Based Programs, While Being
Recognized as a Top Performer for Quality, Cost, and Equity
Value-based care is a continuous journey as we learn, evolve, and
expand our efforts across our organization. Essentia Health has
achieved success in both Medicaid and Medicare value-based programs,
saving tax dollars while maintaining a high level of quality and
patient satisfaction. We are pleased and proud of our achievements, yet
we know we can do more.
Outcomes from our value-based care programs include:
Medicare Shared Savings Program (MSSP) savings $42.4 million
from 2018-2021.
Minnesota Integrated Health Partnership (IHP) savings of $28
million from 2018 2021.
Nearly 40 percent of our revenue flowing through value-based
programs.
Approximately 80 percent of value-based contracts having
downside risk.
We have demonstrated our commitment to providing affordable, high-
quality health-care services for our patients and communities. As a
participant in MSSP since 2013, Essentia Health transitioned from
shared savings only into the risk-sharing track in 2016. Since then, we
have demonstrated consistently high performance. In fact, our providers
met 98 percent of the quality targets, earning full quality points for
performance year 2021 and generated a 4 percent savings rate, or $13
million for the Medicare program. From 2018 through 2021, Essentia
Health has generated cumulative savings to the Federal Government of
over $42 million as an MSSP ACO (Appendix B). We have also demonstrated
success in Minnesota's Integrated Health Partnership (IHP) as well.
From 2018 through 2021, Essentia Health achieved savings of $28 million
for the Minnesota State Medicaid program. Through this work, we have
proven that investing into value-based care models can be successful
and have brought forward a pathway to the future of providing care in
rural areas. We must, however, continue to evolve the way we deliver
care to ensure long-term sustainability for our patients and the
communities we are privileged to serve.
Quality of care has not been comprised but enhanced in our journey.
While focusing on care coordination, appropriate utilization, improving
outcomes and lowering cost, our quality of care has continued to
increase. This year, Essentia Health was named one of the top-
performing health-care systems in the State from Minnesota Community
Measurement (MNCM), a statewide resource for timely, comparable
information on health-care quality, costs and equity (Appendix C).\18\
Essentia Health scored significantly above statewide averages on 13 of
21 eligible clinical-quality measures for 2021. We have continued to
expand our value-based program portfolio with government and commercial
payers with more than 200,000 attributed members in 23 programs with 53
percent in government programs and 47 percent are in commercial payer
arrangements.
---------------------------------------------------------------------------
\18\ Anthony Matt, ``Essentia Health ties for first atop rankings
of high-performing health-care systems in Minnesota,'' Essentia Health
Newsroom, January 12, 2023. https://www.
essentiahealth.org/about/essentia-health-newsroom/report-ranks-
essentia-among-top-performing-health-care-systems/ (accessed May 12,
2023)
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learnings and recommendations to rural health-care providers
We Have Implemented a System and Created a Culture That Supports Value-
Based Care to Many Communities and Care Sites That Have Joined
Essentia Health During Our Journey
To be successful in value-based care, it starts with a desire and
commitment to start the journey and achieve the goals. A culture of
teamwork and care management is key to building a value-based care
program. For small and rural practices, a foundation of EHR and other
IS systems support likely cannot be implemented in small practices
alone. Shared infrastructure that supports clinics, hospitals, and
other sites of care will provide a network to reach populations across
a region and coordinate across primary and specialty care services.
A common electronic health record with strong population health
capabilities is necessary to understand social determinants of health
and preventative care interventions. Health care providers must also be
able to access measurement and data resources to track progress and
develop local insights in care successes and care gaps to be addressed.
They also benefit from tools for standardizing metrics across programs.
In rural areas, health systems must extend their capabilities by
partnering with community resources to address local non-medical needs.
Connecting to other social services is a critical part of population
health improvement, including access to healthy food, transportation,
and housing.
Other key learnings include:
Set short-term goals that reward development and
implementation of the infrastructure with a path to more
complex models in later years.
Align all payers within the same model redesign so rural
value-based care participants do not have the burden of
managing multiple different systems.
Design models to accommodate lower patient volumes in rural
settings to assist with setting benchmarks and targets and in
the management of outlier cases.
public policy recommendations
What Policymakers Can Do To Advance Value-Based Care to the Next Level
Policymakers play an important role in supporting value-based care.
Essentia Health asks Congress to support critical resources for health-
care providers, reduce regulatory burden, and enhance the design of
value-based payment models.
Continued Support for Critical Resources
Extend the Bonus Payment for Advanced Alternative Payment Models (APMs)
Enacted in the Medicare Access and CHIP Reauthorization Act
(MACRA), Congress provided a 5-percent incentive bonus for APMs with
downside performance risk. This incentive payment has been important
for Essentia Health to continuously invest in program management to
participate in MSSP. Appropriate financial incentives will help attract
providers to participate in these models to reduce cost and support
their transition to value. We appreciated that Congress enacted an
extension of the 3.5-percent incentive bonus for 2023.\19\ We urge
policymakers to reinstate a 5-percent Medicare bonus payment for new
and existing advanced APM participants.
---------------------------------------------------------------------------
\19\ Consolidated Appropriations Act, 2023, Pub. L. 117-328,
https://www.congress.gov/bill/117th-congress/house-bill/2617 (accessed
May 13, 2023).
Protect the 340B Prescription Drug Discount Program
The 340B Prescription Drug Discount Program helps rural hospitals
stretch limited Federal resources and is used to support health
services and programs throughout our communities. Protecting this
program is crucial for rural hospitals. The savings help provide
essential services to their communities, but unfortunately the program
is also coming under attack from drug manufacturers placing unlawful
restrictions on covered entities, negatively impacting hospitals and
the ability to acquire prescription drugs under the program.
Reduce regulatory burden
The COVID-19 pandemic brought unprecedented challenges and strain
on Essentia Health and our Nation's health-care delivery system.
However, the pandemic also provided a unique opportunity. Under the
emergency, HHS invoked their authority and waived hundreds of
regulatory requirements placed on health-care providers. This
alleviated barriers that resulted in rapid innovation to meet the
challenges brought on by the pandemic.
Continue to Remove Regulatory Barriers To Improve Access to Telehealth
Throughout the pandemic, telehealth and virtual platforms has
increased access and safely provided appropriate levels of care.
Essentia Health strongly supports enhanced access to telehealth and
digital health services and encourages Congress to alleviate regulatory
barriers and enact policies to increase access to care through these
modalities. Congress needs to consider ways to maximize access for
patients, especially those who reside in rural and underserved areas.
We thank Congress for enacting legislation to extend certain telehealth
flexibilities issued during the public health emergency through 2024
\20\ and urge a comprehensive bill to permanently extend telehealth
flexibilities made available during the pandemic.
---------------------------------------------------------------------------
\20\ Consolidated Appropriations Act, 2023.
---------------------------------------------------------------------------
Extend the 96-Hour Rule Waiver for Critical Access Hospitals (CAH)
CAHs are required to maintain an average patient length-of-stay
under 96 hours, which was waived during the PHE.\21\ With the PHE now
expired, CAHs are faced with compliance risk of the 96-hour rule while
continuing to provide services to patients that cannot be discharged in
a timely manner. Essentia Health will face challenges to meet the 96-
hour rule due to very tight health-care system capacity driven by high
acuity and lack of post-acute care discharge availability. Continued
flexibility and stability will allow hospitals to provide access for
their patients closer to home. Essentia Health recommends extending the
96-hour rule waiver through 2024 to align with the extension of various
PHE telehealth waivers previously enacted by Congress.
---------------------------------------------------------------------------
\21\ Department of Health and Human Services, Changes to FY 2000
Hospital Inpatient Prospective Payment System (PPS) Policies as
Required by the Medicare, Medicaid, and State-Child Health Insurance
Program Balanced Budget Refinement Act of 1999 (BBRA), Pub. L. 106-113,
Transmittal No. A-00-17, April 2000, https://www.cms.gov/Regulations-
and-Guidance/Guidance/Transmittals/Downloads/A001760.pdf (accessed May
15, 2023).
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Enhance Value-Based Payment Models
Enact the Value in Health Care Act
Introduced in the previous Congress, the Value in Health Care of
2021 \22\ would make a number of positive changes to the ACO program.
The bill would modify risk adjustment criteria, improve benchmarking,
alleviate barriers to program participation, and extend the advanced
Alternative Payment Model (APM) bonus payment. We ask Congress to re-
consider introducing and advancing this legislation to help providers
nationwide move to value-based care.
---------------------------------------------------------------------------
\22\ Value in Health Care Act of 2021, H.R. 4587, https://
www.congress.gov/bill/117th-congress/house-bill/4587 (accessed May 12,
2023).
Incentivize Participation in Alternative Payment Models
(APMs)
To incentivize APM participation, it is essential to remove
barriers and give additional flexibility and tools to innovate care.
Specifically, Congress should remove distinctions that penalize safety
net providers; improve financial methodologies so APM participants are
not penalized for their own success; reduce regulatory burdens by
offering increased flexibilities and waivers for clinicians moving to
risk; and provide technical assistance for new participants.
Establish Alignment and Parity Between Alternative Payment
Model (APM) and Medicare Advantage (MA) Program
Requirements
Overall, we support increased alignment between APMs and the MA
program to ensure that APMs are not disadvantaged. This includes
establishing parity between program flexibilities and network adequacy
requirements including telehealth to reduce clinician burdens and
improve patient access to care. Additionally, Congress should encourage
more multi-payer value-based arrangements and examine how APM incentive
payments and shared savings payments, which are incorporated into MA
benchmarks, are equitably passed on to physicians and other clinicians.
---------------------------------------------------------------------------
\23\ HDPulse, An Ecosystem of Minority Health and Health
Disparities Resources, National Institute on Minority Health and Health
Disparities, Created May 15, 2023, https://hdpulse.nimhd.nih.gov.
---------------------------------------------------------------------------
conclusion
On behalf of Essentia Health, we thank Chairman Cardin, Ranking
Member Daines, and members of the Senate Committee on Finance,
Subcommittee on Health Care, for the opportunity to testify on today's
hearing: ``Improving Health Care Access in Rural Communities: Obstacles
and Opportunities.'' We are honored to share with members of the
subcommittee our value-based care journey, which has significantly
lowered health-care spending while increasing the high quality of care
and improving patient outcomes. Based on our journey, we hope our
testimony today has demonstrated that value-based care is not only a
possibility--it is a necessity to achieve health and vitality in rural
areas of our country.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Questions Submitted for the Record to David C. Herman, M.D.
Questions Submitted by Hon. Chuck Grassley
Question. I'm the lead sponsor of the bipartisan Pharmacy and
Medically Underserved Areas Enhancement Act. The bill would allow
pharmacists to be paid by Medicare for services they're licensed and
trained to perform. This will improve seniors' access to wellness
screenings, diabetes management, and treatment, and more. Currently, 90
percent of Americans live 5 miles or less from a community pharmacist.
Given the access and workforce challenges facing health care in rural
America, why is it important to expand access to pharmacist services
for seniors?
Answer. Access to pharmacy services plays an important role in the
continuum of care. In rural areas, community pharmacies offer access to
over-the-counter medications (OTC) and prescription drugs, yet they
also provide an important role in education, including medication
management. Through these valuable services, a pharmacist will work
directly with the health-care team to help patients manage medications
and achieve health-care goals.
Local community members who need medications for an acute illness
or injury can receive assistance from a pharmacist to select the most
appropriate OTC medication or supplies for treatment at home.
Furthermore, community pharmacists help patients navigate financial
barriers and identify alternatives to make care more affordable. To
further help provide services in rural areas, tele-pharmacy can also
reach patients closer to home. At Essentia Health, our tele-pharmacy
program is deployed across the organization to help patients with
multiple medications manage their care. Our pharmacists are members of
the clinical care team and provide access to patients with
comprehensive opioid addiction treatment, hypertension, hyperlipidemia,
and transitions of care. Through the tele-pharmacy diabetes care
management program, this program has led to improvements in health
outcomes and reduced hospital readmissions. However, these services are
not reimbursable unless they are provided in a clinic. Reimbursing
these services through telehealth delivery by the system that cares for
the patient longitudinally would allow for further rural expansion of
this critical health sustaining service.
Pharmacists providing services in rural areas were instrumental
during the COVID-19 pandemic. By connecting patients with access to
COVID-19 testing and vaccinations, pharmacists provided public health
services and helped alleviate the burden on hospitals that were facing
high patient volumes due to the pandemic. Simply put, rural pharmacists
are known by members of their community as a trusted resource.
Question. Over 600 rural hospitals stand to benefit from my
bipartisan Rural Hospital Support Act. The bill would permanently
extend the Medicare-Dependent Hospital and Low-Volume Hospital
programs, along with establishing a new rebasing year for Sole
Community Hospitals. Each of these rural hospital programs offer much
needed flexibility and support for rural communities. Why is it
important to maintain these rural hospital programs?
Answer. Essentia Health supports provisions of the Rural Hospital
Support Act that would permanently extend the Medicare-Dependent
Hospital and Low-Volume Hospital programs. We appreciate your
leadership to sustain access to services in rural communities and
provide resources to hospitals that meet these criteria.
Congress established the Medicare-Dependent Hospital (MDH) program
in 1987. This program allows hospitals with 100 or fewer beds that
serve a high proportion of Medicare patients to receive a slightly
enhanced reimbursement compared to the normal payment rate larger
hospitals receive. Similarly, Congress established the Low-Volume
Hospital adjustment (LVH) in the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003. This law was enacted in
response to a report from the Medicare Payment Advisory Commission
(MedPAC) that warned about a widening gap between rural and urban
hospital financial viability. However, due to only a very limited
number of hospitals benefitting from the program, Congress expanded the
program eligibility in 2010 and reauthorized it again in the
Consolidated Appropriations Act, 2023. The LVH program provides rural
hospitals with low volumes a 0-25-percent payment increase on a sliding
scale based on their inpatient volumes. The current improved low-volume
adjustment better accounts for the relationship between cost and
volume, improves equity across low volume hospitals, and maintains
access to care in rural areas.
Rural hospitals are essential access points for care, economic
anchors for communities, and the foundation of rural health
infrastructure. These hospitals have maintained their commitment to
ensuring local access to high-quality, affordable care in spite of
unprecedented financial and clinical challenges. In 2022, this program
has helped provide approximately $1.6 million in supplemental payments
for our hospitals in Virginia and Detroit Lakes, MN, which goes toward
maintaining vital services for these communities. We thank Congress for
continuing this program and strongly support legislation that would
make this program permanent.
Question. Is our health-care system, including the Federal
Government as a payer, doing enough to move to value? Are there actions
that need to be taken within the Merit-based Incentive Payment System
(MIPS) and Alternative Payment Models (APMs) to speed up the transition
to value?
Answer. Essentia Health commends Congress and the Centers for
Medicare and Medicaid Services for their commitment to value-based
care. The existing fee-for-service system prevalent across health care
is financially unsustainable. Currently, there exists a myriad of
policies and payment adjustments embedded into Medicare fee-for-service
for providers and hospitals. These include quality reporting programs,
value-based purchasing, hospital readmissions reduction, health-care
acquired conditions penalty, and the Merit-based Incentive Payment
System. These policies are all aimed to provide some incentives for
providers and hospitals to deliver value-based care.
Since its creation, the Center for Medicare and Medicaid Innovation
(CMMI) has developed a variety of payment models. Essentia Health made
a substantial leap into value-based care in 2012 as an early enrollee
in the Medicare Shared Savings Program (MSSP). Embarking on a new way
of measuring and providing care in partnership with the Federal
Government was a challenging decision for our organization, yet it was
a necessary step in moving away from a fee-for-service model. We
advanced these efforts when the Minnesota Department of Human Services
(DHS) launched a managed Medicaid program called Integrated Health
Partnerships (IHPs) in 2013. In the IHP program, Minnesota DHS
contracts with ACOs to achieve cost and quality targets. Essentia
Health has remained in both of these programs, moving to risk-bearing
models in 2016 for MSSP and 2018 for the IHP program.
Essentia Health applauds efforts from CMMI to create new payment
models for organizations to choose. While we have demonstrated success
in the MSSP ACO model, it is not suited for all types of providers and
health system arrangements. We appreciate and support the acceleration
of new models of care for providers and hospitals, yet this work should
not come through compromising existing MSSP ACO participants. We
understand the challenge of balancing flexibility and simplicity with
new models of care that are often at odds with traditional care models.
Much like health-care providers, government and commercial health
plans are at varying levels of maturity in their value-based care
journey. While our value-based government payer programs have been
primarily in Medicare and Minnesota Medicaid, we are pleased the North
Dakota Department of Health and Human Services (ND HHS) has embarked on
the journey to implement a value-based model to replace fee-for-service
Medicaid. Based on our experience with the Minnesota IHP, Essentia
Health has engaged with ND HHS and the governor's office to promote the
benefits of outcomes-based models. This new program starts by rewarding
process and engagement (pay for reporting) and ramps up over time
toward rewarding health outcomes (pay for performance). We appreciate
the partnership and willingness to seek input from providers to create
a model with short-term and long-term goals. Essentia Health remains
committed to partnering with the North Dakota Medicaid program in the
transition to value-based care.
While the government remains a key part of value-based payment
strategy, private payer partnerships are just as fundamental to
success. Essentia Health has established criteria to evaluate payer
programs and determine alignment with our system strategy through
financial, systematic and joint accountabilities. From a financial
perspective, models with a glide path toward increased risk/reward
allow the payer and provider to create a long-term program together.
Payer models that offer providers options on levels of risk allow the
necessary time for providers to build the infrastructure needed to be
successful. Access to timely data is part of the foundation of value-
based care. Payers that are engaged in advancing value-based care
provide detailed membership and claims data to providers to support the
analytics and care interventions needed. Finally, agreeing to fair
terms and joint accountabilities will help ensure success with
government programs, along with private payer plans.
There is a point where value-based care provides a better overall
approach than fee-for-service across all payers. As an integrated
health system, we have learned that participating as an MSSP ACO
provides a broad level model across our organization to invest in
preventive care and disease management. Some models that are narrowly
focused, such as for a certain type of services (i.e., cardiology,
oncology) may be appropriate for some providers based on their size and
scope. However, it becomes challenging to manage dozens of value-based
care models with different performance measures, benchmarks, and
targets across a payer portfolio for an integrated system.
Congress and CMS need to provide a viable pathway for entry into
risk-based APMs while also providing the right support and resources
for participants that have been in risk-based models for several years.
To that end, the following are recommendations to policymakers that
would accelerate the adoption of value-based care models:
Reduce administrative burden. Being successful in risk-based
APMs requires significant investment in administrative
functions. We believe new models should focus on reducing
administrative requirements as a way for new providers to
participate. For example, CMS requires MSSP ACOs to develop and
implement electronic clinical quality measures (eCQMs). This is
a significant investment of resources with little benefit to
patient care. Furthermore, there is active movement toward
streamlining quality measurement through digital quality
measures (dQMs) that would extract data directly from an
electronic medical record. This would allow for rapid
measurement of quality without unnecessarily requiring
participants to invest in significant resources to build eCQMs.
Financial viability. Models need to have a clear path that
identifies success and financial viability built within the
model. Furthermore, Congress needs to enact legislation to
maintain the 5-percent advanced APM incentive payment that was
originally enacted in the Medicare Access and CHIP
Reauthorization Act (MACRA). This is important for new and
existing participants to have a financial incentive to help
with costs associated with managing the program.
Health inequities and social needs. We strongly support
efforts to advance health equity and address social needs
through population health models. Payment models should include
a focus on health equity and social determinants of health.
Data improvements. Data is the bedrock of managing a value-
based model and is critical to developing strategies to improve
population health. This could be enhanced with improvements to
timeliness, standardization and performance benchmarks.
Reward existing advanced APM participants. We support
pathways for new participants that provide a ramp to risk-based
arrangements. However, we caution that new models should not
compromise existing risk-based ACO participants.
Question. You mentioned in your written testimony the successes of
Essentia Health removing $102 million from the cost of care over a 3-
year period through value-based arrangements. Is this work bending the
cost curve? Is it doing enough?
Answer. Value-based care is a continuous journey as we learn,
evolve, and expand our efforts across our organization. Essentia Health
has achieved success in both Medicaid and Medicare value-based
programs, saving tax dollars while maintaining a high level of quality
and patient satisfaction. We are proud of our achievements to improve
quality and help to bend the health-care cost curve, yet we know we can
do more. Nationally, we all need to work toward the same goal of
improving quality and lowering cost. If more providers get involved in
value-based arrangements--public and private--the opportunity for
improved care is exponential.
Outcomes from our value-based care programs include:
Medicare Shared Savings Program (MSSP) cumulative savings of
$42.4 million from 2018-2021.
Minnesota Integrated Health Partnership (IHP) savings of $28
million from 2018-2021.
Nearly 40 percent of our revenue flowing through value-based
programs.
Approximately 80 percent of value-based contracts having
downside risk.
We have demonstrated our commitment to providing affordable, high-
quality health-care services for our patients and communities. As a
participant in MSSP since 2013, Essentia Health transitioned from
shared savings into the risk-sharing track in 2016. Since then, we have
demonstrated consistently high performance. In fact, our providers met
98 percent of the quality targets, earning full quality points for
performance year 2021 and generated a 4 percent savings rate, or $13
million for the Medicare program.
We have demonstrated success in Minnesota's Integrated Health
Partnership (IHP) as well. Through this work, we have proven that
investing into value-based care models can be successful and have
brought forward a pathway to the future of providing care in rural
areas. We must, however, continue to evolve the way we deliver care to
ensure long-term sustainability for our patients and the communities we
are privileged to serve. As was also mentioned by other panel members
during testimony, support for community based programs which address
health-related social factors is critical to improving health and
further reducing the cost of care.
Question. I'm committed to improving access to care by expanding
our health-care workforce. A key way we can do that is by modernizing
Medicare so that health-care workers are being paid at the top of their
license and training. My efforts don't change State licensing laws, but
rather reflect the decisions States have already made. I'm the sponsor
or cosponsor of several bills to improve access to pharmacists,
audiologists, and physical therapists under Medicare. Last Congress, we
improved access to marriage and family therapists and mental health
counselors under Medicare. You mentioned the shortages among our
health-care workforce in your written testimony. Is modernizing
Medicare to pay for services that pharmacists, audiologists, and
physical therapists are licensed to perform an important step to
addressing the workforce shortages?
Answer. As we face significant workforce challenges, value-based
care supports our clinicians and care teams. Provider wellness has been
at risk in our Nation's health-care system, and the pandemic heightened
these challenges further. Implementing value-based care programs
enhances the care clinicians can provide through care coordination and
other services that connect patients with the resources they need to be
healthy. A team-based approach to care allows clinicians to spend
valuable time with their patients and to contribute their own
innovation. Value-based care provides opportunities to make the
delivery of health care more rewarding and fulfilling. Paying for
services provided at the top of a provider's license is important and
allows them to be appropriately reimbursed for their services. This
supports team-based care.
Medicare should evaluate the extent to which existing policies that
arbitrarily restrict education and training programs and coverage of
certain services by specific providers limit access to care.
Unfortunately, CMS and the Medicare Area Contractors (MACs) are
inappropriately re-interpreting existing rules that does not
appropriately recognize an integrated health-care system. Specifically,
in their view, if a hospital is part of a system CMS will no longer
reimburse the hospital for their Nursing and Allied Health Educational
costs (42 CFR 413.85). This includes our Pharmacy and Pastoral Care
residency programs provided at Essentia Health. This reinterpretation
of outdated regulations needs to be modernized with the transition of
many hospitals being part of a health system. A hospital should not be
penalized for being part of an integrated delivery system that provides
training opportunities for our next generation of workforce
Congress and CMS need to also recognize the care team of certified
and trained professionals. Under existing rules, Medicare will not
cover services provided by certified Tobacco Treatment Specialists
provided by registered nurses for tobacco cessation. This is similar to
an RN who is a certified diabetic educator providing counseling and
education to patients to manage their diabetes. This unnecessarily
limits access to care that would otherwise be provided by an
appropriately trained professional. These are just a few examples of
how regulations inappropriately restrict access to care to
professionals that are trained and certified to deliver care. We
greatly appreciate the work done by Congress to improve access to
therapy services by appropriately trained professionals.
______
Questions Submitted by Hon. Sheldon Whitehouse
Question. Many providers and health systems have correctly
identified the benefits to participating in APMs like the Medicare
Shared Savings Program, but still many high-cost providers continue to
find traditional fee-for-service to be too financially attractive for
them. Could you outline what more can be done to improve incentives
within APMs to increase participation?
Answer. While we applaud efforts made thus far to encourage value-
based care, Congress and CMS can do more to accelerate this journey.
Specifically, policymakers need to provide a viable pathway for
providers and hospitals to enter into risk-based APMs while also
providing the right support and resources for participants that have
participated in risk-based models for several years. To that end, the
following are recommendations to policymakers that would accelerate the
adoption of value-based care models:
Reduce administrative burden. Being successful in risk-based
APMs requires significant investment in administrative
functions. We believe new models should focus on reducing
administrative requirements as a way for new providers to
participate. For example, CMS requires MSSP ACOs to develop and
implement electronic clinical quality measures (eCQMs). This is
a significant investment of resources with little benefit to
patient care. Furthermore, there is active movement toward
streamlining quality measurement through digital quality
measures (dQMs) that would extract data directly from an
electronic medical record. This would allow for rapid
measurement of quality measurement without unnecessarily
requiring participants to invest in significant resources to
build eCQMs.
Financial viability. Models need to have a clear path that
identifies success and financial viability built within the
model. Furthermore, Congress needs to enact legislation to
maintain the 5-percent advanced APM incentive payment that was
originally enacted in the Medicare Access and CHIP
Reauthorization Act (MACRA). This is important for new and
existing participants to have a financial incentive to help
with costs associated with managing the program.
Health inequities and social needs. We strongly support
efforts to advance health equity and address social needs
through population health models. Payment models should include
a focus on health equity and social determinants of health.
Data improvements. Data is the bedrock of managing a value-
based model and is critical to developing strategies to improve
population health. This could be enhanced with improvements to
timeliness, standardization and performance benchmarks.
Reward existing advanced APM participants. We support
pathways for new participants that provide a ramp to risk-based
arrangements. However, we caution that new models should not
compromise existing participants.
Question. The burden of prior authorization and disputes between
providers and payers about claims and payment denials are time-
consuming, expensive, and ultimately bad for patients. Can you discuss
the extent that transitioning from the fee-for-service model to value-
based care could help diminish these administrative disputes?
Answer. Prior authorization is a requirement established by health
insurance plans for patients to obtain preapproval of a medical
service, procedure, or medication. Health plans use criteria such as
medical guidelines, utilization, cost, or any other elements in
rendering a coverage decision. This process can be challenging for
health-care providers because the standards are often opaque. Certain
health plans often classify their medical necessity criteria as
proprietary and do not share specifics with medical providers.
The process for obtaining prior authorization varies by insurer and
involves submission of administrative and clinical information by the
treating physician and sometimes the patient. Yet the lack of
transparency is a frequent reason that prior authorization and claim
submissions are delayed or denied. Essentia Health highlighted these
issues in public comments submitted earlier this year to CMS regarding
Medicare Advantage Organizations (MAOs) in response to proposed
regulations that would increase health plan oversight and better align
with traditional Medicare policies.
Improving the prior authorization process can be part of the
learning journey in value-based care. For payers waiving prior
authorization, the responsibility for total cost of care resides with
the provider in a value-based care arrangement. The provider is
accepting financial accountability to ensure medically necessary care
is being delivered. This balance of oversight and allowing physicians
to practice medicine helps to advance value-based care while
alleviating administrative burden. Empowering physicians to work with
patients on the best options for care without the need for prior
authorization barriers helps to provide timely access to care.
______
Prepared Statement of Mark Holmes, Ph.D., Director, Cecil G. Sheps
Center for Health Services Research; Director, North Carolina Rural
Health Research Center; and Professor, Health Policy and Management,
Gillings School of Global Public Health, University of North Carolina
Chairman Cardin, Ranking Member Daines, and members of the
committee, my name is Mark Holmes. I am director of The Cecil G. Sheps
Center for Health Services Research and North Carolina Rural Health
Research Center at the University of North Carolina at Chapel Hill. I
am also a professor in the UNC Gillings School of Global Public Health.
I have been a rural health researcher for 25 years; my expertise is in
hospital finance and health policy, especially Federal public insurance
payment policy. Growing up in Caro in Michigan's rural thumb, I
witnessed firsthand some of the health challenges facing our rural
communities.
The Cecil G. Sheps Center for Health Services Research is one of
the Nation's leading institutions for health services research. Our
interdisciplinary researchers undertake innovative research and program
evaluation to understand health-care access, costs, delivery, outcomes,
equity, and value. The Sheps Center has a longstanding reputation for
conducting high-quality, objective research that informs science,
practice, and policy. The Center's program on Rural Health Research is
one of many Sheps Center programs which are very active in generating
the evidence needed to inform pressing challenges facing State and
Federal policymakers as they seek to ensure access to health-care
services. I am delighted to speak on this important topic. I am unable
to cover all the salient issues in rural health today, so I will focus
my comments on three main points:
1. Rural health-care infrastructure continues to erode, and
this threatens the health and well-being of the 60 million
Americans who live in rural areas.
2. Congress can improve the health of rural communities by
addressing some specific policy issues in rural health
workforce.
3. The common narrative of rural places as sicker, poorer, and
older is mostly accurate, but is too fatalistic--rural
communities have shown remarkable innovation, and recent policy
initiatives have been successful.
threats to a robust rural health-care system
Since 2005, nearly 200 rural communities have lost their
hospital.\1\ Although roughly half of these hospitals have continued to
provide some kind of health care to their community, the remainder do
not--they become condominiums, a car wash, or more often completely
abandoned. We also know how important hospitals are to rural economies;
recent research has shown that closures can lead to decreases in the
size of the labor force and the population living in the community.\2\
Those hospitals that do survive have steadily gotten smaller. Rural
hospitals have cut services like maternity care and home health
services,\3\ and inpatient care in rural hospitals has fallen by 13 to
20 percent in the last decade,\4\ with most of this decrease driven by
rural residents being increasingly likely to receive inpatient care at
urban hospitals.\5\ Approximately 20 percent of Americans live more
than 60 minutes from a medical oncologist,\6\ and the financial burden
of increased travel time reduces the use of lifesaving treatments and,
paradoxically, increases the cost of care; geographic barriers to care
actually lead to higher costs in the long run.\7\ Rural residents who
drive an hour a day--each way--for 5 weeks in a row to get their
radiation treatment are facing fatigue of long car travel while
fighting cancer.
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\1\ Rural Hospital Closures. The Cecil G. Sheps Center for Health
Services Research, University of North Carolina at Chapel Hill, https:/
/www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-
closures/.
\2\ Malone, TL, Planey, AM, Bozovich, LB, Thompson, KW, Holmes, GM.
The economic effects of rural hospital closures. Health Serv Res. 2022;
57( 3): 614-623. doi:10.1111/1475-6773.13965.
\3\ Knocke, K, Pink, G, Thompson, K, Randolph, R, Holmes, M.
Changes in Provision of Selected Services by Rural and Urban Hospitals
between 2009 and 2017. NC Rural Health Research Program, UNC Sheps
Center. April 2021. FB 174.
\4\ Malone, TL, Pink, GH, and Holmes, GM (2021), Decline in
Inpatient Volume at Rural Hospitals. The Journal of Rural Health, 37:
347-352. https://doi.org/10.1111/jrh.12553.
\5\ Friedman, HR, Holmes, GM. Rural Medicare beneficiaries are
increasingly likely to be admitted to urban hospitals. Health Serv Res.
2022 Oct;57(5):1029-1034. doi: 10.1111/1475-6773.14017. Epub 2022 Jul
13. PMID: 35773787.
\6\ Levit, LA, Byatt, L, Lyss, AP, Paskett, ED, Levit, K, Kirkwood,
K, Schenkel, C, Schilsky, RL. Closing the Rural Cancer Care Gap: Three
Institutional Approaches. JCO Oncol Pract. 2020 Jul;16(7):422-430. doi:
10.1200/OP.20.00174. Epub 2020 Jun 23. PMID: 32574128.
\7\ Rocque, GB, Williams, CP, Miller, HD, Azuero, A, Wheeler, SB,
Pisu, M, Hull, O, Rocconi, RP, Kenzik, KM. Impact of Travel Time on
Health Care Costs and Resource Use by Phase of Care for Older Patients
With Cancer. J Clin Oncol. 2019 Aug 1;37(22):1935-1945. doi: 10.1200/
JCO.19.00175. Epub 2019 Jun 11. PMID: 31184952; PMCID: PMC6804875.
This diminishing access has led to increasing rural-urban
disparities in health outcomes. In 1999, the death rate in the most
rural counties was 6 percent higher than it was in large urban
counties; in 2019, it was 28 percent higher.\8\ Meanwhile, research led
by experts at the Centers for Disease Control and Prevention (CDC)
found that communities served by closing rural hospitals experienced an
increase in preventable admissions.\9\ Death rates from COVID-19, while
initially higher in urban areas, became higher in rural as early as
September 2020.\10\
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\8\ Analysis of United States Department of Health and Human
Services (U.S. DHHS), Centers for Disease Control and Prevention (CDC),
National Center for Health Statistics (NCHS), Multiple Cause of Death
1999-2020 on CDC WONDER Online Database, released 2021. Data are
compiled from data provided by the 57 vital statistics jurisdictions
through the Vital Statistics Cooperative Program.
\9\ Khushalani, JS, Holmes, M, Song, S, Arighanova, A, Randolph, R,
Thomas, S, Hall, DM. Impact of rural hospital closures on
hospitalizations and associated outcomes for ambulatory and emergency
care sensitive conditions. J Rural Health. 2022 May 5. doi: 10.1111/
jrh.12671. PMID: 35513356.
\10\ United States Department of Agriculture, Economic Research
Service. Rural death rates from COVID-19 surpassed urban death rates in
early September 2020, https://www.ers.
usda.gov/data-products/chart-gallery/gallery/chart-detail/
?chartId=100740.
The rural health-care system consists of a wide variety of health-
care providers, such as Federally Qualified Health Centers and Rural
Health Clinics (RHCs). There are several technical fixes that would
allow RHCs to play a more expansive role in rural health care, such as
correcting eligibility caused by a change in the definition of rural
used by the Census Bureau, removing the historical requirement that
RHCs cannot ``be a facility that is primarily for mental health
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treatment,'' and expanding use of home health by RHCs.
Hospitals are typically one of the most important health-care
providers in a rural community, and they have had weak and declining
finances for years. In 2018, roughly half of rural hospitals were
unprofitable, and financial distress is one of the leading causes of
rural hospital closure. As hospitals close, residents face a decrease
in access to health care. Facing this decline in access, Congress, the
Medicare Payment Advisory Commission, and others have long proposed new
models of care that focus on a hospital's emergency department
services. Senator Grassley's dedication to this issue manifested in the
Rural Emergency Hospital (REH) provision in the Consolidated
Appropriations Act of 2021. This model has some appealing elements, and
at least five rural hospitals have officially converted to REHs, but
interest has been muted due to some program design elements that can
only be addressed legislatively. I applaud Congress for acting
innovatively to address rural health needs. Continued monitoring of
this provider type will be necessary to ensure it is meeting the needs
Congress intended. Meanwhile, rural hospitals are becoming increasingly
part of a larger health-care systems, and this can lead to further
service erosion--work by researchers out of the Agency for Healthcare
Research and Quality has found that rural hospitals that merge are more
likely to close their obstetric and surgical units.\11\
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\11\ Henke, RM, Fingar, KR, Jiang, J, Liang, L. and Gibson, TB.
Access to Obstetric, Behavioral Health, and Surgical Inpatient Services
After Hospital Mergers in Rural Areas. Health Affairs 2021 40:10, 1627-
1636.
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rural areas are facing acute health workforce shortages
Rural places have faced persistent workforce shortages and over the
past 20 years, it has become even more difficult to recruit, retain and
sustain rural health-care workers ranging from doctors to nurses to EMS
personnel in rural areas.\12\ Without an adequate health workforce, it
is becoming more difficult for individuals in rural areas to access
health care.\13\ Many proposed policy solutions to address these
workforce challenges focus on one profession, for example nurses, or
one stage of the career, such as graduate medical education. To shore
up and grow the rural health workforce, it is critical that we look to
solutions that aren't siloed in this fashion and support health-care
workers across their entire career trajectory.\14\
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\12\ Rural Health Research Gateway. Trends in Health Workforce
Supply in the Rural U.S., https://www.ruralhealthresearch.org/projects/
926.
\13\ Strengthening the Rural Health Workforce to Improve Health
Outcomes in Rural Communities Council on Graduate Medical Education
24th Report, 2022, https://www.hrsa.gov/sites/default/files/hrsa/
advisory-committees/graduate-medical-edu/reports/cogme-april-2022-
report.
pdf.
\14\ Fraher, E, Brandt, B. Toward a system where workforce planning
and interprofessional practice and education are designed around
patients and populations not professions. J Interprof Care. 2019 Jul-
Aug;33(4):389-397. doi: 10.1080/13561820.2018.1564252. Epub 2019 Jan
23. PMID: 30669922.
Evidence-based investments that increase the number of health
professionals training in rural areas, increase the number of
preceptors and faculty, provide support to early career health-care
workers, address workplace violence, and focus on retaining mid- to
late-career health-care professionals can be further scaled. Health
professionals that train in rural areas are five times as likely to
remain in practice in rural areas.\15\ By growing the number of rural
training opportunities and then ensuring that resources are available
to retain that workforce across their careers we can ensure that the
workforce needed to meet the needs of rural areas is there for decades
to come.\16\
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\15\ Russell, DJ, Wilkinson, E, Petterson, S, Chen, C, Bazemore, A.
Family Medicine Residencies: How Rural Training Exposure in GME is
Associated With Subsequent Rural Practice. J Grad Med Educ, August 1,
2022; 14 (4): 441-450. doi: https://doi.org/10.4300/JGME-D-21-01143.1.
\16\ Kumar, S, Clancy, B. Retention of physicians and surgeons in
rural areas--what works?, Journal of Public Health, Volume 43, Issue 4,
December 2021, pages e689-e700, https://doi.org/10.1093/pubmed/fdaa031.
Decades of research have taught us that one of the most effective
ways to boost health workforce in rural and underserved areas is to
train them in rural and underserved areas.\17\ Efforts to expand
physician training have paid great dividends; for example, during the 4
years of the Rural Residency Planning and Development program, there
have been more new rural residency slots (463) than were established
during the prior decade (418).
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\17\ E.g., Holmes, GM. Increasing physician supply in medically
underserved areas. Labour Economics. Volume 12, Issue 5, 2005, pages
697-725, ISSN 0927-5371, https://doi.org/10.1016/j.labeco.2004.02.003.
Congress has enacted legislation to address rural physician
shortages via training. The Consolidated Appropriations Act of 2021
included a number of provisions that expand rural resident training
opportunities. Section 126, for example, increased the number of
physician residency slots, to be phased in over a number of years. To
qualify, training programs must meet one of four criteria, including
being located--or being treated as being located--in a rural area.
Legal decisions have led to a rapid increase in the number of urban
hospitals who reclassify as rural; this means that, under current
legislation, they are treated as rural hospitals in all respects,
including eligibility for residency slots. Despite a 10-percent floor
on the number of expanded residency slots allocated to rural hospitals,
only 6 percent of slots were allocated to hospitals located in rural
areas; another 42 percent were allocated to urban hospitals that have
been reclassified as rural.\18\ This may not have been Congress's
intention.
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\18\ Centers for Medicare and Medicaid Services. Section 126 Round
1 Awards, https://www.cms.gov/files/zip/section-126-cap-increases-
round-1.zip.
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rural can innovate and lead when policies are
rural-appropriate and supportive
We commonly hear about rural America being sicker, poorer, and
older. It is also relatively well-known rural residents are less likely
to have health insurance,\19\ travel farther for health care,\20\ and
have more chronic diseases. The CDC has found that rural residents are
more likely to die of the five leading preventable causes of death.\21\
These are accurate descriptions of a population that provides much of
America's food, fun, and fuel. As much as it describes the health
challenges in parts of the country that have fewer physicians, nurses,
and hospitals, I often worry that it suggests government is powerless
to improve rural health. When Congress and policymakers have developed
policy to address rural needs, it has led to dramatic improvements in
conditions for typically relatively small expenditures. In the early
1990s, rural hospitals were closing at a dramatic pace, and Congress
introduced the Critical Access Hospital program in 1996. That program
has helped stabilize the rural health-care system for over 1,300 rural
communities. Although roughly one quarter of acute care hospitals are
CAHs, the program only accounts for five percent of total hospital
outlays by Medicare.\22\
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\19\ Turrini, G, Branham, DK, Chen, L, Conmy, AB, Chappel, AR, and
De Lew, N. Access to Affordable Care in Rural America: Current Trends
and Key Challenges (Research Report No. HP-2021-16). Office of the
Assistant Secretary for Planning and Evaluation, U.S. Department of
Health and Human Services. July 2021.
\20\ Ostmo, P, Rosencrans, J. Travel Burden to Receive Health Care.
Rural Health Research Gateway, 2022, https://
www.ruralhealthresearch.org/assets/4993-22421/travel-burden-recap.
pdf.
\21\ National Center for Chronic Disease Prevention and Health
Promotion. Rural Health: Preventing Chronic Diseases and Promoting
Health in Rural Communities, https://www.cdc.gov/chronicdisease/
resources/publications/factsheets/rural-health.htm.
\22\ Medicare Payment Advisory Commission. Critical Access
Hospitals Payment System, https://www.medpac.gov/wp-content/uploads/
2021/11/medpac_payment_basics_21_cah_final_
sec.pdf.
Perhaps because of the more limited resources in rural communities,
there are many examples where rural health-care innovation has led the
way. Telehealth, community health workers, expanded scope of practice
and task shifting, drones, new payment models, and leveraging strong
trust in community leaders (faith leaders, agriculture, other community
organizations) are all examples where lessons from rural innovation
have helped fuel transformation throughout the health-care system.
Community paramedicine is a promising model that leverages existing
rural resources to meet uniquely rural needs.\23\ By tailoring the
design to its specific environment and resources, a Critical Access
Hospital in North Carolina found a path to expanding maternity services
in the rural community it serves.\24\ Others in the rural Southeast
have designed programs ensuring access to maternity care, addressing
substance use using peers, high risk pregnancies using telehealth
networks, and providing family planning counseling using rural-specific
messaging. During the pandemic we saw rural hospitals adapt, often
working with urban hospitals to absorb excess demand when there was
more rural capacity. This kind of innovation that adapts and is
responsive to the needs and assets of the community should be
encouraged.
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\23\ Bennett, KJ, Yuen, MW, and Merrell, MA (2018), Community
Paramedicine Applied in a Rural Community. The Journal of Rural Health,
34: s39-s47, https://doi.org/10.1111/jrh.12233.
\24\ Page, CP, Chetwynd, E, Zolotor, AJ, Holmes, GM, Hawes, EM.
Building the Clinical and Business Case for Opening Maternity Care
Units in Critical Access Hospitals. NEJM Catal Innov Care Deliv
2021;2(5). DOI: 10.1056/CAT.21.0027.
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conclusion and future directions
Although rural residents--and those who visit rural communities--
face real barriers to achieving their full health opportunities, there
are policy strategies that Congress can consider in order to mitigate
some of the barriers. History has shown that thoughtful legislation
designed to address rural-specific challenges and leverage the assets
of rural America has been successful in improving the lives of the 60
million who live in our rural communities. It is important to continue
to recognize that rural health-care systems are different, and not
simply ``small versions of urban'' and can yield similar outcomes, when
given the opportunity.\25\ The pandemic exposed the fragility of our
rural health-care system. Fortunately, Congress has a number of policy
opportunities to make real improvements for rural America.
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\25\ Centers for Medicare and Medicaid Services. Rural-Urban
Disparities in Health Care in Medicare, November 2020, https://
www.cms.gov/files/document/omh-rural-urban-report-2020.pdf.
______
Questions Submitted for the Record to Mark Holmes, Ph.D.
Questions Submitted by Hon. Thomas R. Carper
Question. Pharmacists play an important role in ensuring access to
care for patients across the country, especially in rural communities.
During the COVID-19 pandemic, pharmacists were crucial access points
for communities to receive COVID-19 testing and vaccinations.
Having seen how pharmacists' knowledge and skill sets were
leveraged during the COVID-19 pandemic to increase access to care, how
can we use lessons learned from the COVID-19 pandemic to continue this
access to care for other conditions through the use of pharmacists?
Answer. Although this is not my area of expertise, the studies
below may be helpful. Additionally, the RUPRI Center for Rural Health
Policy Analysis out of the University of Iowa is an expert in this
area. Some research has shown that because pharmacists are more
geographically dispersed than physicians, they may be an underutilized
and viable strategy for delivering certain health-care services, such
as vaccines (e.g., Shah et al., 2018). An article in the Journal of
Rural Health (Adunlin et al., 2021) discussed the potential role of
rural pharmacies for COVID and other infection disease management. An
article from Vaccine (AlMahasis et al., 2021) showed that rural
pharmacies continued to provide other vaccination services at about the
same rate before and after pandemic onset.
Shah PD, Calo WA, Marciniak MW, Gilkey MB, Brewer NT. Support for
Pharmacist-Provided HPV Vaccination: National Surveys of U.S.
Physicians and Parents. Cancer Epidemiol Biomarkers Prev. 2018
Aug;27(8):970-978. doi: 10.1158/1055-9965.EPI-18-0380. Epub 2018 Jun 5.
PMID: 29871883; PMCID: PMC6092750.
Adunlin G, Murphy PZ, Manis M. COVID-19: How Can Rural Community
Pharmacies Respond to the Outbreak? J Rural Health. 2021 Jan;37(1):153-
155. doi: 10.1111/jrh.12439. Epub 2020 May 30. PMID: 32277726; PMCID:
PMC7262086.
AlMahasis SO, Fox B, Ha D, Qian J, Wang CH, Westrick SC. Pharmacy-
based immunization in rural USA during the COVID-19 pandemic: A survey
of community pharmacists from five southeastern States. Vaccine. 2023
Apr 6;41(15):2503-2513. doi: 10.1016/j.vaccine.2023.03.002. Epub 2023
Mar 7. PMID: 36898932; PMCID: PMC9988709.
Questions Submitted by Hon. Chuck Grassley
Question. You stated in your written testimony that nearly 200
rural communities lost their hospital since 2005. The Rural Emergency
Hospital (REH) designation became available in 2023. If the REH program
was available at the time, how many hospitals could have been saved?
Answer. The Rural Emergency Hospital (REH) designation is an
important innovation in America's efforts to maintain access to
hospital care in rural areas. The intent of the REH is to provide a new
model of care that is financially and operationally viable over the
long term. For communities faced with imminent closure of their acute
care hospital, the REH could be a compelling option for maintaining
local access to emergency and outpatient services--an option that
wasn't usually viable before REHs. Currently seven hospitals (and an
eighth imminent) have availed themselves of this new Medicare
designation. Although it is impossible to know how many closed
hospitals could have been replaced by a REH, it is likely that many of
the 196 hospitals that closed since 2005 (https://www.shepscenter.
unc.edu/programs-projects/rural-health/rural-hospital-closures/) would
have considered the REH as a strategy to maintain services in the
community. It will be important to monitor the implementation of REHs
and to assess their impact on access, cost, and quality of care. As has
been the case for other Medicare payment designations, it will also be
important to evaluate whether changes to REH design, eligibility,
reimbursement, and services are warranted to meet the goals of the
legislation.
Question. I'm the lead sponsor of the bipartisan Pharmacy and
Medically Underserved Areas Enhancement Act. The bill would allow
pharmacists to be paid by Medicare for services they're licensed and
trained to perform. This will improve seniors' access to wellness
screenings, diabetes management, and treatment, and more. Currently, 90
percent of Americans live 5 miles or less from a community pharmacist.
Given the access and workforce challenges facing health care in rural
America, why is it important to expand access to pharmacist services
for seniors?
Answer. Research has shown that because pharmacists are more
geographically dispersed than physicians, they may be an underutilized
and viable strategy for delivering certain health-care services, such
as vaccines (e.g., Shah et al., 2018). Despite the documented return on
investment for clinical pharmacy services such as medication management
and chronic disease management (e.g., NASEM report 2021, Tran et al.,
2022, Chisholm-Burns et al., 2010), reimbursement for clinical services
is complex (Pollack et al., 2023). Payment for clinical pharmacy
services is not systematically covered by Medicare and Medicaid and
payment strategies varies widely by State. Coupled with transportation
challenges in rural areas, proximity to pharmacists implies that
expanding scope and reimbursement of appropriate services may increase
access to critical health-care services in rural areas, especially
those where the population is medically underserved and faces a
shortage of health-care providers.
National Academies of Sciences, Engineering, and Medicine 2021
(NASEM). Implementing High-Quality Primary Care: Rebuilding the
Foundation of Health Care. Washington, DC: The National Academies
Press, https://doi.org/10.17226/25983.
Chisholm-Burns MA, Kim Lee J, Spivey CA, Slack M, Herrier RN, Hall-
Lipsy E, Graff Zivin J, Abraham I, Palmer J, Martin JR, Kramer SS, Wunz
T. US pharmacists' effect as team members on patient care: Systematic
review and meta-
analyses. Med Care. 2010 Oct;48(10):923-33. doi: 10.1097/
MLR.0b013e3181e57962. PMID: 20720510.
Tran T, Moczygemba LR, Musselman KT. Return-On-Investment for
Billable Pharmacist-Provided Services in the Primary Care Setting. J
Pharm Pract. 2022 Dec;35(6):916-921. doi: 10.1177/08971900211013194.
Epub 2021 May 26. PMID: 34036819.
Pollack SW, Skillman SM, Frogner BK. Assessing the Size and Scope
of the Pharmacist Workforce in the U.S. Center for Health Workforce
Studies, University of Washington, Sep 2020. Available here: https://
familymedicine.uw.edu/chws/wp-content/uploads/sites/5/2020/09/
Pharmacist-Size-Scope_FR_Sep4_2020.pdf.
Question. Over 600 rural hospitals stand to benefit from my
bipartisan Rural Hospital Support Act. The bill would permanently
extend the Medicare-Dependent Hospital and Low-Volume Hospital
programs, along with establishing a new rebasing year for Sole
Community Hospitals. Each of these rural hospital programs offer much
needed flexibility and support for rural communities. Why is it
important to maintain these rural hospital programs?
Answer. Our rural health research center regularly tracks the
profitability of rural hospitals. In a pre-COVID study (https://
www.shepscenter.unc.edu/download/19974/), we found that rural PPS
hospitals with 0-25 beds and
Medicare-Dependent Hospitals (MDHs) had the lowest profitability
compared to other hospitals--these were the only hospitals with
negative median total margins. We also found that MDHs are smaller and
are more likely to be located in more rural areas with a higher
percentage of elderly--both of these factors increase the risk of
financial distress. In a forthcoming brief focusing on COVID years, we
find that MDHs were the only Medicare payment designation for which
median profitability was lower in 2021-22 than 2018-19.
In another pre-COVID study (https://www.shepscenter.unc.edu/
download/13871/), we found that Low-Volume Hospitals (LVHs) are
typically smaller, more geographically isolated, and have lower total
and operating margins than other rural hospitals. In a forthcoming
brief focusing on COVID years, we find that LVHs had lower total,
operating, and Medicare inpatient margins than other rural hospitals,
and that LVHs would have substantially lower profitability margins
without the LVH adjustment, with the largest impact on Medicare
inpatient margins.
The implication of both of these research studies is that LVHs and
MDHs are types of rural hospitals that face extraordinary financial
pressure. They are among the most financially fragile rural hospitals,
and the LVH or MDH designations and continued support are necessary to
avoid jeopardizing the long-term sustainability of hospitals with these
designations.
Question. Is our health-care system, including the Federal
Government as a payer, doing enough to move our health-care system to
value? Are there actions that need to be taken within the Merit-based
Incentive Payment System (MIPS) and Alternative Payment Models (APMs)
to speed up the transition to value?
Answer. A transition to value-based care is largely predicated on
having sufficient volume over which to manage the variability of
individual health outcomes and costs. Rural communities are often
challenged to meet these volumes. Furthermore, given high rates of
``bypass'' of hospital and other types of health care, rural providers
may have less influence over the health care their residents receive
than urban, larger providers. Many Federal (as well as non-Federal)
value-based designs face difficulties in implementing the urban designs
in rural areas. Smaller volumes mean the statistical precision of
measures is lower, meaning incentives are based on ``noisier'' values.
The specifics of some payment mechanisms more common in rural areas
(e.g., all-inclusive rates in rural health clinics; cost-based
reimbursement in critical access hospitals) means that value-based
designs utilizing PPS claims as a backbone for attribution and total
cost of care calculation need to be tailored to rural areas. Two-sided
risk models may be more challenging for rural providers with lower
liquidity and ability to manage the financial risk. Prioritizing rural-
centric design, rather than urban-centric tweaked for rural specifics,
has shown to be more effective in transitioning rural areas to value.
Question. I'm committed to improving access to care by expanding
our health-care workforce. A key way we can do that is by modernizing
Medicare so that health-care workers are being paid at the top of their
license and training. My efforts don't change State licensing laws, but
rather reflect the decisions States have already made. I'm the sponsor
or cosponsor of several bills to improve access to pharmacists,
audiologists, and physical therapists under Medicare. Last Congress, we
improved access to marriage and family therapists and mental health
counselors under Medicare. You mentioned the shortages among our
health-care workforce in your written testimony. Is modernizing
Medicare to pay for services that pharmacists, audiologists, and
physical therapists are licensed to perform an important step to
addressing the workforce shortages?
Answer. Many of the principles supporting increased use of
pharmacists in my earlier response apply here. In general, ensuring
that the health workforce practices to the top of their training will
increase access.
______
Question Submitted by Hon. Sheldon Whitehouse
Question. The burden of prior authorization and disputes between
providers and payers about claims and payment denials are time-
consuming, expensive, and ultimately bad for patients. Can you discuss
the extent that transitioning from the fee-for-service model to value-
based care could help diminish these administrative disputes?
Answer. A primary tension in our health-care payment system is that
the payers and providers have misaligned incentives. Traditional fee-
for-service designs often use prior authorization and other utilization
management tools to discourage the use of low-value care. One promise
of value-based care designs is that they better align the incentives:
providers are accountable for cost. As incentives for eschewing low-
value care and instead focusing on high-value care are incorporated
into value-based designs, through (for example) total cost of care,
quality metrics, or other objectives, are recognized by providers, the
importance of utilization management reduces. An article in HFM
(Butcher, 2019) discusses this principle in one commercial plan: as it
shifted to value-based payment, it eliminated PA for many services. Of
course, it is important to recognize that value-based payment may
change the dynamic of the patient-provider relationship; facing these
new incentives, do providers use utilization management type-
approaches, replacing the payer-based utilization management tools?
There are, of course, other opinions. For example: ``Part of the
appeal of VBP contracting is that it promises to free provider
organizations from the complexities of FFS payment. In reality,
however, the mechanics of claims and denials are still baked into the
VBP system. The bottom line is that denials management will remain a
critical function in health care financial management for the
foreseeable future. . . . A strong denials management program is
critical to calculating accurate cost-of-care benchmarks and therefore
ensuring the best chance of hitting cost targets and securing shared
savings incentives.''
HFM, March 2021, https://www.hfma.org/cost-effectiveness-of-health/
financial-sustainability/denials-management-an-underrated-tool-for-
optimizing-value-base/.
______
Prepared Statement of Sara K. Rich, MPA, President and CEO,
Choptank Community Health System
introduction and background
Chairman Cardin, Ranking Member Daines, and members of the
committee, thank you for the opportunity to testify on obstacles that
rural communities face in accessing health care and how community
health centers are overcoming those obstacles.
Choptank Community Health System's mission is, ``to provide access
to exceptional, comprehensive and integrated health care for all.''
Choptank teams focus on providing access to care for the communities we
serve each day and continuously develop innovations and solutions to
ensure our mission shines through all our endeavors.
As a private, nonprofit community health center, we provide access
to quality health care through the delivery of comprehensive medical,
dental, and behavioral health-care services in Caroline, Dorchester,
Kent, Queen Anne's, and Talbot Counties on Maryland's Eastern Shore.
Choptank opened its first primary care office in Caroline County in
July 1980 and has been providing quality health care in this rural area
continuously for 43 years. Choptank is a Federally Qualified Health
Center (FQHC) with oversight from a community board.
In the U.S., nearly 20 percent of residents live in rural areas,
but only 10 percent of health-care providers work in these areas.
Twenty-five percent of Maryland's total population lives in an
officially designated rural area, all five counties in the Choptank
service area are designated as rural.
The region also includes some of the most medically underserved
counties in the State. Caroline, Dorchester and Kent Counties have a
Health Professional Shortage Designation (HPSA) for dental, mental
health and primary care. In addition, Talbot County has HPSA
designation for dental care.
Through program development and expansion, Choptank has grown to
seven medical office locations, five dental locations, and seven
behavioral health service sites. All dental and behavioral health
services are co-located with medical services. All Choptank care
locations and program sites are accredited by The Joint Commission and
have achieved Primary Care Medical Home (PCMH) distinction.
In 2022, Choptank provided care to 29,777 patients representing
99,205 visits, with 7,950 being virtual via phone or video. Eighteen
percent of the patients seen were Hispanic or Latino/a. In terms of
reported race, 1 percent of patients were Asian, less than 1 percent
were Native Hawaiian, 3 percent were Other Pacific Islander, 23 percent
were Black/African American, 2 percent were American Indian/Alaskan
Native, 59 percent were White, less than 1 percent were more than one
race, and 13 percent chose not to disclose. More than 4,000 patients
were best served in a language other than English.
Choptank is committed to providing equitable access to quality care
for all residents of our service area. We provide sliding fee coverage
to those patients who are uninsured or under insured. Patient-reported
income shows that 23 percent of patients were at or below Federal
Poverty Levels (FPL) of 100 percent; 12 percent were 101-150 percent of
the FPL; 6 percent were 151-200 percent; and 8 percent were over 200
percent. Thirty-three percent of the patients seen were children under
age 18; 24 percent were ages 18-29; 28 percent were ages 40-64; and 14
percent were age 65 and up. Forty-four percent of 2022 Choptank
patients had Medicaid, 15 percent Medicare, 28 percent private
insurance, and 13 percent had no insurance.
Choptank served 646 veterans in 2022, an increase from the prior
year. Nearly 2,600 patients were seen in our school-based health
program. Three hundred and seventy-three agricultural workers or
dependents were seen through our migrant health program. Choptank
provided care to 191 homeless patients in 2022.
My testimony will identify obstacles to accessing care in rural
areas and show how Choptank is overcoming those obstacles. I will close
with some recommendations on how this committee and Congress can
support health centers and other providers' work in this area.
obstacles and opportunities to access
Rural areas often share similar characteristics that are unique
from other geographic designations. These include distance to obtaining
services, lack of transportation, health-care access and availability
and poorer health outcomes. For example, in the Choptank service area,
rates of smoking, obesity, excessive drinking, children in poverty, and
teen births are higher than State of Maryland rates.
Workforce Shortages
On the Eastern Shore, the workforce shortage has been exacerbated
by the closure of large service providers for behavioral health and
women's health. In response, Choptank and their board of directors
committed to rapid expansion of the new behavioral health service line.
To date, Choptank has a behavioral health therapist at each location
and has added this service in the school-based health centers. A part-
time child and adolescent psychiatrist has also been hired. Recruitment
efforts continue to fill the remaining vacancies.
A Choptank physician facilitated a warm hand-off with a 71-
year-old White female struggling with depression. The therapist
was able to work with her during the warm hand-off; however,
due to Medicare not accepting Licensed Clinical Professional
Counselor (LCPC) licensure, we could not connect her with the
therapist in her health center. The patient had no
transportation to a site with an LCSW-C and no computer or
Internet at home to access telehealth services. Choptank has to
refer this patient to another organization, which is equally as
difficult due to the obstacles the patient faces. LCPCs have
been approved for Medicare reimbursement, but this does not
begin until 2024.
Choptank also committed to expanding prenatal care and women's
health offerings by hiring a certified nurse midwife to rotate
throughout the health centers. This is in addition to two family
medicine physicians offering prenatal care in their practice and the
multiple medical providers providing women's health services. Choptank
ensures that our family practice providers are trained in various
women's health services.
A 29-year-old White single-parent female initially had a
routine pregnancy. It was complicated by high sugar levels
during her diabetes screening test. She stopped drinking soda
and her follow-up test to verify diabetes was negative. An
ultrasound showed a tumor on the baby's hand with an extremely
large blood vessel tracking up his arm. Mom was transferred to
Maternal Fetal Medicine locally and ultimately to Baltimore.
After delivery, we followed up on mom's well-being, because the
baby has required 2+ months in the NICU in preparation for
surgery. When mom developed postpartum depression, our co-
located behavioral health therapist was able to start therapy
for her right away while her primary care provider started her
on medication. Mom plans to bring her baby to Choptank for
pediatrics once he is discharged home.
Access to dental care has been a high priority in Maryland for many
years because of the death of 12-year-old Deamonte Driver due to a
dental infection. Choptank's robust dental program has expanded to
include specialty care for pediatrics and oral surgery. At this time,
the oral surgeon position has been vacant for a year and a half with
recruitment continuing.
Our mobile health school-based dental team was providing care
in Dorchester County. They were parked in front of the school,
when there was a knock on the van door. A parent was bringing
her daughter to school late because of tooth pain. Mom didn't
know what to do. The family was new to the area and the
daughter, an 8-year-old African American female, wasn't
enrolled for our program but she came in, and our dental
hygienist saw the patient and provided an evaluation
immediately. The patient had an abscess on a baby tooth that
was painful to the touch. The dental hygienist reached out to
our dental case manager and the patient had an emergency visit
at our Cambridge dental center that same day.
Maryland recently expanded coverage for adult dental Medicaid
patients. This is a huge need, especially on the Eastern Shore. The
obstacle is that most private practices do not accept Medicaid, leaving
Choptank care for more patients than ever before.
A 39-year-old White male was referred to Choptank for oral
surgery. He drove 90 minutes for a consultation at our
Federalsburg dental center. Instead of referring him to an oral
surgeon, our dental team took additional x-rays to determine if
we could do the needed extraction in- house. Our dentist was
able to perform the procedure, which meant the patient did not
have to travel further or pay additional charges. Oral surgery
is a huge need on the Eastern Shore.
Recruitment for dental hygienists has been difficult with vacancies
open for more than a year and a half. At this time, the Eastern Shore
does not have a training program for dental hygienists. Clinical
support staff are critical in the ability of our health centers and
providers to take care of the patients that need health-care services.
For dentists to work at an optimum level, two dental assistants are
needed per provider. Often, dentists are working with one assistant and
have had to share an assistant with another provider. The same holds
true for medical providers. Medical assistants also represent a
workforce shortage for Choptank. This reduces access to health care for
patients. Developing a pipeline of new providers and clinical support
staff is critical for health care especially in rural areas.
Efforts to expand the Choptank service area's rural primary care
workforce include a partnership with the University of Maryland School
of Medicine (UMSOM). UMSOM received a planning grant from HRSA in 2019
to explore the development of a rural residency training track in
collaboration with Choptank and the University of Maryland Shore
Regional Health (SRH). The funding allowed for the design of a rural
family medicine training experience for graduated new physicians.
Physicians who train in an FQHC are nearly twice as likely to begin
their careers in a similar setting providing significant benefits to
rural communities. In recognition and support of addressing the health-
care needs on the Eastern Shore of Maryland, the Maryland State
legislature passed a bill allocating $1.5 million in funding for the
rural residency track.
Choptank has a longstanding partnership with NYU/Langone for
Advance Education in General Dentistry (AEGD) residents. This program
has been critical in providing access to dental care in our health
centers and served as a recruiting resource as we have hired many of
the residents to join Choptank as a dentist when they have completed
their training. Historically, Choptank would train 2 residents each
year. In 2023, Choptank has 4 residents from NYU/Langone. Plans are
underway to bring a pediatric dental residency to Choptank with NYU/
Langone. Choptank has hired a pediatric residency director to build and
lead the new program.
To address the shortage of clinical support staff, Choptank
partnered with a local community college, Chesapeake College, which has
health-care training programs and a with a state-of-the-art facility
for mock patient care experiences. Thanks to American Rescue Plan
funds, Choptank developed a scholarship program to support
certification for medical and dental assistants who chose to work at
Choptank.
New providers are hired and must relocate to the Eastern Shore,
they often face barriers in securing housing. Recently, a dentist was
hired and was unable to move into a rented apartment for nearly 3
months. She stayed in a hotel until more permanent housing was
available. Choptank is exploring partnerships with the local chambers
of commerce and economic development to strategize how housing can be
more accessible, especially to health-care professionals coming to the
area.
Broadband Access
The need for reliable Internet services became even more critical,
especially in rural areas during the COVID-19 pandemic. Health
providers across the country had to pivot to virtual visits overnight
to provide access to care for their communities. During that time, 65-
70 percent of medical visits were provided virtually, representing more
than 9,000 patients seen. Obstacles were rampant as many patients did
not have reliable Internet in their homes and couldn't access it
elsewhere. Often, the planned virtual visit was converted to a phone
visit so that the provider could connect with their patient. Audio-only
visits are a life-line to some of our most vulnerable patients who face
multiple obstacles in obtaining health care including chronic disease,
transportation and Internet access.
Transportation
Through the work of the Maryland Mid-Shore Rural Health
Collaborative, transportation continued to be identified as the most
common barrier to accessing health care in rural Maryland for all types
of health-care services. Obstacles identified include lack of broad bus
routes, limited hours of operation/ schedule and limited medical
transportation services. Some communities do not have any public
transportation available. Due to the large geographic area of the
Eastern Shore, travel times can be extensive.
Choptank utilizes community health workers to assist patients in
planning for transportation to and from their medical and dental
appointments to reduce this barrier to accessing care. Telehealth
including audio-only visits helps reduce the need for travel in some
cases. Medicaid transportation is limited and does not yet include
coverage for dental visits.
Redetermination
With the unwinding of the COVID-19 public health emergency, States
will now have to begin eligibility redeterminations for Medicaid
enrollees after nearly 3 years. National estimates from Geiger Gibson
indicate that up to 15 million Medicaid enrollees will lose coverage.
This will impact community health centers that provide care for one in
six Medicaid beneficiaries. According to the National Association of
Community Health Centers, Medicaid beneficiaries who are patients at
health centers have lower overall costs to Medicaid than non-health-
center patients while also having better health outcomes. Medicaid
redetermination is estimated to impact health center revenue and reduce
patient access and staffing. According to the Maryland Health Benefit
Exchange, estimates indicate that approximately 80,000 residents could
lose coverage.
States, including Maryland, are partnering with community health
centers to provide outreach and education to patients who need to renew
coverage depending on their eligibility or to find new coverage. It is
important for these patients to not stop accessing primary care
services during this transition period so that they can continue their
partnership with their providers' care team and make progress on their
treatment plans. Choptank is developing messaging to share with
patients at check in and have members of the population health
department reaching out to patients who are due to reapply for
coverage.
Opportunities through non-traditional delivery models
Providing health care in a rural area requires thinking outside the
traditional health-care delivery models. Community health centers
thrive in this area, and Choptank is no exception.
School-Based Health Centers
Since 1999, Choptank has been providing school-based health center
services. In partnership with the school systems, and health
departments, Choptank provides medical and dental services in nine
schools in Caroline County, five in Talbot County, three in Queen
Anne's, and one in Kent County. There are 14 sites providing dental
only, including four in Kent County. These centers are open every
school day and provide in-person, virtual, and curbside services as
well urgent care to enrolled students and school staff. Other services
include health education and risk assessment, physical exams, dietary
support, asthma management, and sick/acute care. School-based dental
services are provided by a dental hygienist at all our schools
throughout the school year. Services may include a screening, cleaning,
dental sealants, fluoride treatment, and referrals when needed.
Our school-based team in Queen Anne's County were connected
with two Hispanic middle school students--aged 12 and 14,
siblings--by the school guidance counselor and school nurse.
The families' resources were limited--no insurance,
transportation, or housing--and they had not been seen by a
medical or dental provider in several years. Our medical and
dental provider were able to see the students immediately and
evaluate them for health and dental needs, provide education,
and prescribe antibiotic for a dental abscess. The children are
scheduled for appointments to establish primary medical and
dental care at our Goldsboro Health Center. They have been
connected to transportation services, and our population health
team for assistance with connection to insurance and other
needed resources.
Expansion of School-Based Health Center's Scope
To further meet the need for health care, two of the school-based
health center sites are now community health centers located in a
school. These centers are at Tilghman Elementary and Rock Hall
Elementary. With the support of the local school systems and their
understanding of community need, they agreed to partner with Choptank
and open the school site to residents in the community.
Population Health and the Maryland Primary Care Program
Choptank and most other Maryland community health centers are part
of the Maryland Primary Care Program (MDPCP). The program recognizes
primary and preventive health investments as key to bending the cost
curve and avoiding costly health-care use. The program aims to reduce
avoidable hospitalization and emergency department visits and build a
robust primary care delivery system to identify and respond to medical,
behavioral, and social needs. Accomplishing these goals lowers the
total cost of care across all provider settings.
Through the MDPCP, CMS's Center for Medicare and Medicaid
Innovation provides needed funding to community health centers (and
other primary care practices) corresponding to Medicare-attributed
beneficiaries. The funding supports positions that would otherwise not
be possible such as care navigators to ensure timely screenings, data
analytics to close care gaps, and care coordinators that train and
assist patients in monitoring and managing chronic conditions outside
the center's walls. Choptank is new to MDPCP, having started in January
2023. Maryland community health centers that began the program in 2021
acknowledge that investments were needed to facilitate care delivery
transformation, supporting patient engagement and better health
outcomes. This program helps health centers follow patients beyond the
time that they spend with their provider.
A 37-year-old White male was diagnosed with diabetes in October
2022 with an A1C of 14.3. Normal range is 5.7-6.4. He had not
seen a doctor in 5 years. The Choptank provider referred the
patient to one of our care coordinators. She called the patient
to discuss checking his blood sugar twice a day and to provide
additional education. She learned that the patient had poor
health-care literacy. The care coordinator provided an
introductory discussion about the overall impact of food,
activity, proactive self-management, and potential damage from
poorly controlled diabetes. He had weekly calls with a case
manager, and as of March, his A1C is down to 7.0.
The Power of Partnerships
Partnerships that focus on innovation and creativity are
instrumental tools for health centers as we continually look for ways
to provide access to underserved populations. Choptank is proud of the
partnerships we have developed to help us meet our goals of equity
outreach.
Community partners like Building African American Minds, the Multi-
Cultural Resource Center, and the Avalon Foundation have provided
opportunities for us to participate in festivals and events that help
us meet our community where they live. Choptank's presence at these
celebrations builds credibility and breaks down the trust barriers
often found in these communities.
Our towns and municipalities have provided support in helping us
identify and reach populations geographically challenged. This has
especially been helpful for us with our recent expansion to Kent
County. The local elected officials, fire departments, EMS, and even
police departments have been instrumental in sharing and helping spread
the word about our services expanding to the area. We are working with
many of these departments to implement a grant from the Maryland
Community Health Resources Commission that will help us provide quality
care to our patient population with mental health and substance use
treatment and unable to access care in our site. Along with our
services, we will collaborate with community programs to provide access
to technology (i.e., tablets, computers, Internet) for telehealth
services for those unable to connect to telehealth in their own
residence. And a local police department is providing us with parking
for our mobile health unit when it is not in service.
Local health departments and public school systems partner and
collaborate with us to support our school-based health centers. With
their support, we opened five new centers including four in two new
counties last year. These new centers serve both students and staff and
for many rural families provide the only medical and dental services
they have access to. We are proud to share that Choptank was recently
recognized as the Business Partner of the Year by one of the school
systems we serve.
Businesses also play a role in our ability to break down the
barriers of access. Just 2 weeks ago Talbot County Economic Development
recognized Choptank as a 2023 Community Impact Award Winner. It is
because of partnerships with local businesses that we can impact the
communities we serve. While exploring ways to reach our communities, we
approached Preston Motor Group to see about helping us with a mobile
health unit. Through grant funding received by HRSA, and a discount
from Preston, we were able to purchase a transit cargo van. Outfitted
for medical and dental services, the unit allows us to meet our
patients where they are. The unit travels across all the Mid-Shore
communities we serve and visits community events providing health
screenings. The mobile unit provides school-based medical and dental
services during the school year. And, in the summer months, the unit
provides a platform for Choptank's migrant program team to visit
various farms, agricultural nurseries, and crab houses across the
Shore. Through our continued partnership with Preston, we now have
three mobile health units helping us provide increased access to our
services.
In March, our MHU traveled to Rock Hall, MD to support other
community partners in providing screenings for local watermen.
Many of the residents in this area do not routinely access
medical care- specifically preventative and wellness services.
Screenings provided included lab evaluation for diabetes, a
skin screening, blood pressure, and hearing screenings. One
gentleman we connected with was a 74-year-old waterman who had
not seen a provider in years and had an elevated blood
pressure. He stated that he didn't go to the doctor because
``he didn't see the need to leave Rock Hall.'' Fortunately, one
of the providers at the screening was the primary care provider
at our newly opened Rock Hall Elementary School health center.
After our provider explained that he didn't need to leave Rock
Hall for care, he agreed to schedule a follow-up and has been
seen for treatment.
Choptank Community Health System has community in our name for good
reason--community is at the core of everything we do. When local
agencies and community partners work together, the result is healthier
communities.
opportunities to increase rural health access
Providing access to health care in a rural area presents obstacles;
however, we are fortunate to have several available resources to make a
difference in the lives of patients, families, and the communities we
serve. The following are actions needed to continue and enhance access
to care in rural areas:
Reimbursement for population health services: This will
enhance the health-care system's ability to provide ongoing
services outside the health center's walls to impact health
outcomes.
Make permanent reimbursement for telehealth patient care,
including audio-only visits: Telehealth and audio-only visits
are a lifeline for patients in rural communities. By limiting
reimbursement, access to care is also limited.
Safeguard the Prospective Payment System (PPS) to ensure
access to quality health care: Health centers are good stewards
of the PPS system and are able to provide services to patients
that impact health equity including interpreters, community
health workers, and other assistance.
New Access Point Funding for new health centers including
mobile health units: Health centers make a difference in rural
and urban communities. Expanding their reach will impact
America's health outcomes.
Reauthorize Federal 330 funding: This funding serves as the
foundation and backbone for health centers, and many would not
be able to continue providing the level of service that they
currently are without this support. This funding has not kept
up with inflation and in real terms has actually declined by
9.3 percent since 2015. The result is that health centers
struggle to compete with salaries being offered by larger and
wealthier competitors.
conclusion
Community health centers are the key to providing access to high-
quality, affordable, and equitable health care. The investments made in
America's health centers have made a difference in the lives of
millions across the country. Community health centers, like Choptank,
work to figure out how we can best meet the needs of the communities we
serve and are constantly reinventing how we provide access to care so
we can meet our mission.
Chairman Cardin, Ranking Member Daines, and members of the
committee, thank you for the opportunity to share the obstacles
impacting health care in our rural communities on the Eastern Shore of
Maryland. With all of us working together, we will continue to improve
health-care outcomes for those we serve.
On behalf of Choptank Community Health System, we appreciate the
committee's interest and commitment to rural health care.
Source Materials and Additional Information
Isaccs, Brandon. ``Save Rural Health Care: Time for a
Significant Paradigm Shift.'' The Journal of the American
Osteopathic Association 119, no. 9 (September 2019): 551-5.
https://doi.org/10.7556/jaoa2019.098.
Maryland State Office of Rural Health. Retrieved May 11,
2023 from https://health.maryland.gov/pophealth/Pages/Rural-
health.aspx.
2021 Primary Care Needs Assessment. Office of Primary Care
Access Prevention and Health Promotion Administration. Maryland
Department of Health. Retrieved May 11, 2023, from https://
health.maryland.gov/pophealth/Documents/Primary%20care/
Final%2Needs%20Assessment%20090221.pdf.
County Health Rankings and Roadmaps 2023. Retrieved May 11,
2023, from https://www.countyhealthrankings.org/explore-health-
rankings.
Levin, Z., Meyers, P., Peterson, L., Habib, A., and
Bazemore, A. ``Practice Intentions of Family Physicians Trained
in Teaching Health Centers: The Value of Community-Based
Training.'' J Am Board Fam Med. 2019 Mar-Apr;32(2):134-135.
doi: 10.3122/jabfm.2019.02.180292. PMID: 30850449.
Maryland Rural Health Association. ``2018 Maryland Rural
Health Plan,'' 2018. Retrieved May 11, 2023, from http://
mdruralhealth.org/docs/MDRH-Plan-2018-WEB.pdf.
______
Questions Submitted for the Record to Sara K. Rich, MPA
Questions Submitted by Hon. Thomas R. Carper
Question. Since my time as Governor of Delaware, I have been
focused on making sure kids can get the care they need, where they're
at--in schools. During that time, we were proud to put a wellness
center in every public school. Last Congress, I introduced the
Kickstarting Innovative Demonstrations Support (KIDS) Health Act of
2022 with Senator Sullivan. This legislation works to improve
coordination between mental health and community health care providers
to better support children's needs through a ``whole-child health
care'' model. It is clear we share an understanding on the value of
school-based services. During your tenure as CEO, Choptank has
increased the number of school-based health centers offering services
to children in two additional counties.
How are the social determinants of health considered when
implementing these programs in rural communities and what policy should
Congress--in particular this committee--consider for improving access
to whole-child health in rural communities across the Nation?
Answer. Maryland school-based health centers provide education and
preventive care services such as vaccines, acute/sick care, and ongoing
care for children with behavioral health needs and chronic conditions
such as asthma and diabetes. School-based health center providers and
students often develop trusting relationships critical to the child's
health and wellness. School-based health centers are uniquely
positioned to address social determinants of health through strong
student relationships and local partnerships. For example, during the
COVID-19 pandemic, the strong collaborative relationship between
Choptank and school systems increased community access to testing,
education, and vaccination.
The State of Maryland recently issued a recommendation that school-
based health centers should be reimbursed by Medicaid at a higher rate
to support school-based health-care providers and allow them to expand
services further. Congress should consider policies and initiatives to
increase reimbursement and support a wider range of school-based
health-care services, such as behavioral health, oral health and
nutrition services to improve access in rural communities.
Question. Pharmacists play an important role in ensuring access to
care for patients across the country, especially in rural communities.
During the COVID-19 pandemic, pharmacists were crucial access points
for communities to receive COVID-19 testing and vaccinations.
Having seen how pharmacists' knowledge and skill sets were
leveraged during the COVID-19 pandemic to increase access to care, how
can we use lessons learned from the COVID-19 pandemic to continue this
access to care for other conditions through the use of pharmacists?
Answer. The COVID-19 pandemic demonstrated the vital role of
pharmacists in expanding access to care and maintaining continuity of
care during a crisis. Expanding pharmacists' scope of practice will
allow patients to access a broader range of services. Maryland passed a
bill expanding reimbursement for pharmacists in 2023. Increased
reimbursement will enable health-care providers to support and
integrate more pharmacists into care teams.
Integrating pharmacists into care teams benefits health systems,
regardless of practice setting, by providing medication reconciliation,
education to improve medication adherence, and developing and
implementing infectious disease protocols. Patients may also interact
with a pharmacist before their next medical appointment, strengthening
patient access and support addressing the full range of health needs
for patients. Other care team providers also gain knowledge from
pharmacists, further increasing patient safety and enhancing care
coordination.
The PREP Act allowed pharmacists, pharmacy interns, and pharmacy
technicians to administer COVID-19 and seasonal flu vaccines during the
COVID-19 pandemic. This flexibility increased their workforce capacity
and ability to deftly administer more vaccines. While this flexibility
has been extended until December 2024, making this successful
flexibility permanent will better utilize the whole pharmacy teams'
skillset and meet more patients' needs. As with other health-care
solutions, telehealth has proved instrumental in connecting pharmacists
with socially and physically isolated patients during and after the
COVID-19 pandemic. Supporting telepharmacy and digital health solutions
will extend pharmacists' reach, especially in underserved areas.
______
Question Submitted by Hon. Chuck Grassley
Question. Our Nation's maternal mortality rate is too high and has
increased 47 percent since 2018. At the same time, over 80 percent of
pregnancy-related deaths are preventable. These challenges impact women
of color and women living in rural areas the most. There's a lot we can
do but aren't. My bipartisan Healthy Moms and Babies Act would help
address these maternal health challenges. It takes best practices from
across the country to improve care, including care coordination,
telehealth, and supporting community-led efforts. Given your experience
with the National Center for Child Death Review, are most pregnancy-
related deaths preventable? What actions can we take to prevent these
deaths in rural America? Additionally, what actions should we take to
improve the maternal mortality rate, especially among women of color
and women living in rural America? Do you have a best practice you can
share that is helping address these challenges?
Answer. There is a growing recognition that non-obstetric health-
care professionals play a large role in reducing maternal morbidity and
mortality. In 2022, the American Conference for Obstetrics and
Gynecology, the American Academy of Family Physicians, and other
national health-care associations announced a multidisciplinary effort
to identify and manage obstetric emergencies during pregnancy and the
postpartum period. As of 2022, FTCA-deemed Federally Qualified Health
Centers are required to train all clinical staff that see women of
reproductive age on identifying obstetrical emergencies.
In recent years, Maryland has passed several laws to address and
expand access for mothers through Medicaid. The laws include free doula
coverage for Medicaid beneficiaries, Medicaid coverage for undocumented
women and children, and guaranteed extension of Medicaid benefits 12
months postpartum. The American College of Obstetricians and
Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine
reported that the continuous presence of a doula during pregnancy is
one of the most effective tools to improve labor and delivery outcomes.
Further, extending postpartum Medicaid coverage is known to reduce
maternal mortality for women of color and those living in rural America
by extending access to affordable care.
Question Submitted by Hon. Sheldon Whitehouse
Question. The burden of prior authorization and disputes between
providers and payers about claims and payment denials are time-
consuming, expensive, and ultimately bad for patients. Can you discuss
the extent that transitioning from the fee-for-service (FFS) model to
value-based care could help diminish these administrative disputes?
Answer. Moving toward per-member per-month risk-adjusted payments,
rather than fee-for-service, promotes appropriate, preventive, and
timely care delivery. While billing for services remains essential to
track usage, the threat of denials is diminished. At the center of most
value-based care programs are attribution methodologies that assign
patients to providers. While attribution of FQHC patients is typically
straightforward, disengaged patients who need care quickly don't always
understand which center they should go to. Because FQHCs turn no one
away, it will be necessary for payers to work with providers to inform
attribution and not deny claims related to attribution. All care
delivered to a Medicaid MCO patient should be paid for in an FQHC,
irrespective of unknown primary care provider assignment.
As we move towards more value-based care arrangements, there are
myriad ways patients can be attributed. According to a 2023 JAMA
article,\1\ in the last 20 years, more than 170 different attribution
models have been developed, with at least 30 methods implemented.
Attribution accuracy varies widely between 20 percent to 69 percent
accuracy. If not correctly attributed, this could place undue
administrative burden on providers trying to resolve the issue and hurt
overall patient care coordination efforts. Moving towards value-based
care has the opportunity to increase efficiency while positively
impacting patient care, but if issues with attribution are not
remedied, patient care will be impacted.
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\1\ https://jamanetwork.com/journals/jama-health-forum/fullarticle/
2802660#::text=Patient
%20attribution%20methods%20are%20used,%2C%20track%2C%20and%20improve%20c
are.
______
Communications
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Alliance for Rural Hospital Access
The McDermott Building
500 North Capital Street, NW
Washington, DC 20001
https://ruralhospitalaccess.org/
U.S. Senate
Committee on Finance
Subcommittee on Health Care
219 Dirksen Senate Office Building
Washington, DC 20510
Dear Chairman Cardin and Ranking Member Daines:
The Alliance for Rural Hospital Access (ARHA, or the Alliance)
appreciates the opportunity to submit this statement for the record on
the ``Improving Health Care Access in Rural Communities: Obstacles and
Opportunities'' hearing held by the Health Care Subcommittee on May 17,
2023.
The Alliance is comprised of hospitals designated as Medicare-Dependent
Hospitals (MDHs), Rural Referral Centers (RRCs) and Sole Community
Hospitals (SCHs) under the Medicare program. MDHs, RRCs and SCHs
provide rural populations with local access to a wide range of health
care services. In doing so, MDHs, RRCs and SCHs localize care, minimize
the need for further referrals and travel, and provide services at
costs lower than their urban counterparts. These hospitals also
commonly establish satellite sites and outreach clinics to provide
primary and emergency care services to surrounding underserved
communities, a function which is becoming increasingly important as
economic factors force many small rural hospitals to close.
Background on Rural Hospital Designations
Medicare Dependent Hospitals: The MDH program was established by
Congress with the intent of supporting small rural hospitals for which
Medicare patients make up a significant percentage of inpatient days
and discharges. Because they primarily serve Medicare beneficiaries,
MDHs rely heavily on Medicare reimbursement to sustain hospital
operations. Consequently, these hospitals are more vulnerable to
inadequate Medicare payments than other hospitals because they are less
able to cross-subsidize inadequate Medicare payments with more generous
payments from private payers. As such, Congress acknowledged the
importance of Medicare reimbursement to MDHs and established special
payment protections to buttress these hospitals. Congress recognized
that if these hospitals were not financially viable and failed,
Medicare beneficiaries would lose an important point of access to
hospital services. To qualify as an MDH, a hospital must be (1) located
in a rural area, (2) have no more than 100 beds, and (3) demonstrate
that Medicare patients constitute at least 60 percent of its inpatient
days or discharges.
Rural Referral Centers: Congress established the RRC program to support
rural hospitals that treat a large number of complicated cases and
function as regional referral centers. Generally, to be classified as
an RRC, a hospital has to be physically located outside a Metropolitan
Statistical Area (indicating an urban area) and either have at least
275 beds or meet certain case-mix or discharge criteria.
Sole Community Hospitals: Congress created the SCH program to maintain
access to needed health services for Medicare beneficiaries in isolated
communities. The SCH program ensures the viability of hospitals that
are geographically isolated and thus play a critical role in providing
access to care. Hospitals qualify for SCH status by demonstrating that
because of distance or geographic boundaries between hospitals they are
the sole source of hospital services available in a wide geographic
area. There are a variety of ways in which hospitals can qualify for
SCH status, but the majority qualify by being more than 35 miles from
another provider.
Challenges Facing MDHs, RRCs, and SCHs
MDHs, RRCs, and SCHs are often the sole source of care within and
around a community. Many patients that live in rural communities depend
on these facilities for a full complement of health care services, from
primary care to sophisticated inpatient treatment. More and more rural
hospitals are struggling and closing, causing access problems for
residents of rural communities. When an MDH, RRC, or SCH closes, the
consequences for the community may be more grave than otherwise.
Over 100 rural hospitals closed from January 2013-February 2020. When
rural hospitals close, people living in areas that receive care from
them must travel farther to get the same services--about 20 miles
farther for common services like inpatient care. People have to travel
even farther--about 40 miles--for less common services like alcohol or
drug abuse treatment.\1\ According to 2023 data from the Center for
Healthcare Quality and Payment reform, more than 600 rural hospitals--
nearly 30% of all rural hospitals in the country--are at risk of
closing because of the serious financial problems they are
experiencing.\2\
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\1\ Rural Hospital Closures: Affected Residents Had Reduced Access
to Health Care Services. January 2021. https://www.gao.gov/products/
gao-21-93.
\2\ Rural Hospitals at Risk of Closing. https://chqpr.org/
downloads/Rural_Hospitals_at_Risk_
of_Closing.pdf.
Hospitals in rural communities often confront extremely difficult
financial circumstances and tend to have negative or very small
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operating margins, making them increasingly vulnerable.
Additional Medicare reimbursement reductions impose further financial
strain, compromising rural hospitals' ability to serve their
communities. These hospitals also often do not have the same
flexibility as other hospitals to discontinue lower margin or
unprofitable services, like mental health services. As mission driven
organizations, and the only source of hospital services for their
community, rural hospitals often will continue to offer services, even
at great financial loss, because there are no other providers offering
those services.
In addition to negatively affecting patient care, the deteriorating
rural health safety net also impacts the local economies that often
depend on these hospitals as large employers in the communities they
serve.\3\
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\3\ Rural hospitals: The beating heart of a local economy. June
2018. https://www.
ruralhealth.us/blogs/ruralhealthvoices/july-2018/rural-hospitals-the-
beating-heart-of-a-local-econ.
These financial challenges were compounded over the past several years
during the COVID-19 pandemic, which placed an additional strain on the
resources and capacities of rural hospital that were already operating
on thin--often negative--margins and serving particularly vulnerable
patient populations.
Recommendations for Congressional Action
Congress and the Centers for Medicare and Medicaid Services (CMS) have
reconfirmed their commitment to these hospitals repeatedly over the
years by providing new protections to ensure their viability and to
ensure patient access to hospital services in rural communities. ARHA
and its members share this goal of ensuring that federal hospital
payment policies recognize the unique role and important contributions
these hospitals bring to the Medicare program and its beneficiaries.
Consistent with this mission, the Alliance appreciates the opportunity
to provide these comments to the Committee, as you continue to examine
opportunities to improve access to health care in rural communities.
The Alliance requests that the Finance Committee consider and advance
legislation to:
Permanently extend the MDH program and low-volume hospital
payment adjustment.
Provide for updated base years for SCHs and MDHs paid on the
basis of their hospital-specific rate.
Address rural health care workforce shortages by ensuring SCHs
and MDHs paid using their hospital-specific rate receive IME
adjustments to encourage these hospitals to localize resident training
in rural areas.
Reimburse rural hospitals equitably for uncompensated care by
ensuring SCHs and MDHs paid on the basis of their hospital-specific
receive a DSH payment adjustment and an uncompensated care pool
allocation.
Direct CMS to extend rural SCH site-neutral exemptions to urban
SCHs and MDHs.
Direct CMS to extend the rural SCH 7.1% payment adjustment to
urban SCHs, and to study the appropriateness of making a similar
payment adjustment for MDHs.
Ensure that any congressional efforts to enact additional site-
neutral payment policies include appropriate exceptions that protect
financially-vulnerable SCHs and MDHs, recognizing the unique role these
facilities have in their communities.
Permanently Extend the MDH Program and Low-Volume Adjustment by
Enacting S. 1110
Finance Committee Members Robert Casey (D-PA) and Chuck Grassley (R-IA)
reintroduced the Rural Hospital Support Act (S. 1110) in late-March.
This bipartisan bill would permanently extend the MDH program and the
low-volume adjustment--support mechanisms created by Congress decades
ago that have traditionally been reauthorized together for limited
periods.
The current authorization runs through September 30, 2024, requiring
Congress to enact another extension before the final quarter of the
118th Congress. A permanent extension of these critical programs would
bring more predictability and consistency to the rural hospitals that
rely upon these payments to remain financially viable. This stability
is often lacking with short-term extensions, given that hospitals
cannot factor these payments into their budgets for the years in which
they are due to expire.
Enacting S. 1110 well in advance of the September 30, 2024, deadline
would provide vulnerable hospitals with more predictable Medicare
reimbursements and greater financial stability, and we urge the Finance
Committee to take up the bill at its earliest convenience.
Provide for Updated Base Years for SCHs and MDHs by Enacting S. 1110
The Rural Hospital Support Act (S. 1110) contains two additional
provisions that would better enable SCHs and MDHs to continue to
provide high quality, cost-
efficient care to the rural populations they serve.
Under Medicare's Inpatient Prospective Payment System (IPPS), SCHs and
MDHs are paid the greater of the federal rate (i.e., the payment that
the hospital would otherwise receive under the IPPS) or a cost-based
payment, which is determined by adding together the federal payment
rate applicable to the hospital and the amount that the federal payment
rate is exceeded by a hospital- specific rate (in the case of MDHs, the
hospital receives 75% of that difference).
Hospital-specific rates are tied to a hospital's costs in a specified
year. For SCHs, the years are 1982, 1987, 1996 or 2006, and for MDHs,
the years are 1982, 1987 or 2002. These years are overdue to be
updated, and S. 1110 would help modernize this reimbursement
methodology by adding 2016--a more recent and contemporary year--as an
available base year from which SCHs and MDHs could derive a hospital-
specific rate.
Advance Workforce Legislation that Provides Fair IME Adjustments to
SCHs and MDHs
Rural health care workforce shortages are well-documented, and Alliance
hospitals can help alleviate physician shortages if they have adequate
resources. Specifically, SCHs and MDHs are well-situated to host
residency programs, but SCHs and MDHs paid on the basis of their
hospital-specific rate (as detailed above) are financially
disincentivized to establish such programs.
If an SCH or MDH did not have a teaching program prior to the year that
it uses to set its hospital-specific rate, the indirect costs of
providing residency training are not reflected in that rate. If these
hospitals establish a new teaching program, they will receive no extra
money if the hospital-specific rate continues to exceed the federal
rate. Even if a hospital had a teaching program in a base year, it
faces similar disincentives to increase the number of residents trained
in the program. Most rural hospitals lack the financial resources to
establish a teaching program without some measure of additional
financial support.
If a hospital paid on the basis of the federal rate initiates a
teaching program, both Direct Medical Education (DME) and Indirect
Medical Education (IME) payments to that hospital increase for each
resident the hospital trains. While SCHs and MDHs paid on the basis of
their hospital-specific rate do qualify to receive DME payments, they
do not receive IME payments.
SCHs and MDHs--which comprise nearly 80% of hospitals eligible to
establish training programs in rural communities--should receive the
same incentives and financial buffer as hospitals paid under the
federal rate. The hospital-specific rate formula for SCHs and MDHs
should not disqualify the hospital from receiving full IME payments as
they would under the federal rate formula. This full federal funding of
DME and IME payments is necessary to establish and operate rural-based
residency training programs.
The Alliance encourages the Finance Committee to include such a
provision in any workforce package it considers this Congress.
Advance Legislation to Equitably Reimburse SCHs and MDHs for
Uncompensated Care
Similarly, if a hospital paid on the basis of the federal rate serves a
disproportionate number of low-income patients, it receives an
increased payment under the Medicare disproportionate share hospital
(DSH) payment adjustment, along with an uncompensated care pool
allocation. However, DSH-eligible SCHs and MDHs that are paid under the
hospital-specific rate do not receive hospital-specific payment
adjustments to compensate them for uncompensated care.
This highlights another inequity that exists between the two payment
mechanisms, and this discrepancy continues to undermine the viability
of rural safety net hospitals. SCHs and MDHs that are paid under the
hospital-specific rate should receive the same financial protections if
they have high rates of uncompensated care, through the receipt of a
DSH payment adjustment and an uncompensated care pool allocation.
Providing SCHs and MDHs with equitable and appropriate compensation
will allow for greater financial stability for these important safety
net hospitals, so they can continue sustaining their communities. The
Alliance urges the Finance Committee to consider this inequity when
crafting legislation to protect and sustain access to care in rural
America.
Direct CMS to Extend Rural SCH Site-Neutral Exemptions to Urban SCHs
and MDHs
Under the Medicare outpatient prospective payment system (OPPS), CMS
pays a ``PFS-equivalent'' rate of 40% of the OPPS payment rate for
hospital outpatient clinic visits coded under HCPCS G0463 when
delivered by a previously excepted off-campus provider-based
department. Beginning in CY 2023, CMS now exempts from this payment
reduction services furnished by excepted off-campus provider-based
departments of rural SCHs.
For years, the Alliance has been urging CMS to reconsider the site
neutral policy, and to exempt SCHs and MDHs from it. While we were
pleased that CMS determined to exempt rural SCHs, we were dismayed that
the agency did not extend the same relief to urban SCHs and MDHs. These
hospitals are similarly disadvantaged by the site neutral policy;
Congress should direct CMS to provide a similar exemption.
CMS uses Metropolitan Statistical Areas (MSAs) to delineate between
urban and rural areas. While the Alliance appreciates the need to
distinguish urban and rural for a number of payment and policy
mechanisms, MSAs are an imprecise tool for differentiating urban and
rural areas. Given that MSAs use counties as building blocks, many
areas are designated as ``urban'' because they have a single urbanized
area. But if the county is unusually large, significant portions of
that county may be as rural as the most isolated frontier area.
Using MSAs to identify urban and rural areas is particularly
problematic in the western United States where there are many very
large counties that comprise MSAs (see, for example, San Bernardino
County in California and Flagstaff and Pima Counties in Arizona).
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
There are instances where an SCH is designated urban by CMS, but
the hospital is actually a considerable distance from the nearest
urbanized area. Verde Valley Medical Center (Provider Number 03-0007),
for example, is located in Prescott, AZ and is considered an urban SCH.
However, the closest urbanized area with more than 40,000 people is
Flagstaff, AZ, which is nearly 100 miles away.\4\ Verde Valley has
undergone an urban-to-rural reclassification, so it is eligible for
these protections. Hospitals like Methodist Hospital South (45-0165) in
Jourdanton, TX have not undergone urban-to-rural reclassification, and
so are not eligible for these protections. These are not urban areas by
most reasonable standards, except the MSA standard.
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\4\ Metropolitan and Micropolitan Statistical Areas of the United
States and Puerto Rico, US Census Bureau. July 2015. https://
www2.census.gov/geo/maps/metroarea/us_wall/Jul2015/cbsa_us_0715.pdf.
For these reasons, CMS should extend this exemption to urban SCHs
because using MSAs to determine urban and rural areas is imprecise, and
distinguishing between urban and rural SCHs when applying payment
policy unfairly disadvantages urban SCHs that are the sole source of
hospital services in their communities, like their rural counterparts.
Urban SCHs are serving communities that are truly rural in character.
In fact, as CMS knows, to be an urban SCH, a hospital has to be even
further (35 miles) from another hospital to qualify than if it were a
rural hospital. CMS also can reduce incentives to undergo urban-to-
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rural reclassification to take advantage of these protections.
Regarding MDHs, US Government Accountability Office (GAO) data shows
that Medicare profit margins and total hospital profit margins declined
for MDHs from fiscal year 2011 through 2017, from -6.9 percent to -12.9
percent and 1.6 percent to -0.2 percent, respectively.\5\ The degree to
which Medicare margins declined for MDHs during this time period (6
percentage points) was greater than the degree to which they declined
for rural hospitals (3.8 percentage points) and all hospitals (2.5
percentage points). The number of MDHs declined 28 percent from 193
hospitals in fiscal year 2011 to 128 hospitals in 2017 as hospitals
became ineligible for MDH status, and 16 closed between 2013 and 2017,
or experienced other changes.\6\
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\5\ GAO, Information on Medicare-Dependent Hospitals, GAO-20-300
(Washington, DC: February 2020). https://www.gao.gov/assets/gao-20-
300.pdf.
\6\ GAO, Rural Hospital Closures: Number and Characteristics of
Affected Hospitals and Contributing Factors, GAO-18-634 (Washington,
DC: August 29, 2018). https://www.gao.gov/products/gao-18-634.
Taken together, supporting SCHs and MDHs by ensuring they receive the
site neutral exemption would help secure access to care in rural and
underserved communities. Rural SCHs, urban SCHs and MDHs are often the
sole health care providers in isolated areas where health care access
is lacking. Our analysis shows that 56% of rural SCHs, 73% of urban
SCHs, and 60% of MDHs are located in at least one type of medically
underserved area as defined by Health Resources and Services
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Administration (HRSA) Medically Underserved Area designations.
------------------------------------------------------------------------
Hospital Hospitals
Hospital Type Count in MUA Percent
------------------------------------------------------------------------
Rural Sole Community Hospital 448 251 56%
----------------------------------------
Urban Sole Community Hospitals 77 33 43%
redesignated as rural under Sec.
412.103
----------------------------------------
Urban Sole Community Hospitals (not 15 11 73%
redesignated as rural)
----------------------------------------
Medicare Dependent Hospital 169 102 60%
\7\ A hospital is determined to be in a
Medically Underserved Area (MUA) if
the hospital's main address meets the
requirement of at least one MUA
designation type based on either
geographic area, specific population
characteristics of that geographic
area (i.e., homeless population), or a
governor's designation. For detail,
please refer to the Health Resources
and Services Administration website:
https://bhw.hrsa.gov/workforce-
shortage-areas/shortage-designation.
------------------------------------------------------------------------
M+ Analysis of Medically Underserved Area (MUA) \7\ designations from
HRSA.
The Alliance shared this analysis and recommendations with CMS in the
2023 rulemaking cycle. CMS declined to make the recommended changes,
relying on a 2005 study of resource costs that found higher resource
costs in rural SCHs, and noting that the 2003 legislation that required
that 2005 study demonstrated that ``Congress did not determine that any
of these hospital types required additional payments for outpatient
services.''
For these reasons, the Alliance encourages Congress to direct CMS to
extend rural SCH site-neutral exemptions to urban SCHs and MDHs.
Direct CMS to Extend the Rural SCH 7.1% Payment Adjustment to Urban
SCHs, and Study the Appropriateness of Making a Similar Payment
Adjustment for MDHs
Under current CMS policy, Medicare payments to rural SCHs for
outpatient services are increased by 7.1%. CMS makes this adjustment
because it found that, pursuant to a study required by Congress,\8\
compared to urban hospitals, rural SCHs have substantially higher
costs, and need a payment adjustment to be comparably treated under the
OPPS. In the 2023 OPPS rule, CMS proposed and finalized a provision to
continue this payment adjustment for rural SCHs.
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\8\ Sec. 411(b), Pub. L. No. 108-173.
For the reasons set forth in the previous section, the Alliance urged
CMS to extend the rural SCH 7.1% payment adjustment to urban SCHs as
well, and to study the appropriateness of making a similar payment
adjustment for MDHs. CMS did not make these changes, and has stated
that it does not have the authority to do so because Congress specified
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that the policy apply to rural hospitals.
As noted above, CMS uses MSAs to delineate between urban and rural
areas, though MSAs are not the most precise tool for actually
characterizing urban and rural areas. As a result, there are instances
where an SCH is designated urban by CMS, but the hospital is actually a
considerable distance from the nearest urbanized area.
By specifying that the 7.1% adjustment applies to all SCHs, as well as
MDHs, Congress can provide another mechanism to contribute to increased
financial stability for rural hospitals.
We have repeatedly pressed CMS to extend this same adjustment to urban
SCHs and MDHs, and CMS has repeatedly said Congress did not direct
that. Congress should clarify its intent with respect to these
adjustments.
Protect SCHs and MDHs from Site-Neutral Payment Reductions
As noted throughout, SCHs and MDHs are in dire financial straits. More
cuts will force further closures. We concur that payment policies could
be refined to better align payment incentives and protect
beneficiaries, but we also encourage Congress to balance beneficiary
financial protection with beneficiary access to care. Payment policy
changes that cause beneficiaries to lose access to hospital services
will not serve beneficiary or taxpayer interests. Congress could exempt
certain rural hospitals from cuts, create stop loss provisions, or at
the very least delay or phase in changes for select rural providers.
Thank you for your consideration of these comments. The Alliance would
be pleased to serve as a resource as the Committee considers
legislation to protect and improve access to care in rural communities.
Please contact me at 202-204-1457 or [email protected] if
you have any questions.
Sincerely,
Eric Zimmerman
______
Alzheimer's Association and Alzheimer's Impact Movement
The Alzheimer's Association and Alzheimer's Impact Movement (AIM)
appreciate the opportunity to submit this statement for the record for
the United States Senate Committee on Finance, Health Subcommittee
hearing on ``Improving Health Care Access in Rural Communities:
Obstacles and Opportunities.'' The Association and AIM thank the
Subcommittee for its continued leadership on issues important to the
millions of people living with Alzheimer's and other dementia and their
caregivers.
We encourage the Committee to consider the below recommendations to
improve care for the growing number of families affected by
Alzheimer's, particularly those in rural areas given the unique
challenges faced in these communities. This statement highlights the
urgency of addressing a harmful decision made by the Centers for
Medicare and Medicaid Services (CMS) that continues to block access to
Food and Drug Administration (FDA)-approved Alzheimer's therapies,
particularly for individuals living in rural areas. Specifically, the
CMS National Coverage Determination (NCD) on ``Monoclonal Antibodies
Directed Against Amyloid (mAbs) for the Treatment of Alzheimer's
Disease'' is imposing severe restrictions on access to the first class
of treatments to change the course of Alzheimer's disease. We also
encourage the Subcommittee to expand rural access to a quality trained
workforce through the expansion of Project ECHO models.
Alzheimer's Nationwide Impact
Founded in 1980, the Alzheimer's Association is the world's leading
voluntary health organization in Alzheimer's care, support, and
research. Our mission is to eliminate Alzheimer's and other dementia
through the advancement of research; to provide and enhance care and
support for all affected, and to reduce the risk of dementia through
the promotion of brain health. AIM is the Association's advocacy
affiliate, working in a strategic partnership to make Alzheimer's a
national priority. Together, the Alzheimer's Association and AIM
advocate for policies to fight Alzheimer's disease, including increased
investment in research, improved care and support, and the development
of approaches to reduce the risk of developing dementia.
An estimated 6.7 million Americans age 65 and older are currently
living with Alzheimer's dementia. In 2023, Alzheimer's and other
dementia will cost the nation $345 billion--not including the value of
unpaid caregiving. Medicare and Medicaid are expected to cover $222
billion--or 64 percent--of those costs while out-of-pocket spending is
expected to be $87 billion. Total payments for health care, long-term
care, and hospice care for people living with dementia are projected to
increase to nearly $1 trillion in 2050. These mounting costs threaten
to bankrupt families, businesses, and our health care system.
Unfortunately, our work is only growing more urgent.
Access to Innovation and Breakthrough Treatments
Alzheimer's is one of the most significant health issues facing
Medicare beneficiaries and their families, and now, for the first time,
treatments have been approved by the FDA that change the course of the
disease. Aducanumab (marketed as Aduhelm) received FDA accelerated
approval on June 7, 2021, and lecanemab (marketed as Leqembi) received
FDA accelerated approval on January 6, 2023. As with the first drugs in
any class, additional therapies build upon initial breakthroughs to
deliver more efficacious treatments. Lecanemab is proven to slow
cognitive and functional decline over 18 months and significantly
positively affects biological markers of Alzheimer's disease. In a
study of 1,800 individuals in the early stages of Alzheimer's,
lecanemab reduced the rate of cognitive decline by 27 percent. On well-
established measures to assess the quality of life for dementia
patients and caregivers, it slowed the decline by half. The peer-
reviewed, published results show lecanemab will provide patients with
more time to participate in daily life and live independently. This
will mean patients have more months of recognizing their spouse,
children, and grandchildren. This will also mean more time for people
to drive safely, accurately, and promptly take care of family finances,
and participate fully in hobbies and interests.
Adding to the strength of evidence around mAbs, on May 3, 2023,
positive top-line results of the Phase 3 trial of donanemab were
released and marked the strongest such results reported to date. The
results showed donanemab met all of its primary and secondary
endpoints, and slowed clinical decline by 35 percent compared to
placebo on the primary outcome measure. According to the pharmaceutical
company, we anticipate the FDA issuing a traditional approval decision
on donanemab as soon as the end of the year. Additional clinical trials
are underway and offer the hope of additional treatments.
This is just the beginning of meaningful treatment advances. History
has shown that approvals of the first drugs in a new category
invigorate the field, increase investments in new treatments, and
encourage greater innovation. The progress we have seen in this class
of treatments and in the diversification of treatment types and targets
over the past few years provides hope to those impacted by this
devastating disease.
While these breakthroughs are exciting and offer hope to those with
Alzheimer's disease and their families, without Medicare coverage of
this class of treatments, access for those who could benefit from these
newly-approved treatments will only be available to those who can
afford to pay out-of-pocket and find a health system willing to
administer them. Without coverage, people, particularly those living in
rural areas, simply are not able to access treatments.
Unfortunately, in 2022, CMS implemented an unprecedented and
restrictive NCD that not only applies to the two currently approved
FDA-approved Alzheimer's therapies but also applies to all future
treatments in the same class. Using coverage with evidence development
(CED) requirements, CMS will only cover mAbs treating Alzheimer's
approved through the accelerated approval pathway for individuals
enrolled in randomized clinical trials, and treatments approved through
the traditional approval pathway when patients are enrolled in
``prospective comparative studies.'' This decision creates an immediate
barrier to care for older Americans, especially those living in rural
and underserved areas as these unprecedented required studies will not
exist in these areas. Unless CMS immediately reconsiders the NCD,
access to these treatments for Alzheimer's will continue to be
extremely limited, and for some in rural and underserved areas
nonexistent, by the agency's CED requirements even after traditional
approval by the FDA.
Americans living with Alzheimer's disease are entitled to FDA-approved
therapies, just as are people with conditions like cancer, heart
disease, and HIV/AIDS. And, they deserve the opportunity to assess if
an FDA-approved treatment is right for them.
The Veterans Health Administration (VHA) now offers lecanemab for U.S.
veterans. Medicare beneficiaries with early Alzheimer's deserve this
same access, not delays. Treatments taken in the early stages of
Alzheimer's would allow people more time to participate in daily life,
remain independent and make health care decisions for their future.
CMS has stated that it is not covering FDA-approved anti-amyloid
treatments for Alzheimer's because it has a different standard than
FDA. The CMS standard is defined in statute as ``reasonable and
necessary for the diagnosis or treatment of illness or injury or to
improve the functioning of a malformed body member.'' Using that
statutory definition, CMS has decided these treatments are unreasonable
and unnecessary for the Medicare population, even though the treatments
have been definitively shown to slow the progression of the disease and
improve the quality of life for patients and their caregivers. This is
unprecedented. CMS has never before determined an FDA-approved drug to
not be reasonable and necessary.
This decision sets a dangerous precedent that could stifle innovation
for Americans who have no other options. If CMS continues to treat the
accelerated approval pathway differently, it will not just be people
living with MCI and early-stage Alzheimer's who are unable to access
treatments that change the course of the disease, it will ripple down
to rare diseases, cancer, and others. If Medicare will not cover new
treatments under accelerated approval, it discourages the research
industry from pursuing crucial treatments for populations with unmet
needs. This delay could mean fewer therapies on a slower timeline when
days, weeks, and months matter. The dangerous precedent will widen the
already existing care gaps in rural and underserved communities across
all diseases.
These new FDA-approved treatments taken in the early stages of
Alzheimer's could mean a better quality of life. They allow people more
time to participate in daily life, remain independent and make future
health care decisions. These benefits will only be realized if patients
have access to the treatments. Any barrier--whether cost, coverage,
logistics, or knowledge--to accessing FDA-approved treatments is
unacceptable and is not patient-focused.
Expanding Capacity for Health Outcomes (Project ECHO)
Communities across America are facing severe health care workforce
shortages. While the shortage of geriatricians and other specialists
extends nationwide, it appears to be most acute in rural settings. It
is crucial that legitimate steps are taken to equip providers in these
areas with the tools and resources needed to provide quality care to
individuals living with Alzheimer's.
We ask that you support an expansion of the use of technology-enabled
collaborative learning and capacity-building models, often referred to
as Project ECHO. These education models can improve the capacity of
providers, especially those in rural and underserved areas, on how to
best meet the needs of all patients, including people living with
Alzheimer's. In 2018, the Alzheimer's Association launched an
Alzheimer's and Dementia Care Project ECHO Network--a highly successful
telementoring program that has trained more than 330 health care
professionals from 116 primary care practices and more than 250
professional care providers from 91 long-term care communities in a
free continuing education series of interactive, case-based video
conferencing sessions across the United States.
Project ECHO dementia models are helping primary care physicians in
real-time, throughout the country, understand how to use validated
assessment tools appropriate for early and accurate diagnoses, educate
families about the diagnosis and home management strategies, and help
caregivers understand the behavioral changes associated with
Alzheimer's. Participants express high levels of satisfaction with the
program and the majority (95%) of primary care clinicians who join the
Alzheimer's and Dementia Care ECHO program said the quality of care
they provide improved as a result of their experience. Long-term and
community-based care providers also benefit from Project ECHO dementia
programs. Recent evaluations demonstrate statistically meaningful
increases in confidence in working with people living with dementia and
overall disease knowledge post-ECHO completion and 92 percent of long-
term care participants felt that the information gained through
participation was valuable in their work.
In 2020, the Alzheimer's Association launched the Alzheimer's and
Dementia Care ECHO Global Collaborative. One partner in this
collaborative is the Dementia ECHO Indian Country Program, designed to
support clinicians at the Indian Health Service and caregivers that
provide care to dementia tribal patients. These teleECHO programs are
interactive online learning environments where clinicians and staff
serving American Indian and Alaska Native patients connect with peers,
engage in didactic presentations, collaborate on case consultations,
and receive mentorship from clinical experts from across Indian
Country. As a result, these ECHO programs enable primary care providers
to better understand Alzheimer's and other forms of dementia and
emphasize high-quality, person-centered care in community-based
settings and aim to improve health outcomes while reducing geographic
barriers and the cost of care through a team-based approach.
Conclusion
The Alzheimer's Association and AIM appreciate the steadfast support of
the Subcommittee and its continued commitment to issues important to
the millions of families affected by Alzheimer's and other dementia. As
the Subcommittee looks to remove obstacles for people living in rural
areas, we stress the urgency of CMS immediately opening an NCD
reconsideration to remove the CED requirements for FDA-approved mAbs.
We also look forward to working with the Subcommittee in a bipartisan
way on opportunities to expand access to quality care for those living
in rural areas through increased use of Project ECHO models.
______
American Academy of Family Physicians
1133 Connecticut Avenue, NW, Suite 1100
Washington, DC 20023-1011
202-232-9033
Fax: 202-232-9044
https://www.aafp.org/
Dear Chairman Cardin and Ranking Member Daines:
On behalf of the American Academy of Family Physicians (AAFP),
representing more than 129,600 family physicians and medical students
across the country, I write to applaud the Subcommittee for its focus
on rural health care with its May 17th hearing titled ``Improving
Health Care Access in Rural Communities: Obstacles and Opportunities.''
Individuals living in rural areas face significant barriers and
challenges to accessing high-quality, comprehensive health care. Rural
hospitals have closed at an alarming rate over the last ten years, and
many rural populations face long travel times for primary and emergency
care. Additionally, while many patients benefited from new telehealth
flexibilities due to the COVID-19 public health emergency (PHE), rural
individuals were less likely to have broadband access and therefore
less likely to connect via video for virtual visits.\1\
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\1\ Federal Communications Commission, ``2019 Broadband Deployment
Report,'' May 2019. Available at: https://www.fcc.gov/reports-research/
reports/broadbandprogress-reports.
The AAFP has long advocated to improve access to high-quality care in
rural communities (https://www.aafp.org/about/policies/all/rural-
practice-keeping-physicians.html). Seventeen percent of our members
practice in rural areas, the highest percentage of any medical
specialty. Family physicians are uniquely trained to provide a broad
scope of health care services to patients across the life span. This
enables them to tailor their practice location and individual scope of
practice to the needs of their communities. As a result, family
physicians are an essential source of emergency services, maternity
care, hospital outpatient services, and primary care in rural areas. It
is with these considerations in mind that we offer the following policy
recommendations to improve health care access in rural communities.
Physician Payment Reform
Independently practicing physicians need an environment that allows
them to thrive, but inadequate payment rates and the continuing
consolidation of insurers and large health systems threatens their
long-term viability, especially in rural communities. Evidence
indicates that consolidation increases health care prices and insurance
premiums, as well as worsens equitable access to care for patients in
rural and other medically underserved communities.\2\,}\3\
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\2\ Yerramilli, P., May, F.P., Kerry, V.B. Reducing Health
Disparities Requires Financing
People-Centered Primary Care. JAMA Health Forum. 2021;2(2):e201573.
Available at: https://jamanetwork.com/journals/jama-healthforum/
articleabstract/2776056.
\3\ O'Hanlon, C.E., et al. Access, Quality, and Financial
Performance of Rural Hospitals Following Health System Affiliation.
December 2019. Health Affairs. Available at: https://
www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.00918.
Medicare's current physician payment system is undermining physicians'
ability to provide high quality, comprehensive care--particularly in
primary care. Statutory budget-neutrality requirements and the lack of
annual payment updates to account for inflation will, without
intervention from Congress, continue to hurt physician practices and
undermine patient care. In October, the AAFP submitted robust
recommendations to Congress on ways to reform the Medicare Access and
CHIP Reauthorization Act (MACRA) to address challenges affecting our
members and their patients (https://www.aafp.org/dam/AAFP/documents/
advocacy/payment/medicare/LT-Congress-MACRA-RFI-102822.pdf). Since
then, both Medicare Payment Advisory Commission and the Board of
Trustees have raised concerns about rising costs for physician
practices and impacts on patient care, with each body recommending that
Congress provide payment updates for physicians. Specifically, the
Board of Trustees warned that, without a sufficient update or change to
the payment system, they ``expect access to Medicare-participating
physicians to become a significant issue in the long term.''\4\
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\4\ 2023 Annual Report of the Boards of Trustees of the Federal
Hospital Insurance and Federal Supplementary Medical Insurance Trust
Funds. Accessed April 6, 2023: https://www.cms.gov/oact/tr/2023.
Congress should heed these warnings. The AAFP strongly urges Congress
to pass the Strengthening Medicare for Patients and Providers Act (H.R.
2474) to provide for an annual update to the Medicare Physician Fee
based on the Medicare Economic Index (MEI). This annual update is an
important first step in reforming Medicare payment to help practices
keep their doors open, resist consolidation, and ensure continued
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access to care for beneficiaries.
In addition to already being insufficient, Medicare payments to
physicians are generally less in rural areas than in suburban and urban
areas, as reflected in the geographic adjustment factors associated
with the Medicare Physician Fee Schedule (MPFS). This current structure
of low payment can prevent physicians from being able to feasibly
accept as many patients as urban and suburban physicians, further
disadvantaging individuals living in rural areas and consequently
reducing their access to primary care services. For this reason, the
AAFP supports the elimination of all geographic adjustment factors from
the MPFS except for those designed to achieve a specific public policy
goal (e.g., to encourage physicians to practice in underserved areas)
(https://www.aafp.org/about/policies/all/medicare-payment.html).
Medicaid also plays an invaluable role in connecting many rural
individuals to health care coverage. In 2018, nearly 25 percent of
rural residents under 65 were on Medicaid and more were dually-enrolled
in Medicare and Medicaid.\5\ However, lack of parity between Medicaid
and Medicare payment rates disproportionately impacts access for rural,
low-income, disabled, and elderly Medicaid enrollees, as Medicaid
payments fall below the actual cost of delivering care in those areas.
On average Medicaid, pays just 66 percent of the Medicare rate for
primary care services and can be as low as 33 percent in some
states.\6\ This reduces the number of physicians who participate in
Medicaid and limits access to health care for children and families.
Increasing Medicaid payment rates will improve access to care for
Medicaid patients, lead to better health outcomes, and reduce
longstanding health disparities. The AAFP urges Congress to pass the
Kids' Access to Primary Care Act of 2023 (H.R. 952) to permanently
raise Medicaid payment rates for primary care services to at least
Medicare levels.
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\5\ Medicaid and CHIP Payment and Access Commission, ``Medicaid and
Rural Health Issue Brief.'' April 2021. Accessed online: https://
www.macpac.gov/wp-content/uploads/2021/04/Medicaid-and-Rural-
Health.pdf.
\6\ Zuckerman, S., Skopec, L., and Aarons, J. (2021, February 1).
Medicaid physician fees remained substantially below fees paid by
Medicare in 2019. Retrieved February 9, 2023, from https://
www.healthaffairs.org/doi/abs/10.1377/hlthaff.2020.00611.
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Strengthen and Target Graduate Medical Education Programs
Most physicians are trained at large academic medical centers in urban
areas, and evidence indicates physicians typically practice within 100
miles of their residency program.\7\ As a result, the current
distribution of trainees leads to physician shortages that are
particularly dire in medically underserved and rural areas. While 20
percent of the U.S. population lives in rural communities, only 12
percent of primary care physicians and eight percent of subspecialists
practice in these areas.
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\7\ Fagan, B.E., Finnegan, S.C., Bazemore. A.W., Gibbons, C.B.,
Petterson, S.M. Migration After Family Medicine Residency: 56% of
Graduates Practice Within 100 Miles of Training--Graham Center Policy
One-Pagers--American Family Physician.
Teaching Health Centers (THCs) play a vital role in training the next
generation of primary care physicians and addressing the physician
shortage. To date, the Teaching Health Center GME (THCGME) program has
trained more than 1,730 primary care physicians and dentists, 63
percent of whom are family physicians. Data shows that, when compared
to traditional postgraduate trainees, residents who train at THCs are
more likely to practice primary care (82 percent versus 23 percent) and
remain in underserved (55 percent versus 26 percent) or rural (20
percent versus 5 percent) communities. This demonstrates that the
program is successful in tackling the issue of physician
maldistribution and helps address the need to attract and retain
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physicians in rural areas and medically underserved communities.
The THCGME program's authorization expires in FY 2024, and we strongly
caution against a short-term extension since it does not provide the
needed stability for current and future residents. In fact, flat
funding of the program would mean a 40-50 percent reduction in per
resident allocation for THC programs, putting them at risk of closure.
Congress should permanently authorize and expand the THCGME program by
passing the Doctors of Community Act (H.R. 2569).
We also strongly urge Congress to pass the Rural Physician Workforce
Production Act (S. 230/H.R. 834), which would provide invaluable new
federal support for rural residency training to help alleviate
physician shortages in rural communities (https://www.aafp.org/dam/
AAFP/documents/advocacy/workforce/gme/LT-Congress-
RuralWorkforceProductionAct-021423.pdf). Specifically, the bill would
remove caps for rural training and provide new robust financial
incentives for rural hospitals, including critical access and sole
community hospitals, to provide the training opportunities that the
communities they serve need.
While the new Medicare GME residency slots approved in the previous
Congress were very much appreciated, additional action is needed to
address disparate access to care in rural and other medically
underserved areas. Merely expanding the existing Medicare GME system
will not fix the shortage and maldistribution of physicians. Any
expansion of Medicare GME slots should be targeted specifically toward
hospitals and programs in areas and specialties of need, including by
considering which ones have a proven track record of training
physicians who ultimately practice in physician shortage areas.
One barrier to creating a more equitable and effective Medicare GME
program is the lack of transparency in how funds are used. Medicare as
the largest single payer--spends about $16 billion annually on GME--but
it does not assess how those funds are ultimately used or whether they
actually address physician shortages.\8\ CMS has indicated their
authority is limited to making payment to hospitals for the costs of
running approved GME residency programs. Congress should pass
legislation granting the Secretary of HHS and the CMS Administrator the
authority to collect, analyze data on how Medicare GME positions are
aligned with national workforce needs, and publish an annual report.
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\8\ Congressional Research Service. Federal support for graduate
medical education: An overview. https://fas.org/sgp/crs/misc/
R44376.pdf. Published December 27, 2018. Accessed February 9, 2023.
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Federal Programs to Support Physicians in Rural Areas
International Medical Graduates (IMGs) have a significant impact on
addressing health care clinician shortages and improving access to care
in rural communities. The Conrad 30 Waiver Program has brought more
than 15,000 foreign physicians to underserved and rural communities.
The program ensures that physicians who are often educated and trained
in the U.S. can continue to provide care for patients at a time when
pervasive workforce shortages continue to restrict patients' access to
necessary care. We urge Congress to pass the Conrad State 30 and
Physician Access Act (S. 665) to provide immigration certainty to the
thousands of international medical graduates caring for patients in
underserved communities (https://www.aafp.org/dam/AAFP/documents/
advocacy/workforce/gme
/LT-Senate-IMGandConrad30-092822.pdf).
The National Health Service Corps (NHSC) also plays a vital role in
addressing the challenge of regional health disparities arising from
physician workforce shortages by offering financial assistance to meet
the workforce needs of communities designated as health professional
shortage areas. We urge the reintroduction and passage of the
Strengthening America's Health Care Readiness Act, which increases
investment in the National Health Service Corps and allocates 40
percent of the funding for racial and ethnic minorities and students
from low-income urban and rural areas (https://www.aafp.org/dam/AAFP/
documents/advocacy/workforce/debt/LT-Senate-
SupportingStrengtheningAmericasHealthCareReadinessAct-01
2821.pdf).
Strengthen and Sustain the Health Care Safety Net
Community Health Centers (CHCs), including Federally Qualified Health
Centers (FQHCs) and Rural Health Centers (RHCs) provide comprehensive
primary care and preventive services to some of the most vulnerable and
underserved Americans. Family physicians are the most common type of
clinician (46 percent) practicing in CHCs, and thus are well-positioned
to ensuring accessible and affordable primary care and reducing racial,
ethnic, and income-based health disparities.\9\ CHCs also play an
important role in training family physicians, and research shows that
CHC-trained family physicians are more than twice as likely to work in
underserved settings than their non-CHC-trained counterparts.\10\ The
AAFP urges Congress to increase investment in CHCs, including a long-
term authorization for CHCs, to meet the health workforce needs of the
underserved and to increase access to comprehensive primary care in
rural communities.
---------------------------------------------------------------------------
\9\ National Association of Community Health Centers, ``Community
Health Center Chartbook 2022.'' Accessed online: https://www.nachc.org/
wp-content/uploads/2022/03/Chartbook-Final-2022-Version-2.pdf.
\10\ Morris, C.G., Johnson, B., Kim, S., Chen, F. Training family
physicians in community health centers: A health workforce solution.
Fam Med. 2008;40(4):271-276.
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Telehealth
Permanent telehealth policies must include coverage of and proper
payment for audio-only telehealth services across programs. As
acknowledged earlier, the lack of modern broadband infrastructure has
proven to be a primary barrier to equitable telehealth and digital
health access for rural Americans, who are ten times more likely to
lack broadband access than their urban counterparts, leading to fewer
audio/video visits.\11\, \12\, \13\ One recent
study of FQHCs found that, by mid-2022, one in five primary care visits
and two in five behavioral health visits were audio-only, and audio-
only visits were still more common than video visits.\14\
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\11\ Kelly A. Hirko, Jean M. Kerver, Sabrina Ford, Chelsea
Szafranski, John Beckett, Chris Kitchen, Andrea L. Wendling. Telehealth
in response to the COVID-19 pandemic: Implications for rural health
disparities, Journal of the American Medical Informatics Association,
Volume 27, Issue 11, November 2020, Pages 1816-1818, https://doi.org/
10.1093/jamia/ocaa156.
\12\ Congressional Research Service, ``Broadband Loan and Grant
Programs in the USDA's Rural Utilities Service.'' March 22, 2019.
Accessed online: https://sgp.fas.org/crs/misc/RL33816.pdf.
\13\ ``Ensuring The Growth of Telehealth During COVID-19 Does Not
Exacerbate Disparities in Care,'' Health Affairs Blog, May 8, 2020.
DOI: 10.1377/hblog20200505.591306.
\14\ Uscher-Pines, L., McCullough, C.M., Sousa, J.L., et al.
Changes in In-Person, Audio-Only, and Video Visits in California's
Federally Qualified Health Centers, 2019-2022. JAMA. 2023;329(14):1219-
1221. doi:10.1001/jama.2023.1307.
Adequate payment for audio-only telehealth services helps facilitate
equal access to care for rural and underserved communities and enables
patients and physicians to select the most appropriate modality of care
for each visit. Physicians should be appropriately compensated for the
level of work required for an encounter, regardless of the modality or
location. The cognitive work does not differ between in-person and
telemedicine visits. Policies should be geared at providing more tools,
not less, to primary care physicians so they can provide the familiar
and quality care their patients seek. Congress should implement
policies that strengthen patients' relationships with their primary
care physician, and physicians should not be paid less for providing
patient-centered care. Payment should reflect the equal level of
physician work across modalities while also accounting for the unique
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costs associated with integrating telehealth into physician practices.
The AAFP strongly urges Congress to pass the Protecting Rural
Telehealth Access Act (S. 1636/H.R. 3440), which would ensure rural and
underserved community physicians can permanently offer telehealth
services, including audio-only telehealth services, and provide payment
parity for these services (https://www.aafp.org/dam/AAFP/documents/
advocacy/health_it/telehealth/LT-Senate-
ProtectingRuralTelehealthAccessAct-042522.pdf). The available data
clearly indicates that coverage of and fair payment for audio-only
services is essential to facilitating equitable access to care after
the PHE-related telehealth flexibilities expire.
This legislation would also permanently remove the current section
1834(m) geographic and originating site restrictions to ensure that all
Medicare beneficiaries can access telehealth services at home, which
the AAFP has advocated to Congress in favor of previously. The COVID-19
pandemic has demonstrated that enabling physicians to virtually care
for their patients at home can not only reduce patients' and
clinicians' risk of exposure and infection but also increase access and
convenience for patients, particularly those who may be homebound or
lack transportation. Telehealth visits can also enable physicians to
get to know their patients in their home and observe things they
normally cannot during an in-office visit, which can contribute to more
personalized treatment plans and better referral to community-based
services.
Finally, the Protecting Rural Telehealth Access Act would permanently
allow RHCs and FQHCs to serve as distant site for telehealth services.
As noted above, FQHCs and RHCs are essential sources of primary care
for patients in underserved communities, including low-income
individuals and those living in rural areas. During the pandemic, FQHCs
and RHCs have made significant investments to integrate telehealth into
their practices and ensure equitable access to telehealth services for
their patient populations. Passing this bill would ensure these
facilities can continue to provide telehealth services, improve
equitable access to health care for historically underserved patients,
and preserve care continuity with their primary care physicians.
Access to Mental and Behavioral Health
The AAFP has continuously advocated for and supported legislative
proposals to permanently remove CMS' in-person requirement for tele-
mental and behavioral health visits (https://www.aafp.org/content/dam/
AAFP/documents/advocacy/health_it/telehealth/LT-Congress-
CONNECTforHealthAct-013023.
pdf). Evidence has shown that telehealth is an effective modality for
providing mental and behavioral health services.\15\, \16\
Meanwhile, family physicians report that persistent behavioral health
workforce shortages create significant barriers to care for their
patients, which are even more pronounced in rural areas. Arbitrarily
requiring an in-person visit prior to coverage of tele-mental health
services will unnecessarily restrict access to behavioral health care.
Removing the in-person requirement would improve equitable access to
care for low-income patients and those in rural communities. We note
that our position on in-person visit requirements is unique to tele-
mental health services.
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\15\ Pew Trust (December 14, 2021). State Policy Changes Could
Increase Access to Opioid Treatment via Telehealth. The Pew Charitable
Trusts. https://www.pewtrusts.org/en/research-andanalysis/issuebriefs/
2021/12/state-policy-changes-could-increase-access-to-opioid-treatment-
via-telehealth.
\16\ SY, L.-T., J, E., D, C., and PY, C. (2018). A Systematic
Review of Interventions to Improve Initiation of Mental Health Care
Among Racial-Ethnic Minority Groups. Psychiatric Services (Washington,
DC), 69(6), 628-647. https://doi.org/10.1176/APPI.PS.201700382.
Additionally, to improve access to integrated tele-mental and
behavioral health care in primary care settings, the AAFP encourages
Congress to establish a new program for adults that mirrors the
Pediatric Mental Health Care Access Program (PMHCA) at the Health
Resources and Services Administration (HRSA). This program, which was
most recently reauthorized in 2022, promotes behavioral health
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integration into pediatric primary care by using telehealth.
PMHCA has helped address increased mental and behavioral health needs
in light of ongoing workforce shortages by meeting children and
adolescents where they are. In Fiscal Year 2020, approximately 3,000
children and adolescents in 21 states were served by pediatric primary
care providers who contacted the pediatric mental health team. Two out
of every three of these patients lived in rural and underserved
counties.\17\
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\17\ Health Resources and Services Administration, ``Pediatric
Mental Health Care Access Program.'' Available at: https://
mchb.hrsa.gov/programs-impact/programs/pediatric-mental-health-care-
access.
Family physicians frequently share concerns and frustration that when
they refer their patients for mental or behavioral health care, their
patients are not always able to find a clinician in-network or one
accepting new patients. As a result, family physicians see patients
with exacerbated behavioral health symptoms and are sometimes forced to
send them to the emergency department when there are no other acute
care options. Given the well-documented shortage of mental and
behavioral health clinicians and the growing demand for specialized
care, a HRSA-funded program that provides primary care clinicians with
virtual access to specialists could increase timely access to care for
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adult patients, particularly in rural areas.
Thank you for the opportunity to offer these recommendations. The AAFP
looks forward to continuing to work with you to advance policies that
improve access to health care for our nation's rural communities.
Should you have any questions, please contact Natalie Williams, Senior
Manager of Legislative Affairs at [email protected].
Sincerely,
Sterling N. Ransone, Jr., M.D., FAAFP
Board Chair
Founded in 1947, the AAFP represents 129,600 physicians and medical
students nationwide. It is the largest medical society devoted solely
to primary care. Family physicians conduct approximately one in five
office visits--that's 192 million visits annually or 48 percent more
than the next most visited medical specialty. Today, family physicians
provide more care for America's underserved and rural populations than
any other medical specialty. Family medicine's cornerstone is an
ongoing, personal patient-physician relationship focused on integrated
care. To learn more about the specialty of family medicine and the
AAFP's positions on issues and clinical care, visit www.aafp.org. For
information about health care, health conditions and wellness, please
visit the AAFP's consumer website, www.
familydoctor.org.
______
American Association of Colleges of Osteopathic Medicine
7700 Old Georgetown Rd., Suite 250
Bethesda, MD 20814
(301) 968-4100
www.aacom.org
Statement of David Bergman, J.D., Vice President of Government
Relations
Chairman Cardin, Ranking Member Daines, and esteemed Committee members,
as you examine opportunities to improve access to healthcare in rural
communities, the American Association of Colleges of Osteopathic
Medicine (AACOM) believes that the physicians trained at our nation's
colleges of osteopathic medicine (COMs) are an important part of the
solution. We commend you for holding today's hearing and appreciate you
permitting AACOM to offer this written testimony for the record. AACOM
stands ready to work with you and your Senate colleagues to advance
policies and programs that will help ensure our nation has the
healthcare workforce we need for the patients of today and tomorrow.
About AACOM and Osteopathic Medicine
AACOM is the leading advocate for the full continuum of osteopathic
medical education (OME) to improve public health. Founded in 1898 to
support and assist the nation's osteopathic medical schools, AACOM
represents 40 accredited COMs--educating more than 35,000 future
physicians, 25% of all U.S. medical students--at 64 teaching locations
in 35 states, as well as osteopathic graduate medical education
professionals and trainees at U.S. medical centers, hospitals, clinics
and health systems.
Osteopathic medicine encompasses all aspects of modern medicine,
including prescription drugs, surgery and the use of technology to
diagnose and treat disease and injury. Osteopathic medicine also
confers the added benefit of hands-on diagnosis and treatment of
conditions through a system known as osteopathic manipulative medicine.
Doctors of Osteopathic Medicine (DOs) are trained in medical school to
take a holistic approach when treating patients, focusing on the
integrated nature of the various organ systems and the body's
incredible capacity for self-healing. DOs are licensed in all 50 states
to practice medicine, perform surgery and prescribe medications. The
osteopathic medical tradition holds that a strong foundation as a
generalist makes one a better physician, regardless of one's ultimate
practice specialty--which is the reason why more than half of DOs
currently practice in primary care.\1\ In excess of 7,300 DOs were
added to the U.S. physician workforce in 2022, adding to the 141,000
DOs already in practice.\2\
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\1\ National Resident Matching Program, 2021 Main Residency Match,
available at https://www.nrmp.org/wp-content/uploads/2021/08/Advance-
Data-Tables-2021_Final.pdf.
\2\ American Osteopathic Association, 2022 report tracks increased
growth in the osteopathic profession, available at https://
osteopathic.org/about/aoa-statistics/.
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Osteopathic Physicians Play a Significant Role in Addressing Workforce
Shortages and Expanding Access to Care
According to the Bureau of Health Professions, osteopathic medicine is
the fastest growing medical field in the United States. Over the past
decade in the U.S., the total number of DOs and osteopathic medical
students has grown more than 81%.\3\ Moreover, greater than 25% of U.S.
medical students are enrolled in colleges of osteopathic medicine
(COMs)--a proportion that is expected to grow to 30% by 2030.\4\
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\3\ American Osteopathic Association, OMP Report, available at
https://osteopathic.org/about/aoa-statistics/.
\4\ American Association of Colleges of Osteopathic Medicine,
https://www.aacom.org/become-a-doctor/about-osteopathic-medicine/quick-
facts#::text=Today%2C%20more%20than%2025%20
percent,training%20to%20be%20osteopathic%20physicians.
Osteopathic physicians comprise one of the youngest segments of the
healthcare workforce. More than 82,000 actively practicing DOs are
under the age of 45, and 35% of DOs are under the age of 35.\5\ The
medical field continues to face devastating impacts left by the COVID-
19 pandemic. The level of stress and burnout during the pandemic caused
several physicians to retire early, take temporary leave, or
permanently leave the practice of medicine. The field of osteopathic
medicine is working to address the gaps in the physician workforce
created by the pandemic. Osteopathic medicine is building a young,
dynamic and resilient workforce that is helping to meet health system
challenges.
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\5\ American Osteopathic Association, OMP Report, available at
https://osteopathic.org/about/aoa-statistics/.
While workforce shortages persist across the nation, some areas are
impacted more heavily than others. This is especially true for rural
and underserved communities. For individuals living in rural areas of
the United States, staff shortages do not just lead to longer wait
times for appointments, but can also lead to hospital and clinic
closures, eliminating access to the only accessible healthcare
providers. Rural residents often must wait hours for ambulances or
travel hundreds of miles just to see a doctor. These long wait times
can be the difference between life and death, where serious health
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conditions are exacerbated.
Rural areas often lack access to quality health care. Of the roughly
2,000 U.S. counties classified as rural, more than 170 lacked an in-
county critical access hospital, federally qualified health center, or
rural health clinic--facilities collectively referred to as safety-net
providers.\6\ Twenty percent (20%) of our country's population resides
in rural areas, and they tend to have worse health outcomes than their
urban or suburban counterparts.\7\
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\6\ Kaufman, B.G., et al., The Rising Rate of Rural Hospital
Closures. J Rural Health, 2016. 32(1): p. 35-43.
\7\ American Hospital Association, Rural Report: Challenges Facing
Rural Communities and the Roadmap to Ensure Local Access to High-
quality, Affordable Care, available at https://www.aha.org/system/
files/2019-02/rural-report-2019.pdf.
Additionally, rural communities are routinely situated in remote areas
with little to no economic infrastructure, making it difficult to
attract and retain medical talent.\8\ These vulnerable communities have
a dire need for healthcare providers, yet only 11% of physicians choose
to practice in rural areas.\9\ Often times, even where rural facilities
exist, they are frequently understaffed and experience burden from
workforce shortages. In fact, according to the Health Resources and
Services Administration (HRSA), in March 2023 almost 70% of areas
designated as primary medical health professional shortage areas were
considered rural or partially rural.\10\
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\8\ National Rural Health Association Policy Brief, Health Care
Workforce Distribution and Shortage Issues in Rural America, available
at https://www.ruralhealth.us/getattachment/Advocate/Policy-Documents/
HealthCareWorkforceDistributionandShortageJanuary2012.pdf.aspx?
lang=en-US.
\9\ The Association of American Medical Colleges, Attracting the
next generation of physicians to rural medicine, available at https://
www.aamc.org/news-insights/attracting-next-generation-physicians-rural-
medicine.
\10\ Bureau of Health Workforce, Health Resources and Services
Administration (HRSA), U.S. Department of Health and Human Services
Second Quarter of Fiscal Year 2023 Designated HPSA Quarterly Summary,
https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport.
The physicians who do practice in rural areas tend to be older, work
longer hours, see a greater number of patients and perform a greater
variety of procedures than their counterparts who practice in urban
settings.\11\ This strain on rural physicians increases the likelihood
they will experience provider burnout and abandon the practice of
medicine. Of note, from 2000 to 2017, the number of physicians under
age 50 living in rural areas decreased by 25%. By 2017, more than half
of rural physicians were at least 50 years old, and more than a quarter
were at least 60.\12\ This highlights the need to recruit more younger
physicians into the rural workforce.
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\11\ National Rural Health Association Policy Brief, Health Care
Workforce Distribution and Shortage Issues in Rural America, available
at https://www.ruralhealth.us/getattachment/Advocate/Policy-Documents/
HealthCareWorkforceDistributionandShortageJanuary2012.pdf.aspx?
lang=en-US.
\12\ Skinner, Lucy, et al. ``Implications of an aging rural
physician workforce.'' N Engl J Med 381.4 (2019): 299-301.
Serving rural and underserved populations is a priority for AACOM and
our member schools. While large academic medical centers represent only
five percent of all hospitals in the U.S.\13\ and only 20% of all
hospital admissions, surgical operations and outpatient visits,
community-based hospitals and facilities provide the overwhelming
majority of healthcare.\14\ That is why AACOM and its member
institutions promote training in diverse healthcare settings, such as
community hospitals and health centers located in rural parts of the
country.
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\13\ Association of American Medical Colleges, Letter to Senators
Patty Murray and Richard Burr, June 30, 2021, available at https://
www.aamc.org/media/55191/download?attachment.
\14\ Burke, L.G., Frakt, A.B., Khullar, D., Orav, E.J., Jha, A.K.
Association Between Teaching Status and Mortality in U.S. Hospitals.
JAMA. 2017;317(20):2105-2113. doi:10.1001/jama.2017.
5702.
Sixty percent (60%) of osteopathic medical schools are located in a
federally designated Health Professional Shortage Area (HPSA), and 64%
require clinical rotations in rural and underserved communities.
Moreover, 88% of COMs have a stated public commitment to rural health.
Research shows that the location of medical education and residency
training impacts practice location, so the osteopathic rural training
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model leads to more physicians in these underserved areas.
Training medical students in rural communities has been shown to
mitigate chronic and acute shortages in these areas. Nearly half of
graduating 2020-2021 osteopathic medical students plan to practice in a
medically underserved or health shortage area; of those, 49% plan to
practice in a rural community.\15\ Significantly, more than 73% of DOs
practice in the state where they do their residency training, and that
percentage increases to 86% when they attend both medical school and
have their residency in the state.
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\15\ American Association of Colleges of Osteopathic Medicine,
2020-2021 Academic Year Graduating Seniors Survey Summary Report,
available at https://www.aacom.org/searches/reports/report/2020-2021-
academic-year-graduating-seniors-survey-summary-report.
Moreover, most medical students graduating with a DO degree are opting
to practice primary care. In 2023, 55.9% of senior DO medical students
in the U.S. went into primary care, compared to only 36.2% of MD
seniors.\16\ Nationwide, 57% of DOs practice in primary care, including
family medicine, internal medicine and pediatrics.\17\ DOs have
increased access to many underserved populations by providing primary
care to rural populations.
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\16\ National Residency Matching Program. Advanced Data Tables 2023
Main Residency Match, available at https://www.nrmp.org/wp-content/
uploads/2023/04/Advance-Data-Tables-2023_
FINAL-2.pdf.
\17\ American Osteopathic Association, OMP Report, available at
https://osteopathic.org/about/aoa-statistics/.
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AACOM Policy Recommendations
Osteopathic medicine has a blueprint for success in combatting the
physician workforce shortages that plague our country's healthcare
system. We respectfully offer several recommendations for the 118th
Congress to ensure an adequate healthcare workforce for the nation:
Increase the funding for and number of graduate medical
education (GME) positions, prioritizing development in rural and
underserved areas. GME is the pathway for DOs and MDs to gain
experience and hone their clinical skills. Current federal funding
levels for GME are insufficient in addressing the shortages faced by
hospitals, doctors' offices and clinics throughout the nation,
especially in rural communities. Congress needs to boost the number of
residency positions and modify policies to allow GME funding to flow to
rural and underserved areas. Doing so allows for these areas to have
more access to the care they need.
Implement policies that leverage all available physicians by
ensuring that DOs and MDs have equal access to federally-funded GME
programs. At least 32% of residency program directors never or seldom
interview DO candidates, and of those that do, at least 56% require
them to take the USMLE (the MD licensing exam), in addition to the
osteopathic medical exam, COMLEX-USA.\18\ The demands of medical school
are arduous, and osteopathic medical students should not be subjected
to the 33 hours and $2,235 (as well as prep costs and time) that are
required to take the USMLE. Moreover, these burdensome and unnecessary
practices thwart the development of osteopathic physicians, which in
turn contribute to the nation's doctor shortage, especially in rural
and underserved areas. AACOM recommends that Congress pass the
bipartisan Fair Access In Residency Act (H.R. 751) to ensure that all
federally funded GME programs are open to DOs and equally accept the
COMLEX-USA and USMLE, if an examination is required for acceptance.
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\18\ National Residency Matching Program, 2022 Program Director
Survey, available at https://www.nrmp.org/match-data-analytics/
residency-data-reports/.
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Provide permanent funding for the Teaching Health Center
Graduate Medical Education (THCGME) Program. This vital program trains
students in outpatient settings, such as Rural Health Clinics (RHCs),
Federally Qualified Health Centers (FQHCs) and tribal health centers.
THCGME Program training sites prioritize care for high-need communities
and vulnerable populations, with more than half located in medically
underserved communities. The program is important to the osteopathic
community: In 2021, there were 460 DO residents training in a THC--60%
of all THCGME residents. Due to their reliance on variable annual
discretionary funding, THCs face operational and planning struggles,
which frustrate the growth and development of new and existing
programs. Permanent robust funding is needed to strengthen the THCGME
Program and establish a healthy, stable infrastructure for physician
training in outpatient settings. AACOM recommends that Congress pass
the Promoting Access to Treatments and Increasing Extremely Needed
Transparency (PATIENT) Act of 2023, which would increase THCGME Program
funding by $50 million every 2 years and extend the program through
fiscal year 2029.
Expand funding and support for community-based training models,
including clinical rotations in rural and underserved communities.
According to the Health Resources and Services Administration's (HRSA)
Advisory Committee on Interdisciplinary, Community-Based Linkages,
there is a growing trend toward providing care in smaller community-
based clinics instead of academic hospitals. As the provision of care
has shifted to community-based settings, so has the training of medical
students. Clinical training in these settings expose medical students
to the unique healthcare needs of rural and underserved populations and
prepare them to serve those areas after graduation. Research suggests
that medical education in a rural location increases the likelihood of
rural practice. However, over three-quarters of all medical schools
report concerns with the number of clinical training sites and the
quality and supply of preceptors, especially in primary care. To
support this trend toward less expensive and less centralized care,
Congress must modify existing funding streams and establish new
programs to support rural, community-based training. With rural
communities suffering the most from physician shortages, Congress
should fund a new program within HRSA that creates a consortium of
osteopathic medical schools, rural health clinics and federally
qualified health centers to increase medical school clinical rotations
in rural community-based facilities.
Increase funding for Title VII programs. Currently, Title VII is
the only source of federal dollars that promotes the practice of
primary care in rural and underserved communities. Its vital programs
offer a lifeline to medical students facing financial barriers and
underserved communities afflicted by physician shortages. The Title
VIII Nursing Workforce Development Programs play an essential role in
Boosting annual appropriations for Title VII programs will strengthen
our healthcare workforce nationwide, and especially in underserved
communities.
Conclusion
On behalf of the 64 osteopathic medical school campuses and the 35,000
medical students they serve, thank you for your consideration of our
views and recommendations. Again, we are eager to be a resource as you
examine and consider solutions to the nation's healthcare challenges.
For questions or further information, please contact David Bergman,
J.D., Vice President of Government Relations, at [email protected].
______
American Association of Nurse Anesthesiology
Statement of Angela Mund, DNP, CRNA, President
Introduction
Chairman Cardin, Ranking Member Daines, and Members of the
Subcommittee, thank you for the opportunity to offer this statement for
the record. The American Association of Nurse Anesthesiology (AANA) is
the professional association for Certified Registered Nurse
Anesthetists (CRNAs) and student registered nurse anesthetists,
representing more than 59,000 members across the country. CRNAs provide
acute, chronic, and interventional pain management services. In some
states, CRNAs are the sole anesthesia providers in nearly 100 percent
of rural hospitals, affording these medical facilities obstetrical,
surgical, trauma stabilization, and pain management capabilities.
We applaud the Senate Committee on Finance for its leadership in
holding this hearing on improving healthcare access in rural
communities. This hearing has added importance given the Public Health
Emergency (PHE) ended on May 11, 2023, which marks an end to the
flexibilities for providers at a time when our healthcare workforce is
already strained. In addition, 170 rural hospitals closed in the last
decade and 450 hospitals are vulnerable to closing, according to the
National Rural Health Association, only adding to the strain on the
workforce in this realm.
CRNAs play an essential role in ensuring that rural America has access
to critical anesthesia services, often serving as the sole anesthesia
provider in rural hospitals, affording these facilities the capability
to provide many necessary procedures, including surgical and
obstetrical care.
Furthermore, CRNAs are more likely to work in areas with lower median
incomes and larger populations of citizens who are unemployed,
uninsured, and/or Medicaid beneficiaries.\1\ The importance of CRNA
services in rural areas was highlighted in a recent study that examined
the relationship between socioeconomic factors related to geography and
insurance type and the distribution of anesthesia provider type. The
study correlated CRNAs with lower-income populations and correlated
anesthesiologist services with higher-income populations. Of importance
to the implementation of public benefit programs in the U.S., the study
also showed that compared with anesthesiologists.
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\1\ Liao, C.J., Quraishi, J.A., Jordan, L.M. Geographical Imbalance
of Anesthesia Providers and its Impact on the Uninsured and Vulnerable
Populations. Nurse Econ. 2015;33(5):263-270. https://
www.semanticscholar.org/paper/Geographical-Imbalance-of-Anesthesia-
Providers-and-Liao-Quraishi/77112f1f7ca09a86142b4f5e7c065ae9a073dec2.
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Addressing Barriers and Constraints in Rural Communities
Current data indicate that there is an anesthesia workforce shortage.
To address the current rural workforce shortage, we need to ensure that
all providers are practicing to the top of their education and
training. CRNAs are a proven, high-quality anesthesia pain management
provider, and exercise independent, professional judgment within their
scope of practice. A 2021 study found that starting in 2017, there was
an estimated 10.7% excess demand for anesthesia services, meaning there
was an anesthesia workforce shortage of approximately 9,000 providers
before the pandemic began and current workforce issues arose, and those
shortfalls were projected to continue into the future.\2\ Allowing
CRNAs to work to the top of their scope has proven benefits to patients
and facilities. Multiple scientific and clinical studies across a
variety of practice settings have shown this to be true. A study in the
Journal of Medical Care showed that increased CRNA scope led to no
measurable differences in outcomes.\3\ Similarly, a study published in
Health Affairs found that states that had opted out of the Centers for
Medicare & Medicaid Services (CMS) supervision requirement saw no
change in outcomes.\4\ These findings are further supported by a review
of literature done by the Cochrane Library that found no identifiable
differences in anesthesia delivery based on the anesthesia care
model.\5\ The proven ability of CRNAs to practice autonomously was also
verified by data in the maternal care space,\6\ in a study of
complications during cesarean sections,\7\ and in certain pain
management techniques.\8\ What remains unproven is the need and value
of CRNA supervision requirements. Since March of 2020, Medicare has
temporarily waived the physician supervision requirement of CRNA
anesthesia services as a part of the Hospital and Critical Access
Hospital Conditions of Participation (CoPs) and ambulatory surgical
center Conditions for Coverage (CfC). During the three-year period of
this waiver there has been no data to show that outcomes have
deteriorated. In fact, there has been a significant decrease in
liability premiums witnessed in recent decades and these declines
continued after the time CMS issued the blanket waiver on supervision.
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\2\ Negrusa, Sebastian, Hogan, Paul, Cintina, Inna, Quraishi,
Jihan, Hoyem, Ruby, et al. Anesthesia Services: A Workforce Model and
Projections of Demand and Supply. Nursing Economics; Pitman Vol. 39,
Iss. 6.
\3\ Negrusa, et al. Scope of Practice Laws and Anesthesia
Complications: No Measurable Impact of Certified Registered Nurse
Anesthetist Expanded Scope of Practice on Anesthesia-related
Complications. Medical Care 54(10): p913-920, October 2016.
\4\ Dulisse, Brian, Cormwell, Jerry. No Harm Found When Nurse
Anesthetists Work Without Supervision by Physicians. Health Affairs.
Vol. 29 #8. August 2010. https://www.
healthaffairs.org/doi/abs/10.1377/
hlthaff.2008.0966?journalCode=hlthaff.
\5\ Lewis, S.R., Nicholson, A., Smith, A.F., Alderson, P. Physician
anaesthetists versus non-
physician providers of anaesthesia for surgical patients. Cochrane
Database of Systematic Reviews 2014, Issue 7. Art. No.: CD010357. DOI:
10.1002/14651858.CD010357.pub2. Accessed 10 February 2023. https://
www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010357.
pub2/full.
\6\ Needleman, J., Minnick, A.F. Anesthesia provider model,
hospital resources, and maternal outcomes. Health Serv Res. 2009
Apr;44(2 Pt 1):464-82.
\7\ Simonson, Daniel C., Ahern, Melissa M., Hendryx, Michael S.
Anesthesia Staffing and Anesthetic Complications During Cesarean
Delivery: A Retrospective Analysis. Nursing Research 56(1):p 9-17,
January 2007.
\8\ Beissel, D.E. Complication Rates for Fluoroscopic Guided
Interlaminar Lumbar Epidural Steroid Injections Performed by Certified
Registered Nurse Anesthetists in Diverse Practice Settings. J Healthc
Qual. 2016 Nov/Dec.
Additionally, during this same period six additional states have opted
out of CMS's supervision requirements (Arizona, Oklahoma, Utah,
Michigan, Arkansas, and Wyoming) totalling 23 states that have
recognized that federal supervision requirements are unproven and act
as an unnecessary barrier to care. Forty-three states have no
supervision requirements in their nursing/medicine laws or rules. Data
shows that CRNA supervision by physician anesthesiologists is one of
the least cost-effective models of anesthesia delivery and that CRNAs
practicing autonomously are the most cost-effective for facilities and
patients. As we look at how to best utilize our current healthcare
workforce, especially in rural areas, we must ask at what cost to
patients and facilities do we continue to force unnecessary supervision
requirements on CRNAs? We strongly encourage Congress to pass
legislation to end Medicare's supervision requirements and allow
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facilities to determine how best to maximize the anesthesia workforce.
To address the current rural workforce shortage, we need to ensure that
all providers are practicing to the top of their education and
training. Other unnecessary barriers to care in the Medicare and
Medicaid programs reduce patient access to care, add to costs, and
reduce competition. In their 2021 report, ``The Future of Nursing 2020-
2030: Charting a Path to Achieve Health Equity,'' the National Academy
of Medicine specifically called for the elimination of barriers to
advance practice registered nurses (APRNs) providing care.\9\ This
echoes data from a study published in Nursing Economic$ that shows that
CRNA care is correlated more with vulnerable populations such as
Medicaid-eligible patients, rural populations, and lower incomes.\10\
In addition, 2022 the National Plan for Health Workforce Well-Being
released by the National Academy of Medicine calls for preventing and
reducing the unnecessary burdens that stem from laws, regulations,
policies, and standards placed on health workers. Placing added
barriers to CRNAs can adversely affect healthcare access for these at-
risk populations. Currently, Medicare statute, regulations and policy
include a number of barriers to patient care that do not serve
patients, including not expressly stating that CRNAs abilities for
ordering and referring medically necessary services, disincentives for
physician anesthesiologists to teach students in a nurse anesthesia
program, and not allowing APRN recognition in regard to the use of the
Medicare locum tenens modifier.
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\9\ National Academy of Medicine; National Academies of Sciences,
Engineering, and Medicine; Committee on the Future of Nursing 2020-
2030; Mary K. Wakefield, David R. Williams, Suzanne Le Menestrel,
Jennifer Lalitha Flaubert, Editors. https://nap.nationalacademies.org/
catalog/25982/the-future-of-nursing-2020-2030-charting-a-path-to.
\10\ Liao, C.J., Quraishi, J.A., Jordan, L.M. (2015). Geographical
Imbalance of Anesthesia Providers and its Impact on the Uninsured and
Vulnerable Populations. Nursing Economic$, 33 5, 263-70. https://
www.semanticscholar.org/paper/Geographical-Imbalance-of-Anesthesia-
Providers-and-Liao-Quraishi/77112f1f7ca09a86142b4f5e7c065ae9a073dec2.
In order to address the dual need of workforce shortages and ensuring
patients in rural communities have access to the care they deserve, the
Committee should review two pieces of legislation. We strongly urge the
passage of H.R. 2713, the Improving Care and Access to Nurses (ICAN)
Act. This legislation would remove barriers to care and increase access
to services provided by CRNAs and other APRNs under the Medicare and
Medicaid programs. In addition, we urge the Committee to pass H.R. 833,
the Save America's Rural Hospitals Act. This legislation would provide
needed relief to rural hospitals and to expand access to care for
patients.
Conclusion
Everyone deserves access to the highest quality healthcare that CRNAs
provide without undue burdens. CRNAs should also be able to perform
anesthesia and pain management services to the full extent of their
training without barriers to their practice. I thank the Subcommittee
for its attention to this important issue and look forward to working
with you as you seek to improve healthcare in our nation's rural
communities. The AANA hopes to be a partner and work with you as you
address the issues facing healthcare in our nation. Should you wish to
discuss these issues further, please contact Matthew Thackston,
Director of Federal Government Affairs at [email protected] or (202)
741-9081 or Kristina Weger, Director of Federal Government Affairs at
[email protected] or (202) 741-9084. We look forward to working with you.
______
American College of Surgeons
20 F Street, NW, Suite 1000
Washington, DC 20001
T 202-337-2701
F 202-337-4271
https://www.facs.org/
The American College of Surgeons (ACS) appreciates the opportunity to
share a statement for the record for the Senate Finance Health Care
Subcommittee hearing entitled ``Improving Health Care Access in Rural
Communities: Obstacles and Opportunities.'' The ACS appreciates the
Committee's attention to the critical issue of health care access. Not
every policy proposal included in this statement falls within the
Finance Committee's jurisdiction, however the ACS welcomes the
opportunity to share thoughts on the health care workforce shortage and
the impact on access to care, and discuss legislative priorities aimed
at addressing this issue.
Background
Increasing evidence indicates a maldistribution of surgeons in the
United States, with significant shortages particularly in rural and
underserved areas. A congressionally mandated 2020 report \1\ conducted
by the Health Resources and Services Administration (HRSA) examined
surgical shortage areas and showed a maldistribution of the surgical
workforce, with widespread and critical shortages of general surgeons
particularly in rural areas. Likewise, a 2021 report \2\ from the WWAMI
Rural Health Research Center found that between 2001 and 2019, rural
areas experienced a 29.1% decrease in the supply of general surgeons,
and in 2019, 60.1% of non-metropolitan counties had no active general
surgeon at all. This crisis extends beyond general surgeons as well. A
2021 report \3\ released by the American Association of Medical
Colleges projects shortages of 15,800-30,200 in all surgical
specialties by 2034. This is a critical component of the ongoing health
care workforce shortage because surgeons are the only physicians
uniquely trained and qualified to provide certain necessary, lifesaving
procedures.
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\1\ https://www.facs.org/media/aqaj2m1r/hrsa-general-surgeon-
projection-report-to-appropriations.pdf.
\2\ https://familymedicine.uw.edu/rhrc/wp-content/uploads/sites/4/
2021/03/RHRC_PBMAR
2021_LARSON.pdf.
\3\ https://www.aamc.org/media/54681/download?attachment.
Better data is needed to fully understand why these shortages exist and
inform policy solutions. However, several factors are apparent today.
The U.S. population continues to grow and age, increasing demand for
physicians across the country. At the same time, the health care system
has grown more and more complex, subjecting physicians to an arduous
and ever-changing landscape of regulation and administrative burden.
The COVID-19 pandemic exacerbated already high rates of physician
burnout, leading many practicing physicians to leave the workforce.
Repeated cuts to Medicare reimbursement have forced some physicians to
see fewer patients or shut their doors altogether. Finally, limited
rural Graduate Medical Education (GME) positions and the financial
burden of medical education pose barriers to recruiting new physicians
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and encouraging them to practice in underserved areas.
Congress must act to address these critical issues. The ACS remains
committed to working with policymakers to increase access to surgical
care across the country and support the surgical workforce across the
surgeon's career to ensure that all patients can receive the high-
quality care they need.
Legislative Proposals
Ensuring an adequate and diverse surgical workforce that is
representative of the population is a critical first step in
guaranteeing access to high quality surgical care and reducing
disparities in health outcomes for patients across the country. The ACS
has long supported legislative efforts to increase the number of GME
positions available in underserved areas in order to get more qualified
medical students into the field of surgery. However, we also assert
that increasing the number of positions alone is not enough. We must
ensure that the right type of physician is at the right place, at the
right time, to optimally meet the needs of a particular population.
Recruiting diverse physicians who are representative of the population
to the surgical workforce leads to improvements including better access
to care for the underserved, better quality of care, increased patient
trust in their health care providers, novel questions in research, and
more inclusive and broad reaching solutions to policy challenges.
The high cost of medical education is one barrier to individuals
wishing to pursue a career in surgery. Physicians often accumulate
immense student debt during their education, and then must undertake
several years of residency training with low pay, during which time
their student loans accrue significant interest. This financial burden
may deter students from pursuing certain specialties, practicing in
underserved areas, or even entering the health care profession at all.
The ACS supports legislative efforts to reduce the burden of student
loan debt on physicians, including the Resident Education Deferred
Interest Act (S. 704/H.R. 1202), which would allow borrowers in medical
or dental internships or residency programs to defer student loan
payments without interest until the completion of their programs, and
the Specialty Physicians Advancing Rural Care Act (S. 705/H.R. 2761),
which would establish a new loan repayment program for specialty
physicians practicing in rural areas.
Incentives like loan repayment programs can encourage surgeons to
practice in underserved areas and help address the maldistribution that
currently exists in the workforce. However, better data is critical to
accurately identify shortage areas. The ACS believes the periodic,
repetitive collection and analysis of workforce data on both a regional
and national basis, undertaken in consultation with relevant
stakeholders, should be a top priority. One step Congress can take to
strengthen health care workforce data collection is to fully fund the
National Health Care Workforce Commission. The Commission was
established more than a decade ago as a multi-stakeholder body charged
with developing a national health care workforce strategy, including
reviewing current and projected health care workforce supply and demand
and analyzing and recommending federal policies affecting the
workforce. Unfortunately, this body was never funded and therefore has
not been able to begin this important work. The ACS supports funding
the Commission at $3 million for fiscal year 2024. Doing so will direct
needed resources to address the nation's workforce challenges and
provide a new opportunity for direct stakeholder engagement.
Unfortunately, current available data are not able to indicate if the
supply of surgeons in a given geographic area is adequate to provide
access to the services demanded by the population. This is largely
because there is no agreed upon definition of what constitutes a
shortage of surgeons for a given population, and unlike other key
providers of the community-based health care system, HRSA does not
maintain a geographic shortage area designation for surgery. The ACS
believes there is an urgent need to establish a surgical shortage
designation. The Ensuring Access to General Surgery Act (S. 1140/H.R.
1781) would direct HRSA to study and define general surgery workforce
shortage areas and collect data on the adequacy of access to surgical
services, as well as specifically grant the agency authority to
designate general surgery shortage areas. Determining what constitutes
a surgical shortage and designating areas where patients lack access to
surgical services will provide HRSA with a valuable new tool for
increasing access to the full spectrum of high-quality health care
services.
In addition to a general surgery shortage area designation, the ACS
supports reauthorizing the Health Professional Shortage Area (HPSA)
Surgical Incentive Payment Program (HSIP) for a period of 5 years. The
HSIP, which expired in 2015, provided a payment incentive to surgeons
who performed major operations--defined as those with a 10-day or 90-
day global period under the Medicare Physician Fee Schedule--in a
geographic HPSA. A 5-year reauthorization of the HSIP will provide
general surgeons, who are a key element of rural, frontline care, with
the additional support they need to recover after the COVID-19 pandemic
and continue serving rural communities. Renewing this program and
targeting it to general surgery workforce shortage areas as described
above would be a potent tool in reducing geographic workforce
maldistribution.
Identifying where health care shortages exist and incentivizing
surgeons to practice in those areas is critical. It is equally critical
to support surgeons in their roles and prevent skilled practitioners
from leaving the workforce due to burnout, administrative burden,
safety concerns, or other factors. The ACS is grateful for passage of
the Dr. Lorna Breen Health Care Provider Protection Act, which aims to
reduce and prevent suicide, burnout, and mental and behavioral health
conditions among healthcare professionals, and looks forward to
continuing to work with Congress on the issue of physician health and
well-being.
Likewise, the ACS supports legislative actions to eliminate unnecessary
requirements that overburden surgeons and their practices and may
hinder timely access to surgical care. One such bill is the Improving
Seniors' Timely Access to Care Act (S. 3018/H.R. 8487 in the 117th
Congress) which will help alleviate administrative burden for
physicians by improving the transparency and efficiency of prior
authorization under Medicare Advantage. The ACS also maintains that
surgeons should be free to practice where they choose. Unfortunately,
many employed surgeons are subject to non-compete agreements, which
prohibit individuals from joining a competing firm or starting a new
venture in the same field after leaving their employer, at times
preventing them from starting a private practice or moving to practice
in an underserved area. The Workforce Mobility Act (S. 220/H.R. 731)
would free physicians from non-competes, providing them with an option
to work for a competitor, rather than be forced to move hundreds of
miles or forgo a professional opportunity.
Finally, the ACS supports the directive that surgery should be
performed by surgeons. Decades of efforts by non-physician health care
providers to expand their scope of practice further into medicine
continue to be considered in many state legislatures. The ACS remains
committed to working with our partners in the surgical community and
with Congress to ensure that patients receive surgical care by
surgeons.
Concluding Remarks
The ACS is dedicated to working with Congress on addressing the
maldistribution of surgeons across the country and supporting surgeons
throughout their careers. Optimal quality, the centerpiece of the ACS'
mission, is not achievable without optimal access. Identifying
communities with workforce shortages and incentivizing surgeons to
practice in those areas is critical to guarantee all patients have
access to quality surgical care. Designating general surgery shortage
areas will help to identify underserved communities with surgical
workforce challenges. Additionally, Congress should consider enhancing
funding for graduate surgical education, providing loan repayment
programs to surgeons who choose to practice in areas of need, funding
the National Health Care Workforce Commission, and continuing its focus
on physician health, well-being, and administrative burden reduction.
This is only the beginning of the conversation. New issues that will
shape the health care workforce continue to emerge, and Congress and
stakeholders will have to work together to respond. For example, the
newly implemented Rural Emergency Health Program has the potential to
exacerbate surgical shortages. The ACS would welcome the opportunity to
discuss how the program may be adjusted to maintain patient access to
surgical care. Access to care is also impacted by shortages among other
members of the care team, not just surgeons, and these shortages are
growing. The end of the COVID-19 public health emergency brings changes
to several federal and state policies and programs, the impact of which
has yet to be seen. Finally, ongoing physician payment instability adds
to the financial hardship surgeons already face due to record inflation
and high practice costs, and further exacerbates disparities in access
to care and health outcomes among rural and underserved populations.
The ACS thanks the Finance Committee for its thoughtful attention to
the nation's health care access challenges and looks forward to
continuing to work with lawmakers on these important issues. For
questions or additional information, please contact Carrie Zlatos with
the ACS Division of Advocacy and Health Policy at [email protected].
______
American Dental Association
1111 14th Street, NW, Suite 1200
Washington, DC 20005
T 202-898-2400
F 202-898-2437
https://www.ada.org/
On behalf of the American Dental Association's (ADA) more than 159,000
dentist members, thank you for the opportunity to submit testimony for
the Senate Finance Health Care Subcommittee's hearing, ``Improving
Health Care Access in Rural Communities: Obstacles and Opportunities.''
Addressing dental workforce shortages and maldistribution in rural
areas so that everyone has optimal access to oral health care is one of
the ADA's top priorities. America's dentists thank you for your
leadership and focus on rural health care access.
We would like to highlight four pieces of legislation that reflect
ADA's support for solutions targeted at student debt and public
service, innovative programs, and Medicaid expansion.
Student Debt and Public Service
Student loan debt presents a major impediment to attracting new
dentists to underserved and rural communities. Ensuring that loan
forgiveness programs are well funded, easy to navigate and expanded to
include shorter time commitments or fewer mandatory weekly hours worked
could go far in attracting new dentists to these communities. Other
incentives should also be considered, including tax incentives, small
business grants and more attractive loan terms for purchasing or
building a new dental practice in communities of need.
The Indian Health Service Health Professions Tax Fairness Act
The Indian Health Service Health Professions Tax Fairness Act would
amend the tax code to allow dentists and other health care
professionals participating in the Indian Health Service (IHS) Loan
Repayment Program to exclude interest and principal payments from their
federal income taxes, as well as certain benefits received by those in
the Indian Health Professions Scholarships Program. This bill would
allow qualifying IHS employees the same tax-free status enjoyed by
those who receive National Health Service Corps (NHSC) and Army loan
repayments. Congress made these loan repayment programs offered by the
National Health Service Corps and the U.S. Army permanently tax exempt
in 2012.
Under the IHS and NHSC programs, health care professionals provide
needed care and services to underserved populations. However, the IHS
uses a large portion of its resources to pay the taxes that are
assessed on its loan recipients. In years past, IHS spent nearly 30
percent of its Health Professions account on taxes. Based on the 2021
average new award of $45,850, making the IHS loan repayments and
scholarships tax-free would save the agency over $11.6 million a year
and would fund an additional 253 loan repayment awards without
increasing the Service's annual appropriation.
The loan repayment program has already proven to be among the IHS's
best recruitment and retention tools. Exempting the scholarship and
loan repayment funds from gross income would make this tool even more
attractive to potential participants. Because IHS currently has a very
high vacancy rate, enhancing popular recruitment and retention tools is
crucial to providing adequate access to care for IHS beneficiaries,
especially in rural areas.
S. 862, Restoring America's Health Care Workforce and Readiness Act
The Restoring America's Health Care Workforce and Readiness Act would
double funding for the National Health Service Corps' (NHSC)
scholarships and loan repayment programs for health care workers who
serve in federally designated shortage areas. It would also provide
$625 million in funding in FY 2024, increasing to $825 million in FY
2026. By reauthorizing the mandatory portion of the NHSC through 2026,
this bipartisan bill prevents the NHSC's programs from expiring in
September of this year.
The ADA strongly supports increasing NHSC scholarship and loan
repayment opportunities for dentists, dental hygienists, and other
health care professionals. Expansion of NHSC programs would address
problems with health workforce distribution and local shortages, while
also providing an opportunity for dentists and others to reduce student
loan debt through service. The burden of paying off student loans for
graduate dental education often contributes to geographical gaps in
availability of dental services and access to oral health care because
indebted graduates must seek out less risky and more lucrative
opportunities. The Restoring America's Health Care Workforce and
Readiness Act would encourage dentists and promising dental students to
practice in underserved areas by providing loan repayment and
scholarships in exchange for a service commitment.
The bill also would establish a NHSC Emergency Service demonstration
project to improve the national health care surge capacity to respond
to public health emergencies like the COVID-19 pandemic. The
demonstration project would operate from 2024 to 2026, with up to
$50,000,000 in funding, and participants would be eligible to receive
loan repayments of up to 50 percent of the amount of the highest new
award made through the NHSC loan repayment program.
S. 704, Resident Education Deferred Interest Act or the REDI Act
S. 704, the Resident Education Deferred Interest Act (REDI Act), is a
bipartisan bill that would allow borrowers to qualify for interest-free
deferment on their student loans while serving in a medical or dental
internship or residency program. The bill would address the difficulty,
or inability, of those who must undertake several years of residency
with very low pay to begin repaying student debt immediately. Although
residents qualify to have their payments halted during residency
through deferment or forbearance, their loans nevertheless continue to
accrue interest that is added to the balance.
The REDI Act prevents physicians and dentists from being penalized
during residency by preventing the government from charging interest on
loans during a time when physicians and dentists are unable to afford
payments on the principal. The REDI Act does not provide any loan
forgiveness or reduce a borrower's original loan balance. By allowing
medical and dental residents to save thousands of dollars in interest
on their loans, the REDI Act makes opening practices in rural and
underserved areas or pursuing an academic or research career in those
areas more attractive and affordable to residents.
Innovative Programs
Reauthorize Action for Dental Health
ADA has long championed the Action for Dental Health (ADH) program,
which provides federal funding for the dental health needs of
underserved, often rural, populations. ADH funding is directed towards
dental disease prevention through improved oral health education,
reduction of geographic and language barriers, and improved access to
care, among other initiatives. Programs supported by ADH advance the
important goal of decreasing dental health disparities in communities
where better access to care is most needed.
The ADA is asking Congress to reauthorize the Action for Dental Health
Act of 2018 (Pub. L. 115-302) grants for innovative programs for a
five-year period, from fiscal year 2024 through fiscal year 2028. To
ensure program accountability and transparency, the ADA also asks that
Congress require the Secretary of Health & Human Services (HHS) to
submit a report to Congress on the extent to which the grants increased
access to dental services in designated dental health professional
shortage areas.
Medicaid Expansion
S. 570, Medicaid Dental Benefit Act
The Medicaid Dental Benefit Act would make comprehensive dental care a
mandatory component of Medicaid coverage for adults in every state. By
securing Medicaid dental coverage for adults, Congress can drive health
and economic gains for families, states, and our nation. Covering
dental benefits in Medicaid would also expand access significantly in
rural areas, where nearly one in four non-elderly people are covered by
Medicaid.\1\
---------------------------------------------------------------------------
\1\ The Role of Medicaid in Rural America, https://www.kff.org/
medicaid/issue-brief/the-role-of-medicaid-in-rural-america/
#:%7E:text=Medicaid%20plays%20a%20central%20role,other%20
areas%20(61%25%20vs.
Many adults who rely on Medicaid benefits find that there is little, if
any, coverage for dental care. A long-standing lack of focus on adult
oral health care from federal and state governments has created a
patchwork of dental coverage by state Medicaid programs. American
adults on Medicaid find options for dental care vary based on their
state. Less than half of the states provide ``extensive'' dental
coverage for adults in their Medicaid programs. The others offer
limited benefits, emergency-only coverage, or nothing at all for
adults. Without a federal requirement, and given the competing
priorities for state budgets, the optional adult dental benefit is
---------------------------------------------------------------------------
often not provided by states.
This lack of state coverage is particularly problematic because the
millions of adults who rely on Medicaid are the least likely to access
dental care (including basic preventive services), face the biggest
cost barriers to dental care, and are more likely than their higher
income counterparts to experience dental pain, report poor mouth
health, and find their lives to be less satisfying due to their poor
oral health.
Ensuring that states provide comprehensive dental services to adult
Medicaid beneficiaries is a sound economic investment. Recently, new
research from the ADA's Health Policy Institute estimated what it would
cost to secure dental coverage for the millions of adults who rely on
Medicaid for their health care. The study \2\ shows that across the 28
states that currently do not provide comprehensive dental coverage, the
net cost of providing extensive adult dental benefits is $836 million
per year. This includes an estimated $1.1 billion per year in dental
care costs and $273 million per year in medical care savings.\3\ As
Medicaid oral health coverage opens the door to regular care in more
appropriate and cost-effective settings, fewer people would turn to
emergency departments to relieve dental pain. This change could save
our health system $2.7 billion annually.\4\ Also, poor oral health
creates social and economic barriers that prevent many low-income
adults from economic advancement.\5\ Eliminating these barriers would
generate additional savings and empower people to pursue better jobs
and careers.
---------------------------------------------------------------------------
\2\ Making the Case for Dental Coverage for Adults in All State
Medicaid Programs, https://www.ada.org/-/media/project/ada-
organization/ada/ada-org/files/resources/research/hpi/
whitepaper_0721.pdf?rev=cf603f948e6a4dd09fb62386e3ee2083&hash=4986B3ED8A
5FD4F99A
1D28F61D3C2DA1.
\3\ Making the Case for Dental Coverage for Adults in All State
Medicaid Programs, https://www.ada.org/-/media/project/ada-
organization/ada/ada-org/files/resources/research/hpi/
whitepaper_0721.pdf?rev=a70876d749bf4e00965b122aed23ceb0&hash=38CB60D2D0
BE01DA
90BD606423142A2D.
\4\ Emergency Department Visits for Dental Conditions--A Snapshot,
https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/
resources/research/hpi/hpigraphic_0420_1.
pdf?rev=2912d9465aef4958882a485ae5f00665&hash=4B00090BAF2BC8FCBEC83FE9B1
91F13B.
\5\ Oral Health and Well-Being Among Medicaid Adults by Type of
Medicaid Dental Benefit, https://www.ada.org/-/media/project/ada-
organization/ada/ada-org/files/resources/research
/hpi/
hpigraphic_0518_1.pdf?rev=17671fb131f845d6a3662779c5de2de1&hash=51EC39EA
18B6F
6981BDFB7795D8E337C.
In conclusion, the ADA would like to reiterate its gratitude for your
prioritization of rural access to care issues. Dental access issues
should always be included in discussions of general health care access
issues, remembering both the unique aspects of dental practice and that
oral health is health. The ADA's priorities for addressing rural access
---------------------------------------------------------------------------
to care are:
Lessening the burden of student loan debt and making practicing
in underserved areas more attractive through public service by passing
S. 862, Restoring America's Health Care Workforce and Readiness Act and
the Indian Health Service Health Professions Act;
Supporting innovative programs directed towards communities in
need by reauthorizing Action for Dental Health; and
Expanding Medicaid by passing S. 570, the Medicaid Dental
Benefit Act.
The ADA looks forward to working with the Finance Health Subcommittee
on rural access to care issues in the future. ADA is continuing to work
on legislative solutions that would provide tax and other financial
incentives to health care professionals who live and practice in rural
and underserved communities. If you have any questions, please contact
Chris Tampio at [email protected].
______
American Hospital Association
800 10th Street, NW
Two CityCenter, Suite 400
Washington, DC 20001-4956
On behalf of our nearly 5,000 member hospitals, health systems and
other health care organizations, our clinician partners--including more
than 270,000 affiliated physicians, 2 million nurses and other
caregivers--and the 43,000 health care leaders who belong to our
professional membership groups, the American Hospital Association (AHA)
appreciates the opportunity to submit this statement for the record as
the Committee on Finance Subcommittee on Health Care examines obstacles
and opportunities to improve health care access in rural communities.
We appreciate the Subcommittee's interest in ensuring rural Americans
have access to high-quality, affordable health care.
OBSTACLES AND CHALLENGES FACING
RURAL COMMUNITIES
Rural hospitals and health systems are the lifeblood of their
communities and are committed to ensuring local access to health care.
At the same time, these hospitals are experiencing unprecedented
challenges that jeopardize access and services. These include the
aftereffects of a worldwide pandemic, crippling workforce shortages,
soaring costs of providing care, broken supply chains, severe
underpayment by Medicare and Medicaid, and an overwhelming regulatory
burden.
Rural hospitals make up about 35% of all hospitals in the U.S. Nearly
half of rural hospitals have 25 or fewer beds, with just 16% having
more than 100 beds. Given that rural hospitals tend to be much smaller,
patients with higher acuity often travel or are referred to larger
hospitals nearby. As a result, in rural hospitals, the acute care
occupancy rate (37%) is less than two thirds of their urban
counterparts (62%). Compared to their non-rural counterparts, a
significantly higher percentage of rural hospitals are owned by state
and local governments--35% compared to just 13% of urban hospitals.
Trends Affecting Rural Hospital Financial Sustainability
There are a number of trends driving rural health care challenges and
rural hospital closures, forcing hospitals to take a wide variety of
approaches in addressing them. Despite myriad challenging
circumstances, there are many pathways for rural hospitals'
sustainability. We appreciate the Committee's focus on better
understanding the obstacles to maintaining and improving access to care
in rural communities because that is an essential step in developing
policy responses to support rural hospitals and the patients and
communities they serve.
Patient Volume and Health
Population densities are categorically lower in rural areas, and as a
consequence, rural hospitals have much lower patient volumes. Lower
patient volumes makes it challenging for rural hospitals to maintain
fixed-operating costs.
Lower patient volumes also can impede rural hospitals participation in
performance measurement and quality improvement activities. Rural
providers may not be able to obtain statistically reliable results for
some performance measures without meeting certain case thresholds,
making it difficult to identify areas of success or areas for
improvement.
Additionally, quality programs often require reporting on measures that
are not relevant to the low-volume, rural context. This can limit rural
hospitals' participation in innovative payment models that can help
improve patient outcomes and provide alternative streams of revenue.
In addition to lower patient volumes, rural hospitals often treat
patient populations that are older, sicker and poorer compared to the
national average. For example, a higher percentage of patients in rural
areas are uninsured. A 2016 Department of Health and Human Services
Assistant Secretary for Planning and Evaluation issue brief found that
26% of uninsured, rural patients delayed seeking care due to cost.
These delays contribute to sicker, and subsequently more costly,
patients seeking care. Indeed, this challenging patient mix and lower
volumes strains rural health systems as the resources needed to provide
care are more varied and intense than those in other regions. These
delays in care are further worsened by the fact that people in rural
areas face geographic isolation and limited access to transportation to
receive care at medical facilities.
Overcoming Low Reimbursement
The bulk of rural hospital revenue comes from government payers, of
which Medicare comprises nearly half. Yet, both Medicare and Medicaid
reimburse less than the cost of providing these services. This resulted
in rural hospitals incurring $5.8 billion in Medicare underpayments and
$1.2 billion in Medicaid underpayments in 2020, on top of $4.6 billion
in uncompensated care provided by rural hospitals. For Medicare
reimbursements in particular, these underpayments grew by nearly 40%
from 2016 to 2020. Medicare sequester cuts, which fully resumed July 1,
2022, have further strained rural hospital finances and that would be
further compounded if Medicaid DSH cuts were allowed to go into effect
Oct. 1, 2023. Additionally, any proposal for site-neutral policies
would have a detrimental effect for rural communities.
Two programs designed to address rural financial issues, the Medicare-
dependent Hospital (MDH) and enhanced Low-volume Adjustment (LVA)
program--which provide vital support to rural hospitals to offset
financial vulnerabilities associated with being rural, geographically
isolated and low-volume--are scheduled to expire September 30, 2024.
COVID-19 relief prevented many closures over the last several years but
now that assistance has expired, the financial position of many rural
hospitals, especially MDH and LVA hospitals, is more precarious. In
2020, one in five rural closures were MDHs. Extending these programs or
making them permanent will be critical to these rural hospitals moving
forward.
In the commercial insurance market, rural hospitals are often forced to
accept below average rates or are left out of plan networks entirely.
Rural hospitals with low commercial patient volume and a lack of market
power are often forced to ``take it or leave it'' when large insurers
refuse to negotiate. In cases where rural hospitals are, in effect,
excluded from certain plan networks due to unfair insurer negotiation
tactics, patient access can be negatively affected.
Many patients residing in rural areas may already have to drive long
distances to seek in-network care. Health plan practices that restrict
access to network providers in rural areas further exacerbate these
challenges by impeding timely patient access to care, compromising the
stability of rural health care providers, and circumventing the intent
of network adequacy requirements.
Additionally, affordable coverage remains a pressing challenge facing
the health care system. Lack of health insurance coverage in rural
areas results in high uncompensated care costs for hospitals. Medicaid
expansion is one policy that has helped rural hospitals remain viable.
The majority (74%) of rural closures happened in states where Medicaid
expansion was not in place or had been in place for less than a year.
Research has found that Medicaid expansion has been associated with
improved hospital financial performance and lower likelihood of
closure, especially in rural areas that had many uninsured adults prior
to expansion.
Managing Staffing Shortages
Rural hospitals face significant staffing shortages that predated the
pandemic but have been significantly exacerbated over the last three
years. Only 10% of physicians in the United States practice in rural
areas and over 65% of primary care Health Professional Shortage Areas
(HPSAs) are located in rural or partially rural areas.
The shortage of primary care services has detrimental effects on the
overall health of rural populations. For example, health outcomes in
rural areas are significantly lower compared to more densely populated
regions. Additionally, while clinical care shortages exist across the
care continuum, the shortage of behavioral health and substance abuse
professionals in rural populations is immense. Recent research finds
that 65% of rural counties do not have a psychiatrist; 47% do not have
a psychologist; and 81% do not have a psychiatric nurse practitioner.
Clinician shortages are difficult to fill as rural hospitals find it
challenging to recruit and retain qualified practitioners.
Recruitment and retention of health professionals has long been a
persistent challenge for rural providers. Acute workforce shortages and
increasing labor expenses resulting from the pandemic have placed
additional pressure on rural hospitals. Many rural providers are
seeking novel approaches to recruit and retain staff. Existing federal
programs, such as the National Health Service Corps, work to
incentivize clinicians to work in rural areas. Other programs, such as
the Rural Public Health Workforce Training Network Program, help rural
hospitals and community organizations expand public health capacity
through health care job development, training and placement. Additional
and continued support to help recruit and retain health care
professionals in rural areas is needed from the federal governments.
Increased Cost of Caring--Rising Input Costs
Hospitals and health systems are facing significant financial
challenges due to the increased cost of caring for patients. Expenses
for labor, drugs, purchased services and personal protective equipment
have all increased compared to pre-pandemic levels.
Hospitals have seen a 17.5% increase in overall expenses between 2019
and 2022, according to data from Syntellis Performance Solutions, a
health care data and consulting firm. Further exacerbating the
situation is the fact that the staggering expense increases have been
met with woefully inadequate increases in government reimbursement.
Specifically, hospital expense increases between 2019 and 2022 are more
than double the increases in Medicare reimbursement for inpatient care
during that same time. Because of this, margins have remained
consistently negative, according to Kaufman Hall's Operating Margin
Index throughout 2022.
In fact, over half of hospitals ended 2022 operating at a financial
loss--an unsustainable situation for any organization in any sector,
let alone hospitals. So far, that trend has continued into 2023 with
negative median operating margins in January and February. According to
a recent analysis, the first quarter of 2023 saw the highest number of
bond defaults among hospitals in over a decade. This also is one of the
primary reasons that some hospitals, especially rural hospitals, have
been forced to close their doors. Between 2010 and 2022, 143 rural
hospitals closed--19 of which occurred in 2020 alone. Finally, despite
these cost increases, hospital prices have grown modestly. In fact, in
2022, growth in general inflation (8%) was more than double the growth
in hospital prices (2.9%).
The explosive growth in contract labor expenses in large part fueled a
20.8% increase in overall hospital labor expenses between 2019 and
2022. Even after accounting for the fact that patient acuity (as
measured by the case mix index) has increased during this period, labor
expenses per patient increased 24.7%. These increases are particularly
challenging, because labor on average accounts for about half of a
hospital's budget.
Increased drug and medical supply costs have also contributed to
ongoing financial challenges. For the first time in history, the median
price of a new drug exceeded $200,000--a staggering figure that implies
a double-digit year-over-year price growth. Department of Health and
Human Services (HHS) found that drug companies increased drug prices
for 1,216 drugs--many used to treat chronic conditions like cancer and
rheumatoid arthritis--by more than the rate of inflation, which was
8.5% between 2021 and 2022. Increased expenses extend to medical
supplies and equipment as well and hospitals have seen per patient
costs increased by 18.5% between 2019 and 2022, outpacing increases in
inflation by nearly 30%.
Overcoming Regulatory Barriers
Rural hospitals face a number of regulatory burdens that impact their
ability to provide care. According to an AHA study, the nation's
hospitals, health systems and post-acute care providers spend $39
billion each year on non-clinical regulatory requirements. While rural
hospitals are subject to the same regulations as other hospitals, lower
patient volumes mean that, on a per-discharge basis, their cost of
compliance is often higher than for larger facilities. For example,
while Medicare's Conditions of Participation (CoPs) and other
compliance metrics are important to ensure the safe delivery of care,
future CoPs should be developed with more flexibility and alignment
with other laws and industry standards. Rural hospitals can protect
their communities' access to health care by receiving relief from
outdated and unnecessary regulations.
OPPORTUNITIES TO IMPROVE HEALTH CARE FOR RURAL COMMUNITIES
To mitigate rural hospital closures and improve health care in rural
communities, hospitals continue to explore strategies that allow them
to remain viable. Although rural hospitals have long faced
circumstances that have challenged their survival, those dangers are
more severe than ever. As a result, rural hospitals require increased
attention from state and federal government to address barriers and
invest in new resources in rural communities. The AHA continues to
support policies that would help address these challenges, including:
Support Flexible Payment Options
As the health care field continues to change at a rapid pace, flexible
approaches and multiple options for reimbursing and delivering care are
more critical than ever to sustain access to services in rural areas.
Extend the Medicare-dependent Hospital (MDH) and Low-volume
Adjustment (LVA). MDHs are small, rural hospitals where at least 60% of
admissions or patient days are from Medicare patients. MDHs receive the
inpatient prospective payment system (IPPS) rate plus 75% of the
difference between the IPPS rate and their inflation-adjusted costs
from one of three base years. AHA supports making the MDH program
permanent and adding an additional base year that hospitals may choose
for calculating payments. The LVA provides increased payments to
isolated, rural hospitals with a low number of discharges. AHA also
supports making the LVA permanent. The MDH designation and LVA protect
the financial viability of these hospitals to ensure they can continue
providing access to care. AHA urges Congress to pass the Rural Hospital
Support Act (S. 1110) to extend these important programs.
Reopen the Necessary Provider Designation for Critical Access
Hospitals (CAHs). The CAH designation allows small rural hospitals to
receive cost-based Medicare reimbursement, which can help sustain
services in the community. Hospitals must meet several criteria,
including a mileage requirement, to be eligible. A hospital can be
exempt from the mileage requirement if the state certified the hospital
as a necessary provider, but only hospitals designated before January
1, 2006 are eligible. AHA urges Congress to reopen the necessary
provider CAH program to further support local access to care in rural
areas.
Strengthen the Rural Emergency Hospital (REH) Model. REHs are a
new Medicare provider type that small rural and critical access
hospitals can convert to in order to provide emergency and outpatient
services without needing to provide inpatient care. REHs are paid a
monthly facility payment and the outpatient prospective payment system
(OPPS) rate plus 5%. AHA supports strengthening and refining the REH
model to ensure sustainable care delivery and financing.
Rebase Sole Community Hospitals (SCHs). SCHs must show they are
the sole source of inpatient hospital services reasonably available in
a certain geographic area to be eligible. They receive increased
payments based on their cost per discharge in a base year. AHA supports
adding an additional base year that SCHs may choose for calculating
their payments as included in the Rural Hospital Support Act (S. 1110).
Ensure Fair and Adequate Reimbursement
Medicare and Medicaid each pay less than 90 cents for every dollar
spent caring for patients, according to the latest AHA data. Given the
challenges of providing care in rural areas, reimbursement rates across
payers need to be updated to cover the cost of care.
Reverse Rural Health Clinic (RHC) Payment Cuts. RHCs provide
access to primary care and other important services in rural,
underserved areas. AHA urges Congress to repeal payment caps on
provider-based RHCs that limit access to care.
Extend Ambulance Add-on Payments. Rural ambulance service
providers ensure timely access to emergency medical care but face
higher costs than other areas due to lower patient volume. We support
permanently extending the existing rural, ``super rural'' and urban
ambulance add-on payments to protect access to these essential
services.
Flexibility for Critical Access Hospitals (CAHs). We urge
Congress to pass legislation to extend the COVID-19 public health
emergency waiver providing flexibly for the 96-hour average length of
stay CoP. Many CAHs have had to increase their average length of stay
because of challenges transferring patients to other sites of care,
among other factors outside their control. We also support permanently
removing the 96-hour physician certification requirement for CAHs.
Removing the physician certification requirement would allow CAHs to
serve patients needing critical medical services that have standard
lengths of stay greater than 96 hours.
Wage Index Floor. AHA supports the Save Rural Hospitals Act (S.
803) to place a floor on the area wage index, effectively raising the
area wage index for hospitals below that threshold with new money.
Commercial Insurer Accountability. Systematic and inappropriate
delays of prior authorization decisions and payment denials for
medically necessary care are putting patient access to care at risk. We
support regulations that streamline and improve prior authorization
processes, which would help providers spend more time on patients
instead of paperwork. We also support a legislative solution to address
these concerns. In addition, we support policies that ensure patients
can rely on their coverage by disallowing health plans from
inappropriately delaying and denying care, including by making
unilateral mid-year coverage changes.
Maternal and Obstetric Care. We urge Congress to continue to
fund programs that improve maternal and obstetric care in rural areas,
including supporting the maternal workforce, promoting best practices
and educating health care professionals. We continue to support the
state option to provide 12 months of postpartum Medicaid coverage.
Behavioral Health. Implementing policies to better integrate and
coordinate behavioral health services will improve care in rural
communities. We urge Congress to: fully fund authorized programs to
treat substance use disorders, including expanding access to medication
assisted treatment; implement policies to better integrate and
coordinate behavioral health services with physical health services;
enact measures to ensure vigorous enforcement of mental health and
substance use disorder parity laws; permanently extend flexibilities
under scope of practice and telehealth services granted during the
COVID-19 PHE; and increase access to care in underserved communities by
investing in supports for virtual care and specialized workforce.
Bolster the Workforce
Recruitment and retention of health care professionals is an ongoing
challenge and expense for rural hospitals. Nearly 70% of the primary
HPSAs are in rural or partially rural areas. Targeted programs that
help address workforce shortages in rural communities should be
supported and expanded. Workforce policies and programs also should
encourage nurses and other allied professionals to practice at the top
of their license.
Graduate Medical Education. We urge Congress to pass the
Resident Physician Shortage Reduction Act of 2023 (S. 1302),
legislation to increase the number of Medicare-funded residency slots,
which would expand training opportunities in all areas including rural
settings to help address health professional shortages.
Conrad State 30 Program. We urge Congress to pass the Conrad
State 30 and Physician Access Reauthorization Act (S. 665) to extend
the Conrad State 30 J-1 visa waiver program, which waives the
requirement to return home for a period if physicians holding J-1 visas
agree to stay in the U.S. for three years to practice in federally-
designated underserved areas.
Loan Repayment Programs. We urge Congress to pass the Restoring
America's Health Care Workforce and Readiness Act (S. 862) to
significantly expand National Health Service Corps funding to provide
incentives for clinicians to practice in underserved areas, including
rural communities. AHA also supports the Rural America Health Corps Act
(S. 940) to directly target rural workforce shortages by establishing a
Rural America Health Corps to provide loan repayment programs focused
on underserved rural communities.
Boost Nursing Education. We urge Congress to invest $1 billion
to support nursing education and provide resources to boost student and
faculty populations, modernize infrastructure and support partnerships
and research at schools of nursing. AHA also supports expanding the
National Nurse Corps.
Health Care Workers Protection. We urge Congress to enact
federal protections for health care workers against violence and
intimidation, and to provide hospital grant funding for violence
prevention training programs and coordination with state and local law
enforcement
Support Telehealth Coverage
The pandemic has demonstrated telehealth services are a crucial access
point for many patients. We urge Congress to build on the practices
that have proven successful in recent years, including:
Permanently eliminating originating and geographic site
restrictions.
Permanently eliminating in-person visit requirement for
behavioral telehealth.
Removing distant site restrictions on federally-qualified health
centers and clinics.
Ensuring reimbursement parity based on place of service where
the visit would have been performed in-person.
Continuing payment and coverage for audio-only telehealth
services.
Permanently expanding the eligible provider types.
Removing unnecessary barriers to licensure.
Establishing DEA Special Registration Process for Telemedicine
for administration of controlled substances.
Expanding cross-agency collaboration on digital infrastructure
and literacy initiatives.
CONCLUSION
Rural hospitals are the cornerstones of their towns and cities and are
committed to continuing to serve their patients and communities. The
AHA appreciates your efforts to examine ways to improve health care
access in rural communities and looks forward to working with you on
this important issue.
______
Letter Submitted by Emily Berglund, M.S.
Senator Daines,
I am a born and raised Montanan with family residing in the Bitterroot
Valley. By the time I graduated from high school in Helena, I had lost
numerous classmates to mental illness and had spoken to several more
who had plans or were carrying out plans to die by suicide. As a
college and then graduate student at Montana State University, I
volunteered at a local helpline and heard the desperation of those
struggling with depression in our community. As an educator at Carroll
College, I witnessed and lent an ear to too many students who were
struggling with their mental health, unsure of where to go or how to
heal. I have lived the consistent and alarming mental health demands of
my generation and the next, your current constituents and your next.
Inspired by these unwanted experiences, I began working for a company
making tools to help the often overlooked and unreachable youth in
rural America. Digital therapeutics have the power to quickly and
accessibly deliver safe and effective healthcare to teens and young
adults who so desperately need it. These evidence-based treatment apps
are not an idea; they exist. And they have the power to change the
lives of Montana's children. Their continued existence relies heavily
on the support of pathways to reimbursement from influential
legislators like yourself. From one Montanan to another, please create
and support the legislation necessary to get digital therapeutics into
the hands of our community, including the co-
sponsorship of The Access to Prescription Digital Therapeutics Act of
2023 (S. 723/
H.R. 1458). We needed it then, and we need it now.
Earnestly,
Emily Berglund, M.S.
______
Statement Submitted by Robert Charles Bowman, M.D.
Lifetime Rural Medical Educator at Academic Positions in Oklahoma,
Texas, Tennessee, Nebraska.
Long Term Chair of the Society of Teachers of Family Medicine Group on
Rural Health.
Long Term Editor of the North American Section of Rural and Remote
Health.
One of the originators of the pipeline concept of rural training.
Rural Family Physician, Nowata, OK, 1983 to 1987, at the beginning of
DRG and RBRVS decline by design.
My main message about Rural Medical Education is short. It cannot work
to resolve deficits of rural workforce. Neither can nurse practitioner
or physician assistant training. Workforce cannot just be produced. It
has to be supported. The financial design is totally inadequate to
support the required sufficient numbers of workforce. Even worse, most
of the American population is behind and is growing fastest without a
response in terms of workforce increases.
Innovations Are Not Going to Be Solutions
The populations most behind are not going to be served well by
innovation, digitalization, virtual medicine, or regulation. They have
lower levels of education, health literacy, Internet literacy,
bandwidth, and access to communication issues. They most need one on
one person to person care with a best delivery team member--yet their
financial design shapes half enough professionals, less than half
enough delivery team members, and other access barriers make their
health care more challenging.
More than a Minority of the Population Is Impacted
Negatively by Health Care Design
I am encouraging the Senate Finance Committee to understand that what
has long been happening in Rural America, has been present across the
nation urban and rural for many decades.
Rural is small. Rural is not pure for deficits as 25% are quite
favored. Rural is growing slowest in the portions most behind.
Contrast this mix with urban and rural populations in 2,621 counties
lowest in health care workforce are pure for deficits, complexity, and
decline by design. US Counties were stacked by concentrations of
physicians and divided into a top concentration 79 counties with 10% of
the U.S. population in 2010, a higher 20% 152 counties, a middle
concentration 286, and a lowest concentration 2,621 counties with about
130 million people in 2010. There were rural and urban components in
these counties more pure for deficits of workforce and health care
dollars.
Deficits of workforce and access are seen in a 37 million rural
Americans or about 75% of the rural population. The deficits of lowest
levels of workforce are also seen in about 90 million urban Americans
or 32% of urbans. Comparison over time revealed the 2,621 counties as
the fastest growing US population decade after decade. But a rural
urban comparison indicated a stagnant 37 million rural people and a
fastest growing urban component.
In 1970 about 40 million urban Americans were estimated to be found in
the 2,621 counties lowest in health care workforce. They grew to 90
million by 2010. The rate of growth has continued and should shape them
into about 150--160 million by 2070. There is no indication of growth
of their workforce, access, or facilities.
It should be considered important that the fastest growing US
population that is most behind and most complex, is not even on the
radar scope while its remaining health care is being closed and
compromised.
Rural Behind and Urban Behind Are Similar
The rural populations are known to have concentrations of conditions,
diseases, environments, and worst outcomes. But so does the urban
portion of the 2,621 counties lowest in health care workforce.
Diabetes, obesity, smoking, premature death, morbidity, mortality,
mental health, and longevity issues are concentrated together at 45-50%
of each found in this 40% of the population (County Health Rankings,
Census Data).
Readmissions Year 2 Penalties illustrate the differences and the
problem of performance based designs. In year 2 the top penalty was 1
to 2% of Medicare payments withheld. This was seen in 3% of urban
hospitals, 5% overall, 9% of rural hospitals, and 14% of the hospitals
in the 2621 counties most pure for behind in so many areas of health
care dollars, outcomes, supports, access, and more.
Will our designs continue to worsen situations, or will we gain
awareness of most Americans most behind, their situations, their
outcomes, and how health care needs to help them and not harm them.
The Financial Challenge Is the Issue
The key to understanding the financial challenge is awareness.
Designers must understand that these counties have concentrations of
elderly, poor, fixed income, disabled, and worst employers. This shapes
concentrations of the worst Medicare, Medicaid, Dual, high deductible,
and other worst private health plans. These plans pay 15-30% less for
the same services and cause other problems for providers including
massive closures and compromises of their hospitals and practices.
Rural and urban populations in the 2,621 counties lowest in health care
workforce suffer greatly. Historically only Hill Burton and the first
decade of Medicare and Medicaid sent them the better financial design
that built up workforce, facilities, and delivery team members. For the
past 40 years, the financial design has steadily worsened for this 40%
of the population (rural and urban) that will be about 50% or a
majority by about 2060.
Half of the US population, the half growing fastest in numbers and
demand for care and complexity, will suffer from another 40 years of
closures and compromises without major changes in their health care
financial designs.
The focus on rural geographic markers or racial or ethnic minorities
has hidden much greater access problems in the nation, for a majority
of Americans.
Training Interventions Cannot Resolve Deficits and Access Barriers
There is no training intervention that can work to resolve deficits of
half enough primary care, mental health, women's health, and basic
surgical workforce that have always been present over the last 60
years. The deficits and access barriers have been worsened by design
since the 1980s with worse to come.
The Senate Finance Committee would do well to ignore claims that these
workforce and access deficits can be fixed by new types of health
professionals as new types have failed for 50 years including nurse
practitioners, physician assistants, and family physicians. Rural
medical education was my career for over 25 years and few have studied,
taught, or researched it as much. It does not work and it is a best
approach. More graduate medical education dollars cannot help. Teaching
health centers cannot help. The power of CMS dollars is so great that
anything that HRSA does to fund Community Health Centers or training
grants, is already negated by CMS, state, and private payers.
Please ignore claims by schools, programs, associations or their
representatives that they can fix these deficits since massive
expansions of nurse practitioners, physician assistants, and
osteopathic physicians averaging 7% more graduates a year for decades
of class years have not worked (doubling annual graduates each 14
years).
These massive expansions come with consequences such as a less
experienced workforce. This is due to so many more with no experience
graduated each year, fewer active, and rapid departure from primary
care and front line careers as shaped by the financial design.
Note that these expansion rates are multiple times faster than
population growth or demand for care increases and are infinitely
faster than the increases in dollars going to health professionals
which are stagnant to shrinking. (Comment--in other hearings, Congress
would do well to revisit what has happened with overexpansions of
health professionals in the last 100 years with boom and bust cycles).
Of course what may prevent a massive glut, is the sad condition of
practice environments that drive off so many nurses and other health
professionals so rapidly. The financial design and profit focus help to
create toxic practice environments.
Nurse practitioners have doubled twice in the 1990s and their primary
care contribution per graduate has fallen as fast as they have
expanded. Physician assistants and osteopathic graduates have also been
increasing at 7% a class year since the 1960s. Interestingly they have
done little for primary care since their primary care yield per
graduate has been cut in half with each doubling.
Primary care entry and retention sets new low levels with each class
year as you would expect for this poorly supported area. Internal
medicine, family medicine, nurse practitioner, and physician assistant
graduates were previously found at 60-90% in primary care for most of
their careers. Since the 1980s this has changed. Family physicians have
fallen to about 50% due to the opportunities for urgent, emergent,
hospitalist, and other careers and the shambles of primary care design.
NP and PA and IM have fallen below 20% in primary care. Multiple times
more graduates of each type are required to be able to deliver the same
primary care over a career as a single 1980 graduate.
The financial design simply does not have the added dollars in
personnel budgets to accommodate more health professionals or more
delivery team members or more regulation or more certification or more
technology or more micromanagement.
Nurse Practitioner and Physician Assistant Contributions Can Increase,
but Only With Departures of Physicians
It is true that nurse practitioners and physician assistants are
increasing in numbers found in primary care, but this is small in
increase compared to the non-
primary care explosion from these sources. And there is only one reason
for their increase in primary care.
Only departures of internal medicine and family medicine from primary
care allow any increased in primary care from nurse practitioners and
physician assistants.
One suggestion that I have for those that claim that their program or
school or innovation can fix deficits of workforce is to ask them what
the tracking databases show. For an example, I ran tens of thousands of
regressions and did years of research on rural medical education.
Nebraska had one of the best pipeline designs and you could show that
University of Nebraska Medical School Graduates choosing family
medicine (success in pipeline) were 10-12 times more likely to be
located in one of 70 Nebraska counties of need (14 with no physician, 9
with plenty, 93 total). But tracking databases revealed little change
in workforce levels over 20 years.
Rearranging the deck chairs is not solving deficits of workforce and
access. Initials behind the names change, but not the workforce or
access.
The validity of the research is good. Their devotion is great to rural
health. But real success is about a major improvement in the levels of
workforce for better access, economics, health equity, local health
leadership, and more.
Fixed Finances Fix Deficits in Place
All training interventions are rearrangements of the deck chairs on the
Titanic as basic health access goes under for most Americans.
More graduates of more types entering the workforce prefer better
salaries, better benefits, better locations, better health insurance,
and practice environments with more and better delivery team members
and less patient complexity. This is least present for basic health
access primary care and mental health and women's health where most
Americans are most behind.
Even those who prefer to locate in these counties or in primary care
face great difficulties. Primary care has only about 250 billion in
spending, but the spending is maldistributed and supports only about
25% of the primary care workforce poorly with less than 20% of primary
care spending in the 2621 counties lowest in health care workforce.
This is about 50 billion in investment for about 50 primary care
physicians per 100,000 or about half enough. More than 50 billion added
would be required for the practices in these counties to reach adequate
and more than that to move inadequacies in support teams to the more
and better delivery team members required for higher functioning or
person centered care.
Claims by experts that integration, coordination, and outreach can help
are bogus since the various workforce levels and social supports are
half enough or less with fewer and lesser delivery team members to do
the arranging.
Worst Quality Health Insurance Continues to Get Worse
The reductions in spending force these practices into fewer delivery
team members and lesser delivery team members because the various
Medicare, Medicaid, and private plans pay 15-30% less where workforce
is lowest and where the elderly, the poor, the disabled, and the worst
employers and their worst quality worst paying health plans are
concentrated.
This is not about insufficient quantity of health insurance. In 2010
these counties had 40% of the population and about 40-41% of the
uninsured and unemployed. Their problem has always been worst quality
health insurance and worst quality employers.
But it does get worse.
Reductions in funding are seen in Medicare cuts, Medicaid dollars,
private insurance dollars and other sources. Inflation, new technology,
regulation, and micromanagement have been forced on the practices and
this steals dollars from the personnel side of the budget--and they can
support fewer and lesser delivery team members. Lowest valued practices
and populations suffer most from cost cutting designs and also from
costly, burdensome micromanagement.
The basic design harming practice where needed most is stagnant
revenue, increasing usual costs of delivery, more types of innovative
costs of delivery, and higher costs in each innovative added type.
Delivery team members are also squeezed by more to do with fewer and
duties of higher complexity--that often are meaningless when compared
to the one on one interactions with patients that are most compromised.
Does it make sense for innovation to rule from far away or should we
focus on more and better delivery team members for more and better one
on one innovation from within a personal relationship, a practice, and
a community?
The Impossibility of Health Access Recovery
Under the current design with inadequate public plans and other worst
quality health plans from the weaker employers there is no chance to
improve local health care workforce, access, leadership, and other key
areas.
Historically you can review the situations in these counties most
behind. Appalachia is a great example that appears to apply across the
2,621 counties. Only counties that have become interstate hubs and
those that are being absorbed by suburbs can escape. This is most
likely because they have better jobs and employers and personal
finances and have better quality better paying health insurance that
can support more workforce, more team members, and better delivery team
members.
The Compromise of Expansion of the Worst Quality Health Plans
Expansions of the worst quality health insurance that pays the least,
excludes the most, and supports the least--cannot help most Americans
most behind.
Rural economics are about weaker employers, health care, education,
government jobs, and social supports as we have learned from Rural
Health Matters, Doeksen, and others. The same is true for the 2,621
counties lowest in workforce.
Weaker Employers
Trade, mining, and agriculture policies are weakening employers and
populations and plans. Outside ownership is not helpful for local
people. Wall Street wars can take out employers critical to an area--as
with corporate raiders after Phillips Petroleum with impacts on
northeast Oklahoma. Declines in Phillips, oil, agriculture, and state
programs took our county from 5 to 3 physicians, essentially closed the
hospital, and stopped efforts such as Health Fairs, home visits, and
new programs such as an Assisted Living program.
Health Care Compromise By Design
Health care design that minimizes basic services, generalists, and
general specialists contributes the least to health equity, to basic
health access, and to local economics. Hundreds of hospital closures
and more carnage in practices have acted to devastate the health care
economic contribution, a top 5 contributor where most needed.
Education Finance
Education finance is also compromised due to property tax based
education and inadequate revenue impacting most children birth to high
school graduation, or lack thereof. Formulas to compensate districts
for inadequate revenue and more children in poverty may not always work
out.
Government Jobs Federal and State
Government Jobs have been cut at all levels or these jobs have been
centralized away. I saw this during my time as a rural family physician
in the 1980s and it has been present since that time. Sometimes two
communities fight over remaining government jobs or government
supported jobs.
Social Supports Such as Food Stamps, Social Security, Disability
Social supports are essential for food, income, and other support for
these counties and are a top 5 contributor due to concentrations of
poor, elderly, disabled, fixed income, Veterans, Native Americans,
rural African Americans, and Border Hispanic populations. And social
supports are constantly under attack at federal and state levels. It
appears that people that benefit most from the nutrition, jobs,
economics, and support of these programs have to often been convinced
that the programs are evil.
A final plea to reverse the financial designs from DRG, RBRVS, lower
payments as workforce levels get lower.
Health access, jobs, and economics suffer by design, but there are
other key areas to address.
Each hospital closed represents multiple administrators, nurses, social
workers and others who were often locally focused health care leaders.
When my colleague Shane Avery was driven out of rural Indiana along
with his nurse practitioner spouse, who will take over their practice,
patients, community focus, fight against opioids, and more?
DRG, RBRVS and 15-30% lower payments is killing off locally focused
health care leadership. It is not surprising that Congress and CMS have
poor awareness of this, since those who could communicate and raise
awareness have been closed, terminated, and compromised.
Health care and political leaders must understand practices and
hospitals from the inside out--and stop meddling from above and
outside.
Financial designs must not favor the bigs more and more across
proposals, legislation, revision, and implementation. Those most
distant must have a voice--and they are a majority left behind.
Designers Must Be Held Accountable as with Physicians
and Human Subject Researchers
Cost cutting should protect vulnerable populations and their providers,
not abuse them most.
Quality improvement is more and more questionable as we learn that
outcomes are mostly about population and social drivers--and less about
what practices and hospitals can do. Certainly fewer and lesser
delivery team members by design even compromises this area. Congress
should question an Innovation Center that is 5 for 52 in successful
experiments. Perhaps cost cutting and quality improvement are
innovations based on past assumptions.
Experimentation must take a back seat in health care delivery and front
seat must go to delivery team members and their environments. This is
also the way to address burnout, turnover, lack of experience, lower
productivity, and more.
It took the last half of the 19th century to rein in physicians and the
last half of the 20th century to rein in human subject researchers. We
must rein in those who experiment upon tens of millions of Americans
who are most vulnerable, most dependent, least valued, and most
invisible. They need protection from the harms of cost cutting, from
the harms of assuming overutilization to be the problem when
populations with deficits suffer from underutilization and
inappropriate utilization.
______
Center for Fiscal Equity
14448 Parkvale Road, Suite 6
Rockville, Maryland 20853
[email protected]
Statement of Michael G. Bindner
Chairman Cardin and Ranking Member Daines, thank you for the
opportunity to submit our comments. These comments were provided to the
House Ways and Means Oversight Subcommittee on April 26th. The access
to healthcare theme for rural hospitals in the post-Dobbs world seems
especially relevant.
The ultimate answer for rural healthcare is to send people from rural
areas to medical school and nursing school (and to develop career
ladders to both) and have the local hospital systems pay the tuition
and living expenses in exchange for a period of service. This solves
the human capital problem in healthcare, but not the general loss of
rural population which is the story of the last 100 years.
Employee ownership of companies who provide healthcare services
directly rather than through third party insurance will assure everyone
has care, however this may or may not save rural areas if there is
nothing to keep people there.
What we should not do (and stop doing) is to force vulnerable low-
skilled workers into the healthcare field at low levels just because we
have the power to do so. There is a term for that. Slavery.
In prior years, when religious organizations ran hospitals, they were
trusted to provide for the poor. In some cases, it was in the name of
the religious order, such as The Sisters of Charity or The Sisters of
Mercy. . . .
. . . The recent Dobbs Case reminds us of the exemption granted under
law to Catholic Hospitals regarding certain kinds of women's health
care. When only Catholic hospitals are left in some states, due to
consolidation, it makes this policy that more acute. In order for such
hospitals to fully serve women, the drama of abortion politics must
settle into compromise. There are proposals on both sides for a federal
solution--either a federal law banning most abortions or permitting it
in all cases. At some points, electoral stunts need to recede and real
compromise must be sought.
In both scenarios, the need to take the issue away from the states is
obvious. Justice Alito ignored the problems of both slavery and Jim
Crow as reasons why there should not be abortion states and anti-
abortion states. The respondents relied on the question of rights
rather than on the question of powers. Had they examined the
competencies of federal and state government on the question of who
makes the rules on personhood, the answer is obviously that this
responsibility must be federal.
A ruling along those lines would have ended the issue at the status
quo--with no regulation of abortion unless Congress recognized the
rights of the unborn as reservoirs of positive rights. They are already
recognized as having the right to life against government action. It is
the same as the right to life for adults--the right to not be executed
without due process. It is why we do not execute pregnant women, as
well as the right to seek redress for outside injury.
What they cannot claim is a right against the welfare of its mother--
especially if the child is doomed due to a fatal defect. In such cases,
termination is the only ethical solution--even in Catholic hospitals.
Especially if the Catholic hospital is the only hospital for miles
around.
For the larger issue, the right to an abortion in the very early stages
should be federally guaranteed. After the embryo becomes a fetus--a
little person in Latin--then pregnancies should be ended in a live
birth, but with no medical intervention required to save the child
(other than baptism or other religious blessing). This form of
termination should have no upper limit. No one has a right to NOT be
born.
Regardless, the Catholic Health Association should have been asked to
present testimony on this issue. Since they were not included, their
comments should be specifically invited on the issue of charitable
care. Ambushing them with an abortion discussion would be rude.
Finally, in a cooperative economy, where companies are owned by their
employees and also provide cooperative (democratically chosen)
consumption options--especially healthcare--the need for both outside
insurance and charitable care will be eliminated. That day may be
sooner than you realize, as capitalism's flaws are showing.
A few simple steps will quicken the process, such as allowing insured
personal accounts for Social Security holding corporate preferred and
voting stock (not shares in the Wall Street Casino) and giving holders
of public stock the same capital gains exemption given to private
company owners when selling to a qualified broad-based Employee Stock
Ownership Plan. While the first option is unlikely to ever pass, the
second should attract bipartisan support.
Please see our attachment on Asset Value-Added Taxes for more
information.
Thank you for the opportunity to address the committee. We are, of
course, available for direct testimony or to answer questions by
members and staff.
Attachment--Asset Value-Added Taxes--The President's
Fiscal Year 2023 Budget, June 7, 2022
There are two debates in tax policy: how we tax salaries and how we tax
assets (returns, gains and inheritances). Shoving too much into the
Personal Income Tax mainly benefits the wealthy because it subsidizes
losses by allowing investors to not pay tax on higher salaries with
malice aforethought.
Asset Value-Added Tax (A-VAT) is a replacement for capital gains taxes
and the estate tax. It will apply to asset sales, exercised options,
inherited and gifted assets and the profits from short sales. Tax
payments for option exercises, IPOs, inherited, gifted and donated
assets will be marked to market, with prior tax payments for that asset
eliminated so that the seller gets no benefit from them. In this
perspective, it is the owner's increase in value that is taxed.
As with any sale of liquid or real assets, sales to a qualified broad-
based Employee Stock Ownership Plan will be tax free. This change would
be counted as a tax cut, giving investors in public stock who make such
sales the same tax benefit as those who sell private stock.
This tax will end Tax Gap issues owed by high income individuals. The
base 20% capital gains tax has been in place for decades. The current
23.8% rate includes the ACA-SM surtax), while the Biden proposal
accepted by Senator Sinema is 28.8%. Our proposed Subtraction VAT would
eliminate the 3.8% surtax. This would leave a 25% rate in place.
Settling on a bipartisan 22.5% rate (give or take 0.5%) should be
bipartisan and carried over from the capital gains tax to the asset
VAT. A single rate also stops gaming forms of ownership. Lower rates
are not as regressive as they seem. Only the wealthy have capital gains
in any significant amount. The de facto rate for everyone else is zero.
With tax subsidies for families shifted to an employer-based
subtraction VAT, and creation of an asset VAT, taxes on salaries could
be filed by employers without most employees having to file an
individual return. It is time to tax transactions, not people!
The tax rate on capital gains is seen as unfair because it is lower
than the rate for labor. This is technically true, however it is only
the richest taxpayers who face a marginal rate problem. For most
households, the marginal rate for wages is less than that for capital
gains. Higher income workers are, as the saying goes, crying all the
way to the bank.
In late 2017, tax rates for corporations and pass-through income wee
reduced, generally, to capital gains and capital income levels. This is
only fair and may or may not be just. The field of battle has narrowed
between the parties. The current marginal and capital rates are seeking
a center point. It is almost as if the recent tax law was based on
negotiations, even as arguments flared publicly. Of course, that would
never happen in Washington. Never, ever.
Compromise on rates makes compromise on form possible. If the
Affordable Care Act non-wage tax provisions are repealed, a rate of 26%
is a good stopping point for pass-through, corporate, capital gains and
capital income.
A single rate also makes conversion from self-reporting to automatic
collection through an asset value added tax levied at point of sale or
distribution possible. This would be both just and fair, although
absolute fairness is absolute unfairness to tax lawyers because there
would be little room to argue about what is due and when.
Ending the machinery of self-reporting also puts an end to the Quixotic
campaign to enact a wealth tax. To replace revenue loss due to the
ending of the personal income tax (for all but the wealthiest workers
and celebrities), enact a Goods and Services Tax. A GST is inescapable.
Those escapees who are of most concern are not waiters or those who
receive refundable tax subsidies. It is those who use tax loopholes and
borrowing against their paper wealth to avoid paying taxes.
For example, if an unnamed billionaire or billionaires borrow against
their wealth to go into space, creating such assets would be taxable
under a GST or an asset VAT. When the Masters of the Universe on Wall
Street borrow against their assets to avoid taxation, having to pay a
consumption tax on their spending ends the tax advantage of gaming the
system.
This also applies to inheritors. No ``Death Tax'' is necessary beyond
marking the sale of inherited assets to market value (with sales to
qualified ESOPs tax free). Those who inherit large cash fortunes will
pay the GST when they spend the money or Asset VAT when they invest it.
No special estate tax is required and no life insurance policy or
retirement account inheritance rules will be of any use in tax
avoidance.
Tax avoidance is a myth sold by insurance and investment brokers. In
reality, explicit and implicit value added taxes are already in force.
Individuals and firms that collect retail sales taxes receive a rebate
for taxes paid in their federal income taxes. This is an
intergovernmental VAT. Tax withheld by employers for the income and
payroll taxes of their labor force is an implicit VAT. A goods and
services tax simply makes these taxes visible.
Should the tax reform proposed here pass, there is no need for an IRS
to exist, save to do data matching integrity. States and the Customs
Service would collect credit invoice taxes, states would collect
subtraction VAT, the SEC would collect the asset VAT and the Bureau of
the Public Debt would collect income taxes or sell tax-
prepayment bonds.
Digital Therapeutics Alliance
https://dtxalliance.org/
May 31, 2023
U.S. Senate
Committee on Finance
Subcommittee on Health Care
Chairman Benjamin L. Cardin
Ranking Member Steve Daines
430 Dirksen Senate Office Building
Washington, DC 20510
Dear Chairman Cardin and Ranking Member Daines:
The Digital Therapeutics Alliance commends the work of the Senate
Subcommittee on Health Care for examining obstacles and opportunities
to improve health care access in rural communities.
Rural communities often face significant challenges in accessing
healthcare services, including limited resources, long distances to
healthcare facilities, and a shortage of health-care professionals.
However, the emergence of digital therapeutics offers a promising
solution to address these issues and transform the landscape of health-
care delivery in rural areas. By leveraging the power of technology,
digital therapeutics provide accessible, personalized, and evidence-
based interventions, effectively bridging the gap between patients and
care providers.
Increased Access
Digital therapeutics provide a convenient and accessible alternative to
traditional healthcare services for individuals living in rural
communities. Patients can access these interventions through mobile
applications, web-based platforms, and telehealth services from the
comfort of their homes, eliminating the need for long travel times and
expenses associated with accessing healthcare services in urban areas.
This increased access to care ensures that individuals in rural
communities receive timely and effective interventions, reducing the
burden of chronic conditions and preventing the progression of
diseases.\1\
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\1\ https://pharmanewsintel.com/features/challenges-to-improving-
access-to-digital-therapeutics-in-healthcare.
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Personalized Care
Digital therapeutics offer tailored interventions based on individual
needs, preferences, and progress. Machine learning algorithms and data-
driven approaches help analyze user input and provide personalized
treatment plans. These interventions can include cognitive-behavioral
therapy (CBT), mindfulness exercises, psychoeducation, and medication
adherence support. By personalizing care, digital therapeutics foster a
sense of autonomy and empower individuals to actively participate in
their own recovery journey. Moreover, engaging interfaces, gamification
elements, and interactive features enhance user engagement, motivation,
and adherence to treatment protocols.\2\
---------------------------------------------------------------------------
\2\ https://www.forbes.com/sites/glennllopis/2020/08/09/digital-
therapeutics-are-accelerating--personalization-in-healthcare/
?sh=717660162176.
---------------------------------------------------------------------------
Remote Monitoring and Continuous Care
Digital therapeutics enable remote monitoring and continuous care,
particularly critical for individuals living in rural communities with
limited access to healthcare services. Wearables and sensors can track
physiological and behavioral data, providing valuable insights into a
patient's progress and facilitating early intervention. Healthcare
professionals can use these data to adjust treatment plans, provide
feedback, and offer support, ensuring that patients receive
personalized and ongoing care. Moreover, remote monitoring enables
healthcare providers to detect and manage chronic conditions,
preventing the need for hospitalization and reducing healthcare costs.
Cost-Effectiveness
The cost of healthcare services is often a significant barrier for
individuals living in rural communities, who may have limited financial
resources. Digital therapeutics offer a cost-effective alternative to
traditional treatment modalities, eliminating the need for physical
infrastructure, reducing the demand for specialized personnel, and can
be scaled up to reach a large number of individuals simultaneously.
This affordability makes digital therapeutics an attractive solution
for resource-
constrained healthcare systems and ensures that individuals with
limited financial means can access quality care.\3\
---------------------------------------------------------------------------
\3\ https://www.nature.com/articles/s41440-022-00952-x.
Lastly, the challenges of accessing healthcare services in rural
communities demand innovative solutions that can overcome barriers to
access, deliver personalized interventions, and reduce stigma. Digital
therapeutics provide a promising way forward, offering accessible,
personalized, evidence-based, and cost-effective care. As technology
continues to advance, the integration of digital therapeutics into
mainstream healthcare systems has the potential to revolutionize the
delivery of healthcare services in rural communities, improving
outcomes and transforming lives on a global scale. By leveraging the
power of technology, digital therapeutics offer a transformative
solution that bridges the gap between patients and care providers,
ensuring that every individual, regardless of their geographical
---------------------------------------------------------------------------
location, receives timely, effective, and personalized care.
We look forward to further engaging with your committee on these
critical issues. Please contact Sara Elalamy at [email protected]
for any further information or insights.
Sincerely,
Sara Elalamy
Director of U.S. Government Affairs
______
Federation of American Hospitals
750 9th Street, NW, Suite 600
Washington, DC 20001
202-624-1500
FAX 202-737-6462
https://www.fah.org/
May 17, 2023
The Hon. Benjamin L. Cardin The Hon. Steve Daines
United States Senate United States Senate
509 Hart Senate Office Building 320 Hart Senate Office Building
Washington, DC 20510 Washington, DC 20510
Dear Chairman Cardin and Ranking Member Daines,
The Federation of American Hospitals (FAH) is pleased to provide
this Statement for the Record in advance of the Senate Finance
Subcommittee on Health Care's hearing entitled Improving Health Care
Access in Rural Communities: Obstacles and Opportunities. We also
commend the Subcommittee for its leadership in improving rural access
to health care.
The FAH is the national representative of more than 1,000 leading
tax-paying hospitals and health systems throughout the United States.
FAH members provide patients and communities with access to high-
quality, affordable care in both urban and rural areas across 46
states, plus Washington, DC and Puerto Rico. Our members include
teaching, acute, inpatient rehabilitation, behavioral health, and long-
term care hospitals and provide a wide range of inpatient, ambulatory,
post-acute, emergency, children's, and cancer services.
The FAH and our member hospitals share the Subcommittee's goal of
improving access to care in rural communities. More than 60 million
Americans live in rural areas across the country \1\ and rely on their
local hospital as their main access point for receiving the care they
need. These rural hospitals face major stresses and challenges
including growing inflation, a unique patient mix, low patient volume,
a growing workforce crisis, and funding shortfalls. These factors have
contributed to the shuttering of 136 rural hospitals since 2010,
including a record 19 closures in 2020 alone.\2\
---------------------------------------------------------------------------
\1\ FAH Blog: https://www.fah.org/fah-celebrates-rural-hospital-
week-2022/.
\2\ AHA Report: https://www.aha.org/news/headline/2022-09-08-aha-
report-rural-hospital-closures-threaten-patient-access-care.
Fortunately, there are several legislative solutions Congress can
enact to support rural hospitals and their patients. To help further
the Subcommittee's goal of improving health care access in rural
communities, this Statement for the Record addresses: preventing
Medicaid DSH cuts; making permanent Low Volume and
Medicare-dependent Hospital payment programs (LVH/MDH); a rural
Medicare Disproportionate Share Hospital (DSH) equity legislative
concept; health care workforce solutions; maintaining the current ban
on self-referral to physician-owned hospitals; and opposition to site
---------------------------------------------------------------------------
neutral policies.
We look forward to working with the Senate Finance Committee and
appreciate the opportunity to provide input on several key policy
platforms.
Prevent Medicaid DSH Cuts
The FAH strongly supports H.R. 2665, The Supporting Safety Net
Hospitals Act, which eliminates the scheduled Medicaid DSH cuts for
2024 and 2025.
We appreciate the inclusion of the legislation in recent House
Energy and Commerce Committee hearings, and we urge the Senate to
similarly consider the legislation to protect these payments which are
critical for hospitals that provide care to millions of Americans in
rural communities, where they serve a disproportionate number of low-
income and uninsured patients. DSH allotments are scheduled to be
reduced by $8 billion in FY 2024, starting October 1, 2023. If Congress
fails to provide relief from scheduled DSH cuts, the financial
viability of our rural and safety-net hospitals would be further
compromised.
Medicaid patients need to know hospitals will be there when they
need care. This legislation is vital for ensuring access to quality
care for our most vulnerable patients and safeguarding the essential
hospitals that serve them.
Make Permanent the MDH and LVH Adjustment Payment Programs
The FAH strongly supports S. 1110, The Rural Hospital Support Act,
which would make permanent two crucial rural hospital payment programs,
the MDH and LVH Adjustment payment programs.
These programs are essential for small rural providers and are an
important part of ensuring rural facilities remain open for the
communities and patients they serve. We thank the Senate for
reauthorizing the LVH and MDH programs in the Consolidated
Appropriations Act, 2023, which extended the programs for two years
(until the end of 2024).
Making these important programs permanent would build on recent
success and provide the financial stability, security, and certainty
needed to help prevent closures and disruptions to care in rural
communities.
Advance Rural Health Equity by Enacting Rural DSH Parity
The pressures of inflation on top of recovering from the COVID-19
pandemic exposed the need to address equity in many parts of American
society, including health care. We applaud Congress' enhanced focus on
health equity measures across the care continuum and urge lawmakers not
to overlook the significant health disparities found in rural
communities.
One step Congress can take to solve the inequities between rural
and urban care is to pass legislation to remove the current, and
arbitrary, 12% Medicare DSH Payment Adjustment Cap that applies to
rural (with some exceptions) and urban hospitals under 100 beds. This
policy unjustly impacts rural hospitals by creating an unlevel playing
field of payment policies for treating low-income, rural Americans.
By passing rural DSH payment parity legislation, Congress can
ensure equity among rural and urban providers and set us on a path
toward a healthier rural America.
Investment in Health Care Workforce in Rural America
Perhaps the greatest challenge facing rural hospitals today is
maintaining an adequate workforce. Rural hospitals are experiencing a
combination of provider burnout, physician and staffing shortages, and
difficulty attracting workers to rural areas--all factors causing
significant strain on hospital operations.
Hospitals have been doing our part to recruit, train, and upskill
employees. Investments in schools of nursing, such as HCA Healthcare's
Galen College of Nursing, are contributing to private sector solutions
by making high quality programs available to those seeking to enter the
profession. However, ensuring that barriers to learning are addressed
as well as creating incentives for nursing students to both attend
school and retain employment, or return from retirement, could be
significant for the nursing workforce of tomorrow.
Hospitals are also investing heavily in both training and patient
care management innovation to improve the bandwidth of registered
nurses and reduce nurse workload burden. Allowing nurses to reduce
paperwork and non-clinical responsibilities through technology and
process enhancements would have the added benefit of reducing burnout.
Another pathway for new workers in the health care sector is legal
immigration from foreign countries. The downstream impact of reduced
net legal immigration in recent years due to both policy and pandemic
factors has created enormous gaps in ``unskilled'' employment areas,
pushing up the wages for those roles due to worker demand and
shortages. There are an estimated two million fewer working-age
immigrants in the U.S. than there would have been if pre-pandemic
levels were maintained.\3\ Hospitals are seeing entry-level candidates
for non- licensed positions shift to sectors with higher wages in a
less demanding work environment. The result of this is fewer health
care workers staying in the industry at the entry level, which
compounds the demands on nurses and other licensed staff--ultimately
leading to their burnout.
---------------------------------------------------------------------------
\3\ https://www.governing.com/work/where-are-the-workers-labor-
market-millions-short-post-pandemic.
Federal legislative action is essential to help rural hospitals
---------------------------------------------------------------------------
maintain a strong workforce, including:
The Conrad State 30 and Physician Access Reauthorization Act
to improve and extend the existing program that allows
international physicians trained in America to remain in the
country if they practice in underserved areas.
The Healthcare Workforce Resilience Act to recapture 25,000
unused immigrant visas for nurses and 15,000 unused immigrant
visas for physicians that Congress has previously authorized,
and allocate those visas to international physicians and
nurses.
Enhancing investment in provider loan repayment programs,
including the Nurse Corps, to incentivize providing care in
rural and underserved communities without limits to the
clinician's choice to serve in a tax-paying health facility.
Address visa backlogs and ``visa retrogression.'' There are
currently thousands of fully qualified foreign trained doctors
and nurses who have been approved for U.S. green cards but who
are not in the U.S. because of ``visa retrogression,'' causing
applicants to wait for a visa to become available due to the
EB-3 visa category being oversubscribed. In addition to
immigration reform solutions, other actions include eliminating
State Department bureaucratic delays and inefficiencies in
immigration to allow foreign-trained qualified physicians and
nurses to come to the U.S. to fill vacancies unfilled by U.S.
workers.
Enact Bipartisan Senate Rural Health Agenda
A recent study found that more than 600 rural hospitals--nearly 30%
of all rural hospitals in the country--are at risk of closing in the
near future.\4\ We applaud the robust group of bipartisan Senators who
are working to support their rural hospitals by introducing a package
of rural health bills aimed at addressing health care challenges in
rural America.
---------------------------------------------------------------------------
\4\ Center for Healthcare Quality and Payment Reform: https://
ruralhospitals.chqpr.org/downloads/
Rural_Hospitals_at_Risk_of_Closing.pdf.
---------------------------------------------------------------------------
We urge the Senate to enact the following legislation:
The Rural Health Innovation Act to establish a competitive
grant program to increase staffing resources, extend hours of
operation, acquire additional technology and equipment, and pay
for construction costs at Federally Qualified Health Centers
and Rural Health Clinics.
The Rural America Health Corps Act which creates a sliding
scale loan repayment program based on the severity of provider
shortages in the area to incentivize health professionals to
serve in rural communities.
The Save Rural Hospitals Act to establish a non-budget
neutral national minimum of 0.85 to the Medicare hospital area
wage index, ensuring that rural hospitals receive fair payment
for the care they provide and allow them to compete for and
retain high-quality staff.
These policies would help rural hospitals adapt to the unique
headwinds they face and allow them to remain viable within their
communities.
Maintain the Current Ban on Self-Referral to Physician-Owned Hospitals
(POH)
To help achieve the important goal of preserving health care access
in rural communities, it is important that Congress continue to reject
efforts to weaken the existing ban on self-referral to POHs. Such
arrangements are mired in conflicts of interest, and years of
independent data show such arrangements result in over-utilization of
Medicare services at significant cost to patients and the Medicare
program. It is for this reason the FAH strongly opposes S. 470, The
Patient Access to Higher Quality Health Care Act of 2023.
There is a substantial history of Congressional policy development
and underlying research on the impact of self-referral to POHs. The
empirical record is clear that these conflicts of interest arrangements
of hospital ownership and self-referral by owner physicians promote
unfair competition and result in cherry-picking of the healthiest and
wealthiest patients, excessive utilization of care, and patient safety
concerns. The standing policy includes more than a decade of work by
Congress, involving numerous hearings, as well as analyses by the
Department of Health and Human Services (HHS) Office of Inspector
General (OIG), the Government Accountability Office (GAO), and the
Medicare Payment Advisory Commission (MedPAC).
In 2010, Congress acted to protect the Medicare and Medicaid
programs and the taxpayers that fund them by imposing a prospective ban
on self-referral to new POHs. The FAH strongly believes that the
foundation for the current law must not be weakened.
The law helps ensure that full-service community hospitals,
especially those in rural communities, can continue to meet their
mission to provide quality care to patients. Data from the health care
consulting firm Dobson | DaVanzo, released last month,\5\ shows that
POHs, when compared to other hospitals, treat less medically complex
and more financially lucrative patients, provide fewer emergency
services, and treat fewer COVID-19 cases. Specifically, the new study
shows that POHs:
---------------------------------------------------------------------------
\5\ Dobson | DaVanzo Study: https://www.fah.org/wp-content/uploads/
2023/03/2023-FactSheet_20230323_wAppendixandCharts_POH-vs.-NonPOH-
Only.pdf.
Cherry-pick patients by avoiding Medicaid beneficiaries and
uninsured patients;
Treat fewer medically complex cases;
Enjoy patient care margins 15 times those of community
hospitals;
Provide fewer emergency services--an essential community
benefit; and
Despite POH claims of higher quality, are penalized the
maximum amount by CMS for unnecessary readmissions at five
times the rate of community hospitals.
The new data reinforces many of the findings of earlier studies,
discussed above, by the HHS OIG, GAO, and MedPAC, among others,
documenting the conflicts of interest inherent with POHs that led to
the Congressional ban in 2010.
CMS itself recently proposed to reimpose ``program integrity
restrictions'' on POH expansion criteria to guard against ``a
significant risk of program or patient abuse,'' and to ``protect the
Medicare program and its beneficiaries from overutilization, patient
steering, and cherry-picking.''\6\
---------------------------------------------------------------------------
\6\ FAH Blog on POH. April 24, 2023: https://www.fah.org/blog/
physician-owned-hospitals-are-bad-for-patients-and-communities/.
While POHs create unfair competition across all communities in
which they operate, opening the door to POHs in rural communities
specifically would undermine the delicate health care infrastructure
---------------------------------------------------------------------------
and patient mix that rural hospitals rely on to keep their doors open.
Thus, maintaining current law is key to ensuring that rural
community hospitals can continue to provide quality care to all
patients in their communities. Weakening or unwinding the current ban
opens the door to expanding the very behaviors that Congress
successfully has deterred for more than a decade.\7\
---------------------------------------------------------------------------
\7\ FAH Blog on POH: March 28, 2023: https://www.fah.org/blog/new-
analysis-reaffirms-need-to-maintain-current-law-banning-self-referral-
to-physician-owned-hospitals/?swcfpc=1.
---------------------------------------------------------------------------
Oppose Cutting Medicare Through Site-Neutral Payment Cuts
The FAH strongly opposes site-neutral payment policy proposals
under consideration by the House Energy and Commerce Committee that
would reduce hospital-based outpatient department (HOPD) payments in a
non-budget-neutral manner.
If site-neutral payment cuts were to be enacted, rural hospitals
would be the first facilities to feel the financial strain, forcing
difficult decisions regarding the viability of operations in rural
areas. Rural hospitals are the hub of health care services in their
communities, and site-neutral reductions would put the entire rural
health care infrastructure at risk.
Site-neutral payments do not consider one simple fact: hospitals
and doctors' offices are not the same. Hospitals provide critical
services to entire communities, including 24/7 access to emergency care
and disaster relief. They need to maintain the ability to treat high
acuity patients who require more intense care, and therefore require a
different payment structure. Hospital-affiliated sites offer patients
more integrated care across health care settings, services for which
hospitals need to be properly reimbursed to maintain coordinated, high-
quality care for patients.\8\
---------------------------------------------------------------------------
\8\ FAH Blog on Site Neutral: April 23, 2023: https://www.fah.org/
whats-in-a-name-because-there-is-nothing-neutral-about-site-neutral-
policy/.
Increasingly, care is shifting from the inpatient to outpatient
settings, meaning that patients now seen in HOPDs may require a higher
level of care than traditionally offered--or even available--in a
physician's office. A recently released study from the American
Hospital Association backs up this fact.\9\ Researchers found that
HOPDs treat more underserved populations and sicker, more complex
patients than other ambulatory care sites. The study indicates that
relative to patients seen in independent physician offices and
ambulatory surgical centers, Medicare patients seen in HOPDs tend to
be:
---------------------------------------------------------------------------
\9\ AHA Report: https://www.aha.org/guidesreports/2023-03-27-
comparison-medicare-beneficiary-characteristics-report.
Lower-income;
Non-white;
Eligible for Medicare based on disability and/or end-stage
renal disease;
More severe comorbidities or complications;
Dually-eligible for Medicare and Medicaid; and
Previously seen in an emergency department or hospital
setting.
It is vital that payment for outpatient services provided in a HOPD
reflects the higher overhead costs associated with providing care in
that setting.
Additionally, regulatory requirements such as the Emergency Medical
Treatment and Labor Act (EMTALA), hospital Conditions of Participation,
hospital state licensure, and complex cost reports impose substantial
resource and cost burdens that physician offices and ambulatory
surgical centers do not have and therefore are not reflected in their
payments.
Telehealth
One of the silver linings to emerge from the COVID-19 pandemic is
the increase in health care services provided via telehealth.
Telehealth allows timely access to patient-centered care, enhances
patient choice, and most importantly improves access to care in rural
areas where many patients travel over an hour for a routine doctor's
appointment, and often much further to seek specialty care.
Telemedicine eliminates this geographic barrier and greatly lowers the
bar for accessing quality care. Telehealth enables hospitals to meet
patients literally where they are, allowing for more tailored
treatment.
We thank Congress for extending the pandemic era telehealth
provisions through 2024 in the Consolidated Appropriations Act, 2023.
We urge lawmakers to build on this progress and make permanent pandemic
era Medicare telehealth provisions to improve the health of rural
residents by giving them better access to the care they need.
The FAH is committed to working with Congress to ensure the
availability of affordable, accessible health care for all Americans
including those who live in rural areas. If you have any questions or
would like to discuss these policies further, please do not hesitate to
contact me or a member of my staff at (202) 624-1534.
Sincerely,
Charles N. Kahn III
President and CEO
______
Freespira, Inc.
12020 113th Avenue NE
Building C, Suite #215
Kirkland, WA 98034
800-735-8995
FAX: 844-394-2533
https://freespira.com/
May 17, 2023
U.S. Senate
Subcommittee on Health Care
Committee on Finance
Chairman Benjamin L. Cardin
Ranking Member Steve Daines
430 Dirksen Senate Office Building
Washington, DC 20510
Dear Chairman Cardin and Ranking Member Daines:
Freespira, Inc. commends the work of the Senate Subcommittee on Health
Care for examining obstacles and opportunities to improve health care
access in rural communities.
Rural communities often face significant challenges in accessing
healthcare services, including limited resources, long distances to
healthcare facilities, and a shortage of healthcare professionals.
However, the emergence of digital therapeutics offers a promising
solution to address these issues and transform the landscape of
healthcare delivery in rural areas. By leveraging the power of
technology, digital therapeutics provide accessible, personalized, and
evidence-based interventions, effectively bridging the gap between
patients and care providers.
Increased Access
Digital therapeutics provide a convenient and accessible alternative to
traditional healthcare services for individuals living in rural
communities. Patients can access these interventions through mobile
applications, web-based platforms, and telehealth services from the
comfort of their homes, eliminating the need for long travel times and
expenses associated with accessing healthcare services in urban areas.
This increased access to care ensures that individuals in rural
communities receive timely and effective interventions, reducing the
burden of chronic conditions and preventing the progression of
diseases.
Personalized Care
Digital therapeutics offer tailored interventions based on individual
needs, preferences, and progress. Machine learning algorithms and data-
driven approaches help analyze user input and provide personalized
treatment plans. These interventions can include cognitive-behavioral
therapy (CBT), mindfulness exercises, psychoeducation, and medication
adherence support. By personalizing care, digital therapeutics foster a
sense of autonomy and empower individuals to actively participate in
their own recovery journey. Moreover, engaging interfaces, gamification
elements, and interactive features enhance user engagement, motivation,
and adherence to treatment protocols.
Remote Monitoring and Continuous Care
Digital therapeutics enable remote monitoring and continuous care,
particularly critical for individuals living in rural communities with
limited access to healthcare services. Wearables and sensors can track
physiological and behavioral data, providing valuable insights into a
patient's progress and facilitating early intervention. Healthcare
professionals can use these data to adjust treatment plans, provide
feedback, and offer support, ensuring that patients receive
personalized and ongoing care. Moreover, remote monitoring enables
healthcare providers to detect and manage chronic conditions,
preventing the need for hospitalization and reducing healthcare costs.
Cost-Effectiveness
The cost of healthcare services is often a significant barrier for
individuals living in rural communities, who may have limited financial
resources. Digital therapeutics offer a cost-effective alternative to
traditional treatment modalities, eliminating the need for physical
infrastructure, reducing the demand for specialized personnel, and can
be scaled up to reach a large number of individuals simultaneously.
This affordability makes digital therapeutics an attractive solution
for resource-
constrained healthcare systems and ensures that individuals with
limited financial means can access quality care.
The challenges of accessing healthcare services in rural communities
demand innovative solutions that can overcome barriers to access,
deliver personalized interventions, and reduce stigma. Digital
therapeutics provide a promising way forward, offering accessible,
personalized, evidence-based, and cost-effective care. As technology
continues to advance, the integration of digital therapeutics into
mainstream healthcare systems has the potential to revolutionize the
delivery of healthcare services in rural communities, improving
outcomes and transforming lives on a global scale. By leveraging the
power of technology, digital therapeutics offer a transformative
solution that bridges the gap between patients and care providers,
ensuring that every individual, regardless of their geographical
location, receives timely, effective, and personalized care.
Our Freespira digital therapeutic is an evidenced-based, FDA cleared
treatment for Panic Disorder, Panic Attacks, and PTSD. Patients are
treated in their home with Freespira, and many of our patients are in
rural settings. To date, many thousands of patients have been treated
with Freespira, resulting in life-changing improvements in their
symptoms and quality of life.
Unfortunately, only a handful of insurance companies are paying for the
Freespira treatment for their members, so the number of patients
covered is minuscule compared to the number of patients in the U.S.
suffering from Panic and PTSD. We consistently receive requests from
patients diagnosed with Panic and PTSD who want to be treated with the
Freespira treatment, but neither their insurance company nor CMS will
pay for their treatment, thus limiting access. The Freespira treatment
has demonstrated cost reduction in both commercial and Medicaid
populations, yet the lack of clarity around reimbursement for digital
therapeutics creates a significant barrier to patient access, which
does not allow these treatments to reach their full potential in
improving patient outcomes and reducing healthcare costs.
We look forward to further engaging with your committee on these
critical issues. Please contact [email protected] for any further
information or insights.
Sincerely,
Debra Reisenthel
Founding CEO
______
MedRhythms, Inc.
https://medrhythms.com/
May 23, 2023
U.S. Senate
Subcommittee on Health Care
Committee on Finance
Chairman Benjamin L. Cardin
Ranking Member Steve Daines
430 Dirksen Senate Office Building
Washington, DC 20510
Dear Chairman Cardin and Ranking Member Daines:
MedRhythms commends the work of the Senate Subcommittee on Health Care
for examining obstacles and opportunities to improve health care access
in rural communities.
Rural communities face significantly greater challenges in accessing
healthcare services due to limited resources, long distances to
healthcare facilities, and a shortage of licensed healthcare
professionals. Healthcare access and quality, or lack thereof in rural
communities, is a social determinant of health which can be overcome
when Prescription Digital Therapeutics (PDTs) are available. With the
emergence of PDTs, the landscape of healthcare delivery in rural areas
can be transformed. PDTs are evidence-based therapeutic interventions
that are driven by high quality software programs to treat, manage, or
prevent a disease or disorder. They are used independently or in
concert with medications, devices, or other therapies to optimize
patient care and health outcomes.
Increased Access
The adoption of PDTs can level the healthcare playing field for
individuals living in rural communities. PDTs can be provided to
patients in a variety of ways considering their healthcare needs
including software preloaded in a medical device that is delivered to
the patient' home or a downloadable mobile application. These
technologies are designed such that they require very little
connectivity to WIFI or cellular networks to function addressing
another challenge that exists in many rural areas. Furthermore, data
has shown that utilizing these interventions in the comfort of the
patient's home, eliminating the need for long travel times and expenses
associated with accessing healthcare services in urban areas improves
adherence to therapy and health outcomes. This increased access to care
ensures that individuals in rural communities receive timely and
effective interventions, reducing the burden of chronic conditions and
preventing the progression of diseases.
Personalized Care
PDTs offer personalized interventions based on patient specific
clinical goals based on machine learning algorithms and data-driven
approaches. By personalizing care, PDTs foster a sense of autonomy and
empower individuals to actively participate in their own recovery
journey.
Remote Monitoring and Continuous Care
PDTs can enable remote monitoring, particularly critical for
individuals living in rural communities with limited access to
healthcare services. Wearables and sensors can track physiological and
behavioral data, providing valuable insights into a patient's progress
and facilitating early intervention. Healthcare professionals can use
these data to adjust treatment plans ensuring that patients receive
personalized and ongoing care in the most efficient manner. Moreover,
remote monitoring enables healthcare providers to detect and manage
chronic conditions, preventing the need for hospitalization and
reducing healthcare costs.
Cost-Effectiveness
The challenges of accessing healthcare services in rural communities
demand innovative solutions that can overcome barriers to access,
deliver personalized interventions, and reduce cost. PDTs provide a
promising way forward, offering accessible, personalized, evidence-
based, and cost-effective care. As technology continues to advance, the
further integration of PDTs into the healthcare systems has the
potential to revolutionize the delivery of healthcare services in rural
communities, improving outcomes and transforming lives on a global
scale.
We look forward to further engaging with your committee on these
critical issues. Please contact me at [email protected] for any
further information or insights.
Sincerely,
Owen McCarthy
President
______
National Association of ACOs
2001 L Street, NW, Suite 500
Washington, DC 20036
202-640-1985
[email protected]
https://www.naacos.com/
The National Association of ACOs (NAACOS) appreciates the opportunity
to submit comments in response to the health subcommittee's hearing on
``Improving Health Care Access in Rural Communities: Obstacles and
Opportunities.'' NAACOS represents more than 400 accountable care
organizations (ACOs) in Medicare, Medicaid, and commercial insurance
working on behalf of health systems and physician provider
organizations across the nation to improve quality of care for patients
and reduce health care cost. NAACOS members serve over 8 million
beneficiaries in Medicare value-based payment models, including the
Medicare Shared Savings Program (MSSP) and the ACO Realizing Equity,
Access, and Community Health (REACH) Model, among other alternative
payment models (APMs).
NAACOS appreciates the committee's leadership and commitment to
improving access to health care in rural communities. Access to health
care in rural communities presents many unique challenges with many
communities facing shortages of providers. The USDA Economic Research
Service published data last year showing that 40 percent of rural areas
face primary care shortages and 80 percent have shortages of behavioral
health services.\1\
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\1\ https://www.ers.usda.gov/amber-waves/2022/august/the-most-
rural-counties-have-the-fewest-health-care-services-available/.
For years doctors, hospitals, and other providers have been paid for
each service provided--a system commonly referred to as fee-for-
service. In recent years, innovative providers and policymakers have
increasingly recognized the need to transition to alternative systems
that reward accountability and create incentives for providing care in
a coordinated manner focused around placing people at the center of
their care, and keeping them healthy, rather than just treating them
---------------------------------------------------------------------------
when they get sick.
The ACO model provides an opportunity for providers to work
collaboratively along the continuum while remaining independent. With
primary care as the backbone, ACOs can employ a team-based approach
that allows clinicians to ensure patients receive high quality care in
the right setting at the right time. Importantly, ACOs provides
enhanced flexibilities that allow clinicians to develop interventions
targeted to their populations.
Value-based care is the best care model for all patients, and we have
seen significant adoption among rural providers. However, adoption of
ACOs and value-based care has been stalled by several underlying
issues. Specifically, a focus for rural providers is retaining access
to care. Approaches that require savings to Medicare through discounts
or shared savings may not be appropriate for providers who are paid at
cost or are struggling to remain open.
As the committee continues to discuss long-term approaches to improving
health care access in rural communities, we urge the committee to
consider the following recommendations which would attract more rural
providers to participate in value-based care models.
Extend Financial Incentives for Qualifying APMs. Appropriate financial
incentives help attract physicians and other clinicians to participate
in advanced APMs and reward those that continue to move forward on
their value transitions. These incentive payments also provide
financial support that helps rural practices join and remain in risk-
based payment models. Many practices also reinvest these payments to
help expand services for patients.
In 2022, Congress included a 12-month extension of MACRA's advanced APM
incentive payment in the Consolidated Appropriations Act of 2023. While
this short-term extension ensures that the nearly 300,000 clinicians
working to improve the quality and cost-effectiveness of care continue
to have the financial resources to do so, it will expire at the end of
2023. Going forward the committee should consider:
Providing a multi-year commitment to reforming care delivery by
extending MACRA's 5 percent advanced APM incentive payments.
Ensuring that qualifying thresholds remain attainable to promote
program growth by giving the Centers for Medicare and Medicaid Services
(CMS) authority to adjust qualifying thresholds through rulemaking and
set varying thresholds for models that have difficulty qualifying
because of design elements.
Ensure Participants Join and Remain in Existing APMs. Current and past
APMs have allowed physicians and other clinicians to change care
delivery and improve care coordination. It is essential to remove
barriers to participation and give additional flexibility and tools to
innovate care. The MSSP is the largest and most successful value-based
care program in Medicare and the committee should consider the
following recommendations to continue driving innovation:
Removing the high-low revenue designation in the MSSP that
penalizes certain ACOs, especially safety net providers like Rural
Health Clinics (RHCs), Critical Access Hospitals, and Federally
Qualified Health Centers (FQHCs).
Developing systems for Medicare to provide technical assistance
for APMs that serve rural and underserved populations.
Directing CMS to establish guardrails to ensure that the process
to set financial benchmarks is transparent and appropriately accounts
for regional variations in spending to prevent winners and losers.
Engaging with CMS to encourage the agency to pilot test ACO
quality reporting changes to address remaining implementation
challenges that exist with the current policy. Otherwise, some ACOs may
choose to leave the program because of increased costs and burdens.
Provide a Broader, More Predictable Pathway for More Types of
Clinicians to Engage in APMs. Congress established the Center for
Medicare and Medicaid Innovation (CMMI) in 2010 to develop and test
innovative payment and service delivery models. While CMS's population
health models have seen encouraging growth over the last 10 years,
there has been insufficient model development for all types of
physicians and other clinicians.
CMMI has tested over 50 models, expanding our understanding of how to
shift payment and care processes to improve patient outcomes. However,
few models have met the criteria for expansion and lessons learned are
not always translated into new models. Unfortunately, little is known
about the parameters that must be met for expansion and the model
evaluations fail to consider key aspects of innovating care.
Congress should work with CMMI to ensure that promising models have a
more predictable pathway for being implemented and becoming permanent
and are not cut short due to overly stringent criteria. In February,
NAACOS and other stakeholders sent a letter to committee leaders
outlining the following recommendations for improving CMMI,
including:\2\
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\2\ https://www.naacos.com/assets/docs/pdf/2023/118thCongressValue-
BasedCareRecs
CoalitionLetter.pdf.
Broadening the criteria by which CMMI models qualify for Phase 2
expansion (e.g., does the model account for retaining access to care in
vulnerable regions).
Directing CMMI to engage stakeholder perspectives during APM
development, such as leveraging the Physician-Focused Payment Model
Technical Advisory Committee (PTAC).
Evaluate Parity Between Medicare Value Programs. APMs and the Medicare
Advantage (MA) program provide opportunity for providers to innovate
care and move payments away from fragmented care options to coordinate
care that is rewarded for value. As Congress looks for ways to improve
access to care for rural communities it is important to understand how
the differences between programs like APMs and MA impact care delivery.
The committee should work with the Government Accountability Office
(GAO) to design a study to evaluate parity between APMs and MA so
policymakers can seek greater alignment between the programs to ensure
that both models provide attractive, sustainable options for innovating
care delivery, and to ensure that APMs do not face a competitive
disadvantage.
We appreciate the opportunity to express our views and look forward to
working with the committee to ensure that high-quality, coordinated,
and person-centered care is accessible to all Medicare beneficiaries.
______
National Association of Rural Health Clinics
1009 Duke Street
Alexandria, VA 22314
On behalf of the over 5,300 Rural Health Clinics (RHC) across the
nation, we sincerely appreciate the opportunity to provide a statement
for the record.
The RHC program, first created in 1977, provides outpatient care for
over 60% of rural America \1\ and 11% of the entire country
(approximately 37 million patients). Overall, the Rural Health Clinic
program has been tremendously successful at bolstering access to
healthcare across rural America. However, recent trends in healthcare
such as the increased adoption of telehealth and the continued growth
of Medicare Advantage present obstacles to the continued success of our
nation's Rural Health Clinics.
---------------------------------------------------------------------------
\1\ https://www.narhc.org/News/29910/Sixty-Percent-of-Rural-
Americans-Served-by-Rural-Health-Clinics.
While healthcare-wide trends such as increasingly complex prior
authorization burdens and healthcare workforce shortages have major
impacts on Rural Health Clinics, we would like to focus this statement
---------------------------------------------------------------------------
on the following RHC-specific issues:
1--Medicare Advantage;
2--Telehealth Policy;
3--Outdated Conditions for Certification; and
4--Value-Based Care for RHCs.
Medicare Advantage
The RHC program incentivizes providers to practice in rural areas
through two major benefits: enhanced Medicaid reimbursement, and
enhanced Medicare reimbursement. Operating as a rural health clinic
provides no benefit relative to Medicare Advantage (MA) reimbursement.
This fact stands in contrast to Federally Qualified Health Centers
(FQHCs), who receive supplemental payments \2\ from Medicare which make
up the difference between what traditional Medicare would pay and what
the Medicare Advantage plans are offering. This policy ensures that
FQHCs are not disadvantaged if their patients are increasingly enrolled
in Medicare Advantage plans.
---------------------------------------------------------------------------
\2\ https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/
part-405/subpart-X/subject-group-ECFRb16e804c561ceb4/section-405.2469.
As Medicare Advantage enrollment now exceeds \3\ traditional Medicare
enrollment, RHCs are facing increasing financial strain from MA plans
who are spreading rapidly in certain rural markets and refuse to pay
RHCs the All-Inclusive Rate (AIR) that traditional Medicare does. We
conducted a survey of RHCs and found that approximately half of our
RHCs reported that Medicare Advantage plans do not pay the same as
traditional Medicare.
---------------------------------------------------------------------------
\3\ https://www.barrons.com/articles/medicare-advantage-surpasses-
traditional-medicare-2e5ba7b9.
RHCs must negotiate contracts with each and every Medicare Advantage
plan and are reimbursed according to the terms of that contract. Some
RHCs are able to negotiate reimbursement comparable to traditional
Medicare but many RHCs have little leverage to walk away from the
negotiating table in areas where Medicare Advantage plans have
significantly increased enrollment. Our fear is that Medicare Advantage
plans will enroll a substantial portion of the local Medicare
population and refuse to offer RHCs reimbursement rates that are
---------------------------------------------------------------------------
tenable in rural settings.
NARHC advocates for the creation of a reimbursement floor policy. Such
a policy would allow RHCs and Medicare Advantage plans to continue to
negotiate contracts with each other while also ensuring that MA plans
must offer a reasonable reimbursement level that does not jeopardize
access to care. As the FQHC wrap policy provides FQHCs benefits
relative to Medicare Advantage, an RHC floor payment policy would
ensure that the shift from traditional Medicare to Medicare Advantage
does not harm access to care in rural America.
Telehealth Policy
Telehealth represents a massive opportunity to improve access to care
in rural areas. However, the current telehealth policy threatens rural
health clinics, giving fee-for-service providers stronger incentives to
invest in telehealth than safety-net providers. The longer this remains
the case, the more likely it is that RHCs and FQHCs will fall behind in
the adoption of telehealth relative to their traditional peers.
RHCs and FQHCs were not included \4\ in HHS's emergency expansion of
telehealth policy. For a few weeks at the beginning of COVID, fee-for-
service providers were able to offer telehealth services to their
patients, while RHC and FQHC patients were forced to come in-person to
receive a Medicare-covered healthcare service. The CARES Act \5\
rectified this issue and allowed RHCs and FQHCs to serve as distant
site providers but that legislation did not allow RHCs and FQHCs to
bill for telehealth normally. Instead, the CARES Act created a
``special payment rule'' that paid RHCs outside their normal All-
Inclusive Rate methodology at a level that is significantly less than
what RHCs receive for in-person services. This stands in stark contrast
to traditional physician offices which receive payment parity between
in-person and telehealth services.
---------------------------------------------------------------------------
\4\ https://www.narhc.org/News/28244/NARHC-Sends-Letter-to-Trump-
Administration-on-Telehealth-Services-During-Covid-19-Pandemic
\5\ https://www.narhc.org/News/28271/CARES-Act-Signed-Into-Law.
We are concerned with this ``special payment rule'' methodology for a
whole host of reasons. First and foremost, the payment is significantly
less than what most RHCs and FQHCs would receive for providing the same
service in person, disincentivizing safety-net providers from offering
the service via telehealth. Second, the current rules require RHCs and
FQHCs to ``carve-out'' all telehealth costs from their cost report,
which adds significant administrative burden to the cost-reporting
process. Third, the use of a single telehealth code, G2025, billed
whenever an RHC provides one of the 200+ telehealth services
reimbursable by Medicare, has prevented RHCs from tracking annual
wellness visits and other services provided via telehealth properly,
which hinders their ability to properly participate in ACOs and other
---------------------------------------------------------------------------
quality programs.
Complicating matters is the fact that for mental health services
provided via telehealth, RHCs and FQHCs do use their normal coding and
reimbursement mechanisms. This policy is working well, and we believe
that telehealth should work this way for all services, not just mental
health services.
Should Congress agree to reimbursing RHCs and FQHCs through their
normal payment mechanisms, NARHC believes that some guardrails may need
to be created to ensure that only safety-net providers serving safety-
net patients may receive the enhanced reimbursement rates. We do not
want to create a loophole that allows patients and clinicians in well-
served suburban or urban areas to route their telehealth billing
through the RHC and take advantage of the RHC reimbursement
methodology.
We are pleased that the CONNECT for Health Act would eliminate the
special payment rule in favor of normal payment rules for RHCs and
FQHCs and we urge Congress to rectify this issue, at the latest, as
part of any telehealth extension legislation.
Outdated Conditions for Certification
The Rural Health Clinic program was created in 1977, and the
regulations governing the conditions for certification were finalized
in 1978. As you might imagine, the 45-year-old ruleset is in severe
need of modernization. For this reason, we strongly support \6\ the
Rural Health Clinic Burden Reduction Act (S. 198), which is a
compilation of uncontroversial and cost-neutral policies that simply
modernize the RHC conditions for certification.
---------------------------------------------------------------------------
\6\ https://www.narhc.org/News/29766/RHC-Burden-Reduction-Act-
Introduced-by-Senators-Barrasso-Smith-Blackburn-and-Bennet.
When RHCs were created, the program broke ground by being the first
place where Nurse Practitioners \7\ could bill Medicare directly for
their services. However, as this was new territory for Nurse
Practitioners, Congress included a series of physician oversight
responsibilities as a condition for RHC certification.
---------------------------------------------------------------------------
\7\ https://ojin.nursingworld.org/table-of-contents/volume-26-2021/
number-2-may-2021/post-covid-19-reimbursement-parity-for-nurse-
practitioners/.
Flash forward to 2023, and 27 states have granted Nurse Practitioners
full practice authority. But state scope of practice does not matter if
the NPs work in a Rural Health Clinic because the RHC conditions for
certification still require physicians to see patients in the clinic
and review medical charts among other oversight responsibilities. The
end result is that these NP-led RHCs are forced to comply with outdated
federal RHC scope of practice rules even though they would have full
---------------------------------------------------------------------------
practice authority in other facility types in their state.
The current statute governing conditions for certification as an RHC
simply does not allowing clinicians to practice to the top of their
license. The RHC Burden Reduction Act would rectify this by aligning
RHC scope of practice laws with state scope of practice laws.
Other outdated conditions for certification require RHCs to maintain
lab equipment that is rarely used and discourage the integration of
behavioral health in the RHC setting. These rules only add unnecessary
burden and cost for RHCs. Congress has an opportunity to improve rural
health in a cost-neutral manner by passing the RHC Burden Reduction Act
to modernize the Rural Health Clinic conditions for certification.
Value-Based Care for Rural Health Clinics
NARHC supports the establishment of a quality payment program designed
specifically for Rural Health Clinics. As discussed above, the RHC
program offers a unique reimbursement structure for both Medicare and
Medicaid patients and this payment model is the key distinguishing
feature of the entire program. The enhanced payment methodology allows
for clinics and clinicians to operate in rural and underserved areas,
significantly bolstering access to outpatient care in these
communities.
The unique mechanisms of RHC reimbursement have made it difficult and/
or impossible for RHCs to properly participate in Medicare quality
programs. The current slate of quality initiatives available to
providers are designed for traditional fee-for-service (FFS) settings
and do not translate well into the RHC space. As an example, RHCs use a
different form to submit claims to Medicare than their peers, the UB-
04, as opposed to the CMS-1500 that fee-for-service providers use. As a
result of this fundamental fact, RHC Medicare reimbursement is not
compatible with many of the Medicare quality and value-based programs.
We believe that clinicians that bill exclusively through the RHC
payment methodology should have an opportunity to participate in some
type of quality payment program. As HHS sets ambitious goals to have
every Medicare beneficiary in a value-based care relationship by 2030,
it is imperative for us to consider how the safety-net programs,
specifically RHCs and FQHCs, will be able to participate in this
broader vision.
RHC participation in quality programs could be greatly increased and
improved if a quality payment program specifically for RHCs was
created. Because the RHC payment structure is essential to the RHC
program but also quite different than FFS payment, NARHC asserts that
the best way to bring value into the RHC model is to design a program
solely for RHCs using the All-Inclusive Rate methodology as the
foundation. We believe that such a quality reporting program could be
implemented in a cost neutral way that would improve efficiency and
encourage improved value-based care across the entire RHC program.
Conclusion
The National Association of Rural Health Clinics thanks the Senate
Finance Subcommittee on Health for organizing this hearing. We hope
that the above statement helps illuminate some of the policy obstacles
and opportunities facing the 5,300 Rural Health Clinics across the
country. Should the Committee have any questions, the NARHC is happy to
serve as a resource, you may reach us by phone at (202) 543-0348, and
email us at [email protected], or [email protected].
______
Renalis
425 Literary Road
Cleveland, OH 44113
May 17, 2023
U.S. Senate
Committee on Finance
Subcommittee on Health Care
Chairman Benjamin L. Cardin
Ranking Member Steve Daines
430 Dirksen Senate Office Building
Washington, DC 20510
Dear Chairman Cardin and Ranking Member Daines:
Renalis commends the work of the Senate Subcommittee on Health Care for
examining obstacles and opportunities to improve health care access in
rural communities.
Introduction to Renalis
Renalis is a Cleveland-based company committed to developing pelvic
health platforms to improve effectiveness and efficiency of Patient and
Urology Provider interactions, optimize patient outcomes, and decrease
healthcare costs.
Renalis' first commercial platform will be an FDA-approved prescription
digital therapeutic for Overactive Bladder (OAB) in women. Of the 33
million adult Americans suffering from some form of urinary
incontinence, 75% to 80% of those are women. And about 23% of these
women are over 60.
Urinary Care in the Rural Communities
Rural communities face significant challenges in accessing healthcare
services, including limited resources, long distances to healthcare
facilities, and a shortage of healthcare professionals. When a woman
seeks care like OAB, unfortunately, if she happens to live in one of
the over 60% of the counties that have ZERO Urology Providers, she will
not be able to access the high-quality in-person care that she needs.
(Please see last page for the US Map).
OAB affects performance of daily activities and social function such as
work, traveling, physical exercise, sleep and sexual function. If this
condition is left untreated, it leads to impaired quality of life
accompanied by emotional distress and depression.
Innovative Solution to Increase Access
The emergence of digital therapeutics offers a promising solution to
address these issues and transform the landscape of healthcare delivery
in rural areas. By leveraging the power of technology, digital
therapeutics provide accessible, personalized, and evidence-based
interventions, effectively bridging the gap between patients and care
providers.
Digital therapeutics provide a convenient and accessible alternative to
traditional healthcare services for individuals living in rural
communities. Patients can access these interventions through mobile
applications, web-based platforms, and telehealth services from the
comfort of their homes, eliminating the need for long travel times and
expenses associated with accessing healthcare services in urban areas.
This increased access to care ensures that individuals in rural
communities receive timely and effective interventions, reducing the
burden of chronic conditions and preventing the progression of
diseases.
Personalized Care
Digital therapeutics offer tailored interventions based on individual
needs, preferences, and progress. Machine learning algorithms and data-
driven approaches help analyze user input and provide personalized
treatment plans. These interventions can include cognitive-behavioral
therapy (CBT), mindfulness exercises, psychoeducation, and medication
adherence support. By personalizing care, digital therapeutics foster a
sense of autonomy and empower individuals to actively participate in
their own recovery journey. Moreover, engaging interfaces, gamification
elements, and interactive features enhance user engagement, motivation,
and adherence to treatment protocols.
Remote Monitoring and Continuous Care
Digital therapeutics enable remote monitoring and continuous care,
particularly critical for individuals living in rural communities with
limited access to healthcare services. The digital dashboard can track
a patient's progress. Healthcare professionals can use this data to
adjust treatment plans, provide feedback, and offer support, ensuring
that patients receive personalized and ongoing care. Moreover, remote
monitoring enables healthcare providers to detect and manage chronic
conditions, preventing the need for hospitalization and reducing
healthcare costs.
Cost-Effectiveness
The cost of healthcare services is often a significant barrier for
individuals living in rural communities, who may have limited financial
resources. Digital therapeutics offer a cost-effective alternative to
traditional treatment modalities, eliminating the need for physical
infrastructure, reducing the demand for specialized personnel, and can
be scaled up to reach many individuals simultaneously. This
affordability makes digital therapeutics an attractive solution for
resource-constrained healthcare systems and ensures that individuals
with limited financial means can access quality care.
The challenges of accessing healthcare services in rural communities
demand innovative solutions that can overcome barriers to access,
deliver personalized interventions, and reduce stigma. Digital
therapeutics provide a promising way forward, offering accessible,
personalized, evidence-based, and cost-effective care. As technology
continues to advance, the integration of digital therapeutics into
mainstream healthcare systems has the potential to revolutionize the
delivery of healthcare services in rural communities, improving
outcomes and transforming lives on a global scale. By leveraging the
power of technology, digital therapeutics offer a transformative
solution that bridges the gap between patients and care providers,
ensuring that every individual, regardless of their geographical
location, receives timely, effective, and personalized care.
Renalis welcomes the opportunity to discuss in further detail. If you
have any questions regarding these comments, please do not hesitate to
contact me at: (312) 287-1951 or at: [email protected].
Respectfully submitted,
Missy Lavender
CEO and Founder
Attachment: Over 60% of counties have ZERO Urologists.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
TABLE 1-5
Rurality Level of Primary Practice Location
------------------------------------------------------------------------
Number of Practicing
Rurality Level * Urologists Percent (%)
------------------------------------------------------------------------
Metropolitan areas 12,576 90.0
Nonmetropolitan 1,397 10.0
areas
Micropolitan 1,111 7.9
Small town 224 1.7
Rural 62 0.5
Total 13,976 100.0
------------------------------------------------------------------------
Data sources: National Provider Identifier 09/2022 file, Rural-Urban
Commuting Area Codes Data from RUCA3.10.
* An area was classified as a Metropolitan Area with a population size
50,000 or a Nonmetropolitan Area otherwise. The Nonmetropolitan Area
was further classified as Micropolitan Area (population 10,000-
49,999), Small Town (population 2,500-9,999) and Rural Area
(population < 2,500).
[all]