[Congressional Record Volume 164, Number 139 (Tuesday, August 21, 2018)]
[Senate]
[Pages S5783-S5784]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
SA 3886. Mr. GRASSLEY (for himself, Ms. Klobuchar, and Mr. Gardner)
submitted an amendment intended to be proposed by him to the bill H.R.
6157, making appropriations for the Department of Defense for the
fiscal year ending September 30, 2019, and for other purposes; which
was ordered to lie on the table; as follows:
At the end, add the following:
DIVISION C--RURAL EMERGENCY ACUTE CARE HOSPITAL ACT
SECTION _01. SHORT TITLE.
This division may be cited as the ``Rural Emergency Acute
Care Hospital Act''.
SEC. _02. FINDINGS.
Congress finds the following:
(1) According to the University of North Carolina's Center
for Health Services Research, 55 rural hospitals have closed
in the Unites States since January 2010.
(2) In 2014, iVantage conducted a study for the National
Rural Health Association and found 283 hospitals at risk of
closure based upon performance indicators that matched those
facilities already forced to close in this decade.
(3) Researchers at the University of North Carolina
identified inpatient volume as a substantial contributing
factor to the financial performance of rural hospitals, with
many of the at-risk hospitals having an average daily bed
census of less than two.
(4) Adverse impacts to the local economy and the loss of
timely access to emergency medical care are 2 major effects
of rural hospital closures.
(5) According to the National Center for Rural Health
Works, the typical rural hospital creates over 140 jobs and
generates $6,800,000 in compensation while serving an average
population of 14,600.
(6) The 2014 iVantage study estimates that the 283 at-risk
hospitals could result in the loss of 36,000 health care
jobs, 50,000 community jobs, and $10,600,000,000 in gross
domestic product.
(7) Time is the most critical factor for achieving
successful outcomes in emergency medicine, and emergency
medical clinicians refer to the time-sensitive period during
which successful outcomes may be best achieved as the
``golden hour''.
(8) The National Conference of State Legislatures states
that 60 percent of trauma deaths in the United States occur
in rural areas, where only 15 percent of the population is
represented.
(9) The disproportionate percentage of trauma deaths in
rural areas is likely attributable in large part to a
combination of response time to the scene and distance to the
nearest emergency room to stabilize trauma victims.
(10) The percentage of trauma deaths occurring in rural
areas could continue to increase as more rural hospitals
close, further limiting access to emergency services and
requiring patients to travel longer distances to receive
emergency medical care.
(11) The creation of a rural emergency hospital designation
under the Medicare program will allow facilities in rural
areas to provide emergency medical services without having to
maintain inpatient beds.
(12) In addition to providing emergency care, rural
emergency hospitals could convert the space previously used
for inpatient services to provide other medical services
including, but not limited to, observation care, skilled
nursing facility care, infusion services, hemodialysis, home
health, hospice, nursing home care, population health, and
telemedicine services.
SEC. _03. RURAL EMERGENCY HOSPITAL PROGRAM.
(a) In General.--
(1) Rural emergency hospital and services defined.--Section
1861 of the Social Security Act (42 U.S.C. 1395x) is
amended--
(A) in subsection (e), in the last sentence of the matter
following paragraph (9), by inserting ``or a rural emergency
hospital (as defined in section 1861(jjj)(1))'' before the
period at the end; and
(B) by adding at the end the following subsection:
``Rural Emergency Hospital; Rural Emergency Hospital Outpatient
Services
``(jjj)(1) The term `rural emergency hospital' means a
facility that--
``(A)(i) as of December 31, 2016--
``(I) was a critical access hospital; or
``(II) was a hospital with not more than 50 beds located in
a county (or equivalent unit of local government) in a rural
area (as defined in section 1886(d)(2)(D)), or was a hospital
with not more than 50 beds that was treated as being located
in a rural area pursuant to section 1886(d)(8)(E); or
``(ii) was a critical access hospital described in clause
(i)(I) or a hospital described in clause (i)(II) that ceased
operations during the period beginning on the date that is 5
years prior to the date of the enactment of this subsection
and ending on December 30, 2016;
``(B) provides 24-hour emergency medical care and
observation care that does not exceed an annual per patient
average of 24 hours or more than 1 midnight;
``(C) does not provide any acute care inpatient beds and
has protocols in place for the timely transfer of patients
who require acute care inpatient services or other inpatient
services;
``(D) has elected to be designated as a rural emergency
hospital;
``(E) has received approval to operate as a rural emergency
hospital from the State under section 1834(v)(3)(A); and
``(F) is certified by the Secretary under section
1834(v)(3)(B).
``(2) The term `rural emergency hospital outpatient
services' means medical and other health services furnished
by a rural emergency hospital on an outpatient basis.
[[Page S5784]]
``(3) Nothing in this subsection or section 1834(v)(3)
shall be construed to prohibit a rural emergency hospital
from providing extended care services.''.
(2) Payment for rural emergency hospital services.--
(A) In general.--Section 1833(a) of the Social Security Act
(42 U.S.C. 1395l(a)) is amended--
(i) in paragraph (8), by striking ``and'' at the end;
(ii) in paragraph (9), by striking the period at the end
and inserting ``; and''; and
(iii) by inserting after paragraph (9) the following new
paragraph:
``(10) in the case of rural emergency hospital emergency
services and services provided by a rural emergency hospital
or other provider of ambulance services to transport patients
who require acute care inpatient services or other inpatient
services from such rural emergency hospital to a hospital or
critical access hospital, the amounts described in section
1834(v).''.
(B) Payment amount.--Section 1834 of the Social Security
Act (42 U.S.C. 1395m) is amended by adding at the end the
following subsection:
``(v) Payment Rules Relating to Rural Emergency
Hospitals.--
``(1) Payment for rural emergency hospital outpatient
services.--
``(A) In general.--The amount of payment for rural
emergency hospital outpatient services of a rural emergency
hospital is equal to 110 percent of the reasonable costs of
providing such services.
``(B) Telehealth services.--For purposes of this paragraph,
in determining the reasonable costs of providing rural
emergency hospital outpatient services, costs associated with
having a backup physician available via a telecommunications
system shall be considered reasonable costs.
``(2) Payment for transportation services.--The amount of
payment for services provided by a rural emergency hospital
or other provider of ambulance services to transport patients
who require acute care inpatient services or other inpatient
services from such rural emergency hospital to a hospital or
critical access hospital is equal to 110 percent of the
reasonable costs of providing such services.
``(3) Requirements for rural emergency hospitals.--
``(A) State approval to operate as a rural emergency
hospital.--No payment shall be made under this subsection to
a facility, or to a provider of ambulance services providing
transportation services from such facility, unless the State
in which the facility is located has approved the facility's
designation as a rural emergency hospital.
``(B) Certification of rural emergency hospital.--
``(i) In general.--No payment shall be made under this
subsection to a facility, or to a provider of ambulance
services providing transportation services from such
facility, unless the facility has been certified by the
Secretary as a rural emergency hospital.
``(ii) Certification requirements.--The Secretary shall
certify a facility as a rural emergency hospital if the
facility--
``(I) meets the criteria for rural emergency hospitals
described in subparagraphs (A) through (E) of section
1861(jjj)(1);
``(II) either--
``(aa) is verified by the American College of Surgeons or a
State as having the resources required of a level IV trauma
center or higher; or
``(bb) employs healthcare professionals that successfully
completed within the preceding 4 years--
``(AA) the Advanced Trauma Life Support Course offered by
the American College of Surgeons; or
``(BB) another trauma training program for healthcare
professionals that is accepted by a State trauma system for
certification purposes;
``(III) has in effect a transfer agreement with a level I
or level II trauma center; and
``(IV) meets such staff training and certification
requirements as the Secretary may require.
``(4) Coinsurance.--
``(A) In general.--The amount of payment for rural
emergency hospital services or transportation services made
to a rural emergency hospital or other provider of ambulance
services under this subsection shall be reduced by the
coinsurance amount described in subparagraph (B).
``(B) Coinsurance amount.--The coinsurance amount described
in this subparagraph, with respect to an item or service
provided by a rural emergency hospital or provider of
ambulance services, shall be calculated in the same manner as
the coinsurance amount for an outpatient critical access
hospital service is calculated under section 1866(a)(2).''.
(b) Waiver of Distance Requirement for Replacement CAHs;
Subsequent Redesignation of Rural Emergency Hospitals as
CAHs.--Section 1820(c)(2) of the Social Security Act (42
U.S.C. 1395i-4(c)(2)) is amended--
(1) in subparagraph (B)(i)(I), by inserting ``subject to
subparagraph (F),'' before ``is located''; and
(2) by adding at the end the following new subparagraphs:
``(F) Option to waive distance requirement.--Beginning on
the date of the enactment of this subparagraph, for every
critical access hospital located in a State that is certified
as a rural emergency hospital under section 1834(v)(3)(B),
the State shall have the option of waiving the distance
requirement described in subparagraph (B)(i)(I) with respect
to another facility located in the State that is seeking
designation as a critical access hospital under this
paragraph.
``(G) Redesignation of a rural emergency hospital as a
critical access hospital.--A rural emergency hospital that
was previously designated as a critical access hospital under
this paragraph may elect to be redesignated as a critical
access hospital (in the same manner that the hospital was
originally designated as a critical access hospital) at any
time, subject to such conditions as the Secretary may
establish.''.
(c) Studies and Reports.--
(1) Studies.--The Secretary of Health & Human Services
shall conduct 3 studies to evaluate the impact of rural
emergency hospitals on the availability of health care and
health outcomes in rural areas (as defined in section
1886(d)(2)(D) of the Social Security Act (42 U.S.C.
1395ww(d)(2)(D))). The Secretary shall conduct a study--
(A) 2 years after the date of the enactment of this Act;
(B) 5 years after the date of the enactment of this Act;
and
(C) 10 years after the date of the enactment of this Act.
(2) Reports.--Not later than 6 months after each date that
the Secretary of Health & Human Services is required to
conduct a study under paragraph (1), the Secretary shall
submit a report to Congress containing the results of each
such study.
(d) Effective Date.--The amendments made by this section
shall apply to items and services furnished on or after the
date that is 1 year after the date of the enactment of this
Act.
SEC. _04. INCLUSION OF EMERGENCY MEDICINE AS HEALTH SERVICES
UNDER THE NATIONAL HEALTH SERVICE CORPS.
Section 331(a)(3)(D) of the Public Health Service Act (42
U.S.C. 254d(a)(3)(D)) is amended by inserting ``, and
includes emergency medicine provided by physicians in a rural
emergency hospital (as defined in section 1861(jjj) of the
Social Security Act)'' before the period.
SEC. _05. PERMITTING HOSPITALS WITH APPROVED RESIDENCY
PROGRAMS IN EMERGENCY MEDICINE TO INCLUDE TIME
SPENT BY INTERNS AND RESIDENTS IN THE EMERGENCY
DEPARTMENT OF A RURAL HOSPITAL IN FULL-TIME
EQUIVALENT COUNT.
(a) Indirect Medical Education.--Section 1886(d)(5)(B)(iv)
of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is
amended by adding at the end the following new subclause:
``(III) Effective for discharges occurring on or after
October 1, 2017, all of the time spent in patient care
activities in the emergency department of a rural hospital by
interns and residents in emergency medicine from a hospital
with an approved medical residency training program (as
defined in subsection (h)(5)(A)) in such specialty shall be
included in determining the number of full-time equivalent
interns and residents in such program if the hospital with
such program incurs the costs of the stipends and fringe
benefits of the interns or residents during the time the
interns or residents spend in that rural hospital in
accordance with subclause (II). In this subclause, the term
`rural hospital' means a hospital that is located in a rural
area (as defined for purposes of paragraph (2)(D)).''.
(b) Direct Medical Education.--Section 1886(h)(4)(E) of the
Social Security Act (42 U.S.C. 1395(h)(4)(E)) is amended--
(1) in clause (ii), by striking the period at the end and
inserting ``; and'';
(2) by inserting after clause (ii) the following new
clause:
``(iii) effective for cost reporting periods beginning on
or after July 1, 2017, all of the time so spent in the
emergency department of a rural hospital by residents in
emergency medicine from a hospital with an approved medical
residency training program in such specialty shall be counted
towards the determination of full-time equivalency in such
program if the hospital with such program bears all, or
substantially all, of the costs of training such residents in
the rural hospital. In this subparagraph, the term `rural
hospital' means a hospital that is located in a rural area
(as defined for purposes of subsection (d)(2)(D)).''; and
(3) by adding at the end the following new sentence: ``For
purposes of this subparagraph, the emergency department of a
rural hospital described in clause (iii) is a nonprovider
setting.''.
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