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Reforming Rural Health Care in the Era of COVID-19

The COVID-19 pandemic has exacerbated the health care challenges that have long plagued rural communities, and underscores why recent recommendations from the Bipartisan Policy Center’s Rural Health Task Force are now more important than ever.

Today, rural America faces the dual problems of caring for the recent influx of sick patients while figuring out how to cope with massive revenue losses that began early in the pandemic when they had to cancel elective procedures.

Even before the pandemic, rural hospitals were struggling. Indeed, 128 rural hospitals have closed since 2010, including 10 so far this year.1 And according to the 2020 rural hospital sustainability index, an additional 354 rural hospitals across 40 states are at risk of closing with 81% of those considered highly essential to the health and economic well-being of their communities.2

For rural hospitals and clinics, COVID-19 is now threatening their very existence. This puts rural Americans at greater risk of losing their only local access to care both during the pandemic and after the virus is gone. The virus, while initially hitting predominately urban areas, is now spreading in rural communities. As of May 19th, four of the 10 worst current confirmed outbreaks in the U.S. are in rural Southern counties.3 The rates of infection are also rising in other rural communities across the country, largely connected to food-processing facilities, farms, and other large-scale industries where people work closely together and do not have the option of teleworking.4

If implemented by Congress, the task force’s recommendations will better equip rural communities to face the challenges of COVID-19 today and build stronger rural health care systems in the future.

In 2019, BPC’s task force began its work under the leadership of co-chairs former Senate Majority Leader Tom Daschle; former Sen. Olympia Snowe; former Gov. Ronnie Musgrove; and former Gov. and Secretary of Health and Human Services Tommy Thompson. The goal was to produce policy recommendations that would improve access to quality, affordable health care in rural communities. The challenges were many and obvious. Rural residents tend to be older and sicker than their urban counterparts; they are more likely to experience potentially preventable death from the five leading causes: heart disease, cancer, unintentional injuries, chronic lower respiratory disease, and stroke.5 Rural communities struggle to recruit and retain health care providers and often lack the broadband needed to make use of telehealth. In a BPC and American Heart Association poll released last year, more than half of rural residents (54%) said access to medical specialists, such as cardiologists or oncologists, is a problem in their local community and that the availability of appointments (56%) and the distance to receive care (50%) are barriers to accessing health care.6

The pandemic has exacerbated each of these challenges. This virus is more dangerous and deadly for those who are older and those who have serious underlying medical conditions including heart conditions and chronic lung disease.7 Treatment for the very ill often requires sophisticated equipment in intensive care units overseen by specially trained health providers, but health care workforce shortages for both primary and specialty care are widespread in rural areas. In fact, 18 million people live in counties that have hospitals but no intensive care units and nearly 11 million more Americans reside in counties with no hospital at all.8

And rural hospitals are facing more strain than ever as they have canceled elective procedures to preserve beds and personal protective equipment, or PPE, for COVID-19 patients in compliance with guidance from the Centers for Disease Control and Prevention. BPC has heard from rural providers that are losing millions of dollars each month, furloughing staff, and closing facilities. In addition to the financial stresses, these providers expressed concern about supply chain issues and being able to adequately plan for a surge of COVID-19 patients in rural communities.

Congress and the administration have taken significant steps to address these immediate concerns, including earmarking funding for rural providers to help fill the financial gaps and dramatically expanding the coverage of telehealth services available through Medicare.

However,9 rural communities need long-term, permanent policy changes to address the health and health care disparities that make COVID-19 so particularly dangerous to rural residents.

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Recommendations from BPC’s Rural Health Task Force

1. Stabilizing Rural Hospital and Clinic Infrastructure – Near Term Policies

  • Provide immediate financial relief to rural hospitals.
  • Make certain rural hospital designations or payment adjustments permanent.
  • Allow new flexibilities around rural hospital care delivery and expand opportunities for rural hospitals and clinics to coordinate service offerings.
  • Enact payment reforms to shore up rural health clinics and expand access to advanced practice clinicians in rural clinics.

As noted above, even before this crisis, many rural hospitals and health providers faced significant financial instability and rural hospitals were closing at an alarming rate. COVID-19 has placed even more financial pressure on these institutions. Given this, the task force’s proposals offer immediate solutions to stem the tide of rural hospital and clinic closures. Many of these policies are short term in nature and are intended to provide a bridge to longer-term reforms while helping to keep these facilities afloat during this crisis.

2. Transforming Rural Hospital and Clinic Infrastructure – Long Term Solutions

Ensure rural communities have access to sustainable, quality rural hospital and clinic services:

  • Support rural communities in conducting a community needs assessment and developing an action plan.
  • Establish a series of new rural transformation models, including:
    • A Rural Emergency and Outpatient, or REO, hospital designation that recognizes the shift away from inpatient centric care
    • An Extended Rural Services Program
    • Multi-payer global budget models
    • Other Center for Medicare & Medicaid Innovation, or CMMI, initiatives to increase coordination and integration of rural hospital and clinic services
  • Support opportunities to advance rural health care quality.

While short-term help is necessary, it is also important that we look forward and provide rural hospitals and clinics with tools and opportunities to adapt and better serve their communities to address the long-term health care needs and health disparities that exacerbate the threat of COVID-19 in rural America. To accomplish this goal, BPC’s task force recommends that rural communities conduct a wide-ranging needs assessment and establish an action plan.

It also recommends that Congress and the administration establish several new transformation models or pathways that rural hospitals could pursue based on which option best fits their community need and would be sustainable in the future. These include a Rural Emergency and Outpatient, or REO, model, which focuses on outpatient and emergency care, and an Extended Rural Services Program that would allow Federally Qualified Health Centers and Rural Health Clinics to begin offering hospital-level services that might not be available following a rural hospital closure.

The task force also recommends that the Center for Medicare & Medicaid Innovation (CMMI) develop proposals to encourage and incentivize payers and providers to come together in rural communities to advance health care transformation and, where appropriate, reduce health care spending, including through the possible use of global budget models.

3. Transforming Clinician Payment and Delivery in Rural Areas

Ensure access to high-quality, local care:

  • Eliminate barriers to the adoption of value-based care.
  • Improve reimbursement for clinicians practicing in rural areas.
  • Reduce administrative burden for providers.

Rural health clinicians, like rural hospitals, have faced tight financial margins that have been exacerbated by COVID-19. The task force recommends a number of changes that would make it easier for rural providers to participate in the transformation toward a value-based health care system, such as exempting chronic care management services from beneficiary cost-sharing requirements, exempting rural Medicare beneficiaries from the prohibition against same day services, increasing the number of rural-specific CMMI demonstrations, and providing incentives to patients to receive health care locally when possible.

Recommendations also include improving reimbursement rates for clinicians practicing in rural areas and reducing their administrative burdens. These steps are important for ensuring access to the high-quality, local health care needed to help rural residents address the chronic health conditions that COVID-19 exploits.

4. Improving Access to Quality Maternal Care in Rural Areas

Ensure access to obstetric and perinatal services in rural areas.

  • Increase reimbursement rates for rural hospital obstetric units.
  • Enhance the Federal Medical Assistance Percentage rate for rural hospital obstetric units.
  • Increase funding of maternal health training programs for primary care providers.
  • Direct the CDC to improve rural maternal mortality data surveillance.

While less directly related to COVID-19, the Task Force also focused on the shortage of quality maternal care in rural areas. Nationally, maternal mortality has more than doubled over the past two decades, with rural areas faring worse than urban areas.10 11 There are many causes, but evidence shows that a recent loss of rural obstetric services directly correlates with poor clinical outcomes and increased infant and maternal mortality.12 To address these dire concerns, the task force recommends ensuring that rural hospitals receive adequate funding for obstetric services through both a direct increase in reimbursement for hospital-based maternity care and by incentivizing states to increase their reimbursements through an enhanced Federal Medical Assistance Percentage (FMAP).

The task force also recommends strengthening training programs for primary care providers to enable them to better provide pre-natal care when needed and improving the CDC’s rural maternal mortality data collection. These steps will help improve access to quality maternal care in rural communities.

5. Ensuring an Adequate Rural Health Care Workforce

Build a sustainable rural workforce

  • Improve utilization of currently available workforce.
  • Strengthen the Health Resources and Services Administration rural workforce programs.
  • Expand federal rural workforce recruitment and retention initiatives.

The shortage of rural health care providers exacerbates the problems of COVID-19. Treating this virus is labor-intensive and requires a strong, healthy health care workforce, but, as noted above, rural communities have long struggled to recruit and retain health care providers. To address this problem, the task force recommends steps to improve utilization of the current workforce by expanding reimbursement, better enabling providers to work at the top of their license and eliminating restrictions that limit the prescribing of medication assisted treatment for opioid use disorder.

They also recommend improvements to the Health Resources and Services Administration rural workforce programs, an expansion of the number of international medical graduates serving in rural areas, and a new federal tax credit for providers that work in rural communities. These changes will help ensure that rural areas have the medical professionals that they need to meet the needs of their patients, both during times of crisis and to improve every day health.

6. Breaking Down Barriers to Technology in Rural Communities

Increase access to health care services in rural areas

  • Support efforts to expand broadband and collect accurate broadband data in rural and tribal areas.
  • Remove restrictions that prevent full utilization of currently available technology in areas without broadband access.
  • Expand the list of authorized sites of service for telehealth.
  • Streamline licensure requirements.
  • Prioritize rural-specific training curricula for the health IT workforce.

Finally, the task force looked at how technology can better improve access to care in rural communities. COVID-19 has led to a dramatic increase in the use of telehealth across the United States. As Congress and the administration have reduced regulatory barriers, providers have utilized telehealth tools to provide the care that people need from a safe distance. The benefits of telehealth during a pandemic are clear: it limits patient and provider exposure and expands the available workforce, allowing providers from less hard-hit areas to fill in for providers in COVID-19 hot spots. This latter point directly connects to why telehealth, both during and after COVID-19, is so critical in rural communities and why many of the regulatory changes that have expanded the use of telehealth should be maintained after this national public health emergency.

Telehealth enables rural communities to tap into provider networks in areas without provider shortages and helps address the challenges that so many rural residents have when they live long distances from health care providers by allowing them to receive care at home when appropriate. The task force made a number of policy proposals to expand the use of telehealth, some of which have been enacted on a temporary basis during the pandemic. These include removing restrictions on the types of devices that can be used for telehealth, expanding the list of authorized sites, and reducing the licensure barriers to practicing telehealth across state lines. It also recommends strengthening investments in broadband in rural communities and providing funding for rural-specific training for the health IT workforce.

Rural Americans were struggling to access high quality, affordable health care before COVID-19, but this pandemic has demonstrated just how deep and difficult those challenges really are. But there are solutions. The recommendations from BPC’s Rural Health Task Force provide a path forward: policies that will help rural communities pull through the current crisis and build a stronger future.

Read the full report and recommendations here

End Notes

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