Reforming Rural Health Care in the Era of COVID-19

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

^{1 https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/
2 https://guidehouse.com/insights/healthcare/2020/rural-hospital-sustainability-index
3 https://www.facingsouth.org/2020/05/here%27s-what%27s-driving-rural-souths-covid-19-outbreaks
4 https://www.vox.com/2020/4/28/21239536/coronavirus-georgia-south-dakota-missouri-nebraska-rural-america
5 https://www.cdc.gov/media/releases/2019/p1107rural-americans.html
6 https://bipartisanpolicy.org/press-release/new-poll-by-bpc-and-american-heart-association-shows-rural-health-may-be-a-powerful-issue-in-2020-election/
7 https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html
8 https://khn.org/news/as-coronavirus-spreads-widely-millions-of-older-americans-live-in-counties-with-no-icu-beds/
9 https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
10 https://www.cdc.gov/mmwr/volumes/68/wr/mm6818e1.htm?s_cid=mm6818e1_whttp://10.1097/AOG.0b013e31826d60c5
11 https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm?CDC_AA_refVal=https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.ht
12 https://www.ruralhealthweb.org/NRHA/media/Emerge_NRHA/Advocacy/Policy%20documents/2019-NRHA-Policy-Document-Access-to-Rural-Maternity-Care.pdf}