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Reinventing Rural Health Care: A Case Study of Seven Upper Midwest States

Wednesday, January 17, 2018

Reinventing Rural Health Care: A Case Study of Seven Upper Midwest States

In 2017, the Bipartisan Policy Center and the Center for Outcomes Research and Education (CORE) spoke with over 90 national thought leaders and stakeholders about the current state of rural health care in the Upper Midwest region, including Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, and Wyoming. BPC and CORE used these discussions to determine the real-world implications of existing federal policies, to understand ongoing care challenges, and to identify opportunities for improvement in rural health care access and delivery.

This paper details the findings from our outreach efforts. It begins by providing context for the current policy debate and offers a detailed account of different issues and perspectives that are shaping that debate. It then highlights key points and takeaways from the roundtables and interviews and identifies the challenges and opportunities for advancing rural health policies.

What We Learned

Rural health issues affect more than just the Upper Midwest region and the seven states included in this effort. Furthermore, these issues do not exist in isolation – they are interdependent and build off each other. The nation cannot just fix one part of rural health care; the whole system needs be addressed.

Not every rural community needs to have a Critical Access Hospital (CAH); communities should tailor available services to the needs of the community, which for many rural areas are driven by changing demographics.

BOTTOM LINE: In order to build tailored delivery services, policies need to be flexible and not just have a “one-size-fits-all” approach. The Rural Emergency Acute Care Hospital Act envisions transforming CAHs in certain communities from small inpatient care centers to new models, such as rural emergency centers.

Once the right system and services have been identified for a community, funding mechanisms and payment models should reflect the specific challenges that rural areas face – such as small population size and high operating costs. Sparse populations mean a smaller number of patients, so reimbursement metrics must take into account low patient volumes. Rural health care providers are eager to participate in value-based alternative-payment models, but they need workable approaches and metrics.

BOTTOM LINE: Policymakers should consider the unique challenges faced in rural areas when developing metrics and funding mechanisms. Rural health systems should work together in order to secure appropriate funding mechanisms and implement innovative models.

With the appropriate services and funding, rural communities can build sustainable and diverse workforces. Rural health can no longer survive on the back of one physician serving an entire community 24/7. Building and supporting the primary care physician workforce should be a high priority, and the expectation of care quality should be the same in rural as in more urban areas of the country. Also, alternative providers practicing at the top of their licenses, such as nurse practitioners and physician assistants, can fill vital primary care roles in the community. The health care workforce in rural communities should reflect the complex physical, behavioral, and social needs of their members. Communities should start young and think local for recruitment with pipeline programs that encourage interest in the health sector in local middle- and high-school students. Universities and colleges should reserve spots in medical programs for rural residents.

BOTTOM LINE: Communities should focus on right-sizing the health care workforce for their needs. Health care administrators are starting to think creatively by employing case managers, community-health workers, and in-home providers to help meet the needs of the community; policies should support these efforts.

Finally, health professionals working in rural areas need the right tools for success. Telemedicine is one tool that can be used support both rural patients and rural providers. Not only do these services improve access by connecting remote patients with specialists located elsewhere, but they provide much-needed peer support to rural health professionals who often work in professional isolation. Telemedicine may prove to be critical in improving provider recruitment and retention, though challenges remain with broadband availability and reimbursement.

BOTTOM LINE: As workforce models change, rural health systems need to equip health professionals with the tools necessary to provide quality care to patients. Telemedicine is a promising way to increase patient access and create a peer network for rural providers.

Due to its complex nature, coordinated federal, state, and local efforts will be needed to support improvements to rural health care. This requires the effort of policymakers from all 50 states.

What's the Current Policy Trajectory?

A few highlights of current activities and proposals:

The Save Rural Hospitals Act proposes providing financial relief to rural hospitals by eliminating the Medicare sequester for rural hospitals and by providing a permanent extension of rural and super-rural ambulance payments, as well as by establishing a new designation for rural hospitals that allows them to transform into outpatient-care hospitals.

Under one draft legislative proposal developed by the National Rural Health Association to give CAHs an on-ramp to move into value-based payments, participating CAHs would receive a 2 percent increase in Medicare reimbursement for submitting quality data and would be required to join an accountable care organization (ACO) within three to five years.

On the regulatory front, the Centers for Medicare & Medicaid Services’ Center for Medicare & Medicaid Innovation (CMMI) has significant authority and funding to test (and expand, if successful), innovative models to improve health care quality and value. CMMI launched Pennsylvania’s Rural Health Model in 2017 to test global budgeting and community-specific transformation plans in rural Pennsylvania.

Legislative and federal-agency efforts are supported by the work of outside organizations, in some cases under contracts with federal agencies. For example, The National Quality Forum is developing rural-specific quality performance measures that can be used as a basis for value-based reimbursement in rural areas.

Proposals to build and sustain a diverse rural health care workforce, such as in the Strengthening Our Rural Health Care Workforce Act of 2016, include:

  • Graduate Medical Education (GME) proposals, which would distribute GME positions to rural institutions and would reauthorize the Primary Care Residency Expansion Program and the Area Health Education Center program, as well as expand loan-forgiveness programs to dental therapists and community paramedics.
  • Residency reimbursement proposals, which would require Medicare to reimburse medical residency training that occurs in Critical Access Hospitals.

The CHRONIC (Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care) Care Act would expand the use of telemedicine treatment of stroke and dialysis patients, and for use in ACOs. The bill would explicitly allow Medicare Shared Savings Programs and ACOs to receive allowable telemedicine services in the home. The CHRONIC Care Act unanimously passed the Senate in September 2017.

The CONNECT (Creating Opportunities Now for Necessary and Effective Care Technologies) for Health Act of 2017 would expand the use of telemedicine within Native American, rural health clinic, and federally qualified health-center sites. It would create a remote patient-monitoring (RPM) benefit for certain high-risk patients and would allow the use of telemedicine and RPM in global bundled payments.

The Centers for Medicare & Medicaid Services (CMS) has expanded telehealth reimbursement, including through new Medicare billing codes, in 2018 physician payment regulations.

Rural Health Care Challenges, Opportunities, and Interdependencies

BPC’s series of roundtables and interviews with stakeholders across the Upper Midwest concentrated on three major areas of focus – the rural health care provider workforce, critical access hospitals, and telemedicine. Often, policy solutions in these areas take a siloed approach to reform.

However, BPC found many interdependencies between the key challenges and opportunities that demand a more holistic approach to reform. View the full infographic.