Brock Slabach, MPH, FACHE

Chief Operations Officer

bslabach@ruralhealth.us�X: @bslabach

#ruralhealth

November 2, 2023

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The Landscape of Rural Health

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Rural Health Association of Oklahoma

The Times They are a-Changin’….

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Destination NRHA

Plan now to attend these 2024 events.

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Rural Health Policy Institute Feb. 13-15, 2024 Washington, DC

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Annual Conference May 7-10, 2024 New Orleans, LA

Rural Hospital Innovation Summit May 7-10, 2024 New Orleans, LA

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Rural Health Clinic Conference Sept. 24-25, 2024 Kansas City, MO

Critical Access Hospital Conference Sept. 25-27, 2024 Kansas City, MO

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Visit ruralhealth.us

for details and discounts.

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Why rural?

Our Future Depends on our Advocacy

• Investing in a Strong Rural Health Safety Net
• Reducing Rural Healthcare Workforce Shortages
• Addressing Rural Declining Life Expectancy and Inequality

• Addressing Rural Declining Life Expectancy and Inequality
• Reducing Rural Healthcare Workforce Shortages
• Invest in a Strong Rural Health Safety Net

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Rural Social Drivers of Health

Adapted from KFF

Future: The Political Drivers of Health

• Political drivers of health create the social drivers. Some examples:
• Medicaid Expansion
• GME Polices and specialties
• Poor environmental conditions
• Unsafe neighborhoods
• Lack of healthy food options

• Defined: The Political determinants of health involve the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance health equity or exacerbate health inequities.

--Daniel E. Dawes (2020)

The future of health equity begins and ends with the political determinants of health. --Leslie Erdelack

Future: Commercial Drivers of Health

• Commercial actors (CA) shape regulation and policies
• Favorable policies increase sales of possibly harmful products
• Policies enable CA to externalize the cost of harm
• Externalized costs met by states and individuals affected
• CAs enjoy large profits that propels a growing power imbalance

Defined as systems, practices, and pathways through which

commercial actors drive health and equity.

Source: The Lancet, March, 2023

Four industries (tobacco, unhealthy food, fossil fuel, and alcohol) are responsible for at least a third of global deaths per year.

Source: The Lancet, March, 2023

Capitol Hill Listens to You

Federal/State Officials value and want to hear YOUR input

• Capitol Hill values rural health advocate input.
• The Hill wants YOUR story.
• You and your legislators are neighbors.
• YOUR voice is important to help get meaningful legislation passed. As a provider and employer in a district, you understand how legislation will most impact a Member’s constituency.

The real problem of humanity is the following, we have:

• paleolithic emotions
• medieval institutions
• godlike technology

Edward O. Wilson

https://www.nytimes.com/2019/12/05/opinion/digital-technology-brain.html

The Stories We Tell

Population Health Disparity�Rural v. Urban

Percentile Ranking

Oral Health Disparities in Rural

© 2022 The Chartis Group, LLC. All Rights Reserved.

Page 12

Prevalence of Medicare Patients with 6 or more Chronic Conditions�

The Geography of Food Stamps

Source: Daily Yonder, 2018

The Digital Divide in Rural America

Rural Hospital Closures

Source: UNC Sheps

Center for Rural Health

150 Closures since 2010

REH Conversion Map

17 Conversions Since Program Started

3 in Oklahoma: Perry, Blackwell and Buffalo

Potential Legislative Fixes and/or Areas for Clarification

• Expanded eligibility for closed facilities prior to 2020
• Inclusion of swing beds
• Participation in the 340B program
• AFP hospital market-basket update—inflation?
• Clarification of CAHs Necessary Provider (NP) and flip back to CAH
• Did not reclassify to rural prior to Dec. 27, 2020, ineligible for REH

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USDA/NRHA Rural Hospital TA Program

• Rural Hospitals that are current borrowers from USDA are eligible for full-range of services:
• Strategic, Financial, Operational Assessment (SFOA)
• Target services, for example:
• Revenue Cycle
• 340B
• Cost Report Review
• Rural Hospital that are not current USDA borrowers:
• Debt capacity/Market Analysis
• TA is free-of-charge to hospital
• Contact Brock Slabach or Tommy Barnhart at NRHA�

Maternal Mortality Crisis

Maternity Deserts Nationwide

• 56% of rural counties lack hospital-based OB services
• Substantial state and regional variability
• Loss of hospital-based OB services is most prominent in rural communities:
• With a high proportion of Black residents
• Where a majority of residents are Black or Indigenous have elevated rates of premature death

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• https://rupri.public-health.uiowa.edu/publications/policybriefs/2023/Hospital%20System%20Participation%20and%20Services.pdf

Rural Nursing Home Closures

• 10% of rural counties are nursing home deserts
• From 2008-2018, 400 rural counties experienced at least 1 nursing home closure

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• https://rupri.public-health.uiowa.edu/publications/policybriefs/2021/Rural%20NH%20Closure.pdf

Behavioral/Mental Health Workforce

https://www.ruralhealthresearch.org/assets/411-1089/071817-behavioral-health-workforce-supply-webinar-ppt.pdf

Common Denominators where Covid Deaths Rates were High

What is clear is that COVID-19 exploited and compounded existing local racial inequities, health disparities, and partisan politics to create a syndemic—a combination of local factors that interact, increasing the burden of disease from this pandemic and the likelihood of poor outcomes.

--Thomas Bollyky, Lancet, 2023

Looking Ahead:�Innovation

Payment Transition Plan: CMS & CMMI

Goal: 100% of Medicare payments to providers are through a VBP approach

Million Hearts Campaign �Focus on Health Equity

CMMI: AHEAD Model

CMMI has announced a new innovation model for up to 8 states starting in 2025 that will include the following:

• Global Budget for hospitals (similar to PaRHM)
• Include a TCOC target/approach
• All-payer participation
• Include a primary care/provider incentive
• Directed toward safety-net providers (including rural)
• Address Mental health, SUD and SDOH
• Address Health Equity

CMMI: AHEAD Model

Tentative timeline for model release/implementation:

• December, 2023 release NOFO
• 2024 Select Model Participants
• 2025 Implement Model
• 10-year horizon for demonstration
• $12M grant for lead agency—5 years

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Like the Pennsylvania model, AHEAD model requires state to organize and implement the features of this program.

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Medicare Advantage Data—2022

• Overall MA enrollment grew by 8.7 percent (2.3 million) from 2021 to 2022.
• The rate of growth was higher in nonmetropolitan counties (13.4 percent) than in metropolitan counties (7.9 percent).
• Overall, more than half of MA enrollees (57.9 percent) were in Health Maintenance Organization (HMO) plans.
• The largest proportion of nonmetropolitan enrollees (51.5 percent) were in Local Preferred Provider Organization (PPO) plans
• The largest proportion of metropolitan enrollees (61.4 percent) were in HMO plans

“Offering a rural payment add-on for MA plans that

operate in rural areas may incentivize the delivery

of high-quality care in rural areas” Health Payer Intelligence

ACO Advanced Investment Payment

CMS finalized new policies for Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) to support providers treating rural and underserved populations, including changes to:

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• Provide Advance Investment Payments (AIPs) to Certain ACOs
• A one-time payment of $250,000
• Eight quarterly payments, based on the number of assigned beneficiaries capped at 10,000
• Smooth the Transition to Performance-Based Risk
• Support Longer Term Participation in ACOs
• Promote Health Equity
• Update the Financial Methodology
• Reduce the effect of ACO performance on historical benchmarks
• Address market penetration
• Strengthen incentives for ACOs serving medically complex and high-cost populations
• Next application period in 2024 for a Jan. 1, 2025 start date. More information.

News from Washington:�Preparing for the Future

Recent Activities

• Recent comments on proposed rules:
• Comment on Requirements Related to Mental Health Parity and Addiction Equity Act proposed rule.
• Response to Physician-Focused Payment Model Technical Advisory Committee on Rural Participation in APMs RFI

Recent Activities

Drug Enforcement Administration Second Temporary Extension of COVID-19 Telemedicine Flexibilities.

• Amends rule from May.
• NRHA summary.
• Extends all telemedicine flexibilities for prescribing medications for OUD and other controlled substances through December 31, 2024.
• Prior rule extended through November 11, 2023.
• DEA plans to issue final policy by fall 2024.

Current Activities

Minimum Staffing Standards for LTC Facilities proposed rule.

• 2 main provisions for nursing homes/SNFs:
• Must have RN on site 24/7.
• Must meet 0.55 hours per resident day (HPRD) for RNs and 2.45 for nurse aides.
• Rural facilities must comply with RN requirement within 3 years.
• Rural facilities must comply with HPRD within 5 years.
• One-year hardship exemption (may be renewed) for certain facilities.
• More in-depth info from listening session presentation.

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Current Activities

Minimum Staffing Standards for LTC Facilities proposed rule.

• Member comment template now available!
• NRHA draft comment available for review.
• NRHA summary.
• Comments are due November 6 via regulations.gov.
• Please fill out nursing home membership survey!

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MPFS NPRM

CY 2024 Medicare Physician Fee schedule (MPFS) proposed rule.

• NRHA summary.
• Comments were due September 11 via regulations.gov.
• Physicians facing -3.3% payment cut in 2024 due to statutory requirements and budget neutrality.
• Proposing new G codes to cover community health integration (incl. CHW services), SDOH risk assessments, and principal illness navigation.

MPFS NPRM

CY 2024 MPFS cont.

• Marriage & family therapists, mental health counselors can bill Medicare directly for services Jan. 1, 2024.
• Addiction counselors that meet Mental Health Counselors (MHC) requirements can enroll in Medicare as MHC.
• HCPCS code for psychotherapy services furnished outside of a facility.
• Implementing telehealth flexibility extensions from Consolidated Appropriations Act of 2023.

MPFS NPRM

CY 2024 MPFS cont.

• RHCs/FQHCs:
• Can bill for community health integration & principal illness navigation.
• Remote physiologic monitoring and remote therapeutic monitoring in the general care management code.
• General supervision for behavioral health services furnished incident to physician/NPP’s services.
• Minor changes to Medicare Shared Savings Program.

CY2024 Medicare Advantage Policy and Technical Changes

• Prior authorization
• Can only be used to confirm diagnosis, determine medical necessity
• MA plans must comply with coverage and benefit conditions in traditional Medicare, national & local coverage determinations
• When Medicare coverage criteria are not established, MA plans:
• Must make publicly accessible coverage policies based upon widely used treatment guidelines or clinical literature
• MA plans cannot revise its medical necessity determinations
• 90-day transition period for ongoing course of treatment

CY2024 Medicare Advantage Policy and Technical Changes

• Network adequacy
• MA plans must arrange for out-of-network medically necessary items and services that are not available in-network
• Behavioral health
• Clinical psychologists and social workers now subject to time, distance, and minimum number requirements – can receive 10% credit
• Did not finalize MOUD-waivered providers for network adequacy requirements
• Primary care appointment wait times apply to behavioral health care
• Emergency services: immediately
• Not emergency but requires medical attention: within 7 business days
• Routine/preventive: within 30 business days
• Emergency medical services include mental health services. MA plans must cover emergency services without regard for prior authorization

CY2024 Medicare Advantage Policy and Technical Changes

• Targeting misleading marketing and advertising
• MA ads must include specific plan name
• Superlatives prohibited without supporting documentation
• Prohibited from advertising benefits not available in a service area
• Must provide annual notice that beneficiaries may opt out of business calls
• Pre-enrollment checklist must include “effect on current coverage” item
• Scope of appointments, business reply cards, and other contact mechanisms are valid for 12 months
• Prohibited from using Medicare name, CMS/HHS logo in misleading way

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CY2024 Medicare Advantage Policy and Technical Changes

• Health equity
• Health Equity Index is added to the Star Ratings program to encourage MA plans to focus on improving care for enrollees with social risk factors.
• MA plans must develop procedures to identify and offer digital health education to help enrollees access medically necessary telehealth benefits

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CAH Issues

• 96-hour average length of stay
• Longer waits for tertiary transfer
• PAC placement more difficult due to staffing shortages
• Increased Obs. Status by commercial insurance/Medicaid MCOs
• Solutions:
• Remove requirement altogether
• Raise the average to 120 hours, for example
• Other ideas?
• 72-hour qualifying length of stay for Swing Bed placement
• Solution: Remove requirement altogether or lower the threshold to 36 hours, for example. Other?

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Fall/Winter Outlook

• Calendar year final payment rules out in early November (OPPS, Physician Fee Schedule).
• OPPS remedy for 340B payment policy final rule under review at OMB.
• Pending interim final rule on Medicaid redetermination process.
• CY 2025 Medicare Advantage Policy & Technical Changes proposed rule expected in December/January.

Updates from Congress

Responses to Congressional RFIs

• NRHA Submitted responses to several Congressional Requests for Information
• House Ways and Means Committee RFI: Improving Access to Health Care in Rural and Underserved Areas.
• House Budget Committee RFI: Reducing Costs & Improving Outcomes
• Senator Bill Cassidy RFI: Reforming the Centers for Disease Control and Prevention
• Access the Responses at: �https://www.ruralhealth.us/advocate/legislative-branch

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Congressional Bipartisan Rural Health Caucus 

• Relaunched by Reps. Jill Tokuda (D-HI) and Diana Harshbarger (R-TN). 
• Caucus Kickoff on September 20th.
• 45 Representatives have joined the CBRHC.
• The Caucus will be an opportunity to host briefings and events to educate and inform Members of Congress and the public. 
• Will allow Members to interact with patients, providers, and health advocates.
• Another great legislative vehicle to help move NRHA’s rural health priorities.

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Rural Health Care Facilities Revitalization Act 

• H.R. 5989 Introduced on 10/19/23 by Rural Health Caucus Members: Reps. Caraveo (CO-08), Moylan (GU), and Salinas (OR-06).
• The bipartisan Act authorizes rural health facilities to use federal agricultural funds to ensure their long-term financial stability. Access to additional funding through USDA can help rural hospitals to maintain sustainable operating margins. 
• The Act would allow rural health care facilities, including hospitals, mobile health care clinics, home health agencies, and long-term care facilities, to use Community Facility Loans or loan guarantees under the U.S. Department of Agriculture to :
• Refinance debt, update telehealth, and medical equipment, among other needs.
• A waiver of credit requirements is available for facilities in financial distress. 

CDC Office of Rural Health Authorization

• H.R. 5481/ S. 2977 Introduced by Rep. Michael Guest (MS-03) and Sens. Merkley (OR) and Hyde-Smith (MS). 
• Congress for appropriated 5 million dollars to stand up an Office of Rural Health (ORH) within the CDC in the Consolidated Appropriations Act of 2023.
• NRHA strongly encourages the HELP committee to fully authorize the CDC Office of Rural Health to ensure this important work continues beyond a single year appropriation

FY 2024 Appropriations Update 

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• Speaker Mike Johnson has stated his intentions to put forth another stopgap measure, a Continuing Resolution (CR), to extend funding past Nov 17. 
• The next CR may extend funding until Jan. 15 or April 15, 2024, giving the House more time to advance all 12 appropriations bills.
• A vote on the Labor/ Health and Human Services, and Agriculture appropriations bills are proposed to be held on the Week of Nov 13. 
• Senate leaders struck a deal on the Minibus yesterday, which includes funding for Agriculture, Mil-Con-VA, and THUD. Votes on Amendments to this package to be held this morning. With the intention that the bills will head to the floor for a vote in the next week. 

NRHA FY24 Appropriations Requests 

• CDC Office of Rural Health - $10m
• Increase funding for Rural Maternal and Obstetric Management Strategies – $24.6m
• Rural Hospital infrastructure and sustainability- $35 m  
• Rural Residency Planning and Development Program- $14.5m
• Medicare Rural Hospital Flexibility Grant Program - $73m 
• Behavioral Health and SUD treatments - $175m

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ADVOCATE WITH US!

https://www.ruralhealth.us/advocate/rural-health-advocacy-campaigns

Legislation We Support

• S. 2477, Equitable Community Access to Pharmacist Services Act
• Introduced by Sens. Thune (R-SD) and Warner (D-VA).
• House Companion by Reps. Smith (R-NE) and Matsui (D-CA). 
• Allows for Medicare reimbursement for certain services provided by pharmacists including tests, treatments, and vaccines for influenza, RSV, COVID-19, and Strep. 
• H.R. 4829, Physical Therapist Workforce and Patient Access Act
• Introduced by Reps. DeGette (D-CO) and Armstrong (R-ND).
• Allows physical therapists to be eligible for National Health Service Corps.
• H.R. 4605, Healthy Moms and Babies Act: 
• Introduced in House by Reps. Carter (R-GA) and Bishop (D-GA). 
• Senate Companion by Sens. Grassley (R-IA) and Hassan (D-NH). 
• Improves maternal health coverage, supports care coordination, focuses on quality measures under Medicaid and CHIP. 

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Legislation We Support

• H.R. 4713, Rural Hospital Technical Assistance Program Act:
• Introduced in the House by Reps. Derek Kilmer (D-WA), Ronny Jackson (R-TX), and Jodey Arrington (R-TX).
• Makes an existing U.S. Department of Agriculture (USDA) program which provides technical assistance for rural hospitals permanent.
• H.R. 4603, Rural Wellness Act:
• Introduced by Reps. Caraveo (D-CO) and Finstad (R-MN).
• Prioritizes programs designed to increase access to behavioral and mental health treatment in rural communities in certain Rural Development grant programs.

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Support the Rural Health Infrastructure

• NEW: S. 1571: Rural Hospital Closure Relief Act of 2023
• Restore Necessary Provider status for CAH conversion
• Support the rural safety net hospitals
• H.R. 833 Save America's Rural Hospitals Act
• H.R. 1565 Critical Access Hospital Relief Act
• repeals the 96-hour physician-certification requirement for inpatient CAH services
• S. 803: Save Rural Hospitals Act of 2023
• Establish a national minimum rate of 0.85 for the AWI reimbursement rate
• S. 1110: Rural Hospital Support Act of 2023  
• make permanent the MDH program and enhanced LVA and MDHs and SCHs to choose an additional base year
• S1673/HR1666: Ambulance Add-on

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Support the Rural Health Infrastructure

• Modernize the RHC program
• S. 198/H.R. 3730, Rural Health Clinic Burden Reduction Act
• Developing RHC Quality Reporting Program with enhanced payment   
• Ensure the 340B Drug Pricing Program remains a viable lifeline 
• H.R. 2534: PROTECT 340B Act of 2023
• Evaluating other 340b reform proposals 
• Extending authorization for CHC and NHSC. 
• H.R. 2559: Strengthening Community Care Act of 2023

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Strengthen the Rural Health Workforce

• Expand the Medicare Graduate Medical Education (GME) program
• S. 230/H.R. 83 Rural Physician Workforce Production Act
• S. 665 Conrad State 30 and Physician Access Reauthorization Act 
• H.R. 751 Fair Access in Residency Act 
• Support development and capacity of health care providers
• H.R. 2761 Reintroduce Improving Care and Access to Nurses Act
• Support loan repayment programs 
• S. 940 Rural America Health Corps Act

Address Rural Health Equity 

• Expand Access to Maternal Health Services
• S. 948 Healthy Moms and Babies Act  
• H.R. 3305 Black Maternal Health Momnibus Act  
• Permanently Expand Telehealth Provisions 
• S. 1636 Protecting Rural Telehealth Access Act
• S. 1642 Reconnecting Rural America Act 
• Reintroduction of CONNECT for Health Act – Coming Soon!
• Including in person payment parity for RHC and FQHC services 
• Expand Access to Emergency Medical Services (EMS)
• S. 1673/ H.R. 1666 Protecting Access to Ground Ambulance Medical Services Act 

3 percent increase in the rate for ground ambulance services that originate in rural areas. Super Rural Bonus 22.6 percent increase in the base rate for ground ambulance transports that originate in an area in the lowest 25th percentile of all rural areas

• Support Rural Public Health Capacity 
• Reauthorize and increase funding for new CDC Office of Rural Health 

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CAH Issues

• 96-hour average length of stay
• Longer waits for tertiary transfer
• PAC placement more difficult due to staffing shortages
• Increased Obs. Status by commercial insurance/Medicaid MCOs
• Solutions:
• Remove requirement altogether
• Raise the average to 120 hours, for example
• Other ideas?
• 72-hour qualifying length of stay for Swing Bed placement
• Solution: Remove requirement altogether or lower the threshold to 36 hours, for example. Other?

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The Congressional Bipartisan Rural Health Caucus Advocacy Campaign

• This is an opportunity to provide a space for Members of Congress to highlight challenges and advocate for policy solutions related to the delivery of health care and mental health services in rural and remote communities

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• There are currently 45 Members within the Caucus and counting! We encourage you to contact your district Member of Congress to consider joining the caucus to help increase access to quality, affordable health care and mental health services for all rural Americans.   

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• The Caucus will host member meetings, briefings, and events designed to inform and educate Members of Congress of some of the most pressing rural health care issues and highlight potential policy solutions to enhance the quality and efficiency of health care services in rural areas

New advocacy materials!

• Hospital bills 1-pager
• Summaries of our main hospital bills to share with elected officials.

New advocacy materials!

• 340B Priorities 1-Pager
• Protect contract pharmacy arrangements
• Pass PROTECT 340B Act
• DSH waiver extension

New advocacy materials!

Farm Bill Priorities 1-Pager

• Supporting Rural Development, broadband programs
• Rural Hospital TA Program Act
• Hospital capital
• List of marker bills

Thank you.�

bslabach@ruralhealth.us�@bslabach

#ruralhealth