Rural hospital leaders made their case for regulatory relief from federal policies – like the 96-hour physician certification requirement, direct physician supervision of outpatient therapeutic services and meaningful use standards for health information technology – at a June 9 briefing on Capitol Hill. 

The 96-hour physician certification requirement as a condition for reimbursing a critical access hospital “shifts our focus from patient needs and quality to meeting regulatory needs … and takes decisions about patient care out of the hands of the doctor,” said Susan Starling, president and CEO of Marcum & Wallace Memorial Hospital in Irvine, Ky. “How do you explain to an 85-year-old patient who is sick that they are being transferred out of their community for hospitalization … away from their family, home and support system all because of a regulation?”

The physician certification requirement is an outgrowth of the Centers for Medicare & Medicaid Services’ (CMS) "two-midnight” inpatient admission policy – “one of those burdensome regulatory policies that is going to be very difficult for us to implement,” said Starling.  

“To be admitted to our hospital you must be sick enough to stay at the hospital for longer than two days, which is the two-midnight rule, but not too sick that you have to stay longer than four days, which is the 96-hour condition of payment,” she told congressional staff. “You are jumping through regulatory hoops. And if you don’t fit into these specific parameters, you can’t be admitted to our hospital for care. I don’t think you want this to be the standard of care for patients in rural America.”

Starling received the 2013 AHA Shirley Ann Munroe Leadership Award, which recognizes the accomplishments of small or rural hospital leaders who have improved health care in their communities.

Panelist Christina Campos, CEO of 10-bed Guadalupe Hospital in Santa Rosa, N.M., took aim at CMS’s direct supervision policy, which requires a supervising physician or non-physician practitioner to be immediately available whenever a Medicare patient receives outpatient therapeutic services. CMS in 2009 characterized the direct supervision requirement as a “restatement and clarification” of existing outpatient payment policy that had been in place since 2001 – a move that put hospitals at increased risk for unwarranted enforcement actions.

Like the AHA and other rural hospital leaders, Campos called for setting a default standard of general supervision for outpatient therapeutic services – a standard that does not require the direct presence of a physician.  

“Everybody is asking for something more, whether it’s electronic medical records or the 96-hour rule or direct supervision,” she noted. “We feel like we are dying a death of a million paper cuts. We are asking to be allowed to do our job with the resources we have so people get the care they need when they need it.”

Montana Hospital Association President Dick Brown highlighted the need for innovative solutions to ensure residents in rurally isolated areas continue to receive access to care.

“One of rural America’s biggest challenges is getting CMS to acknowledge the realities of rural health care and move forward with innovative solutions,” he said. “Rural states need the opportunity to continue to grow their own health care programs by exploring options through demonstrations. That means we need the flexibility to experiment with new ways of providing health care.”

The panelists urged Congress to pass important rural legislation, including the Critical Access Hospital Relief Act, H.R. 169/S. 258, the Protecting Access to Rural Therapy Services Act, or PARTS Act, H.R. 1611/S. 257, and the Rural Community Hospital (RCH) Demonstration Extension Act, H.R./S. 607. The Critical Access Hospital Relief Act would remove the 96-hour physician certification requirement as a condition of payment; the PARTS Act would adopt a default standard of general supervision for outpatient therapeutic services; and the RCH Demonstration Extension Act would extend for five years a program that enables rural hospitals with fewer than 51 acute-care beds to test the feasibility of cost-based reimbursement.




Rural Hospital Panel