Advocating for Rural Health Providers

00;00;00;01 - 00;00;28;20
Tom Haederle
For rural health care providers. 2022 ended on an up note when age was able to secure some important policy wins in the final omnibus appropriations package to fund the government. That was last year. However, this year brings a new set of challenges, goals and opportunities. Welcome to Community Cornerstones: Conversations with Rural Hospitals in America, a new series from the American Hospital Association.

00;00;29;03 - 00;01;00;18
Tom Haederle
I'm Tom Haederle with AHA Communications. We hope these 15 episodes will shed new light on the challenges, triumphs and issues facing rural health care providers who are a health lifeline for approximately 20% of Americans. In this episode, three AHA rural health care policy experts discuss the 2023 Rural Advocacy agenda for Congress and the administration. It includes flexible payment options, expanded telehealth coverage and help with workforce issues, to name but a few.

00;01;01;06 - 00;01;15;08
Tom Haederle
Lead ing the discussion is Aimee Kuhlman, vice president for advocacy at Grassroots of the AHA. This series was recorded at the AGs 2023 Rural Conference in San Antonio. Now let's go to Amy and her colleagues.

00;01;16;11 - 00;01;47;14
Aimee Kuhlman
Hello, I am Aimee Kuhlman, Vice President of Advocacy and Grassroots at the AHA, and I'm joined by my colleagues, Travis Robey, vice president, the AHA’s Political Affairs, and Shannon Wu, senior associate director, the AHA’s Payment Policy. Welcome, Shannon, and welcome, Travis. Today we announced our AHA Rural Advocacy Agenda for the 118th Congress. And I'm going to ask Travis and Shannon to share with us the details of that agenda.

00;01;47;26 - 00;02;03;28
Aimee Kuhlman
However, before we do that, I would like to review with you what was accomplished in the second session of the last Congress and how that lays the foundation for us moving forward. Travis, walk us through what occurred in the last few months in 2022.

00;02;04;02 - 00;02;24;14
Travis Robey
Thanks, Amy. Happy to do that. Glad to be joining a here from the Rural conference. We had a lot of great wins at the end of the Congress in December that were included in that final big omnibus appropriations package to fund the government. We were able to extend for two years the Medicare low volume adjustment and the Medicare dependent hospital programs.

00;02;24;23 - 00;02;51;27
Travis Robey
We were able to extend the higher reimbursement rate for rural ambulance services that included a 3% add on for rural ambulance services and a super rural bonus of 22.6% for hospitals in the lowest 25th percentile of rural counties by population density. We also had some big wins on the workforce front, added 200 additional slots for graduate medical education.

00;02;52;02 - 00;03;21;06
Travis Robey
Half of those were reserved for behavioral health residencies and there were also a rural set asides as part of that package. We also extended the Conrad State 30 program that allows foreign born physicians to stay in the U.S. if they practice in underserved communities. And then just one other broader agenda item I wanted to flag. We block the 4% across the board cut that would have gone through under the Medicare statutory pay as you go laws.

00;03;21;12 - 00;03;24;11
Travis Robey
And fortunately, we were able to stop that from moving forward.

00;03;24;17 - 00;03;38;10
Aimee
Sounds like it was a busy end of the year. Travis I know that we share credit with our hospital and state association leaders whose advocacy helped make this possible. Shannon, how about on the policy side? What was achieved there?

00;03;38;15 - 00;04;01;15
Shannon Wu
Well, I'm pleased to report last year we were able to successfully advocate for an additional $2 billion for hospitals under both the inpatient and outpatient hospital payment systems from what was being proposed by Centers for Medicare and Medicaid Services to what was finalized. We worked hard with CMS and the Hill to highlight the dire financial situations many hospitals were facing and continue to face.

00;04;02;01 - 00;04;28;14
Shannon Wu
Second, we were also successful in advocating for a very favorable facility payment amount in the rural emergency hospital model. CMS went through its rule making process last year and finalized a 3.3 million annual payment for a given REH facility in 2023. And as Travis mentioned, we were also successful in distributing 200 additional Medicare funded graduate medical education slots just this past month.

00;04;28;14 - 00;04;33;07
Shannon Wu
And so we look forward to advocating for additional workforce issues in the upcoming year.

00;04;33;12 - 00;04;40;03
Aimee Kuhlman
Thank you, Shannon. As we look toward the next Congress, what are the priorities on our rural advocacy agenda? Travis?

00;04;40;09 - 00;05;05;13
Travis Robey
Well, we just rolled out our 2023 rural advocacy agenda here at the Rural Conference, and we've got a robust agenda of programs and policies that we're going to be working with Congress and the administration on to move forward. They fall into a few different buckets. The first is supporting flexible payment options, and that includes things like extending the Medicare dependent hospital and low volume adjustment programs.

00;05;05;13 - 00;05;28;17
Travis Robey
Again, we got that two year extension in the end of the year package, but that means we need to start building support to get those reauthorized again. We also want to reopen the necessary provider designation for critical access hospitals that lets a hospital be a CAH if they're within 35 miles of another facility. The next big bucket is ensuring fair and adequate reimbursement.

00;05;28;28 - 00;05;48;24
Travis Robey
That includes a policy like reversing the rural health clinic cuts from the 2020 end of the year package, extending the ambulance, add on payments again. Again, there was a two year extension in the December bill, so we need to keep building support for that again. And we have a robust commercial insurer accountability plan that we're going to continue to build on.

00;05;49;03 - 00;06;30;28
Travis Robey
Also, workforce issues continue to be a top tier priority. We hear from across the field, but particularly for rural hospitals. And we really need to increase the pipeline of physicians and nurses. That's the core of our strategy here. And that includes more GME slots, including to continue to get more in rural communities, expanding the Conrad 30 program to keep more and more on physicians in the U.S. loan repayment programs like the National Health Service Corps and National Nurse Corps that incentivize health graduates to practice in underserved areas and even more funding for nursing education, including more funds for nurse faculty, because that's a key bottleneck in the pipeline right now.

00;06;31;11 - 00;06;45;05
Travis Robey
And the last couple of things I flagged, we want to continue supporting expanded telehealth coverage, making permanent all of the waivers that we got in the end of the year package and then continue to protect the 340 B program, which is so critical for many rural hospitals.

00;06;45;14 - 00;06;56;05
Aimee Kuhlman
Thanks, Travis. The administration earlier this year announced that the public health emergency will end on May 11. Shannon, what are the implications for rural hospitals?

00;06;56;14 - 00;07;19;05
Shannon Wu
So the end of the public health emergency will trigger the wind down of many PHE specific programs and flexibilities. And one of the most critical components in the next 80 days or so until May 11th is to decipher under which waiver certain operational and regulatory flexibilities, hospitals and other facilities have been operating. And second, to understand when those flexibilities actually go away.

00;07;19;18 - 00;07;44;01
Shannon Wu
So just two weeks ago, the AHA issued guidance out to the field on some of the key changes for hospital operations as a result of the end of the year on May 11th. These include the end to flexibilities related to payment for many COVID 19 related services. How hospitals can use expansion sites of care. And the flexibility given to critical access hospitals for bed limits in the 96 hour rule, among others.

00;07;44;02 - 00;08;04;21
Shannon Wu
And so we laid out a timeline of some of these key provisions, which end May 11th, which end in the fiscal year and calendar year, and which end at some future date. At the same time that we issue the guidance, we also are continuing to advocate for policies that we believe have provided crucial relief to hospitals and that we believe should be extended beyond the PHE were made permanent.

00;08;05;08 - 00;08;35;17
Shannon Wu
So we detailed a long list of recommendations for both the administration and congressional action. These included permanently expanding coverage for telehealth services, eliminating certain nurse practitioner practice limits so they can practice at the top of their license, and eliminating the 96 hour physician certification rule for critical access hospitals. So we will continue to release additional analysis and tools to assist our members in preparing for the end of the PHE and obviously work closely with the administration and Congress in extending or make permanent certain policies.

00;08;35;26 - 00;08;39;14
Aimee Kuhlman
So what's next for advocacy and public policy development at the AHA?

00;08;39;28 - 00;09;11;26
Travis Robey
We're going to continue to pursue a legislation to extend a lot of those flexibilities that were so important during the PCE, particularly the telehealth waivers. Those are absolutely essential. But the other two things that we're focused on are the 96 hour physician certification requirement and the 96 hour average length of stay requirement for critical access hospitals. Those have been so essential during the PHE and continue to be a challenge because of the inability of so many hospitals to be able to discharge patients to post-acute and behavioral health care settings.

00;09;12;08 - 00;09;22;21
Travis Robey
And we're also going to mobilize the field to engage on the entire spectrum of our advocacy priorities over the course of the next weeks, months and the next two years.

00;09;23;00 - 00;09;46;10
Shannon Wu
And as many of our listeners may know, the Rural Emergency Hospital designation is effective as of January 1st of this year. So those eligible facilities, which include critical access hospitals and rural hospitals with 50 beds were less, can begin to convert to those rural emergency hospital designations. And so we continue to engage with CMS in gathering your feedback and making the program more sustainable and flexible for rural providers.

00;09;46;23 - 00;10;06;21
Shannon Wu
And CMS recently released new guidance, and we continue to assess any ongoing concerns in analyzing the impact of some of those new clarifications from CMS. In fact, the AHA will be hosting a webinar with CMS and Hearst personnel on the model to solicit feedback from hospitals and providers, and they will also be there to answer any questions on the model.

00;10;07;00 - 00;10;15;08
Shannon Wu
So the webinar is scheduled for March 1st at noon Eastern and we encourage all of those who are interested to attend and share your feedback with the CMS and HRSA team.

00;10;15;21 - 00;10;34;13
Aimee Kuhlman
Well, it's clear that a lot has been accomplished, but there is still a lot of work yet to be done. I want to thank you, Travis and Shannon, for sharing with us the achievements from our last Congress and the goals for the next. I look forward to working with you and the rest of the field to build momentum and act on these objectives.

00;10;34;28 - 00;10;51;11
Aimee Kuhlman
On behalf of Travis and Shannon, I'm Aimee Kuhlman, and thanks for listening. This has been an AHA Advancing Health podcast.