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Important Rural Health Reform Amendments for the Senate Floor

senate-logoNow that the Senate has voted on cloture to bring its health reform bill, the Patient Protection and Affordable Care Act, to the Senate Floor for debate, health reform is one step closer to becoming a reality. Though most of the debate has focused on ensuring access to coverage, the greater problem in rural America is access to a provider. Being insured makes no difference if you do not have a provider.

Though many of the current bill’s provisions are positive steps to ensuring rural America’s access to both insurance and a provider, there is still much work to do to ensure the bill amounts to true health reform for all Americans, both urban and rural.

To resolve the access to care crisis in rural America, health reform must:

1) Resolve the workforce shortage crisis in rural areas; and

2) Eliminate long-standing payment inequities for rural providers.

The NRHA applauds the critical investment made in the bill in developing and improving the rural health care workforce, as well as the positive improvements in correcting systemic payment inequities that have long plagued rural providers.  The NRHA strongly supports these efforts and recognizes them as the important building blocks needed to resolve the access to care crisis in rural America.

Still, more must be done.  It is disappointing, for instance, that several important payments for rural providers (known as the “rural extenders”) are only authorized for a one year period.  While the bill does address many barriers to rural health care access, the NRHA will be actively supporting Senate Floor amendments to improve the Patient Protection and Affordable Care Act that will improve the ability for rural providers to provide care for the rural patients who rely on them.

The following provisions are necessary to ensuring health reform recognizes the unique challenges faced by rural America, and the NRHA will be actively supporting any Senate floor amendments adding them to the bill:

Eliminate unfair treatment of Critical Access Hospitals in the American Recovery and Reinvestment Act – The American Recovery and Reinvestment Act (ARRA) did not provide the same incentives for CAHs for HIT adoption as PPS hospitals.  To create equity for these rural facilities, CAHs should have priority access to the grant funds offered through the Office of the National Coordinator for HIT under the bill.

Allow Rural Health Clinics to participate in the 340B drug program – The 340B program allows certain safety net facilities to purchase covered drugs at a discounted price.  The Patient Protection and Affordable Care Act expands the list of eligible facilities to include several rural facilities, but neglects to include RHCs.  RHCs provide critical access to underserved communities and should be eligible to participate in this program, which also results in net savings for the federal government.

Ensure continued support for State Offices of Rural Health – State offices of rural health enhance the rural health care delivery system through joint support from the federal and state governments.  They coordinate resources, provide technical assistance, and promote workforce development in all 50 states.  Authorizing language for SORHs must be modified to strengthen the program and continue their work.

Reinstate “Necessary Provider” for Critical Access Hospitals – This would allow states to once again waive the 35-mile requirement and deem a hospital as a “necessary provider” based on unique conditions often only realized by local and state entities.

Allow Critical Access Hospitals flexibility in their bed count – CAHs currently are limited by a hard 25-bed cap.  Allowing CAHs to maintain an average bed count of 20 improves patient access, especially in the case of seasonal or other unexpected influxes of patients.

Increase Medicare payment cap to Rural Health Clinics - The RHC cap must be raised from $76.84 to $86, finally updating a payment structure that is decades old.  Raising the cap will enable RHCs to continue to deliver vital primary care to their patients.

Improve rural workforce development – S. 1628, the Rural Physician Pipeline Act (Sen. Mark Udall), would help medical colleges to develop special rural training programs and recruit from students from rural communities.  This “grow-your-own” approach is one of the best and most cost-effective ways to ensure a robust rural workforce into the future.  S. 1628 must be included in the final health reform bill.

Ensure Rural Access to Anesthesia Services – CAHs frequently use certified registered nurse anesthetists to provide anesthesia services in a cost-effective way.  However, Medicare reimbursement is currently unreliable due to a lack of clarity in current legislation.  Current legislation (S. 1585) would solve this problem and must be included in the final health reform bill.  Additionally, H.R. 3151 seeks to close current loopholes and ensure that Critical Access Hospitals (CAHs) are properly reimbursed for their anesthesiology services.

Eliminate CAH "Isolation Test" for Ambulance Reimbursement - Under current law, CAHs can only receive cost reimbursement for ambulance services if they are the only provider of ambulance services within a 35-mile drive.  This provision would eliminate the 35-mile requirement, ensuring that CAHs are appropriately reimbursed for providing emergency medical services.

Extend the Rural Community Hospital Demonstration Program (Tweeners) – This important and successful demonstration program, originally set for five years, must be allowed to continue during the lag time between the demonstration project’s end, and when CMS makes its final decision to permanently implement the program.   Additionally, the payments must be “rebased” to reflect the true cost of providing care at these facilities.

Ensure Rural Representation on MedPAC – Rural representation on MedPAC should be proportional to the rural representation among Medicare beneficiaries.  It should reflect the 26% of Medicare beneficiaries who reside in rural areas.

Implement an occupational safety program for agricultural workers – The many Americans who work to ensure the country’s food supply face particular health challenges.  Health reform should address this issue by instituting a program to offer health education and support to agricultural workers.

Ensure Fair Payment Rates for Rural Pharmacies – Sole community and independent pharmacists provide essential services to residents of small towns and isolated communities.  Medicaid reimbursement rates, which use an “average manufacturer price” to calculate a pharmacist’s reimbursement for generic drugs can unfairly reimbursement small rural pharmacies – most of who operate on very small financial margins.   Though the Senate bill attempts a permanent “fix” to this problem, it is likely insufficient to protect rural pharmacies from closing their doors, thereby hurting rural patient’s access to the drugs they need.

Protect Access to Care for the Most Geographically Remote Americans – In frontier regions of the country, weather and distance can prevent patients who experience severe injury or illness from obtaining immediate transport to a hospital.  For many in these communities, the local health clinic provides the essential extra care to stabilize the patient until transport is possible.  Such extra care requires additional staffing, equipment and facility capacity - - none of which is currently reimbursed or recognized by Medicare.  Remote facilities (at least 60 miles from another medical facility) that provide stabilization for critically injured or sick patients  prior to transport to another facility must be fairly compensated.

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