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Rebuild Rural: The Importance of Health Care in Infrastructure


Last week, we received further details on President Donald Trump’s infrastructure plan. We were happy to see that rural infrastructure investments are a key component of this Administration’s commitment to growing our national economy. It is essential that we build rural priorities into this massive investment in our nation’s future, and it is even more important that we recognize the special role that health care plays in our country’s infrastructure.

The State of the Rural Economy
Rural communities have not recovered from the Great Recession the way that metropolitan and suburban counties have. 200,000 jobs are still lost annually in rural communities, and as a result, 749 rural counties experience increasing unemployment. In most rural communities, the hospital is the first or second largest employer, but only if the hospital can keep its doors open. More than 44% of rural hospitals operate at a loss and 30% operate below a -3% margin. 83 rural hospitals have closed since 2010, and 674 are vulnerable to closure. If all 674 vulnerable hospitals close, we will lose 99,000 direct health care jobs, 137,000 community jobs, and $277 billion in GDP. Per-Capita annual income in rural communities will decrease by $703, while rural unemployment would increase by 1.6 percentage points. We need investments in rural infrastructure, and especially in health care, to ensure the future of our rural communities.

Ensuring Rural Investments Are Available for Health Care
We are excited to see President Trump’s commitment to rural infrastructure in the outline of this proposed plan. A recent Fact Sheet sent to NRHA and other stakeholders from the National Economic Council outlined three key points as part of the President’s plan to “support and modernize” rural communities that have been left behind:
  1. “$50 billion of the $200 billion in direct Federal funding will be devoted to a new Rural Infrastructure Program to rebuild and modernize infrastructure in rural America.
  2. The bulk of the dollars in the Rural Infrastructure Program will be allocated to State governors, giving States the flexibility to prioritize their communities’ needs.
  3. The remaining funds will be distributed through rural performance grants to encourage the best use of taxpayer dollars.”
We appreciate this huge investment in our rural areas, and we appreciate that the Administration recognizes the role that our governors can play in ensuring that these funds are appropriately directed. That being said, final legislation must include language that allows our state and local officials to allocate these funds to health care infrastructure investments. Especially at a time when we are trying to move control of critical policies from the federal to the state level, we cannot afford to limit our governors and ourselves with a narrow view of what comprises rural infrastructure. Health care infrastructure is more than just buildings and roads: it is the nurses, doctors, and other providers that care for patients; it’s telehealth services that localize specialty care; and it is community resources that provide jobs and opportunities.
Our Approach to Rebuilding Rural America

Health Care is Rural Infrastructure
NRHA has developed a four-pronged approach to make rural Americans healthy and bring back jobs: include provisions to keep rural hospitals open such as those in H.R. 2957, the Save Rural Hospitals Act, maintain jobs, and ensure access to care; cut red tape by reforming existing programs to bring grants and funding to the communities that need them most; improve telehealth and transportation services to increase availability and delivery of care; and address rural health care system workforce shortages. We only need small investments in rural infrastructure to yield big rural health gains.

1. Save Rural Providers
Hospitals are often one of the largest employers in rural areas, thus these institutions are essential to the economic vitality of a rural community. If residents are traveling out of the community for healthcare services, we need to provide those services locally to prevent money from leaving the community. Access to healthcare is necessary to attract and retain businesses in a rural area as well. Employers do not want to locate in a community without an emergency room to care for an employee injured on the job, a place to deliver a baby, or a doctor for basic preventive care. Congress recently reauthorized essential Rural Medicare Extenders, renewing their commitment to rural providers, including hospitals and EMS services. This takes one step in the right direction for ensuring the future of rural health care, but we can do more. Inclusion of our Save Rural Hospitals Act, H.R. 2957, in a larger infrastructure package would stop the flood of rural hospital closures by creating a new and innovative type of rural hospital model. While there are a number of essential provisions in this legislation, one specifically speaks to the Administration’s request to come into the 21st Century to meet the needs of the rural community.

The innovative future model solution, created by the Save Rural Hospitals Act, establishes a new Medicare payment designation, the Community Outpatient Hospital (COH). This model will ensure access to emergency care and allow hospitals the choice to offer outpatient care that meets the population health needs of their rural community. 
  • Eligibility: Critical Access Hospitals (CAH) and rural hospitals with 50 beds or less as of December 31, 2014 are eligible to become COH (this includes facilities as described that have closed within 5 years prior to enactment).
  • Services:
    • Emergency Services – a COH must:
      • Provide emergency medical care and observation care (not to exceed an annual average of 24 hours), 24 hours a day, 7 days a week.
      • Have protocols in place for the timely transfer of patients who require a higher level of care or inpatient admission.
    • Meeting the Needs of Rural Communities. Based upon a community needs assessment, a COH could provide medical services in addition to the Emergency services, but not limited to observation care, skilled nursing facility (SNF) care, infusion services, hemodialysis, home health, hospice, nursing home care, population health and telemedicine services.
      • COHs are encouraged to provide primary care services through a  Federally Qualified Health Center (FQHC) or rural health clinic. These primary care services will ensure the community doesn’t lose primary care and inappropriately use the emergency room.
      • The COH will not operate any inpatient acute care beds, but can operate swing beds and observation beds.
  • Payments: The Medicare payment rate for services furnished at a COH (emergency care and outpatient services) will be 105% of reasonable cost and  provisions for wrap around grants for population health to ensure sufficient payments to allow the COH to serve the needs of the community.
  • Conversion:
    • For every CAH that converts to a COH, another hospital currently not designated as a CAH and located in the same state would be eligible to become a CAH so long as all criteria other than the distance criteria are met.
    • CAHs that convert to COHs may revert back to the CAH designation at any time and under the same conditions they were originally designated.

2. Cut Red Tape
The Administration has demonstrated a commitment to eliminating waste and cutting red tape, and we believe that there is a key opportunity to do so here. Many of the programs offered by USDA Rural Development (RD) and other agencies are underutilized or grants are not awarded to those in the greatest need or for whom the grant would provide the greatest benefit. Changes are necessary to help these agencies more aggressively promote and market assistance programs offered to rural communities to ensure these resources are going where they are needed. Applicants for grant and loan applications often complain that the process is inefficient and not business friendly. Hiring expensive consultants should not be necessary to obtain these needed resources.

We need to examine changes that can be made to ensure that applications are easy to complete and easy to access, and we must work improve the process to have applications considered more efficiently.

3. Build Infrastructure

Telehealth is an important tool in providing access to care in rural America. In 2013, over 40,000 rural beneficiaries received at least one telemedicine visit. Patients report high levels of satisfaction in receiving care via telemedicine. In one CMMI demo 96 percent of patients would recommend telemedicine care to family and friends. Still, telemedicine is only used in 0.2 percent of Medicare Part B visits. We need policies that foster growth. In almost every state, over 90% of the rural population has access to high-speed internet access. However, urban areas are twice as likely as rural areas to have access to copper and cable modem wireline technologies.

We need to provide access to capital through grants and loans for rural facilities to adopt new technology to meet the ever-changing requirements of health care, including all stages of meaningful use. In addition, funding is key to providing educational programs to train rural IT professionals in health care, as well as doctors, nurses, and medical staff how to use technology, including utilization of data and analytic tools to demonstrate and improve quality.

Rural public transit is either non-existent or very limited and more than 90 percent requires a reservation, limiting options for people who need to make unscheduled visits to health care providers, grocery stores or other activities of daily living. We need to identify strategies to assist individuals to ensure that they can access local and distant care.

EMS Services
On average, rural trauma victims must travel twice as far as urban residents to the closest hospital. In an emergency every second counts. As a result of these disparities, 60% of trauma deaths occur in rural America, even though only 20% of Americans live in rural areas. When a hospital closes, EMS services provide essential care for rural Americans.

In the wake of the rural hospital closure crisis, Emergency Medical Services (EMS) often become the only guaranteed access to health services. Dwindling population, losses in the volunteer workforce, and decreased reimbursement rates threaten access to EMS. Nearly one-third of rural EMS are in immediate operational jeopardy. Research grant programs are needed to fund the study of best practices and innovations from local EMS agencies across the U.S. In turn, grants can be offered to states authorities, as well as local EMS officials that adopt innovations and best practices found through this research to encourage broader application of best practices.

The Save Rural Hospitals Act includes new grants for Rural EMS. Hospital based grants are available to assist rural hospitals with the change to value based payment models and for rural hospitals working on population health (included a grant program targeted at COHs).

4. Workforce Development
One of the key pillars of President Trump’s plan is an investment in our nation’s people. As the informative fact sheet explains, we must “INVEST IN OUR COUNTRY’S MOST IMPORTANT ASSET – ITS PEOPLE: The President is proposing reforms so Americans secure good-paying jobs and meet the needs of our industries.” The pillars of this portion of the plan include:
  • “The President’s plan would reform Federal education and workforce development programs to better prepare Americans to perform the in-demand jobs of today and the future.  This includes:
  • Making high-quality, short-term programs that provide students with a certification or credential in an in-demand field eligible for Pell Grants.
  • Reforming the Perkins Career and Technical Education Program to ensure more students have access to high-quality technical education to develop the skills required in today’s economy. 
  • Better targeting Federal Work-Study funds to help more students obtain important workplace experience, including through apprenticeships.”
One of the most enduring characteristics of the rural health landscape is the uneven distribution and relative shortage of health care professionals. Many rural residents experience a lack of basic health services while the larger society cannot absorb all the health care professionals that are produced. National policy is largely designed to solve urban health care delivery problems with rural interests left in the backwash to negotiate policy and regulation patches designed to diminish unintended adverse rural consequences. At a time when the opioid epidemic is tearing apart our rural communities, we need to consider how the lack of behavioral health providers (almost every rural county is a designated behavioral/mental health professional shortage area) only helps to entrench this crisis in our rural communities.

The healthcare workforce needs to be broadly defined to include physicians, midlevel providers, registered nurses, licensed practical nurses, pharmacists, pharmacy technicians, certified nursing assistants, radiology technicians, laboratory technicians, emergency medical technicians, paramedics, surgical assistants, dentists, dental hygienists, dental assistants, dieticians, physical therapists, physical therapy assistants, occupational therapists, speech therapists, health care educators, behavioral health/mental health professionals, health care administrators, and public health workers. NRHA has a series of policy papers focused on the recruitment and retention of each of these groups, but key points for all include:
  • Fostering meaningful work by transforming hospitals into modern day organizations where all aspects of the work are going to be designed around patients and the needs of the hospital staff to care for and support them.
  • Broadening the base of health care workers by creating strategies that attract and retain a diverse workforce of men and women, racial and ethnic minorities and immigrants.
  • Building societal support for the public policies and resources needed to assist recruit and retain a qualified workforce, including adequate payment rates for hospital care and regulatory reform that reduces administrative burden and promotes team approaches to provide quality care
NRHA has recommendations that would immediately address these shortages. There is legislation currently introduced in the House, H.R. 2042, the Access to Frontline Health Care Act, which would create a new Frontline Providers Loan Repayment Program to provide student loan repayment for providers who deliver Frontline Care Services in a Frontline Scarcity Area for at least 2 years.

Graduate Medical Education (GME) statutes, as currently written, have unintended consequences that adversely affect the ability of rural areas to train primary care physicians, with the unfortunate result of hindering the recruitment and retention of such physicians to practice in these areas. S. 455, the Restoring Rural Residencies Act, would allow Medicare to reimburse residency programs for the time residents spend at Critical Access Hospitals (CAHs). Currently, regulations implementing the Affordable Care Act restrict Medicare from covering the costs of training resident physicians at a CAH, and has restricted efforts to expand the training medical professionals in rural communities.

Together, we can find ways to alleviate this workforce shortage, investing in our providers and our patients, and thereby improving the state of the rural economy through job creation and better health.

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