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Red Tape Relief: NRHA Participates in Ways and Means Committee Roundtable

Today, NRHA Member Leslie Marsh, joined by NRHA’s Regulatory Counsel Diane Calmus, spoke at a bipartisan roundtable with Members of the House Committee on Ways and Means Health Subcommittee on regulatory relief for rural providers. NRHA was invited to join the small roundtable to present the key regulatory reforms needed to support rural communities and providers and ensure access to care. Entitled, “Red Tape Relief Initiative,” the roundtable provided members of the Ways and Means Committee the opportunity to hear from the individuals who must deal with burdensome regulations daily. 
Leslie Marsh, MSN, RN is the CEO of Lexington Regional Health Center in Nebraska. During the roundtable, Marsh explained the ways in which regulatory reforms can improve care in rural America. She explained that their Critical Access Hospital serves a diverse population, and one that is still on average sicker and poorer than any urban community in Nebraska. Many in their community have little access to transportation and many also rely on the hospital for help in managing their diabetes, cardiac issues, chronic lung conditions and cancer. Marsh explained how crucial Lexington Regional’s presence in the community is, “Like most rural communities we serve as one of the legs of a three-legged stool, without any one of those legs - healthcare, schools and infrastructure, a rural community quickly begins to crumble.  We inject roughly $30 million into the local economy as it stands now; importantly, if the hospital were to close the school would lose funding, the (meat-packing) plant would have to relocate, young professionals and retirees would relocate.  There is just a snowball effect that takes place when a community loses its hospital.”
For Lexington Regional, the exclusive use standard has been a significant issue. Small rural providers and clinics do not have the ability to accommodate the burden of this regulation, and without visiting specialists using existing spaces, care will simply not occur. Leslie Marsh explained:
“Who are these visiting specialists though and what do they do for rural communities?  They are oncologists, cardiologists, OB/GYNs , pediatricians and the like.  There isn’t enough work for them to support a full-time practice but the specialized care they provide is needed by those in the community.  Imagine if your spouse, parent or child had cancer but no way to get themselves to and from appointments to receive the care they need to survive.  We have those people.  Many have no means to travel and those who can do so at a significant cost.  That is a lot of time for a person to be away from work and the costs associated with traveling 300 miles for care are not insignificant.  Plus, when your loved one is sick and in pain they don’t want to travel – they want to receive care locally.  Without visiting specialists, the patients would need to travel hours to go to an urban hospital. This is necessary care and the patients are made aware the provider is separate from the clinic. The current burdensome policy is not necessary to inform patients of the doctor’s affiliation, a simple temporary sign or a handout could achieve this result without cutting off needed care in rural America.”
As the rural hospital closure crisis continues to escalate, rolling back regulations that are burdensome and unnecessary can help facilities better provide quality, affordable care. Diane Calmus notes, “We hear from our members constantly that regulations are prohibiting them from providing critical, timely care. As rural America continues to struggle to recover from the Great Recession, we need to ensure that policies at the federal level do not negatively affect small providers in remote communities.” 83 rural hospitals have closed since 2010, and 673 are vulnerable to closure. NRHA has identified a series of regulatory concerns that could immediately be addressed by CMS to improve access to care and reduce undue burdens placed on small rural providers.
1. Common-sense approach needed for “exclusive use” standard.
The CMS enforcement in rural communities of the nonsensical “exclusive use” regulation is creating a chilling effect and exacerbating the specialty care shortage crisis that plaques rural America. The burdensome requirements of the regulation do not make sense for small rural facilities.

As a result of these enforcement actions, we have already learned of rural communities that have lost access to specialists including a pediatric gastroenterologist, gynecological oncologist, and pediatric cardiologist. Visiting specialists provide a crucial service in rural communities and commonly provide access to cardiologists, oncologists and pediatric surgeons. Allowing visiting specialists to utilize provider-based clinics allows access to care in rural communities.

2. More accurate price standardization of CAH Swing Bed claims is necessary.
An unintended consequence of the ACA, this rule has allowed CMS to alter its price/payment standardization methodology, thereby treating CAH swing-beds claims differently and inequitably than it does CAH inpatient claims and CAH outpatient claims.  The ramifications of this payment inequity will result in significant losses to CAHs and exacerbate the current escalation of rural hospital closures. 

Price standardization for Critical Access Hospital (CAH) swing-beds can allow CAHs to participate in value programs and allow rural patients to receive care close to home and family. CMS has the authority to revise the price standardization formula for CAH swing bed claims to improve price standardization and maintain rural patients access to care.

3. CAHs and many SCHs should be eligible for indirect GME (IME).
Physician rotation in rural residencies programs in Critical Access Hospitals and other small hospitals in rural America has been proven to dramatically improve workforce shortages in rural and frontier locations.

Only allowing CAHs to put direct GME on cost reports restrictions training resident physicians at a CAH restricts the available physician workforce for rural communities. CMS has chosen not to exercise its ability to allow a CAH to choose whether it wishes to be considered a hospital or a non-provider for GME purposes only, as well as, allow reimbursement for SCHs to include Indirect GME expenses.

4. Performance comparisons should occur between equivalent cohorts in MIPS.
In order to avoid unnecessarily punishing rural providers that are providing excellent care, rural providers should be compared with other rural providers. This approach will also account for the sociodemographic risk factors of rural populations that are not otherwise considered in the MIPS program by comparing like populations. Furthermore, this rural to rural comparison will reduce the impact of small low volume rural providers also accounted for elsewhere in the regulation.

5. Implementation of the Section 603 Site Neutral payment for new off-campus provider based department (PBD) harms rural providers.
Off-campus PBD serve an important role in providing care to many rural Americans. While NRHA understands that the Bipartisan Budget Act of 2015 requires the change, it provides more flexibility than the proposed rule. Specifically, the proposal that a change in location, expansion of services, and change in ownership of the clinic would cause an off-campus PBD to lose its excepted status is beyond the requirements of the legislative language.

NRHA urges CMS to allow existing off-campus PBD to continue to be paid under the OPPS system so far as is allowed by law, which includes the situations described above.

6. Hospital Star Rating treats rural hospitals unfairly—rural relevant measurements are needed.
The majority of facilities that do not meet the requirements to receive a star rating are CAHs, not because they are poor quality, but because CMS has not created measurements tailored to the unique patient volumes and services of rural hospitals. The greyed-out stars appear to be low quality not unrated.

NRHA has long worked with the National Quality Forum, advancing that rural hospitals should report quality measurements that make sense and are relevant to the services that they provide.  That is, CMS has the authority and should create measurements tailored for rural hospitals and the unique patient volumes and services provided at rural hospitals.  

7. Elimination of the 96-hr Condition of Payment requirement reduces unnecessary red tape in line with the congressional intent of the creation of the CAH.
From the creation of the CAH designation until late 2013 an annual average of 96-hour stays allowed CAHs flexibility within the regulatory framework set up for the designation. The new policy of strict enforcement of a per say 96-hour Condition of Payment requirement that physicians at CAHs certify, at the time of admission that a Medicare patient will not be at the facility for more than 96-hours, creates unnecessary red-tape and barriers for CAHs throughout rural America; and eliminates important flexibility to allow general surgical services well suited for these high quality local providers.

NRHA is pleased CMS included a modified enforcement of the 96-hour condition of payment in the 2018 hospital inpatient prospective payment system regulation. However, this regulatory burden remains in place and continues to hinder the appropriate use of CAHs and places a substantial burden on the hospital and those providers caring for patients.

8. Changing the supervision requirements for outpatient therapy services to general supervision from direct supervision protects patient safety and access.
Requiring direct supervision by a physician for outpatient therapy causes rural facilities to reduce therapy services, threatening access. Adopting a default standard of general supervision for outpatient therapeutic services is consistent with the conditions for CAHs and preserves care quality and safety.

NRHA appreciates the two-year moratorium on the enforcement of the direct supervision requirement, as well as the multiple one-year legislative fixes that have passed since this undue burden was first introduced by CMS. However, these ad hoc fixes do not eliminate the regulatory burden since they do not provide the permanent certainty for long term hiring decisions hospitals are making. As such, more action is required to truly fix this regulatory burden.

9. Increased regulatory burden resulting from multiple private plans.
As states move to Medicaid managed care and Medicare Advantage increases its market penetration healthcare providers are faced with meeting slight variations on administrative requirements such as HIPAA trainings.

While the move to managed care and other private provider managed plans can introduce innovations, the change can also bring inefficiencies. For most administrative trainings, a common format or requirement would ease burdens for providers and plans.

10. MIPS reporting.
While these practices are not looking for special treatment, they are disappointed to find the system is simply not working well. In fact we have reports of providers spending over three and a half hours to try and get registered with the system, only to give up before being able to submit their data. Those that make it past the step or registration find there is no confirmation page letting them know they have successfully and correctly submitted.

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