Nov, 15 2018

On National Rural Health Day, We Recommit to Improving Rural Health

Seema Verma
Administrator, Centers for Medicare & Medicaid Services

On National Rural Health Day, We Recommit to Improving Rural Health

Today is National Rural Health Day, an important day for all of us at CMS and, more importantly, for the work we do every day to improve the health of those living in our nation’s rural communities.

Approximately 60 million people live in rural areas – including millions of Medicare and Medicaid beneficiaries. We at CMS recognize the many obstacles that rural Americans face, including living in communities with disproportionally higher poverty rates, more chronic conditions, and more uninsured or underinsured people. Many rural communities lack access to specialty care and have a fragmented healthcare delivery system with an overworked and shrinking health workforce. These challenges cost lives and have an impact on health quality. According to the Centers for Disease Control and Prevention, in 2014, many deaths among rural Americans were potentially preventable, including those from heart disease, cancer, unintentional injuries, chronic lower respiratory disease, and stroke.

Despite many barriers, several rural communities are devising innovative ways to address their unique challenges. Through partnerships, new business models, and technology they are improving the health of their communities and providing patients with a high level of care. In my travels as the CMS Administrator and from visiting the National Rural Health Association in Kansas City, I know firsthand of rural clinicians’ tremendous commitment to serving their communities.

CMS’ role is to help all rural communities embrace innovation and devise sustainable models to improve rural health. We began this journey last spring when we released the agency’s first Rural Health Strategy. Our strategy focuses on ways in which CMS can better serve individuals in rural areas and avoid unintended consequences of policy and program implementation. The strategy has five objectives:

  • Apply a rural lens to CMS programs and policies
  • Improve access to care through provider engagement and support
  • Advance telehealth and telemedicine
  • Empower patients in rural communities to make decisions about their healthcare
  • Leverage partnerships to achieve the goals of the CMS Rural Health Strategy

We built the Rural Health Strategy based on input from rural providers and beneficiaries, and we continue to seek their input as we develop our policies and programs. Our rural health strategy is already in action. But we’ve also begun enacting the strategy and have seen some excellent results.

One area of focus is how to maximize the promise of evolving technology to improve access to care in rural areas. We recently finalized separate payment under the Medicare Physician Fee Schedule for Brief Communication Technology-based Services, often referred to as virtual check-ins. With this new billing code, clinicians can be paid separately when the patient checks in with the practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed. We expect this will increase efficiency for practitioners and convenience for beneficiaries. 

Also, Medicare will now pay separately for Remote Evaluation of Recorded Video and/or Images Submitted by the Patient. This new billing code will allow clinicians to be paid separately for reviewing patient-transmitted photo or video information conducted via pre-recorded “store and forward” video or image technology to assess whether a visit is needed. 

Because End-Stage Renal Disease (ESRD) and stroke patients often have difficulty getting to a clinician’s office, particularly in rural areas, we have expanded telehealth options for more accessible care.  For example, CMS recently finalized proposals that add renal dialysis facilities and beneficiary homes as sites where certain telehealth services could be furnished to Medicare beneficiaries receiving home dialysis. We also finalized a proposal to cover telehealth services furnished in mobile stroke units to Medicare beneficiaries with acute stroke. These changes, part of the implementation of the Bipartisan Budget Act of 2018, are effective January 1, 2019.

We have recently provided information to Congress about current use of Medicare telehealth services and additional opportunities for telehealth to improve care for people in rural and other communities. We believe these efforts to promote increased use of technology can help reduce rural health disparities and improve rural patient satisfaction. We’re committed to maximizing opportunities for making telehealth available for rural patients.

For CY 2019, CMS finalized separate payment for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for communication technology-based services and remote evaluation services that are furnished by an RHC or FQHC practitioner when there is no associated billable visit. Particularly in rural areas where transportation is limited and distances may be far, we believe the use of communication technology-based services may help some patients to determine if they need to schedule a visit at the RHC or FQHC.

Within the Quality Payment Program, we’ve implemented several options to help clinicians in both small and rural practices successfully participate in the Merit-based Incentive Payment System (MIPS). Our flexible approach resulted in notable successes for clinicians in rural practices during the 2017 performance year. We’re pleased to highlight that 94 percent of MIPS-eligible clinicians in rural practices earned a neutral or positive payment adjustment, with 65 percent earning a positive payment adjustment with an additional payment for exceptional performance.

We will continue working directly with clinicians in rural practices to identify opportunities to reduce their participation burden. We will also continue offering our no-cost technical assistance to them through the Small, Underserved, and Rural Support initiative so that they can successfully participate in future performance years.

Today, our Office of Minority Health released a report that compares the quality of care delivered to rural and urban beneficiaries overall. The report also looks at how these differences vary by race and ethnicity. Healthcare professionals, organizations, researchers, and hospital leaders can use this report along with other CMS’s resources to help raise awareness of health disparities, develop interventions for Medicare beneficiaries living in diverse settings, and implement quality improvement efforts that improve health equity.

We know that accurate and appropriate Medicare payment rates are essential to all hospitals, especially rural ones. In past rulemaking actions, we have discussed a multitude of studies, analyses, and reports to find ways to improve the Medicare wage index. Stakeholders have told us they think the existing wage index disparities between high and low wage index areas are too great, particularly for rural hospitals and/or financially struggling hospitals. To address this concern, we invited the public to submit further comments, suggestions, and recommendations for regulatory and policy changes to the Medicare wage index. To frame the discussion and comments from the public, we included a detailed summary of the studies and issues to date as well as references to past discussions of these issues.  As indicated in the FY 2019 Inpatient Prospective Payment System (IPPS) final rule, CMS is actively considering the comments we received in order to inform future actions.

I’m proud of our achievements, but we are not stopping here. We will continue to develop and improve our rural health-related thinking and policies to foster innovation and solutions for rural health.

CMS is dedicated to improving rural health. And we’re dedicated to hearing from the clinicians and health plans on the front lines who know what they need to be successful. In October we convened a very successful listening session with health plans and received many ideas for how we can help make more coverage options available in rural areas.

We will continue listening and are looking for ideas and opportunities for CMS to continue to address rural health challenges in the future. Continuing our work to ensure all rural communities have access to high quality affordable healthcare is one of our key initiatives for 2019.  We look forward to continuing to collaborate with the diverse set of stakeholders who are working to find solutions to rural health challenges out in the field.

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