Feb 12, 2020

Rethinking Rural Health: Maternal and Infant Health RFI

Seema Verma
CMS Administrator

Today I had the privilege of speaking at the National Rural Health Association’s policy institute.  We had a great conversation about rural health, discussing how the unique challenges of rural areas, including geographic isolation and a shrinking healthcare workforce, require unique solutions. 

As part of our discussion, we focused on maternal health, an issue that is especially personal to me. Early in my career, I worked on an infant mortality prevention program. Yet decades later we’re dealing with the same challenges, and in some cases they’ve gotten worse. According to the CDC, in 2018, 658 women died in the U.S. due to pregnancy or delivery complications, and the overall maternal mortality rate was 17.4 deaths per 100,000 live births. Around 50,000 women per year experience unexpected outcomes due to pregnancy or delivery complications that have significant consequences. Much of this is preventable.

Since 2010, more than 120 rural hospitals have closed, and others have stopped providing obstetric services, indicating these challenges are increasingly acute in rural communities. The closures also affect the availability of pediatric inpatient services and pediatric specialties, including neonatal intensive care. Those living in rural areas are less likely to access prenatal services during their first trimester than urban and suburban patients, which may contribute to higher rates of complications. Additionally, racial and ethnic minority women in rural areas, including those living in tribal communities, face even greater challenges accessing health care services.

Under the Trump Administration, CMS is making rural health a top priority. We are using new and creative ideas to ensure that individuals who live in rural America have access to high quality, affordable healthcare. We’re working to remove barriers to care—including maternal care—in rural areas and avoiding unintended consequences of program implementation that focus on urban and suburban areas.

The Rethinking Rural Health Initiative is a vital part of our goal to advance the health of Americans living in rural areas, and we’ve already delivered results through our CMS Rural Health Strategy . For example, CMS now pays for virtual check-ins that allow a patient to speak with their clinician by phone or other telecommunication system. This helps the clinician decide whether the patient needs to make a trip to be seen in-person and can help reduce barriers posed by distance or lack of transportation.

We also made changes to the hospital wage index for inpatient and outpatient settings that help address Medicare wage index disparities between high and low wage index hospitals. This change helps hospitals better serve people living in rural areas with improved access to quality, affordable healthcare.

And beginning in 2020, we lowered the minimum required level of physician supervision for hospital outpatient therapeutic services furnished by all hospitals -- including Critical Access Hospitals in rural areas-- from direct supervision to general supervision. General supervision means that the procedure is furnished under the physician's overall direction and control, but that the physician's presence is not required during the performance of the procedure. This gives rural hospitals, in particular, greater flexibility in their staffing.

As part of the Rural Health Initiative, we also sought to improve access to maternal healthcare for those living in rural communities. In June 2019, CMS and partners hosted an interactive “Conversation on Maternal Healthcare in Rural Communities: Charting a Path to Improved Access, Quality, and Outcomes,” which included participation of nearly 1,000 individuals. In addition, CMS released an issue brief to advance the understanding of issues facing mothers in rural communities.

CMS, as the payer for more than 40% of the nation’s births, has an essential role in ensuring that mothers and infants in rural America have access to quality care. That’s why today we’re posting a Request for Information  seeking public comments on opportunities to improve health care access, quality, and outcomes for women and infants before, during, and after pregnancy in rural communities.

Responses to this RFI will be used to inform future work by CMS toward the development and refinement of programs and policies that allow rural families’ access to high quality health care that result in improved health outcomes. We look forward to receiving your responses and to partnering with you as we work to improve the health of Americans—especially mothers and infants—living in rural areas.