Nov 21, 2019

Rural Health at CMS: What’s Been Done and What’s to Come

Seema Verma
Administrator, Centers for Medicare & Medicaid Services

Rural Health at CMS: What’s Been Done and What’s to Come

For the third time in my tenure at CMS, I am excited to recognize National Rural Health Day and the work CMS is doing to advance the health of nearly 60 million rural Americans. Residents of rural communities face unique barriers – higher rates of poverty, difficulty traveling long distances to a hospital or doctor’s office, and lack of access to innovations. Recent CDC data shows that people in rural areas have higher rates of preventable deaths than people in urban areas. For example, 57% of deaths from chronic lower respiratory disease in rural areas were found to be preventable, compared with only 13% preventable deaths for people with the same condition in urban areas[1].

We have already made considerable advancements on rural health, but as these numbers demonstrate, significant challenges remain. The Trump Administration has a track record of tackling long-standing issues in our health care system — such as our recent efforts on price transparency and health record interoperability – and rural health is another challenge we are taking on. 

CMS’s Patients Over Paperwork initiative has been a critical component in identifying ways to reduce provider burden in rural areas by directly engaging with clinicians and beneficiaries. As of May 2019, CMS estimates burden savings to rural facilities, including Federally Qualified Health Centers, at around $100 million and 950,000 hours between 2018 and 2021.

While today, we are highlighting National Rural Health Day, CMS supports rural communities throughout the year with our Rethinking Rural Health Initiative. Our rural health strategy applies a rural lens to the work of CMS to improve access to care through provider engagement and support, expand access to innovative technologies, empower patients in rural areas to make healthcare decisions, and leverage partnerships to improve health outcomes. 

Provider Engagement and Support

Rural Hospital Reimbursement
Rural hospitals face unique economic challenges, which have resulted in more than 100 rural hospital closures - many in the South - since January 2010. CMS took a significant step this year to increase the wage index for certain low-wage index hospitals, including many rural hospitals, in order to improve rural Americans’ access to needed care.

Before we made these changes for FY2020[2], hospitals located in areas with wages below the national average received a lower Medicare payment rate than hospitals in areas with above-average wages. For example, a hospital in a low-wage rural community could receive a Medicare payment of about $4,000 for treating a beneficiary admitted for pneumonia, while a hospital in a high-wage area (many urban communities) could receive a Medicare payment of nearly $6,000 for the same case due to wage index differences.

CMS addressed wage index disparities by increasing payments to certain low-wage hospitals. Approximately 60% of the hospitals receiving increases in payments due to the wage index change are in rural areas. The change will help these hospitals attract and maintain a highly skilled workforce, which strengthens competition and leads to more options for patients in rural areas.

Innovative Payment Models
Additionally, rural health care providers have often struggled to implement pay-for-performance models due to lack of technical infrastructure and diffuse patient populations, where care coordination and population health management are particularly difficult[3]. CMS has worked to take into account unique needs of rural communities with alternative payment models and value-based payment arrangements.  We know that what works in urban and suburban settings does not always work in rural settings.

For example, rural accountable care organizations (ACOs) with a smaller population of patients can participate in the Next Generation ACO (NGACO) Model, which is a Center for Medicare and Medicaid Innovation (Innovation Center) model that is testing financial incentives to improve health outcomes and lower expenditures for Medicare beneficiaries. Additionally, the Innovation Center’s Emergency Triage, Treat, and Transport (ET3) Model allows ambulance care teams serving Medicare beneficiaries greater flexibility to find appropriate places for treatment that may not always be a hospital. Especially in rural areas, this helps people obtain more convenient access to services and care without expensive, avoidable transports to a hospital emergency department.

Earlier this year, I announced that CMS is looking at a new innovative model specific to rural communities for stakeholder coalitions of providers, purchasers, and payers to invest in increasing access and improving healthcare delivery.

Regulatory Flexibility for Supervision Requirements
CMS also implemented changes to the supervision requirements allowing health care professionals – like physician assistants (PAs) and radiologist assistants (RAs) - more flexibility to deliver care at the top of their scope of practice to improve the efficiency of care delivery. For 2020, CMS updated our regulation on physician supervision to give PAs greater flexibility to practice more broadly in the current health care system in accordance with state law and state scope of practice. This builds on the RA change that went into effect in 2019 to address concerns that supervision requirements for some diagnostic tests were overly restrictive and did not allow for full use of RAs. Such flexibility will allow rural areas that are often facing shortages of health professionals to maximize the use of provider time. 

Innovative Technologies for Rural Communities
CMS has also expanded the availability of telehealth and communication technology-based services in unprecedented ways, which is especially critical in rural areas where geographic barriers can impede access to health care. In 2019, we implemented separate payments under the Medicare Physician Fee Schedule for virtual check-ins and remote evaluations of recorded videos and/or images that a patient submits to their clinician, as well as payments for virtual communications with clinicians at Rural Health Clinics and Federally Qualified Health Centers.

Additionally, CMS expanded the list of telehealth services and finalized policies to implement recent legislative changes for telehealth services related to beneficiaries with end-stage renal disease (ESRD) receiving home dialysis, beneficiaries with acute stroke, and for treatment of a substance use disorder or a co-occurring mental health disorder.

In addition, Medicare Advantage plans can offer more innovative telehealth services as part of their basic benefit bid beginning in 2020, expanding access to care for our beneficiaries. And we have expanded access to telehealth services in certain payment initiatives – including in our recent overhaul of the Medicare Shared Savings Program for accountable care organizations (ACOs).

Empowering Patients
On November 15, 2019, CMS finalized policies that follow directives in President Trump’s Executive Order, entitled “Improving Price and Quality Transparency in American Healthcare to Put Patients First.” These rules lay the foundation for a patient-driven healthcare system by making prices for items and services provided by all hospitals in the United States more transparent for patients so that they can be more informed about what they might pay for hospital items and services. The policies in the final rule will give patients in rural areas more information for decision-making.

Leveraging Partnerships to Improve Health Outcomes
Over the last year, CMS has turned its attention to the urgent problem of maternal health in rural areas. According to the CDC, about 700 women die each year in the U.S. due to pregnancy or delivery complications.  The CDC has determined that 60% of these deaths are preventable[4]. Further, maternal morbidity and severe illnesses affect more than 50,000 women a year[5]. These figures reflect the crisis in maternal health generally, but the problem is worse in rural areas.

Access to care in rural areas is often difficult. Some rural hospitals have stopped providing obstetric and gynecologic services, leaving nearly half of all rural counties in the US without such care. Less than half of rural women have access to perinatal services within a 30-minute drive of their homes, and more than 10% of rural women have to drive 100 miles or more. These access issues affect women’s and infant’s health before, during, and after pregnancy.

This is an issue of great personal concern to me. Early in my career, I worked on a maternal and infant health program. Decades later, we are dealing with the same challenges - some of which have gotten worse. Pregnancy-related deaths have more than doubled in the last 30 years[6]. CMS, which pays for nearly half of America’s births, is working to reverse these trends.

On June 12, CMS hosted “A Conversation on Maternal Health Care in Rural Communities: Charting a Path to Improved Access, Quality and Outcomes” that provided a forum for experts to highlight best practices and innovative solutions to improve maternal health care in rural areas. We published the important highlights and insights shared during the forum in a summary released today[7].

CMS also released a comprehensive issue brief titled “Improving Access to Maternal Health Care in Rural Communities” that provides an overview of the challenges associated with accessing maternal health care in rural communities. It also highlights efforts underway across CMS and examples of local programs that are successfully addressing the maternal health needs of women in rural communities. We will continue to take decisive steps to address maternal health so that women – especially in rural areas – can experience healthy pregnancies.

As we mark another National Rural Health Day, I view the progress we have made with optimism, but also acknowledge there is more to be done. CMS will persevere in our commitment to providing rural Americans with the tailored opportunities necessary to deliver the high-quality healthcare they deserve.

For more information, please visit our CMS rural health page: http://go.cms.gov/ruralhealth

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[2] Fiscal Year 2020 Medicare Hospital Inpatient Prospective Payment System and Long Term Acute Care Hospital Prospective Payment System Final Rule. 42 C.F.R. § CMS-1716-F 2019. Retrieved from https://www.govinfo.gov/content/pkg/FR-2019-08-16/pdf/2019-16762.pdf

[3] Medicare Value-Based Payment Models: Participation Challenges and Available Assistance for Small and Rural Practices. December 2016. Government Accountability Office. GAO-17-55