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Confronting Rural America's Health Care Crisis

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Confronting Rural America's Health Care Crisis IDEAS ACTION RESULTS Confronting Rural America’s Health Care Crisis BPC RURAL HEALTH TASK FORCE POLICY RECOMMENDATIONS April 2020 B P C R U R A L Tom Daschle Bill Frist, M.D. H E A LT H CO-CHAIR Partner and Chairman, Former Senate Majority Leader Cressey & Company TA S K F O R C E Co-Founder, BPC Senior Fellow, BPC MEMBERS Former Senate Majority Leader Ronnie Musgrove CO-CHAIR Chris Jennings Former Governor of Mississippi Founder and President, Jennings Policy Strategies Olympia Snowe Senior Fellow, BPC CO-CHAIR Jennifer M. McKay, M.D. Senior Fellow, BPC Board Member, BPC Medical Information Officer Former Senator, Maine and Physician, Avera Health Tommy Thompson Keith Mueller CO-CHAIR Director, RUPRI Center for Senior Fellow, BPC Rural Health Policy Analysis Former Secretary of HHS Former Governor of Wisconsin Karen Murphy Executive Vice President, Chief Georges Benjamin, M.D. Innovation Officer, and Founding Executive Director, American Director, Steele Institute for Public Health Association Health Innovation, Geisinger David Blair Tom Tauke Chairman, Accountable Health Former Representative, IA-2 Solutions Inc. Board Member, BPC Gail Wilensky Senior Fellow, Project HOPE Henry Bonilla Former Administrator of Former Representative, TX-23 the Health Care Financing Administration (now CMS) Kent Conrad Former Senator, North Dakota Karen DeSalvo, M.D. Chief Health Officer, Google Senior Fellow, BPC Former Acting Assistant Secretary for Health, HHS National Coordinator for Health Information Technology, HHS 2 STAFF Morgan Bailie G. William Hoagland Project Coordinator, Health Project Senior Vice President Tyler Barton Dena McDonough Research Analyst, Health Associate Director, Health Project Project and Prevention Anand Parekh, M.D. Joann Donnellan Chief Medical Advisor Senior Advisor, Communications Marilyn Serafini Katherine Hayes Director, Health Project Director, Health Policy HEALTH PROJECT Under the leadership of former Senate Majority Leaders Tom Daschle and Bill Frist, M.D., BPC’s Health Project develops bipartisan policy recommendations that will improve health care quality, lower costs, and enhance coverage and delivery. The project focuses on coverage and access to care, delivery system reform, cost containment, chronic and long-term care, and rural and behavioral health. ACKNOWLEDGMENTS BPC would like to thank the Helmsley Charitable Trust for its generous support in funding the Rural Task Force’s mission of identifying the barriers and challenges facing rural health care and creating the educational opportunities to affect change. BPC would also like to thank the members of the Honorary Congressional Task Force on Rural Health who provided insight into the complex challenges rural communities face in accessing quality health care, Senator Chuck Grassley (R-IA), Senator Tina Smith (D-MN), Senator Bill Cassidy (R-LA), Senator Angus King (I-ME), Congressman Jodey Arrington (R-TX), and Congresswoman Xochitl Torres Small (D-NM). DISCLAIMER The findings and recommendations expressed herein do not necessarily represent the views or opinions of BPC’s founders or its board of directors. 3 Site Visits Over the course of this project, BPC and the Rural Health Task Force visited a number of rural facilities across the United States. We heard from health care administrators, medical providers, and hospital and clinic staff about the health care challenges and needs in their community. These site visits were instrumental in developing thorough policy recommendations. BPC would like to thank the following: Dartmouth-Hitchcock Health Mt. Ascutney Hospital Hanover, NH and Health Center Windsor, VT Knoxville Hospital and Clinics Northern Light Health Knoxville, IA Portland, ME MaineHealth NorthCrest Health Portland, ME Springfield, TN Marshfield Clinic Health Springfield Children’s Clinic System-Minocqua Springfield, TN Minocqua, WI Stephens Memorial Hospital Marshfield Medical Norway, ME Center- Neilsville Neilsville, WI UnityPoint Health Des Moines, IA Maury Regional Medical Center Columbia, TN Disclaimer The findings and recommendations in this report do not necessarily reflect the views of the organizations listed above. 4 6 Table of Contents 8 EXECUTIVE SUMMARY 17 INTRODUCTION 18 RECOMMENDATIONS 18 Stabilizing and Transforming the Rural Health Care Infrastructure 40 Transforming Clinician Payment and Delivery in Rural Areas 47 Improving Access to Quality Maternal Care in Rural Areas 52 Ensuring an Adequate Rural Health Care Workforce 59 Breaking Down Barriers to Technology in Rural Communities 66 CONCLUSION 67 APPENDIX A: POSSIBLE PAY FORS 69 APPENDIX B: RURAL PROVIDER DESIGNATIONS 70 ENDNOTES 7 Executive Summary The rapid spread of the new coronavirus has awakened the nation to the dire access problems that have long plagued rural communities and has underscored the need for immediate change. The COVID-19 pandemic has highlighted the fragility of the rural health care system, in which hundreds of hospitals have already closed or are in imminent risk of folding. The pandemic now threatens to heap additional financial pressures onto these hospitals, leaving millions in fear that they won’t receive care. COVID-19 prompted a flurry of legislative and regulatory action in early 2020, marking the first important steps in addressing access to care through telehealth. Some of these actions align with recommendations in this report. However, these measures were generally limited to temporary fixes, while the problems need long-term attention. The Bipartisan Policy Center’s Rural Health Task Force has developed recommendations over the last year to stabilize and improve the urgent problems challenging rural communities and to do it permanently. Launched in June 2019, the task force consists of health care experts, business leaders, physicians, and former elected officials. The aim was to produce policy recommendations to stabilize and transform rural health infrastructure, promote the uptake of value-based and virtual care, and ensure access to local providers. The recommendations in this report are the product of extensive outreach, including roundtable discussions with experts and stakeholders, public comments, and multiple site visits in Iowa, Maine, Vermont, Wisconsin, Tennessee, and New Hampshire. Even before coronavirus struck, rural Americans experienced significant gaps in care and a unique set of circumstances. They often must travel long distances to see a doctor or visit the emergency room. Rural communities struggle to recruit and retain health care providers and many areas aren’t equipped with broadband. This makes it difficult for residents to make use of telehealth and virtual care technologies. The rural population is older, sicker, and less likely to be insured or seek preventive services.i,ii According to the Centers for Disease Control and Prevention, this population is more likely than their urban counterparts to experience potentially preventable death from five leading causes: heart disease, cancer, unintentional injuries, chronic lower respiratory disease, and stroke.iii Maternal and infant mortality rates are also on the rise in these areas. 8 The steady stream of recent hospital closures launched rural health care into the national spotlight; COVID-19 has only drawn further attention to the plight of these hospitals and communities. Since January 2010, 126 rural hospitals have closed, and an additional 557 are currently at risk.iv Of the rural hospitals that closed from 2005 through 2017, 43% were more than 15 miles away from the next closest hospital and 15% were more than 20 miles away.v According to the Government Accountability Office, rural residents delay or neglect to seek care if they have to travel longer distances to access services after a local hospital has closed.vi This is particularly problematic for those who are geographically isolated, elderly, or low income. The loss of a hospital in remote areas may lead to a decline in the number of local providers and reduced access to critical and specialist services, including obstetric and maternal care. Local economies are also significantly impacted. On average, the health sector makes up 14% of employment in rural communities, with hospitals typically being among the largest employers. The average Critical Access Hospital, or CAH, employs 127 people with an annual payroll of $6 million.vii Other data show that hospitals in larger rural communities have an average of 520 employees, while those located in smaller, more isolated areas employ an average of 138 staff.viii In March 2020, as coronavirus evolved into a pandemic, Congress voted to temporarily waive telehealth requirements for Medicare providers, allowing the Centers for Medicare and Medicaid Services, or CMS, to reimburse clinicians for telehealth visits with patients at home in an area with a designated emergency. The Trump administration has built on this effort and temporarily expanded access to care by providing regulatory flexibility around the use of telehealth for all Medicare beneficiaries. The flexibilities that have been utilized to address this public health emergency highlight opportunities for permanent improvements to rural health care access. In addition to addressing telehealth, the task force recommendations include short-term stabilization for struggling rural hospitals and multiple pathways to transform into models that are customized to meet the needs of individual communities. For example, following a comprehensive community needs assessment, a hospital might transform
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