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Fed Pledges to Rural Providers Strike the Right Notes

 |  By John Commins  
   February 06, 2013

It's easy for federal officials to acknowledge with great fanfare the special concerns of rural healthcare stakeholders. Making good on promises to address those concerns, however, is never guaranteed.

Still, it was hard not to be impressed this week after listening in on pledges made to rural healthcare stakeholders during a teleconference that included Health and Human Services Secretary Kathleen Sebelius, Agriculture Secretary Tom Vilsack, and Patrick Conway, MD, CMO and director of clinical standards and quality at the Centers for Medicare & Medicaid Services.

The three senior officials detailed Medicare reforms that they determined were obsolete or excessively burdensome on hospitals and healthcare providers. Eliminating those bewhiskered regulations, by CMS estimates, could save nearly $676 million annually—$3.4 billion over five years—and would greatly ease regulatory and staffing burdens for rural providers in particular.

Conway ran through a list of already implemented reforms and proposed reforms that:

  • Eliminate a requirement that critical access hospitals provide diagnostic, therapeutic, laboratory, radiology, and emergency room services directly by staff. Those services can now be contracted out, Conway says, "to provide high-quality care and better access to care when staffing becomes a challenge."

  • Eliminate a requirement that critical access hospitals, rural health clinics, and federally qualified health centers have a physician on site at least biweekly to provide medical direction.

    "Many physicians in extremely remote areas found it difficult to comply with this biweekly schedule. Specifying a specific timeframe for a physician to visit a rural facility does not ensure better healthcare," Conway says. "With the development of telemedicine a physician should have the flexibility to utilize a variety of options to provide medical direction."
  • Allow registered dieticians to order patient diets directly rather than relying on approval from clinicians. "As a practicing hospital medicine physician I have personally—including while working in a hospital this past weekend—seen the potential for medical errors if physicians misunderstand dieticians' recommendations," Conway says.

    "This will provide hospitals with the flexibility to allow dieticians to practice to the full extent of their scope of practice and enter orders directly."
  • Allow rural hospitals with swing beds to be surveyed when the hospital is surveyed, rather than being surveyed separately.
  • No longer require for one director of outpatient services. "Each hospital can determine the most efficient and effective way to manage outpatients. This change is critical for small, low volume rural hospitals with more limited staff resources," Conway says.

In addition, Conway says the Obama administration has already implemented key reforms that were recommended in May 2012 during the White House Rural Stakeholder meeting.

Those include the final rule of the physician fee schedule, which was amended to allow nurse practitioners and physicians' assistants to order portable X-rays.

"This recognizes the important role these providers play in rural clinics and hospitals and the need for flexibility," Conway says. "Lastly we made changes to the electronic health records incentive payments. We now allow cause to include capital lease costs for the purpose of determining their electronic health records incentive payments."

Vilsack, the former Iowa governor, told the teleconference that the reforms and proposed reforms "reflect an understanding that rural America—and those who serve, live, work, and raise in rural America—is potentially a different place than suburban and urban areas and requires a different thought process as it relates to regulations."

"Providing greater flexibility, expanding the leverage of resources, recognizing the various professions that are engaged in healthcare providing in rural areas from dieticians to physicians' assistants and others, allowing flexibility in outpatient services, recognizing that swing beds in hospitals may need different survey requirements, all of that is reflective of an attitude that we are trying to make life easier and at the same time improve health services," Vilsack says.

Sebelius, the former governor of Kansas, told the teleconference that the reforms are a response to the feedback generated by the White House rural stakeholder meeting last spring.

"We understand that one size doesn't fit all when it comes to healthcare and this reflects that understanding," Sebelius says. "For rural providers, the proposals not only save money, they will help ensure that doctors and nurses have more time to devout to their patients."

Sebelius asked rural providers to help CMS educate the 8.5 million uninsured people in rural America who may be eligible for health insurance under the Affordable Care Act.

"Starting October 1, new health insurance marketplaces open for enrollment. Expanding access isn't enough. We need your help to reach out to your communities to get people signed up," she says. "We know that a lot of people are so used to being locked out or priced out of the market, they don't even think about coverage anymore."

"There are also a lot of uninsured young people who may not understand why health insurance is important for their future," she says.

"Reaching them is about more than ensuring that everyone has a chance to get healthy and get the care they need. It's also about reducing the burden of uncompensated care and making sure that fewer people show up in our emergency rooms with illnesses that could have been prevented. The more successful we are in getting people enrolled the more we will reduce the strain on providers and hospitals across the country."

So what can the rest of us in "the flyover" make of all of this outreach?

It appears to be well-intentioned and sincere. Why would it be otherwise? Sebelius and Vilsack are former governors of largely rural Midwestern states, and they know firsthand the lay of the land.

And fortunately, improving quality and access for rural healthcare appears to be one issue that Republicans and Democrats embrace enthusiastically. They understand that healthcare providers fill critical access needs, create jobs, and generate economic activity.

CMS says it wants feedback from rural providers on the proposed rules changes during the 60-day public comment period. Now is the chance for those providers to step up and help shape federal rural healthcare policy.

It's easy to get cynical about all of this and just assume that the Obama administration is just playing politics or that the federal government will ignore recommendations and screw things up. Admittedly, federal healthcare policy can be hard to defend.

It's a lot tougher, however, to weigh in with thoughtful suggestions about how we can improve healthcare delivery in rural America. The stakes in this game are too high to sit on the sidelines. Make sure that CMS hears from you.

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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