Must-Do Task for Rural Providers: Call Congress

If budget balancing gimmicks being considered by Congress take effect in the coming year, they could potentially mean the loss of billions of dollars in Medicare and Medicaid reimbursements for rural providers. Don't let it happen.

Rural providers, you already have enough on your plate tending to an older, sicker, poorer patient mix on a red-lined budget during a time of monumental transition for the healthcare sector.

It's no fun piling on.

Nonetheless, make sure that calling Congress is on the top of your list.

Regardless of your political affiliations or how you feel about the Patient Protection and Affordable Care Act, if you're a physician leader or an executive at your hospital, or if you're simply an average citizen who cares about maintaining quality healthcare in your community, you need to stay abreast of developments on Capitol Hill, and your elected representatives need to hear from you.

If budget balancing gimmicks being considered by Congress take effect in the coming year they could potentially mean the loss of billions of dollars in Medicare and Medicaid reimbursements for rural providers. It won't matter whether you're a blood red Republican or a blue dog Democrat when you're trying to balance the books on diminishing revenues.

One of the biggest potential icebergs out there is the permanent repeal of the widely reviled Sustainable Growth Rate funding formula for physicians' Medicare reimbursements. Virtually no one will weep over SGR's demise if Congress successfully installs a permanent 'doc fix' before the latest stopgap expires on March 31.

The potential trouble comes when lawmakers look for money to plug the estimated $116 billion hole over 10 years that would cover the cost of a permanent fix. This is a huge threat to hospitals in general and rural hospitals in particular because, well, it's happened before.

"Whether it's for the debt ceiling or a temporary doc fix or a permanent SGR fix it all has to be paid for and unfortunately the scenario that played out in the past is to rob Peter to pay Paul," says Maggie Elehwany, vice president of government affairs at the National Rural Health Association.

Do you recall how they paid for that latest temporary SGR bill that expires on March 31?

"They extended sequestration for rural providers for two years," Elehwany says. "A lot of people thought that it was solved when we had that last budget deal and Congress made a bunch of speeches about how we fixed the problems with sequestration. They did curb sequestration for discretionary spending only. For mandatory spending, Medicare, those sequestration cuts are still in effect. Not only are they still in effect, they were expanded for another two years. In 11 years from now we will be done with it, but that is a 2% cut across the board for the next 11 years and no provider can withstand that."

Fixing the SGR will help rural physicians, but not if it comes at the expense of the rural hospitals that provide safety net access for about 60 million Americans.

"What rural providers do is all part of the safety net," Elehwany says. "If you try to help rural physicians and fix the SGR problem that is wonderful, but not if you do that by cutting rural emergency medical services or cutting critical access hospitals or some of these rural Medicare (Preferred Provider Organization) hospitals where nearly every physician out there in rural areas is based."

"If you close the hospitals, the doctors aren't going to be able to practice," she says. "If you cut ambulance funding, there isn't going to be anyone to provider transportation. More than any other type of healthcare delivery system, the rural healthcare providers really are on a team that is united and they need to work together simply because there are so many challenges to overcome: the distances, the geography the weather, mountain ranges… just to serve the population."

More bad news: Attached to the SGR are Rural Medicare Extender provisions that will also expire with a permanent fix. These provisions were tacked on to the SGR after Congress saw the devastating effect on rural hospitals when Medicare switched to the prospective payment system in the 1980s. These include supplemental payments for Medicare-dependent hospitals, low-volume hospitals, and critical access hospitals.

As it stands now, rural hospitals face a potential double whammy. Not only could they be saddled with paying for the SGR repeal, they could also lose this supplemental money that comes with it. A Senate bill creating a permanent fix for SGR doesn't address how to pay for it, but continues some supplemental funding for rural hospitals in a number of areas including ambulance and transportation costs. However, two separate bills in the House don't include any supplement funding for rural health.

"That is our concern. That is where we think we need to do a big education pitch to the House," says Elehwany. "Even in the more urban states every Senator has rural constituents."

Understand that in the halls of Congress right now there are literally hundreds, if not thousands, of well-paid lobbyists trying to protect their particular special interest from any budget cuts. That's why it is so important for rural providers to take the initiative and contact their elected representatives. Groups like the NRHA and the American Hospital Association do a good job making the case for hospitals. But nothing makes an elected representative take notice like an active electorate. While Congress en masse appears to be out of touch with the rest of America, individual representatives and senators are not.

Elehwany offers a handful of effective talking points:

• Rural providers are a safety net for about 20% of the nation's population. Serving this generally poorer, older and sicker demographic requires more federal funding because there is no place to cost shift. It is not hyperbole to say that when rural hospitals close, people will die.
• Rural healthcare is cost effective. "Only an infinitesimally small portion of the federal budget is spent on rural healthcare providers but it's a good bang for the buck," Elehwany says. "It is 3.7% less expensive to treat the identical procedure in a rural community when compared with a suburban or urban community and the reason is that everything in rural is based on primary care."
• Rural hospitals are economic engines for the areas they serve. "If you close that rural hospital or if you force a physician to leave a rural community you are taking a huge economic component out of that community," Elehwany says. "The hospital is often the largest employer in a rural community. If your critical access hospital closes, you lose on average 107 jobs instantly, and that isn't even talking about the ancillary jobs from linen services to restaurants in the areas. And when the hospital closes, the doctors are the next to go and then the pharmacists are the next to go. What business is going to relocate or what family or retiree will stay in a rural community if there isn't some type of quality healthcare?"

Elehwany notes that the last two Congresses have sworn in huge freshman classes in both the House and Senate so they may not completely understand the pressures you are under. Make sure that they do. Send them a letter. Call them on the telephone. Invite them to tour your hospital and meet staff and talk with patients and community leaders to talk about the role that your hospital plays in their lives.

Rural providers have a strong case. You just have to make sure Congress hears you.