Rural Health Gets a Hearing; Is Congress Listening?

A House Ways and Means Health Subcommittee hearing on rural health disparities gave a platform to three rural providers who testified about the burdensome 96-hour rule, the lack of residency slots for new physicians, and onerous regulations for physician supervision of nurse practitioners.

If you're an advocate for rural healthcare and the people who provide it, Tuesday was a good day at the U.S. Capitol.

The House Ways and Means Health Subcommittee hearing on "rural health disparities" included testimony from three rural providers who shared their complaints about the 96-hour rule, the lack of residency slots for new physicians, and overly burdensome regulations for physician supervision of nurse practitioners. These three issues are among the most pressing for rural providers.

People with knowledge of the challenges facing rural healthcare would be pressed to find anything new in testimony presented before the subcommittee, but that doesn't mean these concerns aren't worth reiteration.

In his opening remarks, Subcommittee Chairman Kevin Brady (R-TX) told his colleagues that "our constituents are seeing firsthand the difficulties caused by overregulation and bureaucracy. And it is our rural neighbors who pay the price when it comes to access."

"We are in the midst of a great opportunity to reform how Medicare reimburses hospital and post-acute care providers. I hope today we can make progress in understanding the concerns facing those in rural areas."

Brady singled out the 96-hour-rule as particularly egregious.

"Doctors at critical access hospitals have to certify that it is reasonable that an individual would be discharged or transferred to a hospital within 96 hours of being admitted to a critical access hospital. That arbitrary cut-off doesn't always match the medical reality for patients seeking treatment at facilities near their homes."

He also suggested that rules governing physician oversight might have to be revised.

Not Enough Physicians
"Physician shortages are a reality in many parts of this country," he says. "Rules that change the way routine therapeutic services are handled in rural areas or rules that bar physician assistants from providing services, like hospice, disrupt access and the continuity of care for rural beneficiaries."

Carrie Saia, CEO at Holton Community Hospital, a 12-bed critical access hospital in northeast Kansas, told the committee that the 96-hour rule disrupts care for older, more-vulnerable patients.

"As a rural hospital administrator, I can say with certainty that the discrepancies between the conditions of participation and conditions of payment have caused confusion and challenges for critical access hospitals," Saia testified. "This regulation also impedes the ability of the person who knows the needs of the patient best; the physician and other healthcare providers, and may unnecessarily cause patients to receive care away from their community."

Shannon Sorenson, CEO of Brown County Hospital, 23-bed critical access hospital in Ainsworth, NE, suggested that the rules governing physician supervision don't reflect the challenges of rural providers coping with a physician shortage.

"While physician supervision requirements are less of a challenge for large hospitals, they can be very problematic in areas with few doctors," she testified. "CAHs simply do not have the manpower and resources to abide by these arbitrary regulations. Nor does this regulation allow all of our licensed personnel to perform within the highest level of their scope of practice."

Tim Joslin, CEO of Community Medical Centers, in Fresno, CA, told the committee that his three-hospital health system supports about 250 medical residents in eight areas, including primary care and emergency medicine, and 50 fellows in 17 subspecialties.

"This GME program is a critical feeder to the region's entire physician population and we'd like to grow the program. We are constrained, however," Joslin testified. "Our Medicare funding for GME positions is frozen at a 1997 level," even as the service area's population has increased by one-third since then.

"We have expanded the program on its own beyond what Medicare funds by investing well over $400 million over the last 10 years," Joslin told the committee. "But considering that Community Medical Center now shoulders more than $180 million in uncompensated care each year, the ability to expand our GME program on our own is financially limited. And this, in turn, limits our ability to provide our region's residents access to healthcare now and in the future."

These hospital executives are reflecting the concerns of thousands of their colleagues in every state. It's difficult to predict what will come of this because Congress is so dysfunctional right now. However, it's gratifying to know that these concerns are getting a fair hearing.