Rural Health Policy

Regulatory Review

The Federal Office of Rural Health Policy is charged in Section 1102(b) of the Social Security Act with advising the Secretary of the U.S. Department of Health and Human Services on the effect that federal health care policies and regulations may have on rural communities. Monitoring current and proposed changes, including programs established under titles XVIII and XIX (Medicare and Medicaid), FORHP analyzes their impact on the financial viability of small rural hospitals and clinics, on the ability of rural areas to attract health professionals, and on rural areas’ access to high quality care.

Data collection and analysis is essential to understanding the challenges in rural communities, how those communities are impacted by policy, and setting policy for the future. For this reason, the work of the Rural Health Research Centers informs that of FORHP’s policy team and vice versa.

Policy Updates

August 2

CMS Proposes Medicare Outpatient Payment and Policy Changes – September 24.  CMS seeks comments on its annual rule proposing payment and policy changes for Medicare outpatient services.  Changes in the rule are estimated to reduce payments with equal impact to urban and rural hospitals overall.  Proposals relevant to rural providers include paying for off-campus clinic visits at the physician rate rather than the hospital rate, reducing payments to non-excepted off-campus provider-based departments for drugs acquired through the 340B Drug Discount Program, and removing measures from the Hospital Outpatient Quality Reporting Program.  The rule includes several requests for information (RFI) including providers sharing information with patients about charges and out-of-pocket costs and using Medicare and Medicaid conditions of participation to advance progress toward interoperability. Comments on the proposed rule are due by September 24.

July 19

Comments Requested: CMS Updates Medicare Clinician Payments and Policy – September 10. On July 12, CMS displayed its proposed rule for calendar year (CY) 2019 updates to Medicare payment rates and rules for clinicians, including rural clinicians. Proposed updates under this rule apply to the Physician Fee Schedule (PFS) and the Quality Payment Program (QPP). Major updates under the PFS that are applicable to rural providers include (1) streamlining Evaluation and Management (E&M) payment and reducing clinician burden and (2) adding new payment opportunities for communication technology-based services for Rural Health Clinics and Federally Qualified Health Centers. Rural providers should also note QPP policy proposals such as (1) expanding the definition of MIPS eligible clinicians to include new clinician types (physical therapists, occupational therapists, clinical social workers, and clinical psychologists); (2) adding a third element to the low-volume threshold determination and giving eligible clinicians who meet one or two elements of the low-volume threshold to voluntarily participate in MIPS; and (3) overhauling the MIPS “Promoting Interoperability” performance category to support greater EHR interoperability and patient access to their health information. Additionally, CMS is seeking comment through Requests for Information on promoting interoperability and electronic healthcare information exchange and price transparency.

AHRQ Seeks Nominations to National Advisory Council – August 8.  The Agency for Healthcare Research and Quality (AHRQ) is seeking nominations for seven new members of its National Advisory Council. The panel, which includes representatives from the private health care sector including, health plans, providers, purchasers, consumers and researchers, advises the agency director and the Secretary of HHS on AHRQ activities and priorities for a national health services research agenda. Among other attributes, nominees should be distinguished in the conduct of health care research and demonstration projects, the fields of health care quality research or health care improvement and the practice of medicine.  This is an opportunity for rural providers and researchers to contribute to the work and research priorities of AHRQ. 

July 12

Comments Requested: New Medicare Advantage Demonstration September 4.  CMS will test the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration, which, when approved and adopted would waive Merit-Based Incentive Payment System (MIPS) requirements for clinicians who participate sufficiently in certain Medicare Advantage (MA) plans that involve taking on risk.  This is an opportunity for rural providers participating in MA and MIPS to provide feedback to CMS on possible information collection burdens associated with the demonstration. 

Now Available: MIPS 2019 Payment Adjustment Fact Sheet. CMS posted an additional resource to help eligible clinicians and groups understand their Merit-based Incentive Payment System (MIPS) 2019 payment adjustment based on their 2017 performance. Some rural clinicians and CAHs may participate in MIPS and can review this fact sheet to learn more about how CMS assigns final scores to MIPS eligible clinicians and how payment adjustment factors are applied for 2019 based on 2017 MIPS final scores.

July 5

Comments Requested: Updates to CMS Home Health Payments and Policy – August 31. The Centers for Medicare & Medicaid Services (CMS) displayed a proposed rule for calendar year (CY) 2019 updating payment rates and rules for home health agencies. In addition to a payment rate increase of 2.1 percent ($400 million) compared to last year, the proposal makes changes to the methodology for rural add-on payments mandated by statute and proposes case-mix methodology refinements to be implemented for home health services beginning January 1, 2020, specifically changing the unit of payment from 60-day episodes of care to 30-day periods of care and implementation of the more patient-focused, Patient-Driven Groupings Model (PDGM). Also of note for rural areas, CMS seeks to 1) update the definition of remote patient monitoring, which could now be included as an allowable operation expense; 2) change requirements for accrediting organizations to ensure access to and burden reduction for small or rural non-certified providers and suppliers; 3) establishe health and safety standards and transitional payment for qualified home infusion therapy suppliers; and 4) obtain feedback related to electronic health information and interoperability.

June 28

Provide Feedback on Reducing Regulatory Burden for Care Coordination – August 24CMS seeks public input HRSA exit disclaimer on how to address any undue impact and burden of the physician self-referral law (also known as the “Stark Law”); focusing in part on how the law may impede care coordination.  The Stark Law prohibits physicians from referring patients to Medicare services that the physician has a financial relationship or interest; however, these prohibitions can be a barrier to a physician’s participation in an Advanced Alternative Payment Model or other integrated delivery models of care.  Rural providers and stakeholders may share their thoughts on a variety of questions about the impact of the Stark Law, such as whether exceptions to the law are necessary to protect financial arrangements that involve integrating and coordinating care. 

June 7

CMS Updates Drug Spending Dashboards.  The Centers for Medicare & Medicaid Services (CMS) redesigned their Drug Spending Dashboards to “include year-over-year information on drug pricing and highlight which manufactures have been increasing their prices.”  The interactive online tools use data reported for both Medicare and Medicaid, and are designed to help patients, clinicians, researchers, and the public understand trends in drug spending. Rural access to pharmaceuticals is challenged by typically higher costs due to lower volumeHRSA exit disclaimer

First Medicaid and CHIP Scorecard Released.  The new Medicaid and Children's Health Insurance Program (CHIP) Scorecard, developed by CMS, provides information on State Health System Performance, State Administrative Accountability, and Federal Administrative Accountability.  It reports measures such as enrollment, expenditures, state and federal time to review waivers, and beneficiary outcomes to increase public transparency about the programs’ administration and outcomes, which may be of interest to State Offices of Rural Health and other rural stakeholders. Access to health care through insurance is one of the socioeconomic factors measured in the 2018 County Health Rankings at the top of this newsletter.

New Fact Sheets about Confidentiality of Substance Use Disorder (SUD) Records.  The Department of Health and Human Services released two factsheets to help providers and health information exchange (HIE) organizations understand how to appropriately access and securely share health information with the patient’s consent under Title 42 of the Code of Federal Regulations Part 2 (aka “Part 2”).  This law protects the confidentiality of SUD patient records by restricting the circumstances under which programs or other lawful holders can disclose such records.  As treatment options in rural areas are moving towards integrating behavioral health and primary care services HRSA exit disclaimer, understanding how Part 2 provisions can be used across different environments, including through electronic HIE mechanisms and in provider office settings, will ensure privacy and improve care.

May 24

Rural Feedback Heard on New Directions for the CMS Innovation Center.   CMS posted online the more than 1000 comments received in response to the September 2017 Request for Information (RFI) on a new direction for the Innovation Center to promote patient-centered care and test market driven reforms. They heard from consumers, physicians, health systems, health plans, national and state associations, and community-based providers.  Rural-focused comments covered a range of topics from expanding telehealth and improving availability of care in underserved areas to expanding Medicare Advantage plan options and supporting rural physician participation in Advanced Alternative Payment Models

CMS Encourages Eligible Suppliers to Participate in Diabetes Prevention ProgramBeginning in 2018, both traditional healthcare providers and community-based organizations, including community health workers, can enroll as Medicare suppliers in the Medicare Diabetes Prevention Program (MDPP), a national model offering a new approach to type 2 diabetes prevention. After achieving preliminary or full recognition through the CDC, organizations can enroll in Medicare to become an MDPP supplier on a rolling basis. Rural areas tend to have higher rates of diabetes than urban areas.

GAO Report Assesses CMS Innovation Center Performance.   The Government Accountability Office (GAO) recently concluded that the CMS Innovation Center met its 2015 goal of identifying, testing, and improving health care payment and delivery models, and it partially met the goals of reducing the growth of health care costs and spreading successful practices and models.  Rural Accountable Care Organization (ACO) models, such as the ACO Investment Model, contributed to the goal of implementing new models.  The report also describes how new models are conceived and implemented, including how geographic location can be a factor in the participant selection process.

Date Last Reviewed:  August 2018

Questions about Policy Updates?