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

June 14

Comments Requested: Rural Health Workgroup for Quality Measurement HRSA exit disclaimer – July 2.  The Federal Office of Rural Health Policy has been partnering with Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF) on the Measures Application Partnership (MAP) Rural Health Workgroup. The group was formed by CMS in 2017 to include the perspectives of rural providers and patients as those most knowledgeable about the challenges in rural areas to measuring performance in health care delivery.  The workgroup has developed recommendations and identified a core set of the best available (i.e., “rural relevant”) measures and identified rural-relevant gaps in measurement in the MAP Rural Health Draft Report 2 HRSA exit disclaimer.  Those wishing to comment on these recommendations can create an NQF account and submit onlineHRSA exit disclaimer

Comments Requested: Increasing Investment in the Healthcare Sector – July 7.  The U.S. Department of Health & Human Services (HHS or the Department) seeks comment from the public on an effort to increase private sector innovation and investment in health care.  Specifically, the Department seeks input on the structure of a workgroup formed to increase dialogue and engagement between HHS and “those focused on innovating and investing in the healthcare industry, such as healthcare innovation-focused companies, healthcare startup incubators and accelerators, healthcare investment professionals, healthcare-focused private equity firms, healthcare-focused venture capital firms, and lenders to healthcare investors and innovators.”  The request pertains only to the way such a workgroup may be convened and structured and seeks other ideas for ongoing public-private engagement.  Rural stakeholders may have something to contribute to specific areas of focus and inquiry for the workgroup, including perceived barriers to innovation and competition in the healthcare industry and the effect of HHS programs and regulations on rural areas.

June 7

Deadline for Hospitals EHR Hardship Exception – July 1.  Medicare eligible hospitals and Critical Access Hospitals (CAHs) that are not meaningful users of certified electronic health record (EHR) technology under the Promoting Interoperability Program (formerly known as the EHR Incentive Program) may be exempt from Medicare penalties if they can show that demonstrating meaningful use would result in a significant hardship.  To avoid a payment adjustment, health care providers must complete a hardship exception application and provide proof of hardship. If approved, the exception is valid for the 2019 payment adjustment year only.

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.

May 10

Comments Requested: Policy Updates for Skilled Nursing Facilities – June 26.CMS displayed its proposed rule for fiscal year (FY) 2019 updating payment rates and rules for Skilled Nursing Facilities (SNFs) and non-Critical Access Hospital (CAH) swing beds. The rule includes an overall proposed payment rate increase of 2.4 percent, with rural SNFs and non-CAH swing beds experiencing this payment rate increase as 2.5 percent. CMS has also proposed replacing the current case-mix system with a new system called the Patient Driven Payment Model (PDPM) to be implemented by October 2019, which is projected to increase payments to small and rural SNFs and non-CAH swing beds. The proposed rule also includes changes to the SNF quality reporting program, changes to the SNF value-based purchasing program, and a request for information regarding electronic health information and interoperability.

Comments Requested: Policy Updates for Rehabilitation Facilities – June 26.  CMS displayed its proposed rule for fiscal year (FY) 2019 updating payment rates and rules for Inpatient Rehabilitation Facilities (IRFs). In addition to a payment rate increase of 0.9 percent ($75 million) compared to last year, the proposed rule solicits comments about removing the face-to-face requirement for rehabilitation physician visits, expanding the use of nurse practitioners and physician assistants in meeting the IRF coverage requirements.  The proposal would update the IRF quality reporting program, including adding a new quality measure removal factor and removing two measures from the measure set. Several IRF-Patient Assessment Instrument items have also been proposed for removal, and there is a request for information in the rule related to electronic health information and interoperability.

Comments Requested: Policy Updates to Psychiatric Facilities – June 26.  CMS displayed its proposed rule for fiscal year (FY) 2019 updating payment rates and rules for Inpatient Psychiatric Facilities (IPF). The rule includes an overall proposed increase in the payment rate by 1.25 percent, or $50 million for FY 2019. CMS has proposed to continue to apply the 17 percent payment adjustment for IPFs located in rural areas, which has been in place since 2004.The rule also updates the IPF quality reporting program by proposing the removal of eight (8) measures beginning with the FY 2020 payment determination. Additionally, the proposed rule includes technical changes to some of the IPF regulations and a request for information related to electronic health information exchange and interoperability.

Comments Requested: Policy Updates to Medicare Hospice – June 26.  CMS displayed its proposed rule for fiscal year (FY) 2019 updating payment rates and rules for hospices.  The rule includes an overall proposed payment increase of 1.8 percent ($340 million). CMS also proposed changes to the regulation text allowing physician’s assistants to be recognized by Medicare as an attending physician in addition to physicians and nurse practitioners. The rule also includes a request for information related to electronic health information exchange and interoperability, and proposed changes to the quality reporting program that include removal of routine individual public reporting of 7 hospice item set measures and instead displaying them as a composite.

May 3

Comments Requested: CMS Updates Payment and Policy for Hospitals – June 25. CMS issued its proposed rule for fiscal year (FY) 2019 updating payment rates and rules for hospital inpatient services.  Rural hospitals are expected to receive smaller payment increases (1.1 percent) than urban hospitals (2.1 percent), with larger rural hospitals faring better than their smaller counterparts.  The rule reduces the number of quality measures hospitals are required to report across the five quality and value-based purchasing programs, including 39 measures from the Hospital Inpatient Quality Reporting Program and 10 measures from the Hospital Value-Based Purchasing Program.  Rural Health Value can help rural hospitals continue the transition to value-based careHRSA exit disclaimer Also of note for rural providers, CMS has implemented provisions of the Bipartisan Budget Act of 2018 which extend the Medicare-Dependent Hospital program and Low-Volume Hospital Payment Adjustment for FY 2018 (further described at 83 FR 18301) through FY 2022. 

Comments Requested: HRSA Burden Reduction – July 2.  FORHP’s parent agency, the Health Resources and Services Administration (HRSA) seeks feedback for its ongoing work to reduce public and stakeholder burden.  Comments are open to the public and encouraged for entities significantly affected by HRSA regulations and policy, including state, local and Tribal governments, health care providers, small businesses, consumers, non-governmental organizations and trade associations.

Comments Requested: Improving Prehospital Trauma Care – July 26.  The National Highway Traffic Safety Administration is seeking comment and response to 24 specific questions from the public, governmental agencies, and professional and public interest groups on improving prehospital trauma care in all locations, including rural, suburban, urban, and wilderness areas.

February 14

CMS Annual Call for Medicare EHR Incentive Program Measures  – June 29.   CMS is accepting proposals for new Medicare Electronic Health Record (EHR) Incentive Program measures that advance meaningful use of Certified EHR Technology (CEHRT).  They encourage participating eligible hospitals and Critical Access Hospitals to submit ideas for new measures that emphasize patient outcomes and patient safety as well as improved program efficiency. 

Date Last Reviewed:  June 2018

Questions about Policy Updates?