Emerging Options for Health Care in Rural and Underserved Communities
While COVID-19 economic relief funding may have helped short-term, the past three years laid bare the ongoing struggles of access to care – impacted by lack of reimbursement and workforce among other factors – in many rural and underserved communities. The question remains: what is or can be done? We highlight various innovations or opportunities that may bridge gaps in care in these communities.
Rural Emergency Hospital
The Rural Emergency Hospital (REH) designation was created under the Consolidated Appropriations Act of 2021 and came online in January 2023. According to the National Conference of State Legislatures, 15 states have already enacted enabling legislation: Arkansas, Illinois, Indiana, Iowa, Kansas, Michigan, Montana, Nebraska, Nevada, New Mexico, New York, Oklahoma, South Dakota, Texas, and West Virginia.
We modeled the REH designation and provided our thoughts last year on hospital that would likely be first movers:
- Need for increased net revenues,
- Low inpatient daily census (or trending in that direction),
- Financially struggling or on verge of closure,
- Total revenues of less than roughly $13 million,
- Be part of a health care system that has other hospitals in close proximity.
Recent news articles indicate that hospitals with a low daily census, are financially struggling, smaller revenue or part of a health care system are where there has already been traction. We expect ongoing interest in the near-term as a means of stabilizing smaller, struggling facilities and as other hospitals watch and see the results of transitioning to this new designation.
However, the REH is only one partial solution to an ongoing systemic problem. On top of the fact there are fewer residents in rural or isolated areas, those areas also tend to have more chronic disease, an older population, have other social determinants of health, and rural areas can have difficulty attracting and retaining providers. The model may be a way to keep urgent, emergency and outpatient care in communities, but it cannot solve underlying issues without other solutions.
Mobile health units
As the name implies, mobile health units travel to different locations and provide various services ranging from preventive screenings, dental care, vaccinations to primary care touchpoints and beyond. Mobile units are an important means for expanding care outside of the four walls of a hospital, clinic or health center. Units are also uniquely suited to underserved areas because they can bring services to individuals, including those without means of transportation, instead of forcing individuals to travel further away to brick-and-mortar locations. Mobile units have been increasing in numbers, and we saw that especially during the pandemic.
One new opportunity available to community health centers enacted by Congress in 2022 was the MOBILE Health Care Act. The law allows community health centers to expand access via mobile health units without having to establish another permanent site. Under the law, health centers can utilize federal funds through “new access points” (NAP) grants to establish mobile care delivery units. The law allows existing Section 330 grantees to propose NAP for mobile units alone or in conjunction with a permanent site.
Telehealth and virtual care
During the pandemic, telehealth and other virtual care options were widely used for many services—from primary care to mental health to hospital at home programs to senior living communities. Much of this was made possible by flexibilities and reimbursements available under HHS for both Medicare and Medicaid.
A reminder that many flexibilities would have expired with the end of the Public Health Emergency (May 11, 2023), but federal law now extends Medicare payment for telehealth through 2024, including the following flexibilities:
- Allowing telehealth in non-rural locations (ie: metro, urban areas)
- Allowing the home as an acceptable originating site.
- Allowing for audio-only telehealth, as opposed to the normal “synchronous” audio-video requirement.
- Expanding the list of eligible practitioners who can provide telehealth services to include occupational therapists, physical therapists, speech-language pathologists, and audiologists.
- Allowing federally qualified health centers and rural health clinics to continue to provide telehealth services.
- Delaying the required in-person visit within six months of a mental health services provided via telehealth.
- Permitting telehealth services to meet face-to-face recertification requirement for hospice
There are many who want Congress to extend these flexibilities permanently – including through introduction of the CONNECT for Health Act of 2023 – but for now, they remain opportunities for rural and underserved communities through 2024.
Safety net hospitals
Safety-net hospitals continue to struggle; some have even closed. Recent closures include hospitals in Atlanta, Philadelphia, and San Antonio. Typically, these full or partial closures are driven by the hospitals treating larger populations of lower income individuals with government insurance or no insurance at all. Most hospitals depend on the higher reimbursement rates from private insurance (employer-sponsored) to offset what typically are barely adequate or inadequate Medicare and Medicaid reimbursements.
MedPAC, an advisory board to the Congress, has been researching this issue and recently recommended replacing existing disproportionate share and uncompensated care payments with a new Medicare “safety-net index” to better target dollars to needy hospitals. Their recommendation to Congress would be to transition from disproportionate share and uncompensated care payments to a Medicare safety-net index (MSNI) with payments scaled in proportion to the hospital’s specific MSNI score. Their proposal would also pay commensurate MSNI amounts for services furnished to Medicare Advantage (MA) enrollees directly to hospitals and exclude them from MA benchmarks.
Of course, a large-scale change like this would need much more impact analysis and vetting, plus it is just one approach. Congress would need to enact legislation, making it highly unlikely it will happen now. That said, the issue facing safety-net hospitals in metro areas is becoming more pronounced. Enhanced reimbursement could be an emerging option to shore-up these hospitals.
Innovative workforce approaches
Thinking anew about deploying workforce is also an option to expand access out into rural and underserved areas. For example, community health workers can work to educate individuals on their health care as well as serve as an advocate or support. Community paramedic programs vary but can connect individuals with primary care or serve as a bridge post-hospitalization and fill existing gaps in care. Midwives and doulas can help fills gaps in maternal health care needs. New behavioral health models, including grant programs and digital/telehealth, can assist with gaps in mental and behavioral health care.
Further, new models for staffing that take full advantage of an advance practice provider’s (APPs) scope of practice is another option. For example, some Critical Access Hospitals may utilize APPs for emergency department coverage. Additionally, tele-hospitalist or tele-ER approaches can be added on to this for additional support. While APP scope of practice is dependent on state law/regulation, utilizing these providers could be a viable approach to expanding or filling existing care gaps.
PACE program
If we’re looking at care across the health care continuum – from primary to behavioral to post-acute – the PACE program is an interesting program to consider. If you think about it, the PACE program is decades ahead of current care delivery and value-based payment models. It has been operating successfully on full capitation and requires team-based, whole-person focused care designed to keep individuals well, living in the community and out of more costly settings like hospitals and nursing homes. Even further, the vast majority of individuals in the PACE program are dually-eligible for both Medicaid and Medicare.
We wrote about the PACE program – Program for All-Inclusive Care for the Elderly – in early 2022. The article highlighted how PACE also aligned with existing trends like aging in place, technology/innovations and value-based payments. Even during the pandemic, PACE organizations were able to pivot to telehealth and virtual delivery mechanisms and still maintain high quality outcomes.
One policy barrier is that individuals must live in a PACE service area. Currently, there are 31 states that have PACE programs. Locations tend to be more populated.
New collaborations, models
There may be new models to consider or opportunities to develop new partnerships and collaborations to fill gaps and address access. A few approaches to consider:
- The Making Care Primary and GUIDE Dementia Care are two new models launched by the Centers for Medicare & Medicaid Innovation
- Community health centers partnering with other primary care clinics or hospital
- Primary care practice collaboration with a hospital or senior living community in a value-based payment model (e.g.: an ACO, primary care model)
- Hospital partners with local unit of government (including public health) on wellness checks
- Partnerships with school systems to address pediatric or mental health care needs
- Leveraging or partnering with philanthropic foundations
Successful partnerships or collaborations must determine the specific need to be addressed and the strategic partners that can combine to operationally and financially meet that need.
One closing note, we are also seeing new entrants moving into underserved markets as well. Take Dollar General testing mobile clinics at several stores in Tennessee. Plus, major retailers like Walgreens, Walmart, and CVS which may be in underserved areas, are starting or expanding in-person or virtual health care services.
How CLA can help
Do any of these opportunities pique your interest? Reach out today to start a conversation.
Jennifer Boese is the Director of Health Care Policy at CLA. She is a highly successful public policy, legislative, advocacy and political affairs leader, including working in both the state and federal government as well as the private sector. She brings over 20 years of government relations and public policy knowledge with her to CLA. Well over half of her career has been spent dedicated to health care policy and the health care industry, affording her a deep understanding of the health care market and environment, health care organizations and health care stakeholders. Her role at CLA is to provide thought leadership, policy analysis and strategic insights to health care providers across the continuum related to the industry's ongoing transformation towards value. A key focus of that work is on market innovations and emerging payment models. Her goal is to help CLA clients navigate and thrive in an increasingly dynamic health care environment.
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