[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
RURAL HEALTH CARE DISPARITIES CREATED
BY MEDICARE REGULATIONS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON WAYS AND MEANS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
JULY 28, 2015
__________
Serial 114-HL04
__________
Printed for the use of the Committee on Ways and Means
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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COMMITTEE ON WAYS AND MEANS
PAUL RYAN, Wisconsin, Chairman
SAM JOHNSON, Texas SANDER M. LEVIN, Michigan
KEVIN BRADY, Texas CHARLES B. RANGEL, New York
DEVIN NUNES, California JIM MCDERMOTT, Washington
PATRICK J. TIBERI, Ohio JOHN LEWIS, Georgia
DAVID G. REICHERT, Washington RICHARD E. NEAL, Massachusetts
CHARLES W. BOUSTANY, JR., Louisiana XAVIER BECERRA, California
PETER J. ROSKAM, Illinois LLOYD DOGGETT, Texas
TOM PRICE, Georgia MIKE THOMPSON, California
VERN BUCHANAN, Florida JOHN B. LARSON, Connecticut
ADRIAN SMITH, Nebraska EARL BLUMENAUER, Oregon
LYNN JENKINS, Kansas RON KIND, Wisconsin
ERIK PAULSEN, Minnesota BILL PASCRELL, JR., New Jersey
KENNY MARCHANT, Texas JOSEPH CROWLEY, New York
DIANE BLACK, Tennessee DANNY DAVIS, Illinois
TOM REED, New York LINDA SANCHEZ, California
TODD YOUNG, Indiana
MIKE KELLY, Pennsylvania
JIM RENACCI, Ohio
PAT MEEHAN, Pennsylvania
KRISTI NOEM, South Dakota
GEORGE HOLDING, North Carolina
JASON SMITH, Missouri
ROBERT J. DOLD, Illinois
Joyce Myer, Staff Director
Janice Mays, Minority Chief Counsel and Staff Director
______
SUBCOMMITTEE ON HEALTH
KEVIN BRADY, Texas, Chairman
SAM JOHNSON, Texas JIM MCDERMOTT, Washington
DEVIN NUNES, California MIKE THOMPSON, California
PETER J. ROSKAM, Illinois RON KIND, Wisconsin
TOM PRICE, Georgia EARL BLUMENAUER, Oregon
VERN BUCHANAN, Florida BILL PASCRELL, JR., New Jersey
ADRIAN SMITH, Nebraska DANNY DAVIS, Illinois
LYNN JENKINS, Kansas
KENNY MARCHANT, Texas
DIANE BLACK, Tennessee
C O N T E N T S
__________
Page
Advisory of July 28, 2015 announcing the hearing................. 2
WITNESSES
Daniel Derksen, Director, Arizona Center for Rural Health........ 27
Tim Joslin, CEO, Community Regional Medical Centers.............. 9
Carrie Saia, CEO, Holton Community Hospital...................... 22
Shannon Sorensen, CEO, Brown County Hospital..................... 16
SUBMISSIONS FOR THE RECORD
AAHomecare, statement............................................ 62
AANP, letter..................................................... 66
AATHC, letter.................................................... 69
America's Critical Access Hospital Coalition, statement.......... 73
America's Essential Hospitals, statement......................... 75
Kaweah Delta Health Care District, statement..................... 80
Mayo Clinic Center for Connected Care, statement................. 83
NACDS, statement................................................. 87
NRHA, statement.................................................. 91
Rural Hospital Coalition, statement.............................. 96
Strategic Health Care, letter.................................... 102
Teladoc, statement............................................... 103
WHA, statement................................................... 110
RURAL HEALTH CARE DISPARITIES CREATED
BY MEDICARE REGULATIONS
----------
TUESDAY, JULY 28, 2015
House of Representatives,
Subcommittee on Health,
Committee on Ways and Means,
Washington, D.C.
The Subcommittee met, pursuant to call, at 10:06 a.m., in
Room 1100, Longworth House Office Building, the Honorable Kevin
Brady [chairman of the subcommittee] presiding.
[The advisory announcing the hearing follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman BRADY. Good morning. Welcome to today's hearing to
discuss rural healthcare disparities created by Medicare
regulations. This is an important issue for all, but the
challenges facing beneficiaries and providers are especially
evident to those of us who represent districts that aren't
completely urban.
Our constituents are seeing firsthand the difficulties
caused by overregulation and bureaucracy. And it's our rural
neighbors who pay the price when it comes to access. Take, for
instance, the so-called 96-hour rule. Critical Access Hospitals
are a critical piece of rural health infrastructure. Doctors at
Critical Access Hospitals have to certify that it is reasonable
that an individual be discharged and transferred to a hospital
within 96 hours of being admitted to a Critical Access
Hospital. That arbitrary cutoff doesn't always match the
medical reality for patients seeking treatment at facilities
near their homes. I personally heard from St. Joseph's, a
Critical Access Hospital in my district, on the problems with
the 96-hour rule.
Or consider the rules related to physician supervision:
Physician shortages are a reality in many parts of our country.
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.
We can do better. We must do better. We will do better. We
should provide relief for all of our hospitals and providers
from overly burdensome regulations in bureaucracy. There is no
better place to start that process than with our rural
hospitals. There is much to be done, and today we are lucky to
have here firsthand accounts from providers serving rural
communities. First, we have Shannon Sorensen, CEO of Brown
County Hospital in the Ainsworth, Nebraska, a constituent of
Mr. Smith. Next, we have Tim Joslin, the CEO of Community
Regional Medical Centers in Fresno, California, a constituent
of Mr. Nunes'. Then we have Carrie Saia, the CEO of Holton
Community Hospital, a facility in Congresswoman Jenkins'
hometown in Kansas. Finally, we have Dr. Daniel Derksen from
the University of Arizona.
We are very happy to have you here today.
This is the latest in a series of hearings held by the
Health Subcommittee in the wake of the passage of legislation
to fix the way Medicare pays our Nation's physicians. Now, I
know we mentioned this in our MedPAC hearing last week, but it
stands repeating: We are in the midst a great opportunity to
reform how Medicare reimburses hospitals and post-acute-care
providers, all critical to saving Medicare for the long term.
I hope today we can make progress in understanding the
concerns facing those in rural areas.
And before I recognize the ranking member, Dr. McDermott,
for the purpose of an opening statement, I ask unanimous
consent that all members' written statements be included in the
record.
Without objection, so ordered.
I now recognize Dr. McDermott for his opening statement.
Mr. MCDERMOTT. Thank you, Mr. Chairman.
I want to thank the witnesses for coming this morning. I
look forward to hearing what you have to say. I believe there
is room for us to work together to address how we deliver
health care to people who live in rural areas. I also believe
that if we are going to have a serious conversation about this
topic, we need to get the facts straight. Time and time again,
I hear from Republican colleagues about rural hospitals closing
down, threatening access to health care for many communities.
I happen to represent an area where we have the WWAMI
program, which covers one quarter of the United States' land
mass, so I know about rural areas. And as they do with
virtually every perceived problem in the healthcare system, my
colleagues place the blame for all of it squarely on the
Affordable Care Act. There is another side to this story.
One of the major financial strains placed on hospitals is
uncompensated care--has been for years. When patients, many of
whom are poor and quite sick, are not covered by insurance and
cannot afford to pay out of pocket, hospitals have to pick up
the cost. It has been true--and we have not had the ability in
the law yet to say you don't have got to take care of somebody.
So if somebody comes in, you have to take care of them. And
somebody pays; it is the hospital.
We recognized this problem when we passed the Affordable
Care Act. We worked to reduce uncompensated care coverage--
dramatically through an expansion of coverage of Medicaid. This
would provide some of the more economically or most
economically vulnerable people, many living in rural
underserved areas with access to coverage.
However, under Republican leadership, more than 20 States--
20 States--refused simply to accept Medicaid expansion, simply
because it was part of President Obama's Affordable Care Act.
Their decision has left 4.3 million people without insurance,
forcing hospitals, many of them which serve rural areas, to
pick up the cost. And not coincidentally, 80 percent of the
hospitals that have announced recent closures are in States
that chose not to expand Medicaid--80 percent are in States
that didn't expand Medicaid. This is not a problem of Medicare
regulations governing rural hospitals, nor is it a problem with
the Affordable Care Act. It is a problem with the party that
would prefer to sabotage the President's healthcare program for
political purposes rather than try to make it work.
So if we want to improve access to rural care and address
the issue of rural hospital closures, we have to start by
convincing the leadership to do what they should have done in
the first place and expand Medicaid. To address the needs of
rural communities, we also need to have long-term investments
in our professional workforce.
The United States faces a growing shortage of physicians
and healthcare providers. That is nurse practitioners, PAs, all
the people that provide care in rural ares. And it is predicted
to reach in physicians alone by 2025 between 46,000 and 91,000
people short to provide what is necessary. Rural areas are
going to have a particular scarcity of physicians. We have
tried lots and lots of things in the WWAMI program, but we
continue to run into some of the same problems.
Now, we should be skeptical that the solution of the
problem lies in gutting Medicare support for graduate medical
education in urban areas. There is minimal evidence whatsoever
that this will result in more doctors practicing in rural
areas. It will simply exacerbate the nationwide doctor shortage
and lower the quality of training. There are better ways to
train physicians who serve in rural areas. I encourage my
colleagues to look at some alternatives.
The University of Washington has run the WWAMI program, as
I mentioned, which trains physicians not only in the cities but
out in the rural areas. They are placed out in little bitty
places, and they see what it is like. And they learn what is
necessary, but also getting them to stay is tough. The program
is the finest in primary care and rural in the whole country
and has ably served the communities in Washington, Wyoming,
Alaska, Montana, Idaho, for more than four decades.
There are some other investments I believe we have to make
if we are really going to deal with rural access. We can treat
the medical profession like we treat the armed services and
provide ROTC-style medical school scholarships to doctors who
agree to a tour of service in underserved areas. I call this
RDOCS, and I believe it is a smart investment. We don't think
there is anything wrong with giving somebody a college
education and then keeping him in the Navy or the Army or the
Air Force for 5 years. Why don't we do the same thing with
medicine? Get somebody to sign a contract upfront: I will take
the scholarship, but I will serve 5 years as a result of that.
Now, that is the only way you are going to get people out there
for a long enough period for them to decide, you know, maybe I
want to stay here. That is the real problem.
Moving forward, rather than attacking our existing programs
and pitting urban areas against rural areas, as we are going to
do with this GME and IME and all the rest of it, I invite my
colleagues to consider alternatives that would make a
meaningful difference in rural areas.
I yield back the balance of my time.
Chairman BRADY. Thank you, Dr. McDermott.
We are really excited to have the witnesses today. We think
there is some common ground on areas like this that we can move
forward on.
So, Mr. Joslin, you are recognized for 5 minutes.
STATEMENT OF TIM JOSLIN, CEO, COMMUNITY REGIONAL MEDICAL
CENTERS, FRESNO, CA
Mr. JOSLIN. Thank you, Mr. Chairman, Ranking Member
McDermott, and Members of the Subcommittee. My name is Tim
Joslin, and I am the chief executive officer of Community
Medical Centers, based in Fresno, California. I appreciate the
invitation to testify today about rural healthcare disparities
and the role of federally funded graduate medical education,
known as GME.
Community Medical Centers is the largest healthcare
provider in California's agricultural heart, San Joaquin
Valley. We are a not-for-profit public-benefit operation
operating four hospitals: Community Regional Medical Center in
Fresno; Clovis Community Medical Center; Fresno Heart &
Surgical Hospital; and Community Behavioral Health Center.
Community Medical Centers accounts for one-third of all
inpatient discharges in the five-county region.
We run a level 1 trauma center, a burn center, and an
ambulatory care center. We are also the largest inpatient
provider of Medi-Cal services and uncompensated care in the
region. Our downtown Fresno emergency department is one of the
busiest in the State with some 114,000 visits a year. We
provide all of this with the help of about 300 medical
residents and fellows from the UCSF School of Medicine.
Our challenge is unique and daunting. The rural San Joaquin
Valley, though rich agriculturally, is very poor economically.
Twenty-five percent of residents live in areas of concentrated
poverty, making it the fifth poorest area in the country. In
Fresno County alone, one-third of all children live at our
below the poverty level. About 20 percent of Fresno County
residents do not speak English and one-third of adults have not
obtained a high school diploma. The entire area's population
has significantly higher than average rates of asthma,
diabetes, and obesity. Nearly one-third of the population
qualifies as obese, for example. The Valley also has a higher
than average incidence of chronic lung disease, likely due to
is well-documented air quality issues.
To make these sobering statistics even worse, the San
Joaquin Valley suffers from a doctor shortage. The Valley has
48 primary care physicians per 100,000 residents, well below
the minimum recommended level of 60. If need is the measure,
our region of the country should have more physicians per
capita, not fewer. Graduate medical education is the key to
solving this inequity. Community Medical Centers collaborates
with the University of California San Francisco to support the
training of graduate medical students. We currently support
some 250 medical residents studying in eight areas, including
primary care and emergency medicine. And we support 50 fellows
studying in 17 medical subspecialties. This GME program is a
critical feeder to the region's entire physician population,
and we would like to grow the program.
We are constrained, however. Our Medicare funding for GME
positions is frozen at 1997 level. Community Medical Centers
has expanded the program on its own beyond what Medicare funds
by investing well over $400 million over the last 10 years, but
considering that Community Medical Centers now shoulders more
than $180 million in uncompensated care each year, the ability
to expand our GME program on our own is financially limited.
This in turn limits our ability to provide our region's
residents access to health care now and in the future.
In a region where the need for physicians is perhaps the
greatest in the country, we are at a disadvantage under the
current Federal system of allocating GME slots, yet our ability
to expand access to physicians is highly dependent upon the GME
program. As the Institute of Medicine's recent report noted,
the location of one's medical school and GME training are
predictive of practice location. Our own experience shows this.
Close to 30 percent of our trained residents remain in the
region to practice medicine. The current GME allocation
criteria and caps have led to significant geographic
disparities, as noted in a recent health affairs report, and
are most acutely felt in our region of California.
For example, our region's population has increased by a
third since 1997, yet our federally funded resident physicians
have remained at the 1997 level. This contributes to the
disparity we see in the ratio of physicians to population.
Community Medical Centers supports not only the expansion of
GME but, equally critical, better allocation of GME slots to
underserved regions within a State. We believe that policy
goals of federally funded GME would be better served by a
revised allocation system and urge this committee to consider
proposals. We believe this will directly lead to more efficient
and effective health care in our rural underserved region.
Thank you again for this opportunity.
[The prepared statement of Mr. Joslin follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman BRADY. Thank you, Mr. Joslin.
Ms. Sorensen, you are recognized for 5 minutes.
STATEMENT OF SHANNON SORENSEN, CEO, BROWN COUNTY HOSPITAL,
AINSWORTH, NEBRASKA
Ms. SORENSEN. Good morning, my name is Shannon Sorensen. I
am the CEO of Brown County Hospital, a Critical Access Hospital
located in north central Nebraska. I would like to thank
Chairman Brady, Ranking Member McDermott, and the members of
the House Ways and Means Subcommittee on Health for holding
this hearing.
Approximately one in six Americans live in rural areas and
depend on the hospital in their communities. We are exactly one
of those facilities. Not only does our location, being over 150
miles from the nearest tertiary facility, affect us, our
patient mix being over 70 percent Medicare also makes us more
reliant on public programs. Changes, such as the 96-hour rule,
often have significant and problematic consequences for rural
providers.
Due to the great support of our local community, compared
to many of my peers, our hospital's financial situation is
stable, but we are especially vulnerable to Medicare and
Medicaid payment cuts. We are the communities and hospitals
that most need your help.
The 96-hour rule is especially burdensome in our day-to-day
mission of providing health care in our communities. From the
creation of CAH designation, until late 2013, an annual average
of 96-hour stays allowed CAH's flexibility within the
regulatory framework set up for the designation.
The new policy of strict enforcement of a per-stay 96-hour
cap creates an unnecessary red tape. Not only does it
potentially limit access to health care by forcing rural
beneficiaries to travel farther for treatment, it may deter
them from necessary care, inconvenience patients, and add
travel costs to Medicare. It impedes rural providers in their
ability to care for their patients. Having to focus on
regulatory burdens interferes with the best judgment of
physicians and other healthcare providers, placing them in a
position where our providers are constantly making regulatory
decisions to dictate the medical decisions they need to make.
The 96-hour condition of payment leaves no room for a needed
change in the medical care plan if treatment does not go as
anticipated.
It is also important to note that while we must maintain an
annual average length of stay of 96 hours, we offer some
critical medical services that have standard lengths of stay
greater than 96 hours. Enforcing the condition of payment will
force us to eliminate these 96-hour-plus services and cause
financial pressures that will severely affect our ability to
operate. These are important services in our community and
allow patients to get needed services and recover around their
family and friends.
CAHs in Nebraska and across the country support the
Critical Access Hospital Relief Act, which would remove the 96-
hour condition of payment. I especially want to thank my
Representative, Congressman Smith, for introducing the
important legislation. Rural facilities and providers face many
challenges without the heavy hand of government. We must be
given the flexibility to provide affordable and efficient
health care.
Another burdensome regulation is the expansion of mandatory
direct physician supervision. We simply do not have the
manpower and resources to abide by these arbitrary regulations.
Our highly trained licensed personnel are not able to practice
at the highest level of their scope with this regulation.
For 2015 and beyond, the agency requires a minimum of
direct supervision for all outpatient therapeutic services
furnished in our Critical Access Hospital, unless it is on the
list of services that may be furnished under general
supervision or is designated as nonsurgical extended duration
therapeutic service.
We are deeply disappointed that CMS did not heed concerns
that this policy will be difficult to implement, will reduce
access, and is clinically unnecessary. CAHs and small rural
hospitals support the adoption of the default standard of
general supervision, consistent definition of direct
supervision, and prohibiting enforcement of CMS' retroactive
reinterpretation back to 2001.
H.R. 170 delays the unnecessary and burdensome physician
supervision regulations and requires CMS to study their impact.
We already face many unique challenges, such as providing
quality care with more limited resources; satisfying
complicated administrative requirements with a smaller staff;
complying with numerous Federal regulations, which limit the
discretion of highly trained providers; and now to be located
in the building to render these services.
Our community has one full-time primary care physician who
is supported by two mid-level providers. With some of the
regulatory burdens we face--such as requiring only a physician
to oversee cardiac rehab or only a physician being able to
order durable medical equipment, home health, or hospice
services--any time our lone physician is not on our campus,
takes vacation, or attends continuing education, significant
patient needs have to wait.
Our very capable mid-levels are able to provide the needed
services in our emergency room and throughout the hospital. It
makes no sense to prevent them from being able to do the same
for cardiac rehabilitation, outpatient therapeutic services or
other necessary services.
Medicare provides vital funding for many rural payment
programs, including Critical Access Hospitals. This
subcommittee and Congress has the power to ensure Americans
living in rural America who depend on the hospital will have
access to appropriate care.
Again, thank you, Congressman Smith, for introducing H.R.
169. We appreciate the subcommittee's interest in the matter
and urge it and the Congress to support much needed
legislation. Thank you for your time and listening to our
impact.
[The prepared statement of Ms. Sorensen follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman BRADY. Great, thank you.
Ms. Saia, you are recognized for 5 minutes.
STATEMENT OF CARRIE SAIA, CEO, HOLTON COMMUNITY HOSPITAL,
HOLTON, KANSAS
Ms. SAIA. Good morning, Mr. Chairman, and Members of the
Subcommittee, thank for the opportunity to speak today.
More than 36 percent of all Kansans live in rural areas and
depend on the local hospitals serving their community. Rural
hospitals face a unique set of challenges because of our remote
geographic location, small size, scarce workforce, physician
shortages, higher percentage of Medicare and Medicaid patients,
and constrained financial resources with limited access to
capital.
These challenges alone would make it difficult for many
rural hospitals to survive. However, the increasingly
burdensome Federal regulations that are being placed on
healthcare providers make it difficult to budget, plan, and
adequately prepare for the future.
Today, I would briefly like to share some challenges
specifically related to the Medicare policy on direct
supervision of outpatient therapeutic services and the 96-hour
physician certification requirement.
First, I want to highlight the impact of Centers for
Medicare and Medicaid policy for direct supervision about
patient therapeutic services. This requires that a supervising
physician be physically present in a department at all times
when Medicare beneficiaries receive these services. This policy
places additional unnecessary financial burden on my
organization. Holton Community Hospital is staffed similarly to
many rural hospitals across the Nation. Many have either a mid-
level provider staffing their hospital with a physician
available for supervision or a physician readily available
within 30 minutes response time.
Staffing a physician onsite, as required by the
regulations, will either result in changing our organizations
then profitable bottom line into a negative bottom line or
restrict the ability for us to be able to provide those
services to our beneficiaries in our community.
One example of an outpatient therapy service that is a
significant impact to our beneficiaries is the ability to offer
intravenous infusions on an outpatient basis. There is a
growing need for this service throughout our community. Due to
a noted increase in the last couple of fiscal years, 2013 and
2015, this volume grew by over 22 percent. Not being able to
provide this in our community and having the beneficiaries
travel outside the community to receive this treatment would
ultimately result in the beneficiary--a cost to them as well.
I strongly encourage this committee to extend the
enforcement delay on direct supervision requirements for
outpatient therapeutic services provided in Critical Access
Hospitals for calendar year 2015. I strongly encourage the
committee to work to pass H.R. 2878, as well as legislation
that would address this problem on a more permanent basis.
A second area I would like to highlight today is the 96-
hour physician certification requirement related to the
Medicare condition of participation on the length of stay for
Critical Access Hospitals. The current Medicare condition of
participation requires Critical Access Hospitals to provide
acute inpatient care for a period that does not exceed on an
annual basis 96 hours per patient.
In contrast, the Medicare condition of payment for Critical
Access Hospital requires a physician to certify that a
beneficiary may reasonably be expected to be discharged within
96 hours after admission to the hospital. As a rural hospital
administrator, I can say with certainty that the discrepancies
between the conditions of participation and the conditions of
payment have caused nothing but confusion and challenges for
Critical Access Hospitals.
This regulation also impedes the ability of the person who
knows the patient best--the physician and other healthcare
providers--and may unnecessarily cause patients to leave the
community from which they live to receive care. I urge Congress
to pass the Critical Access Relief Act, H.R. 169, introduced by
Representative Adrian Smith, Lynn Jenkins, Todd Young and Dave
Loebsack. This legislation would remove the Medicare condition
of payment that requires a physician to certify that a patient
is reasonably expected to be transferred or released within 96
hours but would leave in place the Medicare condition of
participation requiring Critical Access Hospitals to maintain
an average annual length of stay of 96 hours or less.
On behalf of my organization and similar rural
organizations across the States of our Nation, I want to
reinforce that it is critically important that our communities
are able to access quality healthcare services. Too often,
increasing and unwarranted Federal regulation burdens add
additional challenges to providers with already constrained
resources. As I highlighted in my written testimony, I have
many examples of great outcomes that beneficiaries receive due
to the ability to access care in a timely fashion. I am honored
to join you today to discuss the action Congress can take to
address rural healthcare disparities created by Medicare
regulations. I would be happy to answer questions.
[The prepared statement of Ms. Saia follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman BRADY. Thank you.
Mr. Derksen, you are recognized for 5 minutes.
STATEMENT OF DANIEL DERKSEN, DIRECTOR, ARIZONA CENTER FOR RURAL
HEALTH, TUCSON, ARIZONA
Dr. DERKSEN. Chairman Brady, Ranking Member McDermott, and
committee members, I really do thank you for your service on
this very important issue. But, especially, I want to thank
you--thank you, thank you--for getting rid of that awful
sustained growth rate formula, so we don't have to come back
every year and do the doc fix.
I am particularly gratified as a family physician myself in
the last 30 years to see a nurse and physician on this
committee. I think it is very important when we inform policy
that we have Members of Congress that understand what it is
like to be in the trenches serving patients.
I want to hit on a couple of issues. I am a family
physician. I work in an academic health center. I ran a faculty
practice plan, the worst 2 years of my life--I call it the
``thousand points of veto,'' with 550 faculty members and 450
resident physicians; everyone felt like we could do things a
little differently than we were. I think it is particularly
important as we look at how professions education is, how do we
get a better return on our Federal investment? We are spending
$15.5 billion on graduate medical education in this country.
Thank you for that investment in higher education. But I think
we could get a better return on that investment. I think we
need to move from protecting the status quo and holding
harmless. Let's hold accountable.
I think we can do better in the $10 billion we are spending
in Medicare GME to diversify our investment portfolio to
include, for example, teaching health centers, which you also
renewed as part of the MACRA legislation to extend teaching
health center funding for another 2 years. In comparison, we
only spent $230 million over the last 5 years in teaching
health centers, which is really to improve the health
profession's workforce in rural areas.
Some States, including in New Mexico and Arizona in the
Southwest, are experimenting with I think very innovative
models in interprofessional teaching health centers, leveraging
Medicaid graduate medical education to achieve better outcomes.
You have heard about some of the arcane rules that make it
very difficult for rural hospitals and Critical Access
Hospitals to maintain and keep their doors open and provide the
services that are so important to rural hospitals. I think the
two-midnight rule, the 96-hour rule really undermine a
physician's judgment. You don't always know, having admitted
hundreds of patients in both urban and rural hospitals myself
in 30 years of practice, how long it is going to be for someone
to be there. I think it is reasonable as a condition of
participation to, on average, have 96 hours' admissions for
Critical Access Hospital, but it is unreasonable and unfair to
make it a condition of payment that if someone exceeds 96 hours
in a Critical Access Hospitals that they won't get paid.
As I was getting on the plane in Phoenix, I got a series, a
flurry of email messages from one of our rural hospitals, our
Critical Access Hospitals, on U.S.-Mexico border. Cochise
Regional serves 20,000 individuals in a county that--its land
mass would contain both Delaware and Connecticut. It is a very
large area. It is critical. They will close their doors on
Friday because Medicare stopped payment to them.
The glacial appeals process will often put a rural hospital
under because it takes so long to work through the appeal. We
have seen over the last 5 years, 54 rural hospitals close
according to the Sheps Center. There is another 283 that are on
the verge of closure, at risk of closure, including hospitals
in States that you all represent. Fourteen of you represent
States that either have hospitals that are closing, especially
in Texas, but also in other areas as well.
I think we need to basically streamline that appeal
process. We need to make sure that those auditors, such as the
RAC auditors, that are paid on a contingency fee, that there is
a penalty when they make a mistake and that we don't put our
rural hospitals at risk of closure by this glacial process.
The last thing I would say is there are some very good
models you can draw on. You heard some last week from Mr.
Miller in the MedPAC about how we might better invest our GME
dollars. There is certainly some wonderful suggestions in the
Institute of Medicine report about how we might do this. But I
think there is also some interesting models happening at the
State level, but we have to titrate these changes that we are
requiring of rural hospitals on quality reporting. We have to
make sure that when they report on quality and their payment is
tied to it, that they are ready to do that. I think Arizona,
for example, through its Medicaid program has a Critical Access
Hospital pool and a rural pool that could be modified slightly
to pay them on the basis of value and outcomes. I think these
issues would really help us move forward in providing the
access in our rural areas, create great jobs in those areas and
continue that 24-hour-a-day, 7-day-a-week access to care that
is so important in our rural communities. Thank you.
[The prepared statement of Mr. Derksen follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman BRADY. Thank you, Dr. Derksen. I agree with you.
We need a new path forward on graduate medical education. And I
think we need to recognize the changes in indirect medical
education, the number of procedures that are occurring,
outpatient versus inpatient, making sure we are really getting
dollars to those who are providing the education and training
for our future doctors.
So, Mr. Joslin, I have a question for you in a second about
increasing risks in positions and rural hospitals. But, Ms.
Sorensen, Ms. Saia, and Mr. Derksen, Critical Access Hospitals
easily meet their annual average 96-hour condition of
participation. But asking local doctors to certificate the
specific patient's needs won't require a 4-day stay or less is
creating we think some real difficulty among our Critical
Access Hospitals.
So can you--for the committee's insight--can you provide
some examples of what services typically fall well under the
96-hour rule and examples of some services that typically are
well over the 96-hour limit? Ms. Sorensen?
Ms. SORENSEN. Typically, we see a lot of the outpatient--
excuse me, not outpatient, but surgical procedures that would
be done in our facility by the qualified providers that we
have, maybe a bowel resection, maybe something related to a
surgical removal, gallbladder, some of those things that didn't
take--the bowel resection, obviously, always follows typically
a 5-day stay. So when we admit on that day, yet we are supposed
to precertify for 96 hours. Yet we are capable of doing those,
we go through the proper training and competencies and surveys
to do those, but for us to send them 150 miles away to get that
done and not being able to come back to us is a big impact.
Otherwise, we, obviously, have an annual average--our annual
average runs around 70 hours so we see a number of those things
that fall underneath that--the pneumonias, the other types of
just acute illness that come in.
The biggest issue becomes if you send in a culture, test
the infection, and it comes back something you weren't
anticipating; now we need to change the medication, and so we
are switching from one antibiotic to another. And now we are up
on 96 hours, so what are we going to do? Are we going to go
into a swing bed for a short stay because if we go there for a
short stay, that is also a red flag? So we create a lot more
barriers by having those issues.
Chairman BRADY. Great examples.
Ms. Saia.
Ms. SAIA. I would just add on, pneumonia is a great example
where if it is simple, treatable, and you get the right
antibiotic on the right day, that is easily treated within a 5-
day stay. But if you have to culture on the second day,
sometimes that culture usually take 72 hours to get the results
back. There you are at your 5-day window. If you need to wait
and see if you need to change the antibiotics to make sure it
responds appropriately, you are past the 5-day window. Just
another example where usually pneumonia can be treated very
easily upon admission. The physician could certify they could
be treated and discharged within 5 days, but during those
first, 2, 3, days, if they are not responding to treatment and
you need to change treatment, then you are past that 5-day
window.
Chairman BRADY. Makes sense.
Dr. Derksen.
Dr. DERKSEN. Thank you, Mr. Chairman.
I ran an academic Locum Tenens Program, where we provided
practice relief in our rural hospitals and emergency
departments across the Southwest. And one of the things we
noticed is things, like pneumonia, congestive heart failure,
routine urosepsis, people with urinary tract infections that
spread to their bloodstream, acute stroke, acute trauma, many
times these are things that we could either treat or treat and
then move on to a higher level of service in that 3-day
timeframe, but you don't always know. A person could come in
with a simple, straightforward immunity-acquired pneumonia, and
then, because they are dehydrated, they develop acute renal
failure. And you may not have the lab results back quick enough
to be able to know right at the time that they are going to
take another day or two until they are ready to go back home.
So those are some examples. Thank you.
Chairman BRADY. So the point isn't the average of 96 hours;
it is the specificity on every case where the patient may have
some different needs that are just evolving as you are treating
them.
Auditing, from Ms. Sorensen and Ms. Saia, I have heard
mixed feedback regarding how CMS is auditing around the 96-hour
COP for Critical Access--can you describe your experience, if
any, with the surveyor who has audited your hospital around the
96-hour rule?
Ms. SORENSEN. Chairman Brady, I don't believe we have had
any experience with an audit on that as of yet.
Chairman BRADY. Well, I am sorry I asked that question for
your organization.
Ms. Saia.
Ms. SAIA. I am sorry you asked that, too. We have not been
audited with regards to the 96 hour. I did before, in preparing
for the testimony, went back and looked through 10 years of our
submissions of where did our annual average end up for that
year in regards to the length of stay, and the max that ever
our average was, was 4 days, around 72 hours, so we have not
been audited.
Chairman BRADY. Oh, I am sure you will be on someone's list
now.
Again, really sorry about that.
Chairman BRADY. Mr. Joslin, last week, the committee heard
testimony from Mark Miller, the executive director of MedPAC.
He testified that increasing residency positions for hospitals
in rural areas doesn't necessarily translate into those
residents staying in rural areas. My experience has been, in
Texas and our district, has been the opposite. Your thoughts,
other than increasing the number of slots, what would you
recommend to us to do to incentivize physicians trained in
rural areas to stay there and practice medicine because it is
so critical for communities like ours and certainly those on
the subcommittee.
Mr. JOSLIN. Yeah, absolutely, it is such a critical issue
because underserved areas are so difficult to recruit
physicians to in the first place. Obviously, the economics play
a major role in that. And so you have to have other ways to get
physicians there. I am not familiar with the testimony of the
MedPAC individual.
Although, my experience has been different. My experience
has been when you do provide training and additional training
in those areas, a large percentage of those residents do stay.
If you look at us, for example, over the last 40 years, we have
trained 3,000 residents, and a 1,000 of them have stayed in the
Valley. They don't just stay in Fresno; they stay in these
outlying rural areas. We serve a 15,000 square mile radius, a
large geographic area. And a lot of that is underserved and
rural, and that is where the physicians are staying. Over the
last 4 years alone, we have had 120 of those residents stay and
practice in these rural areas.
So I would argue that training does pay if it ends relative
to the physicians staying in these areas. At least our
statistics show that at least 30 percent of the physicians that
we train do stay in these areas. So I think that is critical. I
do think there are other things and creative ideas that are
being suggested and how we can provide specific training in
these rural areas that also supplements the GME, slots that are
currently available. It is not just funding additional slots,
but certainly looking at the way those slots are allocated
within States, which is a huge problem for us. In California,
for example, if you look at California, relative to the Central
Valley, it is very skewed because the Central Valley is the
poorest area. As I mentioned earlier, it is about the fifth
poorest area in the country, but when you factor in Los Angeles
and San Francisco, the numbers are very skewed. And so you have
to also then start looking within States and looking at
underserved areas within States. And our area is a perfect
example. In central California, we have 48 primary care
physicians per 100,000 residents. In San Francisco Bay area,
they have 85, and so, obviously, there is not the same dire
need in the San Francisco Bay area, and I am not minimizing
their issues by any means. I am simply saying that when you
look at how you are provided slots, I mean, there are two
issues associated with that. Certainly there is the number of
slots you provide, but certainly just as important is how you
allocate those slots. And really the whole intent of this
program is to help get physicians in underserved areas. There
has to be a key component of that. Our slots have been captive
since 1997, and that issue needs to be respectfully revisited
so that these underserved areas like ours can do something
because if we don't, they are going to continue to do what they
are doing today, which is just showing up in the emergency
room.
Chairman BRADY. Thank you, Mr. Joslin.
And, Dr. McDermott, you are recognized.
Mr. MCDERMOTT. Ms. Saia, you testified before the--you
reported in a Topeka news report saying, quote: ``If Medicaid
would expand, it would be over a $300,000 impact of Holton
Hospital, where some years that is the difference of us being a
profitable hospital or not.'' Would you tell us how expanding
Medicaid would make it better in your State?
Ms. SAIA. How--could you ask the question again?
Mr. MCDERMOTT. What percentage of your patients come in
with no insurance, no anything? I mean, what I am trying to get
at, Governors who made a decision not to do Medicaid expansion
leave you hanging out to dry in the rural areas, with people
coming in who are sick and you can't turn them away. Tell me
about the problem of your hospital.
Ms. SAIA. So expanding Medicaid in different pockets and
different service areas, the emergency department is where our
largest volume of uncompensated care is given, and that
percentage is right around 20 percent, which is smaller than a
lot of other facilities, but that 20 percent is directly
written off as uncompensated care.
Mr. MCDERMOTT. How much money is 20 percent?
Ms. SAIA. Twenty percent of our emergency department
volumes? I would have to submit written testimony back to you.
If I could get back to you----
Mr. MCDERMOTT. I would appreciate that.
Ms. Sorensen, you said before the Nebraska legislature a
reduction in uncompensated care and cost shifting, better work
health, and fewer bankruptcies, less ACA penalties for business
owners, a shift of some of the States direct cost to Medicaid
would generate billions of dollars in Federal money. Tell me
what does not being in Medicaid in Nebraska does for you?
Ms. SORENSEN. For us, it is really the economic impact that
we have. So in our small rural community, we are 70 percent
Medicare and what percentage of that then are also Medicaid,
even just in the impact of we recently had our local nursing
home close within our community, which was about 70 percent
Medicaid as well as. So when we have that high level of care,
that high continuum of care needed within that age and that
population, that is the impact that we see, so now those aren't
even in our community.
We don't have a real high percentage of Medicaid in our
community. We run about 10 percent Medicaid, 8 percent self-pay
in there, but really it just becomes more, as he mentioned,
showing up and the access to the care. So now we are not
getting in and doing the preventative screening. We are not
doing the wellness pieces. We are just showing up in the ER for
nonemergent cases, where the highest cost of care is given.
Mr. MCDERMOTT. When you have a stroke patient in your area,
do you have a lab to test whether they should be given an
infusion of medication to dissolve the clot?
Ms. SORENSEN. We do laboratory testing and CT scan at the
point of arrival. Of course, with our distance, we are
typically arranging for that transfer as soon as possible. And
then, in Nebraska, we are utilizing some of the stroke cares
that they are doing through the University of Nebraska Medical
Center and pushing into all of our facilities on the most
timely amount of care. And so we do stock the medications, but
it also depends on we have to make sure they are stable before
they go on that lengthy of a transfer.
Mr. MCDERMOTT. And do you use helicopters, or do you use
just ambulances?
Ms. SORENSEN. Both. It depends. We have seen more air
transfers out this year. It is as much as it was last year,
already at this point halfway through the year. Some of that
has been due to acuity. Some of that has also been due to time
issues. So but, yeah, we have about 65 transfers that go out a
year. And last year we only had about 14 that went by air, and
we are already at 14 so far this year.
Mr. MCDERMOTT. And if I understood your answer to Mr.
Brady's question, neither of you have been audited so you are
not exceeding or you have not come up on the radar screen at
Medicare headquarters overextending your 96 hours. Is that
right? Is that what you are telling me?
Ms. SORENSEN. Yes. I would say we have not been audited
specifically for the 96-hour per stay. Of course, for all of
our fiscal years, as Ms. Saia mentioned too, our average annual
is well under the 96. So I don't think that would probably be
something----
Mr. MCDERMOTT. Why is it a problem? Everybody says it is a
big problem; we have to got to get rid of this 96-hour rule.
But you never--you don't exceed it in your average, and so I am
trying to understand, give me some examples of patients, you
know, where it became a problem.
Ms. SORENSEN. Absolutely. The biggest issue is going to be,
of course, the annual average falls in okay, but if we had a
patient that had a surgical procedure----
Mr. MCDSERMOTT. Surgical procedure done there at your
hospital?
Ms. SORENSEN. Yes, like a bowel resection or something, so
they will be admitted into that acute status, but we already
know ahead of time, they will probably be there for 5 days,
just to get things back up and going and medically stable and
everything, get them back to eating normal. And so with the
per-stay condition of payment, that has been said to be
enforced, that is where if we are certifying or precertifying
they are going to be there less than 96 hours but really we
anticipate them to be longer, we are not going to get paid for
that stay.
The same thing happens--and maybe Ms. Saia wants to comment
to that--in a pneumonia case, where we will admit on day one,
doesn't seem to be responding to it, get the culture, something
comes back. It comes back unexpected and we need to change
medication. So now, even if we did precertify we reasonably
expect them to be there less than 96 hours, now we are already
at 90 hours; we need to change the medications. Are we running
that risk? We are not even going to get paid for that entire
episode.
Mr. MCDERMOTT. Mr. Chairman, I realize you have given me a
little extra time here. I would like to submit the CMS rules on
the 96-hour rule for the record. The rule explains that CHAs
still get paid after 96 hours if the patient still needs care.
Nobody is denied care. Nobody is denying payment apparently. So
I would like to submit that for the record.
Chairman BRADY. Without objection.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman BRADY. And, clearly, we appreciate the witnesses
being here today. Usually witnesses come because there is a
problem, especially when it deals with treatments for patients
in real life. Today's hearing is about drawing some of those
insights out, see how we can address them.
Mr. Johnson, you are recognized.
Mr. JOHNSON. Thank you, Mr. Chairman.
Thank you all for testifying today, and I appreciate you
for being here. My district in Texas is right outside of Dallas
and fairly suburban, but no mistake, I still understand the
importance of our rural and critical access hospitals. You
drive just one or two counties away, and you are going to find
rural hospitals, and rural hospitals cover about 85 percent of
the Texas geography.
Medicare has long had the so-called 96-hour rule, and some
of you covered that in their testimony, but for years, CMS has
enforced that rule based on the average patient's stay. But now
CMS has changed their enforcement to require doctors to certify
for each and every patient that they do not expect the patient
to be there more than 96 hours.
Changing from an average of 96 to requiring certification
for each patient doesn't at first sound like a big deal, but as
you know and we have been talking about it, the implications
are significant.
Ms. Sorensen and Ms. Saia, could you discuss how this
change to the 96-hour rule has impacted your hospitals, both
from a financial and operational standpoint? And could you also
address in what circumstances a patient might have to be at the
hospital for more than 96 hours? And what happens if a patient
is admitted for more than 96 hours? One at a time go ahead.
Ms. Sorensen.
Ms. SORENSEN. I would just comment to the example I gave a
little bit earlier relative to pneumonia and a change in
medications. A surgical procedure where there was a bowel
resection or organ removal, biopsy excision, those types of
things that may alter that. Also just the usual if treatment
doesn't go as planned and a medical care plan needs to be
adjusted or modified to improve patient status.
Mr. JOHNSON. Go ahead, Ms. Saia.
Ms. SAIA. As previously mentioned, the regulation is
confusing and conflicting from the condition of participation.
So to be able to abide by the regulation as it stands, the
physician must certify that they do not believe the patient is
going to stay longer than 96 hours. So if--and my understanding
and I may be corrected--but my understanding is that the
payment would not occur after 96 hours, and therefore, we would
need to ship the person from our facility to a larger facility
that could care for that patient, that is taking--would impact
the patient as well as where they are getting their care. So it
would move their community--their loved ones to another
facility if we are unable--are those buzzings me, I am sorry--
if we are not able to care for that patient past that 96 hours,
and you just never know. You don't have a crystal ball that
tells you the answers as a provider upon admission what is
going to change during that course of stay. So, with the 96-
hour, the understanding and trying to enforce that and abide by
that, the understanding is that they need to be transferred if
their care needs longer than 96 hours.
Mr. JOHNSON. Were you all geared up to do that? I mean, you
don't have an ambulance on standby just to take somebody to
another hospital, do you?
Ms. SAIA. No.
Mr. JOHNSON. I didn't think so. And I think that is crazy
to even think about, don't you? But do you get paid if they are
over 96 hours?
Ms. SAIA. Do we get paid? Well, so far, the enforcement of
that has been delayed, so we are not upheld to that current
standard right now.
Mr. JOHNSON. Okay.
Ms. SAIA. We are just upheld to the condition to
participation, not of payment.
Mr. JOHNSON. But they are pushing you to do that.
Ms. SAIA. Pushing and we with like you to push for the
delay to continue and look at a more permanent fix. If we are
not able to delay that, could we at least look at a permanent
fix for that?
Mr. JOHNSON. Thank you very much.
Thank you, Mr. Chairman.
Chairman BRADY. Thank you.
Mr. Thompson, you are recognized.
Mr. THOMPSON. Thank you, Mr. Chairman.
And thank you to all the witnesses for coming. It has been
good testimony. And I know you guys--I represented a rural area
for most of the time I spent both in the State legislature and
in Congress, so I know some of the challenges you have. And my
wife is a healthcare provider in a rural hospital in my current
district. And so I know very firsthand how challenging it can
be. So thank you for helping us understand the problems and
trying to figure out some solutions to the challenges that you
face.
I am a big supporter of telemedicine and telemonitoring. I
have had a number of pieces of legislation that has helped
advance this. Mrs. Black and I have legislation in this
Congress to help move that forward again. And I think it is a
way we can address a lot of the problems that we face. So I
would like to know how your hospitals are using--if they are
using, and if so, how they are using both telehealth and remote
patient monitoring?
Start with Mr. Joslin. You don't have to do a thesis.
Mr. JOSLIN. Okay, thank you. We are a safety net hospital,
and we work with the rural hospitals closely. In fact, we
receive about 600 transfers a month from outlying hospitals.
However, we do use telemedicine quite a bit as well. We do it
through the University of California, San Francisco, and with
their specialists as well. But we have been using telemedicine
for the last several years as a key component of the care that
we are providing to help rural hospitals in outlying areas and
physicians and clinics as well, to extend that to as many
providers as possible. Because with what is going on in health
care, the need for population health, how we look at
redesigning the system, it is not just hospital to hospital,
hospitals to physicians, but there are a lot of other types of
providers, and telemedicine is a critical component of that
piece as well.
Ms. SORENSEN. I would agree we are a big proponent of
telehealth. We use tele-emergency, so we have board-certified
emergency docs in our emergency room at the push of a button
24/7. We also have remote pharmacists that oversee 100 percent
of our inpatient medications. Teleradiologists, as well as just
the one-on-one patient visits, many of them are used for
oncology with an occasional orthopaedic followup. Psychology of
course.
The biggest barrier that we have in telehealth is getting
the physicians themselves into a scheduling routine and access
to the electronic devices so that they either can do it right
from their desk or an examine room in their clinic. And then,
of course, reimbursement issues that come into the challenge as
well. They are often not willing to see the patient via
telehealth because of the reimbursement and payment issues. So,
therefore, our patients drive 2\1/2\ hours for that 10-minute
visit that could have been done via telehealth.
Ms. SAIA. We are currently not using telehealth services,
but supportive of that. We are currently looking at meeting the
needs of our community in regards to mental health and
exploring opportunities with a couple of different companies
for telesite coverage.
Mr. THOMPSON. So you see it as something you can use or
maybe should be using as something that can bring some relief.
Ms. SAIA. Yes.
Dr. DERKSEN. In Arizona, we were able to get legislation
through for payment parity, so that insurers would be paying
for telehealth services. We use it for teleradiology and places
that can't afford to----
Mr. THOMPSON. The non face-to-face reimbursement.
Dr. DERKSEN. Exactly. So it has been very important, but it
is also important to strike that balance between making those
services available in rural communities, but making sure that,
through licensing, credentialing, and privileging, that we
assure the high quality of services that are available onsite.
We don't have these kind of folks coming in from other places
that undermine the fiscal viability of a place because someone
else is kind of taking those services out of that community.
Mr. THOMPSON. A couple of you kind of alluded to some
things, but are there any things specifically that would help
you do more or better telehealth? Are there any roadblocks that
Medicare reimbursements provide, or is there anything that
Congress can do to help you better perform telehealth services?
Ms. SORENSEN. I would like to be able to provide written
testimony with some more information because I need to look
into that. But I know that just at a conference that I attended
last week looking at that face-to-face reimbursement rate and
what can actually be billed via that, there is a lot more
opportunities available via telehealth, but right now we need
to get that face-to-face reimbursement rate equal in
telehealth.
Ms. SAIA. If possible, I would like to provide some
additional testimony as well. We have looked at the tele-
emergency coverage, and just the cost upfront I am told the
cost of the salary of one FTE of a nurse. That is a little
bit--when I was originally told that, that is probably less
than what our current salary makes--it was closer to around
$80,000. And just being able to come up with that, making sure
that we have got the adequate room in our emergency department
is also a concern as well, so I would provide more written
testimony on that.
Mr. THOMPSON. Thank you. I would invite to you get that
written testimony, and I would be very interested in seeing it.
I don't know if the committee wants it, Mr, Chairman, but I
sure would like to get it in my office.
Mr. THOMPSON. Thank you very much.
Chairman BRADY. Mr. Smith, you are recognized.
Mr. SMITH. Thank you, Mr. Chairman.
And certainly thank you to our panelists here today, our
witnesses. I most admire your abilities and willingness to be
on the frontlines of health care that are, I am sure,
difficult. I don't pretend to think that the answers are here
in Congress or even that there would be a bunch of answers in
just increasing funding for some broken mechanisms in health
care. I think that these arbitrary regulations that have come
about, whether it is the 96-hour rule, whether it is the
physician supervision, to keep those in place and just expand
Medicaid, as some would suggest a solution would entail, I
think we owe our providers a better policy than that out of
Washington, D.C., that really entrusts our providers.
And, certainly, Shannon, thank you for being here, for
traveling from very rural Nebraska to share your expertise,
your insight. We know that Brown County Hospital is the only
hospital in the county, hence the name. But the county has a
land mass larger than the entire State of Rhode Island, and it
happens to be next door to Cherry County, that is larger than
the State of Connecticut, and it, too, only has one hospital.
So just to try to identify what the issues are here, we
know the Critical Access Hospital designation I think is an
effective component of our policy. But we ought not assume that
every Critical Access Hospital has the same level of care or
the same skills that are within that facility or the same
community profile. And we need some flexibility.
That is why I have introduced the 96-hour rule, as well as
the physician supervision bill that would push back there.
These are arbitrary. I have a hard time even figuring out how
they came about or why they came about. That story has not been
told. But I do know that the 96-hour bill is a very bipartisan
solution, with some 70 cosponsors, very bipartisan like I said.
And these concerns are across America and I would say even in
more urban areas too. Just the impact seems to be felt more at
the rural level.
Now, there were some questions about audits. I mean,
certainly I assume you have been audited but just not for 96-
hour, right, I see strong nods in agreement, yes. So the RAC
auditors, that was mentioned as well; that needs to be
addressed. I am glad that telemedicine was brought up. I think
that telehealth probably even adds to the need to address this
96-hour rule that is arbitrarily out there.
Do you want to elaborate a little bit on the audits that do
take place, Ms. Sorensen or Ms. Saia.
Ms. SORENSEN. Absolutely. We have had audits for claims,
overall episodes of care, what would be considered RAC. Our RAC
activity has not been real high. But we definitely have had
audits. And these are very laborious. They are intensive in
terms of submitting a number of additional supporting
documentation and often for claims that we feel were
unnecessarily audited or reviewed to look at in more detail. In
all of them--and we have even gone to the level of having to
appeal at the administrative law judge level. And the times
that we have done that, we have been successful in appealing
those but have not gone without much effort, time, and
resources that has been needed to do that.
Mr. SMITH. Ms. Saia.
Ms. SAIA. We have been involved with a variety of different
audits, the compensated care issue you mentioned previously.
But our RAC audits have not, we have not had a lot of activity.
There have been a very few small claims. But the time involved
with reviewing those, making sure that claims were correctly
submitted is very time-consuming. We have not been successful
in two of them, in overturning the audit results. But, again,
the activity has not been extremely high in regards to that.
Mr. SMITH. Okay. Thank you. And I do want to certainly
emphasize the diversity of Critical Access Hospitals. As Ms.
Sorensen said, there is one doctor for the entire hospital, the
entire community, the county. Now, some Critical Access
Hospitals would have 10, 15 docs, maybe, offering a different
level of services. So 96 hours of care could mean different
things in different communities. And I would hope that we can
get our policies to reflect that.
Thank you, again, to our witnesses.
Thank you, Mr. Chairman. I yield back.
Chairman BRADY. Thank you.
Mr. Davis, you are recognized.
Mr. DAVIS. Thank you very much, Mr. Chairman.
And I want to thank all of our witnesses.
You know, I was thinking, I grew up in rural America.
Although I represent a large urban population, I have always
had a great deal of affinity and, hopefully, some understanding
of rural America's needs as it relates to health care. In my
family, we often discuss the fact that we believe that my
mother may have died prematurely because she had to travel more
than 150 miles to get to a regional medical center where she
could get dialysis treatment.
I am a big fan of regional medical centers like the ones,
Mr. Joslin, that you come from and represent. But I also
recognize that in training, we need to train the best
physicians that we possibly can, not only in principles and
concepts of medicine, but also there has to be enough
opportunity for the individuals to experience disease entities
enough times to, I mean, I always like physicians personally
that I feel have seen a lot of patients like me and that, in
the process of doing so, probably has a better understanding of
whatever it is that I am there for.
In terms of finding a solution to obviously a very
difficult problem, I mean, we look at reimbursement, and I
think that reimbursement rates that are different based upon
the complexity of small numbers of people that an entity might
be able to see is something to consider. Obviously,
telemedicine, as it continues to advance, and other types of
incentives, how do you feel that these incentives can be
tweaked enough or couched enough to really make a serious
impact on the ability to recruit physicians and other medical
personnel for the rural areas that are having the difficulties
we are discussing?
Mr. Joslin, perhaps we could start with you.
Mr. JOSLIN. It is a great question. I think there is two
parts to that question. There is the question of how you tweak
the system, but I think you have to start out with the
fundamental realization that the system is flawed because the
system is just not--it doesn't produce enough. And we touched
on it earlier. We touched on the number of slots, and we
touched on how these slots are allocated. And then trying to
provide some type of incentive for physicians to want to go and
train in these areas, whether it is financial incentive for
educational purposes or however you structure something, but
the shear magnitude of the issue is just the lack of enough
slots in these underserved areas that there is really no
effective way to move the pieces around until we solve that
fundamental problem. And I think we have to be creative to do
both because obviously there is not unlimited resources. We
don't have the ability to just keep adding. We have a deficit
issue we need to tackle. And so we need to deal with those
types of creative things. And I think those kinds of answers
are going to come in the bigger answer of how we are going to
effectively redefine this healthcare system, to develop a
marriage or partnership between those regional medical centers
you referred to, safety net facilities, and those rural
facilities, and partner with all the other, not only physicians
but other healthcare providers that are out there providing
these types of resources, there is going to ultimately have to
be a different type of system developed so that we can really
reallocate resources within a very limited system itself.
Mr. DAVIS. Ms. Sorensen.
Ms. SORENSEN. I think one of the most beneficial incentives
that we have had really, for example, the meaningful use
incentive, that pushed a lot of facilities into getting to the
medical records so that we can get where we need to go. We are
a long ways from getting where we need to go. But there was at
least the jump into that. For us, from the telehealth
perspective, for example, our e-Emergency that we have, so we
have that board-certified ED doc at the push of a button in our
ER 24/7. And it was a huge recruitment tool for us. We have
recently recruited a family practice physician that will join
us next year. And much of that is the comfort of knowing there
is somebody there to support them. They are not practicing
completely independent.
So much of what Mr. McDermott mentioned earlier in terms of
maybe incentivizing with loans or some type of an arrangement,
in the State of Nebraska, we are looking at trying to help with
student loans and contracts early on for recruitment purposes
and incentivizing them for the services to our communities.
Ms. SAIA. I don't know that I have anything additional to
add in regards to incentives for recruiting. What has worked in
our facility is being a rural area, where, upon graduation,
there is a loan forgiveness for coming to our area. And that
has worked for two of our doctors, one of our doctors, and
three of our midlevels for reimbursement for staying in the
area. What we have tried to do, though, is just have a great
community and a great facility to work in where they want to
stay after those 2 years. And that has been successful for us.
Dr. DERKSEN. I would just like to say that I don't know
about the MedPAC testimony that was provided last week related,
but our evidence in New Mexico and Arizona is that when you
train health professionals in rural areas, they are much more
likely to go. In fact, when we decentralized our family
medicine training and our dental residency training to include
rural experiences, we doubled or tripled the rate of retention
of practitioners going into practice there. It works for nurse
practitioners. It works for dentists. It works for physicians.
It works for allied health professionals. I think the evidence
is incontrovertible. We have to invest in that health
professions training infrastructure to move the health
professions training pipeline closer to the areas of need.
Mr. DAVIS. Thank you, Mr. Chairman.
Chairman BRADY. Thank you, Mr. Davis.
Mr. DAVIS. I thank you for the indulgence.
Chairman BRADY. My pleasure.
Ms. Jenkins, you are recognized.
Ms. JENKINS. Thank you, Mr. Chairman.
And thank you to the panel for being here today. A special
thanks to Ms. Saia. We both hail from the great community of
Holton, Kansas. I am sorry Senator Roberts isn't here. We could
all join in the Holton fighting wildcat song. We appreciate the
good work that you do, running our hospital, Critical Access
Hospital. The community is only about a little over 3,000
folks. And so the hospital is key to the success of our
community.
And there are few issues that I hear more about at home
than ensuring access to quality, accessible, rural health care.
And I believe this hearing is a very important step forward in
addressing the problems that providers and patients face in
rural America.
Carrie, in your written testimony, you speak about the
damaging effects that CMS' direct supervision requirement for
outpatient therapy services would have on hospitals like Holton
Community Hospital. And you mentioned your support for H.R.
2878, the legislation that I have introduced on that matter.
One example that you gave of a routine outpatient therapy
service is intravenous infusion. Drawing on your nursing
background, can you briefly describe what kind of patient might
need an infusion and the process involved for the attending
medical professional?
Ms. SAIA. I would be happy to. There is a wide variety of
examples. The one that comes to mind is a patient that is
suffering from rheumatoid arthritis. They need an outpatient
infusion for their medical condition. So they have been seen by
their primary doctor. They have been referred to a specialist
that comes to our facility and orders a medication. That
infusion is usually one time a week for the course of 6 to 8
weeks. And they would come in and need that infusion given
intravenously. Another example could be blood component therapy
or chemotherapy drugs are also different examples in regards to
that.
Ms. JENKINS. Okay, perfect. Thank you. Could you also
describe the added burden that direct supervision puts on
physicians and ways in which other hospital services suffer
because of it?
Ms. SAIA. With direct supervision, the regulation speaks to
requiring a physician being readily or immediately available.
So if that physician is involved with--Thursdays, we have
stress tests in our facility. And a physician has to be
physically present and cannot do anything else. So for that
physician then to not be able to meet the requirement for
direct supervision, if a patient is getting that infusion on
that day, that would mean two doctors then would be tied up,
one doing stress tests, one doing the outpatient infusion. And
then what would suffer would be the care of just normal care in
our primary clinics because we have two providers, two doctors
tied up doing those two services.
Ms. JENKINS. I see.
Ms. SAIA. If that makes sense.
Ms. JENKINS. It does. Before CMS announced that it was
going to enforce the direct supervision rule, were nonphysician
providers at Holton Hospital able to administer outpatient
therapy services effectively without direct supervision?
Ms. SAIA. They were. We have five different midlevels. They
are all trained in advanced trauma life support, advanced
cardio, CPR, advanced life support, trauma courses. They
provide coverage for our emergency department. But, yet, with
this regulation, they are not able to provide coverage for a
person on an outpatient basis receiving an infusion.
Ms. JENKINS. Okay. Thank you.
I want to touch on another topic. Ms. Saia probably knows
that Holton Community Hospital provides hospice services for
folks who are very ill and likely near the end of their life.
In fact, my own father spent his final days under the care of
the hospice at Holton Community Hospital. And we find that
patients are at their most vulnerable at that stage. And I
worry that folks in rural areas may be limited by the fact that
Medicare's list of authorized hospice providers is not as
inclusive as it should be. And this could lead to gaps in
access to those who may need hospice but are unable to get it.
And I have introduced legislation, along with Mr. Thompson
here on our subcommittee of California, which would recognize
physician assistants as attending physicians to serve hospice
patients. And I am just curious, maybe Ms. Sorensen and Ms.
Saia, do you think that this legislation would help? And I am
getting gavelled down. Maybe if you could----
Chairman BRADY. Yes, briefly would be great.
Ms. SAIA. I think it is being very futuristic and very
supportive of trying to keep the hospice patient in their local
community to receive that, important services, at a very
critical time instead of having them leave their local
community to receive it elsewhere. We are fortunate to have a
medical physician right now available for that. But looking at
the future and knowing the shortages, not only hospice, home
health, DME, those type of services really could be supported
with this legislation.
Ms. JENKINS. Thank you, Mr. Chairman.
Chairman BRADY. Thank you. No one ever calls my legislation
futuristic and visionary, so congratulations.
Mr. Pascrell, you are recognized for 5 minutes.
Mr. PASCRELL. Thank you, Mr. Chairman.
And I want to thank the panel for being so forthright. I
want to remind the panel, as well as the Members of the
Committee, Mr. Chairman, that on June 22, when we had our last
hearing, Dr. Mark Miller was with us from MedPAC, gave us a
report. And in that report, 80 percent of rural hospitals that
have completely closed their doors are located in States that
have not expanded Medicaid, et cetera, et cetera, et cetera.
You know, we need to take the time to read the stuff that gets
to us, Mr. Chairman. That is my point. Because I think many
times, as Mr. Joslin says, you have got to get to the
fundamental problems and ones that we do not want to address.
So I agree that access to health care in rural areas is an
awesome issue. It is worthy of the committee's focus. I come
from North Jersey where the closest rural area is more than a
stone's throw. But I ran point on rural hospitals in South
Jersey. I am very proud of that record. Every day our New
Jersey hospitals face challenges associated with serving urban
populations. Medicare beneficiaries and other patients living
in urban areas need access to quality health care, to provide
economic opportunity, ensure community vitality, just like
residents living in rural areas. I want everybody to be
healthy. And I assert that access to care cannot only be
measured by how long it takes you to drive to the nearest
hospital or the nearest clinic, isolation from transportation
services in urban areas can be just as prevalent and is, in
reports that I have seen, as in rural. In my home town of
Paterson, New Jersey, which is the third largest city in New
Jersey, local hospitals care for a population where 29.1
percent of the residents are living below the Federal poverty
level--that is a problem--where the medium household income is
$32,707--that is a big problem--and 62.5 percent of the
households speak a language other than English. These issues,
along with a number of others, like patient mix, a reduction in
the disproportionate share of hospital payments, which we had
in New Jersey, pose very real challenges for urban hospitals.
But despite these challenges, urban New Jersey hospitals
cannot receive any of the add-on payments that rural hospitals
are eligible for. If we are going to look at this, let's look
at it across the board. The State of New Jersey does not have
any hospitals with Critical Access Hospital, Medicare Dependent
Hospital, or Sole Community Hospital designations.
Mr. Joslin, in your testimony, you painted a good picture
of what your hospital's patient population looks like. Despite
the fact that your hospital is located in a rural area, it is
actually very similar to the patient population at St. Joseph's
Hospital in urban Paterson, New Jersey. I compared it. You
mentioned high rates of poverty, low education levels, and
limited English. Can you discuss some of the challenges
associated with this patient population?
Mr. JOSLIN. Certainly. And your example is absolutely
perfect. When you are looking at urban hospitals, their safety
net providers in economically challenged areas, it is
tremendously difficult to provide all those services that you
need. In our area, a third of the adults don't graduate high
school, a third. You know, a third of the children in our area
are living at or below the poverty level. Twenty percent of the
population doesn't speak English. We are in a huge metropolitan
area, relatively speaking, Fresno County and the outlying
areas. And there are tremendous challenges.
So we have in common what these rural hospitals have in
common, thin operating margins. And we live on the edge
financially because there is not a lot of excess in the system
of what we deal with, same thing that you are dealing with in
your area. So we have to be very efficient. We have to
cooperate with others. We have to take an integrated delivery
approach to this so that if there are issues with
transportation, for example, we can't just admit a patient to
the hospital, discharge them, and say, ``Okay, now go your way
because there are all these resources out there for you.'' We
have to help provide all those additional resources,
transportation, getting them to and from, skilled nursing
facilities, home care, hospice, all these things we have to
help facilitate as well. Because the challenge is--and we had
$180 million last year in uncompensated health care, similar
probably to what your hospitals have.
Mr. PASCRELL. Yes. Mr. Chairman, just one more statement
before I yield.
Chairman BRADY. Quickly please.
Mr. PASCRELL. We want to be fair to everybody. I want to be
fair to everybody. What I want folks to know, I am never going
to vote for any help for rural hospitals unless, instead of
going into the pocket we already have and, therefore, those
hospitals suffering, we need to expand the pocket. We need to
expand Medicaid. And that is really at the bottom of many of
the problems--you talked about getting to the fundamental
problems. That is what I think we need to do.
Thank you, Mr. Chairman.
Chairman BRADY. Thank you, Mr. Pascrell.
I would point out, I think hospitals are struggling with
the $700 billion of cuts to Medicare, many of which landed on
our community and rural hospitals. And they have been feeling
damaged for quite some time. Today's hearing, I understand the
point of Medicaid expansion, but the point today was really
about listening to specific challenges they face and some
proposed bills, bipartisan bills, we hope can help eliminate
some of those concerns.
So, Mrs. Black, you are recognized.
Mrs. BLACK. Thank you, Mr. Chairman.
Thank the panel for being here.
Mr. Chairman, I would like to ask unanimous consent to
submit a letter from the Equal Pay for Equal Care Coalition on
behalf of the Tennessee Hospital Association concerning the
hospital area wage index for the record.
Chairman BRADY. Without objection.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mrs. BLACK. Thank you, Mr. Chairman.
Mr. Derksen, I appreciate your testimony on the acute
financial pressures that rural hospitals face because of
onerous Medicare regulations and cuts in reimbursement. As you
point out in your testimony, for hospitals and rural States,
like Tennessee, the risk of closure is real. I represent, about
50 percent of my district is rural, so we have a lot of those
hospitals that are sitting in that situation.
But I would like to bring up another challenge that is
adversely impacting Tennessee hospitals, which is the Medicare
hospital wage index. This issue hasn't received as much
attention as those that have been identified in your testimony.
But I believe that it will be receiving more and more attention
in the near future as it negatively impacts these hospitals and
potentially will mean closure for them as well, unless that
reimbursement is changed. And although the area wage index is
intended to ensure that Medicare hospital payments reflect the
geographic differences in wages, many, including myself,
believe that the system is broken.
In fact, we had an exchange last week with MedPAC's
executive director, Mark Miller, in which he agreed that the
area wage index is neither accurate nor fair, and it needs to
be repealed. So the area wage index is having an adverse impact
on hospitals in Tennessee and other hospitals in rural areas.
Thus, this letter that I am going to be submitting, which has a
whole coalition of hospitals that are represented, mostly rural
areas, all over the country. These hospitals have seen the area
wage index levels rapidly decreasing over the years, while the
levels for a handful of the others have been increasing. So I
know this is going to be a difficult topic because some have
seen significant increases, while others have seen significant
decreases.
And would you talk about repealing this wage index and
replacing it with a more accurate and fair system that would
help to relieve some of those financial pressures specifically
on those rural hospitals that are in this situation?
Dr. DERKSEN. Mr. Chairman, Representative Black, thank you
for bringing up this issue. This is a crucially important issue
in some parts of our country, including the area I work in in
Tennessee obviously. I think we do need to bring some
rationality to this. I think we need to bring some fairness.
And I certainly appreciate your leadership on this issue. But
there are complicated issues that need to be ironed out. And I
admire the courage to bring this forward. Because whenever
there is winners and losers, the stakes and the fights get
pretty intense.
But I think the issue is there shouldn't be winners and
losers where large swaths of the United States, where 20
percent of our population lives, are basically forced to accept
these very low payments. I don't think it is just with the
Medicare area wage index. I think there are some issues related
to graduate medical education payments that are very, very low.
When I was in New Mexico, we had the lowest per-resident
amount. Why in the world, you know, is Connecticut or New York
hospitals being paid nine times per capita what Texas is being
paid for Medicare GME? I think the work that you have done in a
bipartisan manner in this committee is exactly the kind of
leadership we need. And I think that the types of things that
you have proposed and have been talking about are, it is time
for us to address these issues and to make this a much more
rational policy. Thank you.
Mrs. BLACK. You are welcome.
One other issue, and I know I am not going to have enough
time to really ferret this out, but I would like for the
panelists, if they have an opportunity, to respond back in a
written form about being able to use ACOs in rural areas.
My colleague, Mr. Thompson, did hit on something that we
are working on together on the telehealth, but also what are
the barriers for using the Accountable Care Organizations where
we could have more coordinated care? I know that we are seeing
those maybe be successful in the bigger urban areas. But I
would like to hear from you about where you believe that the
barriers might be in also using ACOs, where we could actually
have those alternative payment models and be able to coordinate
the care. So if you could just let me know or let the panel
know what is hampering those efforts, we would really
appreciate hearing from you. So that would be another area we
might be able to help our rurals in.
Thank you, Mr. Chairman. I yield back.
Chairman BRADY. Great. Thank you.
Mr. Kind, you are recognized.
Mr. KIND. Thank you, Mr. Chairman. Thanks for holding this
hearing.
I want to thank the witnesses for your testimony, your
patience today. And just to follow up on that last point, I am
glad Mrs. Black raised this issue, it was actually a question I
was going to ask you in regards to challenges you face with
ACOs, the implementation in rural areas. I hail from the State
of ACOs. My healthcare providers throughout Wisconsin have been
practicing a more integrated, coordinated, patient-centered
healthcare delivery system for quite some time. What I am
hearing from my Critical Access Hospitals, a lot of rural
providers, is that there are some unique challenges that they
face with the ACO model, medical homes, that more coordinated
care. So anything you can provide our committee to provide some
insights because I have been reaching out to my providers back
home on this as well.
Clearly, that is the direction that the Affordable Care Act
is trying to drive the healthcare system, to more coordination,
more integration in healthcare delivery services. But there are
unique challenges that we recognize in rural areas. And that
needs to be addressed as well.
Let me shift and address a topic that hasn't been addressed
yet today. Maybe you might provide some insights. Clearly,
there has been increased consolidation in the healthcare
industry in recent years. We are seeing more consolidation,
with the bigger providers coming into rural areas, buying up
hospitals and clinics. We are also seeing a huge amount of
consolidation with health insurance companies right now.
Obviously Cigna and Aetna are the latest in the news right now.
But I wanted to get anyone's reaction on the panel today and
these trends that we are seeing, the impact it could have on
rural healthcare providers, both the access and the quality
issues, if you would like to share with us today.
Dr. Derksen.
Dr. DERKSEN. Mr. Chairman, Representative Kind, I think
where integration and consolidation results in quicker access
to health care, to high-quality health care, or it reduces the
rate of cost growth, or it improves health outcomes, and those
are measurable health outcomes, I am all for it.
When integration and consolidation means fewer choices for
providers, for patients, and it increases the costs, I think we
ought to look at those types of issues. And that is where I am
kind of worried. In States where there is robust competition,
for example, in the health insurance marketplace, such as
Arizona, we have at least seven insurers offering 70 different
plans in our 13 rural counties. That is a lot of competition.
As a result, our premiums went down for silver plans 10
percent. I think the marketplace can work, but it requires
robust competition. I have noticed in other States with only
one or two insurers, that those rates go up. And there is these
kind of endless requests for increases in premiums. So I think
there is some advantage to bring it together. I think rural
communities and our community hospitals are looking to partner
in ways through telemedicine, telepsychiatry, through
teleradiology, and other mechanisms. We ought to encourage
that. But let's keep the end in sight here. We want high-
quality care. We want ready access. And we want to control cost
growth. And if those three criteria are met, then that should
be kind of our litmus test to me.
Mr. KIND. Mr. Joslin.
Mr. JOSLIN. I think fundamentally the system is fragmented
and broken. And I think you are seeing consolidations not for
business purposes but for patient care purposes. And I think
the only way we are going to fix this healthcare system is to
partner together and develop new models that are much more
effective in treating patients. If you do the same thing over
and over and over again, obviously, you are not going to get
different results. We have to get creative and look to doing
things differently. So what I look forward to sharing with you
in the coming months are a pilot that we are doing, for
example, where we, in a large urban area, are partnering with a
large provider in the rural area to develop an integrated
network with access to care, I absolutely agree with you,
access to care, the primary driver in this, to make sure there
is a system there for everybody, regardless of resources, that
is available close to where those patients are, and provides
the different level of resources they need. But it has to be
this new level of partnership if the mission is correct. And
the mission has to be accessed to high-quality, affordable
health care. And so you are going to see lots of these models
pop up. Some will be good. Some won't be so good. But we need
to learn from all of them and continue to work towards
developing a better model.
Mr. KIND. I would agree with both of those things.
Mr. Chairman, this might be another topic ripe for a future
hearing, as there are large forces taking place in the
healthcare field and consolidation, both on the provider and
the insurance side. And we are going to have to provide more
oversight.
And, finally, on the training aspect, Mr. Joslin, you talk
about the importance of training in rural areas. I know, in
Wisconsin--this might be true in your areas too--we are really
making a concerted effort to try to recruit in rural areas
before even training because we have found if we can get them
from the rural community, from the quality of life they grew up
in, it is easier to direct them back into those communities to
serve in the healthcare function.
So if you have got some unique programs that you have been
working on as far as recruitment, we would be interested in
hearing about that so we can take that to capacity.
Thank you, Mr. Chairman.
Chairman BRADY. Thank you, Mr. Kind.
Mrs. Noem, you are recognized.
Mrs. NOEM. Thank you, Mr. Chairman.
And thank you for allowing me to take part in this hearing.
I am not a normal member of the Health Subcommittee. But I
represent South Dakota. And I have the entire State. So there
is not much in South Dakota that isn't rural and doesn't face a
lot of the challenges that you all have been discussing today.
And I am glad that Mr. Kind touched on that because that
was something I was going to point out that Mr. Derksen talked
about earlier, was the fact that when you train physicians and
caregivers in rural areas, they tend to come back. We have a
very difficult problem with recruiting physicians to some of
our communities in South Dakota. But we have noticed that if we
have the training in those communities, if we have residencies
available, that that makes a world of difference.
So I want to thank you for discussing that today and
putting that in the record because it is important to make sure
that we have the kind of access to care that we need. And we
have that by making sure there are physicians in the area. And
I have visited many, many of the rural hospitals in South
Dakota. I have seen the necessary care that they provide to our
population and the people that live in my home and the patient
population that they serve. In fact, a lot of my rural
hospitals feel that many times they are treating patients that
may be sicker, that may be older. We have a very--our
population is much older than I think, on average, than some
other States. And they feel like they have more challenges
because of that than some of their urban hospital counterparts.
And they outlined a number of the challenges that they face.
And Congress and the administration have agreed that access
to care is limited in these areas and communities. And people
have to travel farther to get the kind of checkups and
emergency services they need. And this can significantly
increase the cost of health care and impact outcomes in
emergencies when time is critical. In fact, research shows that
rural residents travel twice as far to the closest emergency
room than urban populations do. Rural communities face
demographic challenges both with the Medicare population and
the community population at large. You have discussed many of
these issues today. And as a result of all of these challenges,
a lot of our rural hospitals are operating at a financial loss.
So what concerns me is how we will keep access to care in these
parts of the country. And there are many things that Congress
can do, and there are many proposals and bills that are filed.
I would like to know from each of you what your biggest
challenge is at keeping that access to care in those rural
communities and a suggestion of what Congress, it may be a
payment system, it may be a reimbursement formula, it may be
different policies or regulations that cost you so much money
in complying with them rather than delivering care to patients.
What is your biggest challenge that Congress could immediately
address that would be a relief to our rural community
hospitals?
We will start with Mr. Derksen.
Dr. DERKSEN. Mr. Chairman, Representative Noem, thank you
for bringing up these issues. I think it is very important. I
spent a lot of years trying to figure out ways to get health
professionals trained and ready to practice in rural areas. And
I mentioned one of them. I think the thing before us now
pragmatically that we could invest in is graduate medical
education. And maybe the leverage point there, as we expand
Medicaid in at least 30 of the States so far, is to use
Medicaid graduate medical education where States have far more
flexibility, through State plan amendments and such, of
supporting a rural health professions infrastructure.
But the second thing has been mentioned several times,
there is no greater thing that a Governor can do is to reduce
the uncompensated care. If you just shift uncompensated care
cost to someone else, that is a hidden tax, every bit as
important as any other kind of tax you might levy. And in
Arizona, we are the very last State to do Medicaid. You know,
that was passed in 1965 as part of an amendment to the Social
Security Act. We didn't get around to it for 17 years in
Arizona until 1982. But we did expand Medicaid to 100 percent
of the federal poverty level. We were an early expansion State.
But we had to freeze that. 200,000 people got forced off of
Medicaid during the Great Recession a couple years ago. And
what happened is the uncompensated care costs for our hospitals
doubled and tripled and have put many to the brink of fiscal
extinction. Governor Brewer, not to be confused with a
progressive, you know, Democratic Governor, very conservative,
somehow she restored that coverage back to 100 percent. And
while she was at it, being very unpopular with her conservative
colleagues, expanded it to 138 percent. That single factor of
getting people health coverage, a payment source, has brought--
in 2013, half of our Critical Access Hospitals had negative
margins. Now they are just barely above the positive margin,
but they are in positive. Getting people coverage is there.
Every State does it different.
In Arizona, we do it as the Arizona healthcare cost
containment system. But it is a way to go about assuring
accountability. Every State is going to have to sort through
how best to cover their uninsured. And I think that factor
alone is probably the most important for our rural hospitals
and our rural providers.
Mrs. NOEM. But not necessarily something that Congress can
do.
Dr. DERKSEN. Pardon me?
Mrs. NOEM. Not necessarily something that Congress can make
a decision on today.
Dr. DERKSEN. I think any time you are looking at Medicare
and Medicaid coverage, you can't really separate them easily.
But the types of policies that you are doing here, the types of
payment issues--the hospital, I mentioned that we will close on
Friday because Medicare has frozen payment, well, Medicaid
can't pay them in our State either. So a lot of these issues go
hand in hand. Thank you.
Mrs. NOEM. Mr. Chairman, I realized I am out of time. If
the rest of the panelists wouldn't mind submitting to me your
recommendations on what you believe are the biggest challenges
to maintaining access to care in rural communities, I would
certainly appreciate that.
With that, I yield back.
Chairman BRADY. Thank you. I would like to thank today's
witnesses for their testimony today. And I appreciate your
continued assistance getting answers to the questions that were
asked by the committee. As a reminder, any member who may wish
to submit a question for the record will have 14 days to do so.
If they do, I would ask the panel to respond in writing in a
timely manner.
Again, we are looking for common ground in how we address
these rural healthcare disparities. Today's hearing was
helpful.
With that, the committee is adjourned.
[Whereupon, at 11:45 a.m., the subcommittee was adjourned.]
[Submissions for the record follow:]
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