From the National Rural Health Association

The Federal Communications Commission (FCC; Commission) has released a further notice of proposed rulemaking (FNPRM) to seek input to improve the Rural Health Care (RHC) Program. As you know, the RHC Program provides funding to health care providers for telecommunications and broadband services necessary to provide health care services. With the advancement of telehealth flexibilities in recent years, NRHA understands the importance of the RHC Program when it comes to building out broadband services and wants to ensure member concerns are reflected.

NRHA is working its way through the FNPRM but requests member input to determine whether comments are necessary on some of the issues the Commission is seeking comment on. NRHA has identified these areas for potential comment:

• Defining “rural area” for the purposes of program participation.

Currently, the RHC Program employs a definition of “rural area” that relies upon a health care provider’s location relative to the Census Bureau’s Core Based Statistical Area designation. However, until 2004, the Commission followed the definition used by the Federal Office of Rural Health Policy (FORHP) located within the Health Resources and Services Administration (HRSA).

NRHA asks, has the definition of rural been too limiting for program participation? Is it necessary to adopt a different definition? Perhaps the one used by FORHP should be implemented once again? Alternatively, NRHA has heard significant concerns that the amount of funding in the program has caused issues historically. Would expanding the program to include other entities cause further dilution of the funds?

• Applying geographic cost factors to rurality tiers.

In particular, the Commission asks whether it would be beneficial to use the Rural Urban Commuting Area (RUCA) codes to determine rurality tiers?  Further, the Commission seeks comment on whether to eliminate rurality tiers altogether and establish rates based on an applicant’s census tract information. How do to properly apply geographic cost factors to rurality tiers?

• Funding prioritization.

Adopted in 2019, the rates database lists eligible services in the program, median urban and rural rates for services by state, and underlying rate data used to determine the median rates. But the use of the database was waived in funding years 2021 and 2022 due to anomalies and inconsistencies. Now, the FCC is asking for comment on how best to fix those anomalies, which include examples of lower median rates in more rural tiers as compared with less rural tiers. If the Commission adopt a new rurality tier system, or an alternative to rurality tiers altogether, should the new system be used for funding prioritization as well?

• Application processing, funding decisions, and appeals of decisions.

The Commission seeks comment on any additional measures beyond those already taken that could further enhance the efficiency of application processing and the speed at which funding commitment decisions are made. NRHA has heard significant feedback that the time from application to award is of significant concern. That said, are there suggestions providers have that would improve this process?

• Digital equity and inclusion.

The Commission also seeks comment on how the proposals may promote or inhibit advances in diversity, equity, inclusion, and accessibility?

Your input will be helpful in crafting the direction of NRHA’s comments. If you have thoughts, please reach out to Josh Jorgensen (jjorgensen@ruralhealth.us) to discuss further. Comments are due to the FCC by April 14, 2022.  Thank you for your consideration.

U.S. Department of Agriculture (USDA) Rural Development Under Secretary Xochitl Torres Small announced that the department is accepting applications for grants to help start, expand or improve rural cooperatives and other mutually-owned businesses.

USDA is offering priority points to projects that advance key priorities under the Biden-Harris Administration to help communities recover from the COVID-19 pandemic, advance equity and combat climate change. These extra points will increase the likelihood of funding for projects seeking to address these critical challenges in rural America.

USDA is making the grants available under the Rural Cooperative Development Grant (RCDG) program to help improve economic conditions in rural areas through cooperative development. For fiscal year 2022, the maximum award is $200,000. Grants are awarded on a competitive basis through a national competition.

Nonprofit organizations and institutions of higher education are eligible to apply for grants to provide technical and cooperative development assistance to individuals and rural businesses.

Electronic applications must be submitted to grants.gov by 11:59 p.m. Eastern Time on June 6, 2022. Interested applicants are encouraged to contact their local USDA Rural Development State Office well in advance of the application deadline to discuss their project and ask any questions about the RCDG program or the application process. Contact information for state offices can be found at http://www.rd.usda.gov/contactus/state-offices.

Additional information on the required materials and how to apply for the RCDG program are available on page 19842 of the April 6, 2022, Federal Register.

If you’d like to subscribe to USDA Rural Development updates, visit our GovDelivery subscriber page.

From the National Rural Health Association

On March 30, 2022, Centers for Medicare and Medicaid Services (CMS) issued a proposed rule to provide routine updates to the Medicare Hospice payment system for Fiscal Year (FY) 2023.

Total estimated payments to hospices of a 2.7% ($580 million) increase in their payments for FY 2023. Further, the per patient that is made to a hospice annually. The proposed aggregate cap that limits the overall hospice payments for FY 2023 is $32,142.65.

Other key proposals include:

• Establish a permanent, budget neutral, mitigation policy to smooth the impact of year-to-year changes in hospice payments related to changes in the hospice wage index through a permanent cap on decreases greater than 5%.
• Improve data collection to measure and analyze disparities across programs and policies that apply to the Hospice Quality Reporting Program (HQRP) including development of a new HOPE tool, updates to quality measures, CAHPS hospice survey, and advancing HIE.

At this point, NRHA is not planning to submit comments on the proposed changes.  Please share any questions or concerns with NRHA staff before the May 31, 2022 deadline. To submit comments, please do so through the federal register here. CMS’s FY23 Hospice Payment Rate Update NPRM Fact Sheet can be found here.

From the National Rural Health Association

On March 23, 2022, the Occupational Safety and Health Administration (OSHA) reopened the rulemaking record partially and scheduled an informal public hearing to seek comments on specific topics that relate to the development of a final standard to protect healthcare and healthcare support service workers from workplace exposure to the COVID-19 virus.

The original 2021 OSHA Emergency Temporary Standard (ETS) aimed to protect workers in healthcare settings from occupational exposure to COVID-19. The ETS – which also served as a proposed rule – focused on healthcare workers most likely to have contact with people infected with the virus. The healthcare ETS required covered healthcare employers to develop and implement COVID-19 response plans to identify and control COVID-19 hazards in healthcare settings.

The agency is reopening the rulemaking record to allow for new data and comments on topics, including the following:

• Alignment with the Centers for Disease Control and Prevention’s recommendations for healthcare infection control procedures.
• Additional flexibility for employers.
• Removal of scope exemptions.
• Tailoring controls to address interactions with people with suspected or confirmed COVID-19.
• Employer support for employees who wish to be vaccinated.
• Limited coverage of construction activities in healthcare settings.
• COVID-19 recordkeeping and reporting provisions.
• Triggering requirements based on community transmission levels.
• The potential evolution of SARS-CoV-2 into a second novel strain.
• The health effects and risk of COVID-19 since the ETS was issued.

Comments on OSHA’s limited reopening of the COVID-19 healthcare ETS are due by April 22, 2022, and the informal public hearing will begin on April 27, 2022. Individuals interested in testifying at the online public hearing must submit a notice of intention to appear by April 6, 2022. View OSHA’s Federal Register Notice on govinfo.gov. View OSHA’s press release on the Notice on osha.gov.

NRHA plans to submit comments on the limited reopening reflective consistent with the intent of our 2021 comments. Please reach out if there are specific issues or concerns you’d like NRHA to reflect in our comment letter.  For more information, please contact ccochran@ruralhealth.us.

Even after she’s clocked out, Sarah Lewin keeps a Ford Explorer outfitted with medical gear parked outside her house. As one of just four paramedics covering five counties across vast, sprawling eastern Montana, she knows a call that someone had a heart attack, was in a serious car crash, or needs life support and is 100-plus miles away from the nearest hospital can come at any time.

“I’ve had as much as 100 hours of overtime in a two-week period,” said Lewin, the battalion chief for the Miles City Fire and Rescue department. “Other people have had more.”

Paramedics are often the most highly skilled medical providers on emergency response crews, and their presence can make a lifesaving difference in rural areas where health services are scarce. Paramedics are trained to administer specialized care from the field, such as placing a breathing tube in a blocked airway or decompressing a collapsed lung. Such procedures are beyond the training of emergency medical technicians.

But paramedics are hard to come by, and a long-standing workforce shortage has been exacerbated by turnover and resignations related to pandemic burnout.

Larger departments are trying to attract paramedics by boosting pay and offering hefty signing bonuses. But small teams in underserved counties across the U.S. don’t have the budgets to compete. Instead, some rural crews are trying to train existing emergency responders for the roles, with mixed results.

Miles City is among the few communities in rural eastern Montana to have paramedic-level services, but the department doesn’t have enough paramedics to offer that care 24/7, which is why medics like Lewin take calls on their time off. The team received a federal grant so four staffers could become paramedics, but it could fill only two slots. Some prospects turned down the training because they couldn’t balance the intense program with their day jobs. Others didn’t want the added workload that comes with being a paramedic.

If you’re the only paramedic on, you end up taking more calls,” Lewin said.

What’s happening in Miles City is also happening nationwide. People who work in emergency medical care have long had a name for the problem: the paramedic paradox.

“The patients who need the paramedics the most are in the more rural areas,” said Dia Gainor, executive director of the National Association of State EMS Officials. But paramedics tend to gravitate to dense urban areas where response times are faster, the drives to hospitals are shorter, and the health systems are more advanced.

“Nationally, throw a dart at the map, the odds are that any rural area is struggling with staffing, with revenue, with access to training and education,” Gainor said. “The list goes on.”

The Michigan Association of Ambulance Services has dubbed the paramedic and EMT shortage “a full-blown emergency” and called on the state legislature this year to spend $20 million to cover the costs of recruiting and training 1,000 new paramedics and EMTs.

At the beginning of this year, Colorado reactivated its crisis standard of care for short-staffed emergency medical service crews experiencing mounting demand for ambulances during a surge in COVID cases. The shortage is such a problem that in Denver a medical center and high school teamed up to offer courses through a paramedic school to pique students’ interest.

In Montana, 691 licensed paramedics treat patients in emergency settings, said Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services. More than half are in the state’s five most-populous counties — Yellowstone, Gallatin, Missoula, Flathead, and Cascade — covering a combined 11% of the state’s 147,000 square miles. Meanwhile, 21 of Montana’s 56 counties don’t have a single licensed EMS paramedic.

Andy Gienapp, deputy executive director of the National Association of State EMS Officials, said a major problem is funding. The federal Medicaid and Medicare reimbursements for emergency care often fall short of the cost of operating an ambulance service. Most local teams rely on a patchwork of volunteers and staffers, and the most isolated places often survive on volunteers alone, without the funding to hire a highly skilled paramedic.

If those rural groups do find or train paramedics in-house, they’re often poached by larger stations. “Paramedics get siphoned off because as soon as they have those skills, they’re marketable,” Gienapp said.

Gienapp wants to see more states deem emergency care an essential service so its existence is guaranteed and tax dollars chip in. So far, only about a dozen states have done so.

But action at the state level doesn’t always guarantee the budgets EMS workers say they need. Last year, Utah lawmakers passed a law requiring municipalities and counties to ensure at least a “minimum level” of ambulance services. But legislators didn’t appropriate any money to go with the law, leaving the added cost — estimated to be up to $41 per resident each year — for local governments to figure out.

Andy Smith, a paramedic and executive director of the Grand County Emergency Medical Services in Moab, Utah, said at least one town that his crew serves doesn’t contribute to the department’s costs. The team’s territory includes 6,000 miles of roads and trails, and Smith said it’s a constant struggle to find and retain the staffers to cover that ground.

Smith said his team is lucky — it has several paramedics, in part because the nearby national park draws interest and the ambulance service has helped staffers pay for paramedic certification. But even those perks haven’t attracted enough candidates, and he knows some of those who do come will be lured away. He recently saw a paramedic job in nearby Colorado starting at $70,000, a salary he said he can’t match.

“The public has this expectation that if something happens, we always have an ambulance available, we’re there in a couple of minutes, and we have the highest-trained people,” Smith said. “The reality is that’s not always the case when the money is rare and it’s hard to find and retain people.”

Despite the staffing and budget crunches, state leaders often believe emergency crews can fill gaps in basic healthcare in rural areas. Montana is among the states trying to expand EMS work to nonemergency and preventive care, such as having medical technicians meet patients in their homes for wound treatment.

A private ambulance provider in Montana’s Powder River County agreed to provide those community services in 2019. But the owner has since retired, and the company closed. The county picked up emergency services last year, and County Commissioner Lee Randall said that providing basic healthcare is on the back burner. The top priority is hiring a paramedic.

Advancing the care that EMT crews can do without paramedics is possible. Montana’s EMS system manager, Shari Graham, said the state has created certifications for basic EMTs to provide some higher levels of care, such as starting an IV line. The state has also increased training in rural communities so volunteers can avoid traveling for it. But those steps still leave gaps in advanced life support.

“Realistically, you’re just not going to have paramedics in those rural areas where there’s no income available,” Graham said.

Back in Miles City, Lewin said her department may get an extension to train additional paramedics next year. But she’s not sure she’ll be able to fill the spots. She has a few new EMT hires, but they won’t be ready for paramedic certification by then.

“I don’t have any people interested,” Lewin said. For now, she’ll keep that emergency care rig in her driveway, ready to go.

Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

The U.S. Department of Health & Human Services (HHS), through the Health Resources and Services Administration (HRSA), released a Request for Information (RFI) seeking input on ways to strengthen and improve the Organ Procurement and Transplantation Network (OPTN) through the upcoming Fiscal Year 2023 Request for Proposal (RFP).

The National Organ Transplant Act of 1984 established the OPTN to coordinate and improve the effectiveness of the nation’s organ procurement, distribution and transplantation systems and to increase the availability of, and access to, donor organs for patients with end-stage organ failure.  The law specifies that the OPTN be operated under federal contract.  In the coming months, HRSA will be issuing a Request for Proposal (RFP) for the next OPTN contract.

The RFI will support HRSA’s efforts to increase accountability in OPTN operations, modernize performance of the OPTN IT system and related tools, and improve engagement with donors and patients.  It specifically focuses on opportunities to strengthen equity, access, and transparency in the organ donation, allocation, procurement, and transplantation process in the contract arrangement that results from the forthcoming RFP.

“HRSA is committed to making organ procurement and transplantation more equitable, accessible, and transparent,” said HRSA Administrator Carole Johnson. “The Request for Information released today is an important step in advancing these goals and we look forward to receiving robust feedback on ways to increase organ donation, improve patient and donor engagement, strengthen accountability throughout the system, and best leverage modern technology to support this life-saving work.”

In addition to seeking feedback on the governance, finance, IT, data collection, policy, and operational components of the OPTN contract more broadly, this RFI specifically solicits feedback on ways to incorporate the findings and recommendations of the February 2022 National Academies of Science, Engineering, and Medicine (NASEM) report titled Realizing the Promise of Equity in the Organ Transplantation System, as well as the lessons learned from HRSA’s 2019 market research, conducted in partnership with the U.S. Digital Service, on ways the OPTN IT system should leverage modern IT architecture.

Interested parties may access information regarding the RFI here: https://sam.gov/opp/df25032b76b1467eabae79a2ba222ead/view.   The RFI is open for a 30-day period beginning April 8, 2022. Responses to the RFI are due to HRSA by May 9, 2022 at 1 p.m. ET.

To learn more about HRSA’s organ transplantation activities, please visit www.organdonor.gov.