A new feature article in The Rural Monitor examines the increasing incidence of cyber-attacks on healthcare organizations and the particular vulnerability of rural providers.  According to the Cybersecurity Program at the U.S. Department of Health & Human Services, 60 percent of ransomware attacks – whereby bad actors gain entry to an organization’s online system and lock critical files until a ransom is paid – were aimed at healthcare systems in 2020. FORHP-supported research last year found that rural hospitals are less likely to be attacked, but staff are less equipped to handle them when they do happen, and rural residents who need these services have fewer alternatives for care.

In this learning event hosted by the National Academy for State Health Policy (NASHP), the Centers for Medicare & Medicaid Services (CMS) will give insight and details of a new project from the CMS Innovation Center designed to improve population health while curbing cost for states.  A Notice of Funding Opportunity for the AHEAD Model (Advancing All-Payer Health Equity Approaches and Development) will soon be announced, seeking participation from as many as eight states.  Eligible applicants are state Medicaid agencies, state public health agencies, state insurance agencies, or other entities with the authority and capacity to enter into an agreement with the federal government.  As with all CMS Innovation Models, selected states will receive tools and resources to help move the entire healthcare system toward value-based care, with improved outcomes for all participants in that system – patients first, but also providers, and the public and private insurers that pay providers.  The AHEAD Model will have a focus on engaging rural and safety net hospitals and primary care providers, including Critical Access Hospitals, Rural Emergency Hospitals, and Rural Health Clinics. Thursday, October 26, 2023 at 12:00 pm Eastern.

From the Iowa Capital Dispatch

A bipartisan congressional caucus aims to improve accessibility to quality health care and services in rural U.S. communities.

The Bipartisan Rural Health Caucus had its first meeting Sept. 20 and serves as a forum for U.S. representatives to promote legislation and policy actions regarding rural health. Members came together to discuss the issues their rural communities face.

There will be opportunities for members of the caucus to hear from patients, providers and health advocates about this issue, according to a press release from Rep. Mark Green, a Tennessee Republican. Carrie Cochran-McClain, chief policy officer of the National Rural Health Association, spoke at the first meeting.

The caucus will highlight potential policy solutions, including “stemming hospital closures, ensuring fair and adequate reimbursement rates, strengthening the health workforce, reducing health inequities and expanding telehealth and other innovative care delivery models” according to Green’s press release.

U.S. Reps. Jill Tokuda, a Hawaii Democrat, and Diana Harshbarger, a Tennessee Republican, serve as co-chairs of the caucus, which currently has 34 members made up of both Democrats and Republicans from across the country.

“A bunch of us decided it was time to pay closer attention to our rural communities, especially in terms of health,” Rep. Andrea Salinas, an Oregon Democrat and founding member of the caucus, told States Newsroom.

Harshbarger said that as a community pharmacist for over 30 years, she was proud to join this initiative “to highlight the needs of patients and health care professionals in rural and remote areas.”

“I look forward to working with my counterparts to address issues such as workforce shortages, supply scarcities, limited access to care and other health care challenges to improve patient outcomes,” Harshbarger said in a statement.

Struggling rural communities

Approximately 66.3 million people, or 20% of the national population, live in rural communities, according to the U.S. Census Bureau.

The COVID-19 pandemic brought greater attention to the obstacles rural communities face when it comes to health care. Many people in rural areas experience health care shortages and have to travel long distances to receive care.

“No one should have to travel for hours through treacherous terrain to see a doctor. But for so many in rural Oregon, this is simply reality,” Salinas said in a press release.

Salinas said that amid Oregon’s mental health and substance use crisis, “it’s even more critical that we address these issues now.”

Oregon’s 6th District, which Salinas represents, has experienced additional closures of health facilities in its rural areas, she said. Her district includes rural communities in Polk, Marion and Yamhill counties.

A medical center in Polk County, Oregon, closed its maternity ward due to a shortage of obstetricians and gynecologists, Salinas said. Rural communities in Yamhill County also have a primary care physician shortage, she said.

Salinas’ district has the largest Latino population in Oregon, she said, and this community lacks the care they need.

“Mental health is a big issue for me, and I know in some of our rural counties, we don’t see the type of culturally and linguistically responsive care, especially when it comes to mental health care,” Salinas said.

Green emphasized in a statement the importance of removing barriers to emergency room care, as it “can mean life or death.”

“Tennessee is plagued by rural hospital closures and limited access to emergency medicine. This problem, combined with the second-most hospital closures of any other state, equals an impending disaster for my constituents,” Green said in a statement.

Bipartisan goals

Rep. Susan Wild, a Pennsylvania Democrat, said in a press release that she is excited to work with both her Democratic and Republican colleagues to address these barriers in rural America.

“Whether it’s advocating for fair reimbursement rates for rural hospitals, or pushing to protect the 340B drug pricing program, I’ll continue pushing to make sure that everyone — no matter where they live — can access the quality, affordable care they need to stay healthy,” Wild said.

Tokuda said Congress “must do more to target resources to address the health disparities in rural and remote communities.”

“From increasing mental health needs to expanding broadband to support telehealth and addressing provider shortages, it’s clear that while our districts vary in location and demographic, we are united in the fight to improve health care access,” Tokuda said in a press release.

Salinas said she is encouraged that so many representatives share a desire to combat the consequences of workforce shortages.

“I’m really hoping that we can work across the aisle because I’m consistently saying that the problems we’re seeing around mental health, substance use disorders, lack of access to primary care providers, reproductive care issues — it’s not just a CD6 in Oregon issue, it’s not just an Oregon issue, but it is a nationwide issue,” Salinas said.

Salinas said she is open to considering what red tape could be removed for health care providers. She referenced how during the pandemic, telehealth services offered people the ability to access health care providers from other states.

“So if you’re in a rural community, that really helped, but we also need to figure out the broadband issue,” Salinas said. “There’s so many other issues that go along with getting access to health care.”

Salinas said she hopes members of the caucus can find common ground on what the problems are and how to solve them.

“I’m just hoping to work with my colleagues on both sides of the aisle,” Salinas said, “so no matter who is in power in the House, whether it’s Democrats or Republicans, we can continue to move our rural communities forward.”

From Fierce Healthcare

The Drug Enforcement Administration (DEA) said Friday it will extend telehealth flexibilities that enable clinicians to virtually prescribe controlled medications to their patients through 2024 as it mulls permanent policy changes.

The agency recently held two-day listening sessions to inform the agency’s regulations on prescribing controlled substances via telemedicine.

Telehealth leaders and doctors urged the DEA to allow prescribing via virtual care, arguing that mandates that require in-person doctor visits for patients to get prescriptions for controlled drugs, such as Adderall or buprenorphine used to treat opioid use disorder, severely restrict access to care and could increase patient harm.

“We continue to carefully consider the input received and are working to promulgate a final set of telemedicine regulations by the fall of 2024, giving patients and medical practitioners time to plan for, and adapt to, the new rules once issued,” the DEA said in a statement on its website.

In a notice (PDF) published to the Federal Register, the DEA and the Department of Health and Human Services said they are working to develop regulations “providing access to the practice of telemedicine when consistent with public health and safety, and that also effectively mitigate the risk of possible diversion.”

DEA officials also said the agency was limiting the second extension to a “short, time-limited period” to work on more permanent policy changes and avoid incentivizing new telehealth companies to pop up that might “encourage or enable problematic prescribing practices.”

During the COVID-19 pandemic public health emergency, the DEA granted flexibilities for prescribing controlled substances remotely and waived a requirement, as mandated by the 2008 Ryan Haight Act, that an in-person visit occur prior to prescribing controlled drugs via telehealth.

In February, the DEA issued proposed rules that pulled back some of those flexibilities and reinstated strict limitations on the virtual prescribing of controlled substances. Under the proposed rule, Schedule 2 medications or narcotics would require (PDF) an in-person prescription. Schedule 3 or higher medications, including buprenorphine, can be prescribed for 30 days via telehealth but would require an in-person visit before a refill.

The Biden administration said at the time that the new rule seeks to provide safeguards to prevent online over-prescribing of controlled medications.

The DEA faced immediate and major backlash from doctors and telehealth groups. Many providers voiced concerns about patients’ ability to obtain in-person appointments within 30 days. The DEA received a record 38,000 comments on its proposed telemedicine rules.

The agency then extended telehealth flexibilities for another six months, until Nov. 11.

This second temporary rule extends “the full set of telemedicine flexibilities regarding prescription of controlled medications as were in place during the COVID–19 PHE, through December 31, 2024. This extension authorizes all DEA-registered practitioners to prescribe schedule II-V controlled medications via telemedicine through December 31, 2024, whether or not the patient and practitioner established a telemedicine relationship on or before November 11, 2023,” DEA officials wrote in the notice.

The American Telemedicine Association (ATA) cheered the news that telehealth flexibilities were extended through 2024.

“We are thrilled that the DEA is taking such a thoughtful and thorough approach to creating the right rules around the prescription of controlled substances. This is a critical issue for millions of individuals and their families, as well as clinicians wanting to provide care to their patients, wherever and whenever they need it,” said Kyle Zebley, ATA senior vice president for public policy and executive director of ATA Action, in a statement.

He added, “What this means is that next year is shaping up to be the Super Bowl for telehealth, with many of the telehealth flexibilities enacted during the public health emergency set to expire at the end of 2024, including the High Deductible Health Plan (HDHP) and Health Savings Account (HSA) telehealth tax provision, geographic and originating sites flexibilities, forestalling implementation of Medicare’s telemental health in-person requirements, Medicare face-to-face telehealth requirements for hospice care and the Acute Hospital Care at Home Program. It is time to quadruple down on our efforts leading into 2024. This is a historic opportunity to make crucial changes to our healthcare system that will appropriately expand access to urgently needed care to some of our most challenged and underserved patient populations. This is not rhetoric, it’s real opportunity that we must not squander.”

The Health Innovation Alliance signaled that it was disappointed that the DEA did not go further to enact permanent rules.

“While this extension will help millions of Americans access much-needed medications, an extension is not a permanent rule. The DEA needs to stop dragging its feet, admit that tele-prescribing is a success, and trust in the medical professionals who are treating patients,” the organization said in a statement. “Instead of waiting another year and keeping doctors in limbo, the DEA should act with urgency and make tele-prescribing for controlled substances permanent.”

DEA’s notice did not indicate whether the agency would set up a “special registration” pathway to enable practitioners to prescribe controlled substances via telemedicine without a prior, in-person medical evaluation, something the DEA was mandated to do 15 year ago.

This story was produced by the State College regional bureau of Spotlight PA, an independent, nonpartisan newsroom dedicated to investigative and public-service journalism for Pennsylvania. Sign up for our regional newsletter, Talk of the Town.

When Cris Dush’s state Senate district was redrawn to include part of Centre County last year, the Republican went door to door to connect with new constituents.

Dush met with residents at a pizza shop in Snow Shoe, located just off Interstate 80, to hear more about how the rural community has lost critical businesses in the past few years, including its only grocery store, pharmacy, and medical center.

An electrical fire in 2020 destroyed Hall’s Market, True Value Hardware, Jersey Shore Bank, and a Subway. Then, the only pharmacy closed. Later, the lone medical center also left, citing a decline in patients and revenue. And a local restaurant followed suit earlier this year.

After years of hardship in the Mountaintop region, Dush (R., Jefferson) and first-term state Rep. Paul Takac (D., Centre) — who vowed to prioritize the community despite winning roughly 30% of the vote in Snow Shoe — are helping to deliver aid from the state.

Brought together by the overlap in their districts, the pair have put partisanship aside. They see their position as lawmakers as an opportunity to secure development grants, lobby for state money to buy new equipment, and find ways to bring new businesses to the area.

“We work together as a team,” Dush told Spotlight PA of his relationship with Takac. “We’ve got to get this stuff done, and we got to take care of our people — when people are suffering from not having proper health care and not having access to food, especially when they’re elderly and have to travel long distances.”

With a population of roughly 3,000, the Mountaintop region includes Snow Shoe borough, Snow Shoe Township, and Burnside Township. Snow Shoe borough is contained within the township of the same name. All have individual local governing boards.

The new representation in Harrisburg has given local leaders hope that their community is finally a priority.

“We’ve hoped somebody would come here to try to do something,” Rodney Preslovich, who chairs the Snow Shoe Township Board of Supervisors, told Spotlight PA.

Before redistricting, the once-a-decade process to redraw political lines, Mountaintop residents were represented by state Rep. Stephanie Borowicz, a Republican who now represents Clinton and Union Counties, and now-retired state Senate President Pro Tempore Jake Corman, also a Republican.

Through a spokesperson, Borowicz cited a grant for drinking water infrastructure as something she helped bring to the area. She added that she worked to recruit someone into buying the grocery store to reopen it, “but so far, no one has stepped in,” she told Spotlight PA.

The township supervisors said that calls to Borowicz went unreturned. Corman would help, they said, but only if the township reached out first.

Corman told Spotlight PA that he was “always there to help” in Snow Shoe, citing his involvement in trying to bring more reliable medical care to the area after the center closed.

“Obviously, it’s a big district,” he said. “Sometimes they reach out; sometimes we reach out.”

Snow Shoe Fire Chief Beau Martin said he never had a problem reaching Borowicz, who secured funding for Snow Shoe’s fire and ambulance companies, but added that he sees the new lawmakers in the community more often.

Dush and Takac have helped obtain funding for local infrastructure projects, including repairs at the Snow Shoe Township building, upgrades at the Moshannon Community Center, and a new leaf collection truck for Snow Shoe borough.

“For me, this is an enormous opportunity and a privilege to be able to show that there are people who are interested in wanting to help, that there are programs, there is funding, there are opportunities to improve the quality of life for the residents in those areas,” Takac told Spotlight PA. “And I don’t think that sense of optimism was there.”

Mountaintop residents have dealt with water infrastructure issues for years, specifically having to conserve water and operate under boil advisories due to poor quality.

In the past five years, the water authority has used state funding to install additional meters for monitoring water flow. But elected leaders said continued improvements are crucial for recruiting new businesses.

Ronald Bucha, a township supervisor, thinks an industrial park would thrive in Snow Shoe.

Still in the works — and a top need for residents — is access to fresh food. Since the fire, people have had to travel at least 30 minutes to access essentials not sold at Dollar General.

Officials at every level of government, including U.S. Rep. Glenn Thompson (R., Pa.), are working to launch a food co-op to fill the void left by Hall’s Market closing.

Co-ops can help fill in gaps in the food system, a need that is especially important in rural areas where residents are typically older and might struggle to travel long distances for groceries and other necessities. They’re typically managed and used by community members.

The Keystone Development Center, a Lancaster County-based agricultural co-op, and the U.S. Department of Agriculture are also involved in the Snow Shoe development plans.

The planned co-op doesn’t have a definite timeline or distribution plan yet, but the next step is forming a steering committee of local leaders, Takac said.

A meeting to discuss the committee is scheduled for later this month.

“We are there to assist and to help, but this is going to be a community initiative,” he said.

Local officials decide and direct most community development. They’re particularly responsible for zoning decisions and applying for grants, which can be a lengthy and complex process for local governments that are run primarily by volunteers.

Snow Shoe is no exception, but Dush and Takac have alleviated some of the burden.

Sandra Reiter and Tauni Bowling, who serve on the Snow Shoe Borough Council, said their latest elected officials in Harrisburg have brought a new level of communication to the region by sharing grant opportunities and other resources.

Takac, in particular, has established office hours, where he or a staff member sets up shop at the township building, usually every other week, to help constituents with taxes, renew drivers’ licenses, and answer questions.

“We’ve never had that before,” Preslovich said.