The Pennsylvania Broadband Development Authority (PBDA) has drafted its Volume II of the Broadband Equity, Access, and Deployment (BEAD) Proposal, as required through the National Telecommunication and Information Administration’s BEAD Notice of Funding Opportunity and supplemental guidance. Volume II includes critical components of PBDA’s plans for implementing BEAD grant funding, to ensure that all Pennsylvanians have access to high-speed internet. To draft the document, PBDA complied with NTIA requirements and guidance on elements such as the application process, scoring criteria, labor standards, and other requirements, as well as Commonwealth policies.

Volume II will be available for public review and comment for the required 30 days, from October 16, 2023 through November 14, 2023. Upon receipt and consideration of comments and Board approval, PBDA will submit the Volume for consideration to the NTIA prior to the submission deadline of December 27, 2023.

The public is asked to share comments by 11:59PM on November 14, 2023.

Access the website at Broadband Equity, Access, and Deployment (BEAD) – PA Department of Community & Economic Development and scroll to the “SUBMIT FEEDBACK” button to provide input.

Questions on Volume II of the BEAD Initial Proposal can be directed to PABroadbandAuthority@pa.gov

From Healthcare Dive

HRSA is once again requiring hospitals to register outpatient clinics and list them on Medicare cost reports, setting a higher bar for eligibility in the drug discount program.

Dive Brief

• Hospitals are up in arms over new guidance issued by the Health Resources and Services Administration on Thursday that could restrict the eligibility of their outpatient clinics for drug discounts in the 340B program.
• During the thick of the COVID-19 pandemic in 2020, regulators waived longstanding 340B eligibility requirements for participating hospitals’ offsite locations to help streamline hospital operations. Now, HRSA is once again requiring hospitals to register outpatient clinics and list them on Medicare cost reports, according to a Thursday notice in the Federal Register.
• Many hospitals had expected the 2020 waiver to become permanent, so a number have yet to register their offsite clinics. Hospital association America’s Essential Hospitals said the change will “significantly harm essential hospitals” and their ability to care for patients.

Dive Insight

The 340B drug discount program requires pharmaceutical companies to give discounts on outpatient drugs for providers serving low-income communities. The discounts, which can range from 25% to 50% of the cost of the drugs, can be a big financial aid to those providers, which generally operate under very thin margins.

Yet under the new guidance, even if a hospital is eligible for 340B, its care sites may no longer qualify for the drug discount program.

Hospitals with large outpatient networks could pay more for prescription drugs as a result of the change, said Maureen Testoni, CEO of 340B Health, a trade group representing providers in the program, in emailed comments.

Many hospitals relied on HRSA’s prior language to invest in developing new offsite locations that have yet to start using 340B, according to Testoni.

“This change could require those hospitals to forego months of 340B discounts, pending the filing of the Medicare cost report,” Testoni said. “This would have significant financial consequence, potentially millions in 340B savings.”

But the change is just returning to standards that regulators have used to determine 340B eligibility for decades, HRSA said in the notice.

Regulators said hospitals have largely returned to business as usual coming out of the pandemic, and the waiver has made it harder for HRSA to oversee 340B compliance — a hot-button issue for pharmaceutical companies and lawmakers critical of how hospitals use 340B discounts.

In the notice, HRSA said recent audits of hospital-covered entities found more than one-third of hospitals were using 340B drugs in unregistered sites. Though those hospitals said they would register those locations in a future Medicare cost report, they had not done so as of May.

Now, in order to continue buying 340B drugs, hospitals’ outpatient sites need to either comply with registration requirements or notify HRSA that they’ve started the registration process within three months.

Hospitals that don’t comply could face “audit and compliance action,” HRSA said.

The 340B program has existed since the 1990s, but faces recent upheaval on multiple fronts. A number of major drugmakers are feuding with hospitals and the government, refusing to pay 340B discounts and sparking multiple lawsuits.

Drugmakers say the program doesn’t require hospitals to account for their savings or ensure they’re reinvested in patient care, a complaint shared by some legislators.

Hospitals are also not pleased with recent decisions from the Biden administration regarding 340B, with many airing concerns about regulators’ solution to repay 340B hospitals for years of alleged underpayments.

Click here for the 340B program guidance.

From Becker’s

Only 16 hospitals have converted to rural emergency hospitals since the CMS designation was made available Jan. 1, but more may follow suit in the coming quarters as rural hospitals continue to be challenged by staffing shortages and rising costs, which are stifling recovery efforts and leaving some on the brink of bankruptcy or closure.

Since 2005, 100 rural hospitals have completely shut down, with another 95 facilities no longer providing inpatient services, according to data compiled by the University of North Carolina’s Cecil G. Sheps Center for Health Services Research. Thirty-seven of those rural hospital closures have occurred since 2020.

To address concerns that rural and critical access hospital closures are reducing access to care for people in rural areas, CMS established the rural emergency hospital designation, a new Medicare provider type.

The designation aims to curb rural hospital closures by offering them a chance to close infrequently used inpatient beds and focus on outpatient and emergency department services.

In exchange for giving up their expensive inpatient beds and focusing solely on emergency and outpatient care, rural emergency hospitals receive a 5 percent increase in Medicare payments as well as an average facility fee payment of about $3.2 million a year.

While the designation has helped some hospitals survive under a new provider type, others are still weighing the benefits and drawbacks of implementing such a drastic change to their services and business model.

The hospitals that have made the switch are predominantly in the South and in states that have not expanded Medicaid coverage. Here are the 16 facilities that have converted to rural emergency hospitals, beginning with the most recent:

• Harper Community Hospital (Buffalo, Okla.)
• South Central Kansas Medical Center (Arkansas City)
• St. Bernards Five Rivers Medical Center (Pocahontas, Ark.)
• Assumption Community Hospital (Napoleonville, La.)
• Sturgis (Mich.) Hospital
• TriStar Ashland City (Tenn.) Medical Center
• Stillwater Medical-Blackwell (Okla.)
• Blue Ridge (Ga.) Medical Center
• St. Luke’s Health-Memorial San Augustine (Texas)
• Jefferson County Hospital (Fayette, Miss.)
• Stillwater Medical-Perry (Okla.)
• Anson (Texas) General Hospital
• Alliance Healthcare System (Holly Springs, Miss.)
• Falls Community Hospital and Clinic (Marlin, Texas)
• Irwin County Hospital (Ocilla, Ga.)
• Crosbyton (Texas) Clinic Hospital

St. Bernards Healthcare’s Five Rivers transitioned to a rural emergency hospital on Sept. 1, the first hospital in Arkansas to do so.

With inpatient extended care accounting for only about 5 percent of the hospital’s business, the decision was a relatively easy one for the facility, Randy Barymon, the hospital’s administrator, told local news outlet KAIT8.

“Cost of care has certainly gone up, and reimbursement has gone up. It’s actually harder to get reimbursed for the care that we provide here at Five Rivers,” Mr. Barymon told KAIT8. “I think a lot of rural facilities are seeing a trend down inpatient extended-stay care. This was really just a natural progression for us.”

For Anson General Hospital, the decision to convert to a rural emergency hospital came down to survivability.

The Texas hospital reported three consecutive years of financial losses and patient volumes declined to about 1.7 inpatients a week, on average, partially due to factors related to the COVID-19 pandemic.

“Our numbers drastically declined, and we knew that this was our only hope to stay open,” Chief Nursing Officer Anna Doan, BSN, RN, told Becker’s.

The hospital filed its application in early January and, effective March 27, has been operating as a rural emergency hospital. CEO Ted Matthews retired from the hospital more than a decade ago and returned to helm the facility in February.

“We have embraced this new identity,” Mr. Matthews told Becker’s. “What it allowed us to do is continue to provide access to care. We were the only hospital at one time. Jones County had three hospitals, and we are the lone surviving hospital. And if we had to close, there would have been no hospitals in the county.”

The Appalachian Regional Commission (ARC) awarded nearly $54 million to 64 projects in 217 counties through our POWER (Partnerships for Opportunity and Workforce and Economic Revitalization) Initiative, which supports economic diversification in Appalachia’s coal-impacted communities.

The funds will help create new jobs in several industries, expand workforce training, and attract investment to communities affected by the downturn of the coal industry.  With these awards, POWER has invested a grand total of $420 million in 507 projects impacting 365 counties!

Read more about our largest POWER package to date here.

Jason Bleak runs Battle Mountain General Hospital, a small facility in a remote Nevada gold mining town that he described as “out here in the middle of nowhere.”

When several representatives from private health insurance companies called on him a few years ago to offer Medicare Advantage plan contracts so their enrollees could use his hospital, Bleak sent them away.

“Come back to the table with a better offer,” the chief executive recalled telling them. The representatives haven’t returned.

Battle Mountain is in north-central Nevada about a three-hour drive from Reno, and four hours from Salt Lake City. Bleak suspects insurance companies simply haven’t enrolled enough of the area’s seniors to need his hospital in their network.

Medicare Advantage insurers are private companies that contract with the federal government to provide Medicare benefits to seniors in place of traditional Medicare. The plans have become dubious payers for many large and small hospitals, which report the insurers are often slow to pay or don’t pay.

Private plans now cover more than half of all those eligible for Medicare. And while enrollment is highest in metropolitan areas, it has increased fourfold in rural areas since 2010. Meanwhile, more than 150 rural hospitals have closed since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina. Largely rural states such as Texas, Tennessee, and Georgia have had the most closures.

Medicare Advantage growth has had an outsize impact on the finances of small, rural hospitals that Medicare has designated as “critical access.” Under the designation, government-administered Medicare pays extra to those hospitals to compensate for low patient volumes. Medicare Advantage plans, on the other hand, offer negotiated rates that hospital operators say often don’t match those of traditional Medicare.

“It’s happening across the country,” said Carrie Cochran-McClain, chief policy officer of the National Rural Health Association, whose members include small-town hospitals.

“Depending on the level of Medicare Advantage penetration in individual communities, some facilities are seeing a significant portion of their traditional Medicare patient or beneficiary move into Medicare Advantage,” Cochran-McClain said.

Kelly Adams is the CEO of Mesa View Regional Hospital, another rural hospital in Nevada. He said he applauds Battle Mountain’s Bleak for keeping Medicare Advantage plans out of his hospital “as long as he has.”

Mesa View, which is a little more than an hour’s drive east of Las Vegas, has a high percentage of patients enrolled in Medicare Advantage plans.

“Am I going to say I’m not going to take care of 40% of our patients at the hospital or the clinic?” Adams said, adding that it would be a “tough deal” to be forced to reject patients because they didn’t have traditional Medicare.

Mesa View has 21 Medicare Advantage contracts with multiple insurance companies. Adams said he has trouble getting the plans to pay for care the hospital has provided. They are either “slow pay or no pay,” he said.

In all, the plans owe Mesa View more than $800,000 for care already provided. Mesa View lost about $1.3 million taking care of patients, according to its most recent annual cost report.

NRHA’s Cochran-McClain said the growth in the plans also narrows options for patients because “the contracting that is happening under Medicare Advantage frequently has an influence on steering patients to specific types of providers.” If a hospital or provider does not contract with a Medicare Advantage plan, then a patient may have to pay for out-of-network care. That generally wouldn’t happen with traditional Medicare, which is widely accepted.

At Mesa View, patients must drive to Utah to find nursing homes and rehabilitation facilities covered by their Medicare Advantage plans.

“Our local nursing homes are not taking Medicare Advantage patients because they don’t get paid. But if you’re straight Medicare, they’d be happy to take that patient,” Adams said.

David Allen, a spokesperson for AHIP, an industry trade group formerly known as America’s Health Insurance Plans, declined to respond to Bleak’s and Adams’ specific concerns. Instead, he said enrollees are signing on because the plans “are more efficient, more cost-effective, and deliver better value than original Medicare.”

Centers for Medicare & Medicaid Services press secretary Sara Lonardo said CMS has acted to ensure “that private insurance companies are held accountable for providing quality coverage and care.”

The reach of private Medicare Advantage plans varies widely in rural areas, said Keith Mueller, director of the Rural Policy Research Institute at the University of Iowa College of Public Health. If recent trends continue, enrollment could tip to 50% of all rural Medicare beneficiaries in about three years — with some regions like the Upper Midwest already higher than 50% and others lower, such as Nevada and the Mountain States, but trending upward.

In June, a bipartisan group of Congress members, led by Sen. Sherrod Brown (D-Ohio), sent a letter urging federal agencies to do more to force Medicare Advantage insurers to pay health systems what they owe for patient care.

In an August response, CMS Administrator Chiquita Brooks-LaSure wrote that a final rule issued in April made “impactful changes” to speed up care and address concerns about prior authorization — when a hospital and patient must get advance permission for care to ensure it will be covered by an insurer. Brooks-LaSure noted another proposed rule that, once finalized, could mandate that insurers provide specific reasons for denying care within seven days.

Hospital operators Adams and Bleak also want more federal action, and fast.

Bleak at Battle Mountain said he knows Medicare Advantage plans will eventually move into his area and he will have to contract with them.

“The question is,” Bleak said, “how can we match the reimbursement so that we can sustain and keep our hospitals in these rural areas viable and strong?”

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.”