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.

This Centers for Medicare & Medicaid Services (CMS) announcement includes the following Medicaid/Children’s Health Insurance Program (CHIP) renewal information:

• Free CMS Printed Product Ordering
• Reminder: New Outreach and Educational Resources for Partners
• Upcoming Partner Webinars

FREE CMS PRINTED PRODUCT ORDERING

The following materials below are available for free to order through the CMS Product Ordering website. To order free printed materials, visit the CMS Product Ordering website. If you do not have an account, you will need to request an account on the login page. Once you log into your account, you can enter the term “Unwinding” in the search bar to view the materials that are available for order.

• Postcard for Kids with Medicaid or CHIP (English and Spanish)
• Postcard for Renewing Kids’ Medicaid or CHIP (English and Spanish)
• Fillable Flyer (English and Spanish)
• Non-fillable Flyer (English, Spanish, Chinese, Hindi, Korean, Tagalog, Vietnamese)
• HealthCare.gov Postcard (English and Spanish)
• Health Care Options Fact Sheet (English and Spanish)
• Tear Off Pad (English and Spanish)

REMINDER: NEW OUTREACH AND EDUCATIONAL RESOURCES FOR PARTNERS

Over the last few months, CMS has released several new resources to help partners share information about Medicaid and CHIP renewals with their communities. These resources focus on school-based and early education settings, faith-based organizations, and special populations. Each resource is posted on the Outreach and Educational Resources Page on Medicaid.gov/Unwinding.

School-Based Communications Toolkit: Education and early education professionals can use this toolkit to help share information about Medicaid and CHIP renewals with families. The toolkit includes ready-to-use resources, such as letters to staff and families, social media messages, robocall scripts, and more.

Faith-Based Communications Toolkit: Faith-based organizations can use this toolkit to share important Medicaid and CHIP information with those in their congregations, communities, and with those they serve. The toolkit includes ready-to-use resources, such as bulletin inserts, pulpit messages, social media messages, and more.

Outreach to Families and Children on Medicaid Renewals: Community groups are encouraged to use this slide deck and talking points in their outreach to children and families about what is happening right now with Medicaid and CHIP.

Reaching Out to Asian American, Native Hawaiian, and Pacific Islander People about Medicaid and CHIP Renewals (English): Use this one-page handout to help reach Asian American, Native Hawaiian, and Pacific Islander people and share information about Medicaid and CHIP renewals.

• Recording and Transcript from Webinar on Thursday, August 3, 2023: Reaching Asian American, Native Hawaiian and Pacific Islander (AANHPI) Populations

Reaching Out to Black Americans about Medicaid and CHIP Renewals (English): Use this one- page handout to help reach Black Americans and share information about Medicaid and CHIP renewals.

• Recording and Transcript from Webinar on Thursday, August 10, 2023: Reaching Black American Populations 

Reaching Out to Hispanic or Latino People about Medicaid and CHIP Renewals (English and Spanish): Use this one-page handout to help reach Hispanic or Latino people and share information about Medicaid and CHIP renewals.

• Recording and Transcript from Webinar on Tuesday, August 8, 2023: Reaching Hispanic and Latino Populations (English and Spanish)

Reaching Out to People with Disabilities about Medicaid and CHIP Renewals (English): Use this one-page handout to help reach people with disabilities and share information about Medicaid and CHIP renewals.

• Recording and Transcript from Webinar on Thursday, August 17, 2023: Reaching Aging and Disability Populations 

Reaching Out to People Who Live in Rural Areas about Medicaid and CHIP Renewals (English): Use this one-page handout to help reach people who live in rural areas and share information about Medicaid and CHIP renewals.

• Recording and Transcript from Webinar on Thursday, August 24, 2023: Reaching Rural Populations

Reaching Out to American Indian and Alaska Native People about Medicaid and CHIP Renewals (English): Use this one-page handout to help reach American Indian and Alaska Native people and share information about Medicaid and CHIP renewals.

• Recording and Transcript from Webinar on Thursday, September 7, 2023: Reaching American Indian and Alaska Native Populations

UPCOMING MONTHLY PARTNER WEBINARS

The Department of Health and Human Services (HHS) and CMS continue to host a series of monthly webinars on Medicaid and CHIP Renewals to educate partners. Topics covered during the webinar vary each month. To register for upcoming webinars, please click here.

• October 25, 2023 @ 12:00pm ET
• December 6, 2023 @ 12:00pm ET

Recordings, transcripts, and slides from past webinars can be found on the CMS National Stakeholder Calls webpage

The Pennsylvania Department of Health, Bureau of Emergency Medical Services, is pleased to announce the release of the 2023 PA Department of Health Statewide Protocols via the Department’s website at Regulations (pa.gov).

Additionally, on October 21, 2023, the PA Bulletin will publish the updated Scope of Practice, Required Equipment, and Medication lists.

The educational update courses for the BLS, IALS and ALS protocols have been created and released to TRAIN-PA.

• 2023 BLS Protocol Update BEMS course #1000058611
• 2023 IALS Protocol Update BEMS course#1000058615
• 2023 ALS Protocol Update BEMS course #1000058613

These protocols will be in effect on January 1, 2024. All providers, Medical Command Physicians and Agency Medical Directors are required to complete the protocol update course(s) prior to this date. Once the training is complete, the EMS Agency Medical Director may authorize the use of these protocols prior to January 1, 2024.

EMS providers who are unable to complete the training on TRAIN-PA should contact their Agency Medical Director. A PowerPoint and Lesson Plan will be available for in person training.

For the first time, Medicare is able to directly negotiate the prices of prescription drugs due to President Biden’s prescription drug law, the Inflation Reduction Act. Today, Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure issued the following statement on the announcement that the drug companies that manufacture all 10 drugs selected for the Medicare Drug Price Negotiation Program for the first cycle have chosen to participate in the Negotiation Program. The negotiations with participating drug companies for the selected drugs will occur in 2023 and 2024 with the negotiated prices effective beginning in 2026.

“We look forward to engaging with the drug manufacturers of the selected drugs that have decided to participate in the Medicare Drug Price Negotiation Program,” said CMS Administrator Chiquita Brooks-LaSure. “Our goal is to ensure access to innovative treatments and therapies for people that need them when they need them. Medicare will negotiate in good faith consistent with the requirements of the law on behalf of people with Medicare.”

This announcement is one of a number of steps CMS previously detailed in the Medicare Drug Price Negotiation Program timeline for the first cycle of negotiation. CMS published the list of 10 drugs covered under Medicare Part D selected for the first cycle of negotiation on August 29, 2023. October 1, 2023, was the deadline for companies with a drug selected for the Negotiation Program to choose whether to sign agreements to participate in the negotiation process for 2026. Participating companies with a drug selected for the Negotiation Program had by October 2, 2023, to submit manufacturer-specific data for CMS to consider in the negotiations. Additionally, October 2, 2023, was the deadline for the public to submit data on therapeutic alternatives to the selected drugs, data related to unmet medical need, and data on impacts to specific populations.

Other key upcoming dates for implementation include:

• Fall 2023: CMS will invite each participating drug company with a selected drug to engage in a meeting on its data submission. CMS will also hold a patient-focused listening session for each selected drug. The patient-focused listening sessions, which will include participation from patients, beneficiaries, caregivers, consumer and patient organizations, and other interested parties, will be held between October 30, 2023 and November 15, 2023. The listening sessions are subject to change, including postponement and/or cancellation.
• February 1, 2024: CMS sends an initial offer of a maximum fair price for a selected drug with a justification to each drug company participating in the Negotiation Program.
• August 1, 2024: The negotiation period ends.
• September 1, 2024: CMS will publish the maximum fair prices that have been negotiated for drugs selected for negotiation for 2026.

View the HHS press release.

View a list of the manufacturers of the selected drugs that have decided to participate in the Medicare Drug Price Negotiation Program. This list may be updated in the future.

View a fact sheet on the process for the first round of negotiations with participating manufacturers for Initial Price Applicability Year 2026.

More information on the patient-focused listening sessions is available at https://www.cms.gov/inflation-reduction-act-and-medicare/medicare-drug-price-negotiation-program-patient-focused-listening-sessions.

More information on the Medicare Drug Price Negotiation Program is available at https://www.cms.gov/inflation-reduction-act-and-medicare/medicare-drug-price-negotiation.

Pennsylvania high school students can explore a variety of health careers through PA AHEC’s virtual Students Exploring And Researching Careers in Health (SEARCH) Academy. Each session includes a panel discussion and Q&A with health professionals in the featured health career and a hands-on activity related to that career. The sessions are free and are offered from 6:30-8:30 pm on Thursdays in November and February. Oral health will be discussed on November 2nd. Students must apply before October 23rd for the November dates and January 22nd for the spring dates.

Click here for more information and to apply.

Bethany Rodgers, Pocono Record

Some days, Tiffany Rodriguez’s hands swelled up so badly she could barely make a fist, and simple tasks like hooking her bra or putting on her pants seemed to take forever.

Because of the soaring hypertension she experienced during the second half of her pregnancy, the 31-year-old from Montrose, was also coming down with pounding headaches and noticing spots or blurry patches in her field of vision. As her blood pressure continued to tick upward, doctors were growing concerned about the health of her pregnancy. But Rodriguez was determined to do whatever she could to carry her baby, Carter, until his scheduled delivery in mid-August.

She asked for shorter shifts at the local supermarket deli, a job that keeps her on her feet for hours at a time. She also hustled to a battery of prenatal checkups to make sure her hypertension didn’t worsen into preeclampsia, a serious condition that can cause preterm birth and endanger the life of the mother. Every week, she was supposed to go in for her standard doctor’s visit, plus sit through tests to monitor her baby’s heart rate, a process that could take hours at a time. And with a 30- or 45- minute drive between her rural township and these medical services, these visits could consume half of her day.

There was little choice considering the lack of specialized maternity services in her community, a small northeastern Pennsylvania town ringed with bluestone quarries and soaring old-growth hemlock forests. Rodriguez’s hometown — where she recently returned for a fresh start after leaving a marriage she says was unhealthy — also boasts a brewery, an annual blueberry festival and a handful of fast-food options. But there are no obstetricians working at its local hospital. And there are none at Susquehanna County’s only other hospital, which shut down its maternity unit in the 1990s. A wave of other small-town hospitals in Pennsylvania have followed suit, forcing Rodriguez and many other rural women to seek services and give birth in facilities farther and farther from where they live.

In 2020, six Pennsylvania counties, Cameron, Forest, Greene, Juniata, Sullivan and Wyoming, met the criteria for a maternity desert because of the absence of delivery hospitals or obstetricians in those areas, according to the March of Dimes. These deserts are only expected to multiply, experts say. In some cases, women are so far away from the hospital where they’ll give birth that they have to schedule their deliveries, according to one obstetrician. These deserts can also hinder them from accessing the prenatal care that can keep them and their babies healthy during their pregnancies.

For Rodriguez, several overlapping challenges made it tough to get to appointments. She’s a single mother of a 10-year-old daughter, and finding childcare can be difficult. And it wasn’t always easy to clear space in her schedule at the deli, work she’s banked on to secure an apartment for her, her daughter and her new baby. Then, there are the fuel costs to consider. Rodriguez said one week she spent six days in a row driving to medical appointments in Scranton, Wilkes-Barre and Tunkhannock. “It was like $120 almost in gas just for those days to go to the doctor’s,” she said during an early August interview.

Rodriguez, health workers and Pennsylvania policymakers agree these rural communities need more maternal healthcare resources. But experts say there’s no quick fix to the financial pressures and staffing shortages that are driving delivery rooms and clinics to close, especially with aging populations and declining birth rates.

“Some of the smaller facilities are going to feel (the demographic changes) and then really struggle to be able to keep the lights on,” said Dr. Amanda Flicker, an OB/GYN and chair of the Pennsylvania section of the American College of Obstetricians and Gynecologists. “We just have to decide … that the health of mothers and the safe birth for newborns is something we need to prioritize.”

Expanding deserts

Money is one major driver in the closure of delivery rooms and even entire hospitals across Pennsylvania, health experts say.

Since 2005, nine rural Pennsylvania hospitals have closed or transitioned to specialty care as it’s become increasingly difficult to keep these types of medical facilities operating in the black. Another 17 have chosen to eliminate their labor and delivery units, according to a Hospital and Healthsystem Association of Pennsylvania analysis.

“The fact that we see fewer labor and delivery units in rural communities is not in any way a statement about the dedication of those hospitals to providing comprehensive care,” said Lisa Davis, who directs the Pennsylvania Office of Rural Health. “It just means they may not be able to afford it.”

One issue: Medicaid, which covers about half of all rural births nationwide, fails to provide adequate reimbursement rates for obstetric care, according to a 2022 U.S. Government Accountability Office analysis. Doctors say there are issues with private insurance as well, noting that carriers often offer a bundled payment for obstetrics, regardless of how much care a particular woman ends up needing.

“No matter how many times I see them, whether they get a vaginal delivery or a C-section, I’m getting paid by the insurance company one flat fee for all of their care,” said Dr. Stacy Beck, an OB/GYN at UPMC Magee-Womens Hospital in Pittsburgh and co-chair of the Pennsylvania Maternal Mortality Review Committee.

In addition, obstetricians and gynecologists deal with high liability insurance costs because of the number of malpractice claims they face.

In 2020, insurance premiums for OB/GYNs in Philadelphia totaled almost $120,000 each, about $30,000 more than general surgeons and $95,000 more than internists, according to an American Medical Association analysis of selected insurance companies. The staffing demands of a labor and delivery unit make it even harder to keep them open.

Because babies can arrive at any hour, these units require the round-the-clock presence of nurses and physicians, but it’s becoming increasingly challenging for hospitals to fill these shifts.

The medical field in general is facing labor shortages, and the taxing nature of a job in the maternity ward can make it even harder to retain specialists, according to health experts. As many as three-quarters of OB/GYNs experience professional burnout, an American College of Obstetricians and Gynecologists report found.

“It’s really just, where have the doctors gone?” said Flicker, chair of obstetrics and gynecology in the Lehigh Valley Health Network.

Many are taking early retirements, she said, or moving out of direct clinical care. The same thing is happening with nurses in maternity units, Flicker added.

Even outside hospitals, obstetricians are in short supply in many rural parts of Pennsylvania, and of those who are practicing, a higher percentage are over age 75 compared to other areas of the commonwealth, according to a report by the Center for Rural Pennsylvania.

The number of OB/GYNs in Pennsylvania is expected to flatline between 2018 and 2028, with 0% growth forecasted by analysts at Projections Central, a federally-funded program that makes state and local projections. And that prognostication doesn’t take into account the rural-urban divide.

New physicians are sometimes reluctant to leave urban areas where they have more professional support and community amenities, so reversing that trend could be challenging, experts say. The erosion of robust health systems in some rural communities can also discourage health providers from moving into them, creating something of a vicious cycle, said Davis, director of the rural health office.

In the meantime, services continue receding. Wilkes-Barre General Hospital is among the latest medical facilities to stop delivering babies.

Erica Acosta, director of diversity initiatives at Wilkes University, was one of the women who’d been planning to give birth there. But about halfway through her pregnancy, when the hospital announced it would close its maternity ward, she had to make a quick pivot to another medical center and another physician.

Acosta said she’d chosen her original provider carefully; as a woman of color, she’s intentional about seeking physicians who look like her, although that’s not always easy because of the lack of diversity in the medical field, she said. And though her pregnancy has been free of complications so far, she said it was still difficult to lose an OB/GYN who’d been with her since she started contemplating having a second child.

“It’s very traumatic because you build trust. I told them I want to have a baby. They already knew my life story,” she said. “So now I have to start over and be vulnerable with people I don’t know.”

The importance of maternity care

For many young and healthy pregnant women, prenatal visits mostly provide reassurance that their babies are developing normally and everything is on track, Beck said.

But with increasing obesity rates and the number of women who are having babies later in life, she explained, more pregnancies are no longer in the low-risk category, and these medical appointments can play an essential role in addressing pre-existing diseases and other health concerns.

During early visits, physicians check a pregnant patient’s general health and monitor her for signs of preeclampsia. In certain cases, it might have been years since a person has seen a medical professional.

“Sometimes pregnancy is the only time we get the opportunity to take care of decades of diabetes or high blood pressure that somebody has not been controlling,” Beck said.

Prenatal care is also vital in screening for substance-use disorders, medical experts say. Accidental or intentional overdoses are the leading cause of maternal death in Pennsylvania, and Flicker said it’s scary to see hospitals closing and providers leaving in rural communities where at-risk women live.

Researchers have linked fewer pregnancy appointments to preterm birth and low birth weight. Still, in rural Somerset County, roughly one of every 20 babies is born without any prenatal care, according to the Center for Rural Pennsylvania. And the number of women in southcentral Pennsylvania who are forgoing a first-trimester doctor’s visit is on the rise, said Kim Amsley-Camp, a Chambersburg-based midwife with Keystone Health.

Getting to these appointments can be challenging for many women, especially those who live far away from the nearest hospital or clinic. Women who don’t have their own cars or who share one with a partner struggle to travel to their appointments, especially considering the lack of robust public transportation options in many rural areas, experts say.

Others already have kids and don’t have anyone to watch their children while they’re away at a doctor’s office or can’t afford to take time off from their jobs. Particularly in the aftermath of the COVID-19 pandemic, some people distrust the medical profession, Amsley-Camp said, and many don’t have adequate insurance coverage.

Davis said some pregnant women access services in their local emergency rooms, which she said is an important option but is also expensive and deprives the patient of the ability to form a long-term relationship with prenatal providers. Distance can also create complications when it’s time to give birth, experts say.

For women who aren’t sure if they’re in labor, heading over to the hospital might not be a big deal if they live a few minutes down the road. The decision looks much different when someone is an hour or more away and doesn’t want to make an unnecessary trip, Amsley- Camp said.

Davis has been hearing about paramedics in rural areas delivering babies in the back of ambulances rushing to the hospital but unable to make it in time. Between 2010 and 2020, the number of live births that happened in Pennsylvania homes and doctor’s offices (or other locations outside of a hospital or birthing center) shot up by roughly 50%, even as the overall number of deliveries declined, according to state health department data, though these figures are not broken down between rural and urban counties. Amsley-Camp knows of one woman who gave birth to twins in her driveway.

As people move to rural areas with the telework boom, healthcare access could be one factor as they choose a small-town home, says Abby Weaver, a mother and business owner in Schuylkill County. As Weaver recently navigated a complicated pregnancy, she says she appreciated the proximity of her town’s hospital, which is part of the Lehigh Valley Health Network. A recent Center for Rural Pennsylvania report found that more people were moving into rural counties than out of them in 2019 and 2020. But Weaver, who has been part of Pottsville’s revitalization efforts for the past six or seven years, said new arrivals often expect big-city amenities and services to follow them. “You have to be able to match things like what you see in bigger cities, like a coffee shop, like good health care, like good school systems, for people to choose you,” she said.

What are the solutions?

There aren’t any simple ways to halt the expansion of Pennsylvania’s maternity deserts, but analysts and experts are full of ideas about where to start.

Increasing Medicaid rates — which are set at a state level — could make a dent in the problem, but Davis said because of policymakers’ reluctance to drive up healthcare costs, the chances of that happening in the near future seem remote. The commonwealth’s leaders could also look at expanding transportation services in rural communities, working with the Pennsylvania Department of Transportation to add ride programs, she said. Doing more to recruit health professionals and opening more standalone birthing centers — which now operate only in Pennsylvania’s urban counties — could also make a difference.

Christine Haas, executive director of the Midwife Center in Pittsburgh, said the proliferation of facilities like hers could definitely be part of closing service gaps. But she said various barriers stand in the way: There are steep startup costs for opening a birth center, and these facilities sometimes struggle with state requirements, such as needing to have a physician serve as a medical director. Even the Midwife Center, which Haas said is one of the nation’s largest birth centers, opted against opening a second location because of the challenges involved, she said.

However, change could be on the horizon as congressional lawmakers consider legislation that would aim to improve reimbursement for services offered by freestanding birth centers, Haas said. This bipartisan legislation, called the BABIES Act, has been introduced in both the U.S. House and Senate. The Center for Rural Pennsylvania report also suggests the commonwealth could make more of the midwives, doulas, lactation consultants and other medical professionals to help close some of the provider gaps.

For example, nurse-midwives must now have an established collaborative agreement with a physician in order to practice to the full extent of their training, and many times that means they must affiliate with a large medical system, according to Amsley-Camp. These restrictions can prevent midwives from being able to open their own smaller practices in underserved areas, she said. “To have a practice out of these outlying counties would be fantastic,” she said. “But if the (midwife) is not working for one of these big organizations, the physician is not going to sign on. It’s an unknown entity.”

With the expansion of telehealth, medical providers can also look at handling some prenatal visits virtually rather than making women come into the practice every time. In more remote areas, maybe it makes sense to send pregnant people home with a scale and a blood pressure cuff to use during online appointments so they can avoid a few long drives to the clinic, Flicker said. In order for that to work, though, many rural communities would need better access to broadband.

And with nonprofit groups already targeting rural underserved populations, state lawmakers could consider making more investments in programs that already exist, according to the Center for Rural Pennsylvania report. Federally-qualified health centers, or federally-funded nonprofit clinics that target underserved populations, are one important resource for rural communities, experts say. One of them, Primary Health Network, runs about 50 sites in 16 Pennsylvania counties, providing care regardless of a patient’s insurance status or ability to pay, according to George Garrow, the organization’s chief executive officer. These centers don’t have delivery rooms, but they do provide prenatal and postpartum services and help patients confront any barriers to accessing care, Garrow said.

Rodriguez, the expectant mother in Montrose, said she isn’t sure how she’d have managed if not for Elizabeth Cassidy, a nurse who works for a Pennsylvania nonprofit called Maternal and Family Health Services. While she has to navigate winding rural highways to most of her appointments, Cassidy comes to Rodriguez, spending time chatting on her living room couch or in the local Dunkin’ Donuts. She was the first to help Rodriguez identify her blood pressure as a concern, and the pregnant woman says she’s come to consider the nurse a friend. “I would probably fight somebody if they were mean to her,” joked Rodriguez, who ended up delivering her son Aug. 18.

The nurse-family partnership, a program within Maternal and Family Health Services serving lower-income mothers, assigns nurses like Cassidy to meet with clients throughout their pregnancy and in the first two years of their child’s life. Through the program, Rodriguez has also gotten access to educational resources, baby supplies and sessions with a trained counselor. While Maternal and Family Health Services operates in eastern Pennsylvania, different organizations run nurse-family partnerships in other parts of the commonwealth. However, about 20 counties fall outside the program’s scope, and because it targets first-time mothers and includes income restrictions, not all families are eligible.

Cassidy says the challenges Rodriguez faces in accessing medical care are not uncommon for the women she serves. “Nothing is closer than 40 minutes, 45 minutes for any of these clients,” she said.

The USA Today Network is covering health care access issues in rural parts of the commonwealth. As part of this reporting, we’re interested in hearing from Pennsylvanians in these communities who have struggled to access medical, dental and mental health care. Fill out the form at bit.ly/pa-maternity and your response will go directly to a USA Today Network reporter. You may be contacted for further details about your story.