By Rachel Levine and Andy Carter, For the Philadelphia Inquirer, April 26, 2019

Rural communities and their hospitals are struggling.

In terms of health and well-being, rural Pennsylvania and urban Philadelphia have all too much in common, including high rates of child poverty and mortality, food insecurity, and chronic disease.

In terms of the health care needed to address these issues, rural hospitals face some unique challenges. These include sustaining a wide array of services for smaller numbers of patients due to sparsely populated geographies. About half of Pennsylvania’s rural hospitals operate at a loss and are at risk for closure.

Respected research organizations have reported on this problem nationwide. Since 2010, 104 U.S. rural hospitals have closed, two of them in Pennsylvania.

Pennsylvania’s bold experiment

In partnership with the Center for Medicare & Medicaid Innovation, the Pennsylvania Department of Health’s new Rural Health Model flips the script on hospital care. In place of hospitals’ traditional focus — treating patients when they are sick or injured — the new model also aims to reward hospitals for keeping patients healthy and out of the hospital altogether.

To accomplish these goals, the model changes the way hospitals are paid.

Last week, the Centers for Medicare & Medicaid Services (CMS) released the final Notice of Benefit and Payment Parameters for the 2020 benefit year, a document that sets forth instructions to insurers participating in the Health Insurance Exchanges or “Marketplaces”.  Among the changes for 2020 are flexibilities related to the duties and training requirements for the Navigator program and opportunities for innovations in the direct enrollment process.  In 2018 and 2019, the percentage of enrollments in the federal exchange (healthcare.gov) by rural residents remained unchanged at 18 percent.

The U.S. Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) have announced the CMS Primary Cares Initiative. Administered through the CMS Innovation Center, the new initiative will provide primary care practices and other providers with five new payment model options under two paths: Primary Care First (PCF) and Direct Contracting (DC). Both models provide incentives to reduce hospital utilization and total cost of care by adjusting payments to providers’ performance. While the PCF models focus on individual primary care practice sites, the three DC payment model options aim to engage a wider variety of organizations that have experience taking on financial risk and serving larger patient populations. Last year, the RUPRI Center for Rural Health Policy Analysis and Stratis Health published a policy brief on the priorities of rural health leaders about value-based payment models.

On April 24, 2019, the Trump Administration proposed changes that build on the progress made over the last two years and further the agency’s priority to transform the healthcare delivery system through competition and innovation while providing patients with better value and results. The proposed rule would update Medicare payment policies for hospitals under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) for fiscal year 2020 and advances two key CMS priorities, “Rethinking Rural Health” and “Unleashing Innovation,” by proposing historic changes to the way Medicare pays hospitals.

“One in five Americans are living in rural areas and the hospitals that serve them are the backbone of our nation’s healthcare system,” said CMS Administrator Seema Verma. “Rural Americans face many obstacles as the result of our fragmented healthcare system, including living in communities with disproportionally higher poverty rates, more chronic conditions, and more uninsured or underinsured individuals. The Trump Administration is committed to addressing inequities in health care, which is why we are proposing historic Medicare payment changes that will help bring stability to rural hospitals and improve patients’ access to quality healthcare.”

The inpatient hospital wage index specifies how inpatient payment rates are adjusted to account for local differences in wages that hospitals face in their respective labor markets. It is intended to measure differences in hospital wage rates across geographic regions and is updated annually based on wage data reported by hospitals. Hospitals located in areas with wages less than the national average receive a lower Medicare payment rate than hospitals located in areas with wages higher than the national average. For example, a hospital in a rural community could receive a Medicare payment of about $4000 for treating a beneficiary admitted for pneumonia while a hospital in a high wage area (like many urban communities) could receive a Medicare payment of nearly $6000 for the same case, due to differences in their wage index.

In last year’s proposed rule, CMS invited comments on changes to the Medicare inpatient hospital wage index. Many responses reflected a common concern that the current wage index system makes the disparities between high and low wage index hospitals worse. High wage index hospitals, by virtue of higher Medicare payments, can afford to pay their staff more, allowing the hospitals to continue operating as high wage index hospitals. Conversely, low wage index hospitals often cannot afford to pay wages that would allow them to climb to a higher wage index. Over time, this creates a downward spiral that increases the disparity in payments between high wage index hospitals and low wage index hospitals, and payment for rural hospitals and other low wage index hospitals declines.

To address these disparities, CMS is proposing to increase the wage index of low wage index hospitals. This change would ensure that people living in rural areas have access to high quality, affordable healthcare. CMS is considering several ways to implement this change, and the agency looks forward to comments on the different approaches.

The Trump Administration is also announcing proposals that would ensure Medicare beneficiaries have access to a world-class healthcare system by unleashing innovation in medical technology and removing potential barriers to innovation and competition in order to expedite access to novel medical technology.

“Transformative technologies are coming to the private market, but Medicare’s antiquated payment systems have not contemplated these technologies,” said CMS Administrator Seema Verma. “I am particularly concerned about cases that have been reported to the agency in which Medicare’s inadequate payment has led hospitals to curtail access to needed therapies. We must continually update our policies in response to the rapid pace of advancement in medical science.”

To ensure that Medicare payment supports broad access to transformative technologies, CMS is proposing several payment policy changes. These include proposing to increase the new technology add-on payment, which provides hospitals with additional payments for cases with high costs involving new technologies, including potentially new antimicrobial therapies. The increase would apply to all technologies receiving add-on payments starting on October 1, 2019, so that when a physician determines that a patient needs a qualifying new therapy, the hospital at which the therapy is administered would be able to more completely cover its costs. This change would promote patient access and reduce the uncertainty that innovators face regarding payment for new medical technologies for Medicare beneficiaries.

CMS is also proposing to modernize payment policies for medical devices that meet FDA’s Breakthrough Devices designation. For devices granted this expedited FDA approval, real-world data regarding outcomes for the devices in different patient populations is often limited. At the time of approval, it can be challenging for innovators to meet the requirement for evidence demonstrating “substantial clinical improvement” in order to qualify for new technology add-on payments.

Therefore, CMS is proposing to waive for two years the requirement for evidence that these devices represent a “substantial clinical improvement.” Waiving this requirement would provide additional Medicare payment for the technologies for a period of time while real-world evidence is emerging, so Medicare beneficiaries do not have to wait for access to the latest innovations.

In the proposed rule, CMS highlights the unique challenges associated with paying for CAR-T technology in particular. CAR-T is the first-ever gene therapy and is used to treat certain forms of cancer for which no other treatment options exist. The agency is considering several changes to payment policies for CAR-T for 2020, including additional changes to new technology add-on payments for CAR-T and changes to the formula that is used to calculate payments to hospitals for CAR-T. These changes may help ensure adequate payments to hospitals administering this groundbreaking therapy while CMS continues our work to ensure that we pay for innovative therapies appropriately.

The IPPS and LTCH PPS proposed rule is one of five Medicare payment rules released on a fiscal year cycle, to define payment and policy for inpatient hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, skilled nursing facilities, and hospice. Modernizing and strengthening Medicare through rulemaking is critical to achieving CMS’s objectives, and the IPPS and LTCH PPS proposed rule is an opportunity to further advance its goals.

For a fact sheet on the proposed rule (CMS-1716-P), please visit: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acute

To view the proposed rule (CMS-1716-P), please visit: https://www.federalregister.gov/documents/2019/05/03/2019-08330/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the

Call for Manuscripts: Clinical and Translational Science to Improve Rural Health. Publishers of the Journal of Clinical and Translational Science have issued a call for papers for a special rural-themed edition. They are particularly interested in innovative studies with the intention of improving health care delivery and outcomes among underserved rural populations. 

The Mapping Medicare Disparities (MMD) tool provides interactive maps to illustrate disparities between subgroups of beneficiaries on key measures of health outcomes, use, and spending.  CMS recently added rural and urban data to the population view, so users can view and compare across rural and urban counties. They also added four opioid use disorder indicators, including hospital and ER visits and medication-assisted therapy utilization.

To implement provisions of the Bipartisan Budget Act of 2018, CMS has finalized provisions allowing Medicare Advantage (MA) plans to offer additional telehealth benefits as part of the basic benefits.  While Medicare Advantage plans have always been able to offer more telehealth benefits than traditional Medicare, this rule gives MA plans even more flexibility with paying for these services, which could expand telehealth further.  For example, enrollees in urban and rural areas may be able to receive telehealth from their homes. In 2017, about one in four rural Medicare beneficiaries were enrolled in an MA plan.

During the week of April 1, 2019, CMS released the latest episode of their podcast, CMS: Beyond the Policy. This episode brings highlights from the 2019 CMS Quality Conference, including perspectives from rural providers at the conference. The theme of this year’s conference was “Innovating for Value and Results.”

The Health Resources and Services Administration (HRSA) recently announced an upcoming request for information (RFI) on its Health Centers Program. HRSA will be seeking input from the public on service area considerations that may inform decisions to expand the program through the addition of new service delivery sites onto existing health centers.  The considerations include factors such as proximity to existing health centers, parameters for unmet need, and consultation with other local providers.   The Service Area RFI announcement will begin with a 30-day preview period. Instructions on how to submit feedback are forthcoming. Following the preview period, HRSA will accept public feedback for 60 days.

UNIVERSITY PARK. Pa. — Hannah Ross, a student in the integrated undergraduate/Master of Health Administration program in the Department of Health Policy and Administration (HPA), has recently received two different Penn State awards in recognition of her leadership, scholarship and service to the community.

2019 Jennifer S. Cwynar Community Achievement Award

Ross is 2019 recipient of the Jennifer S. Cwynar Community Achievement Award, which was presented on April 8 during the Annual Stanley P. Mayers Endowed Lecture and Health Policy Administration student awards ceremony. Lisa Davis, director of the Pennsylvania Office of Rural Health (PORH) and outreach associate professor of health policy and administration, presented the award.

The Jennifer S. Cwynar Community Achievement Award recognizes community achievement by an HPA senior undergraduate student who has demonstrated service and commitment to a community or an underserved population, preferably, but not exclusively, in a rural area of Pennsylvania.

Ross was nominated for the award by Diane Spokus, associate director of professional development in HPA. In her nomination, Spokus noted that Ross’ contributions to the HPA undergraduate program have been invaluable.

Spokus noted that she has seen Ross develop leadership, facilitation and management skills through her participation in many educational and professional development activities. She noted these skills were evident when Ross served as the 2018 Jennifer S. Cwyner Undergraduate Intern at Pennsylvania Office of Rural Health (PORH).

While anintern with the PORH, Ross assisted in advocacy and research efforts to guide rural Pennsylvanians and health care providers in improving physical and mental health issues. She also prepared pilot site information about sexual assault exam training in rural hospitals for the Sexual Assault Forensic Examiner Telehealth Center, a project designed to improve sexual assault exams in rural areas.

“We are very pleased to present this award to Hannah Ross and to honor the legacy of Jennifer Cwynar, who was an exceptional student and intern with our office,” Davis said.  “This is one way in which we can encourage excellence in those who will become leaders in advocating for the health of vulnerable populations.”

“In my time as an intern with the Pennsylvania Office of Rural Health, I was honored to continue the work of Jennifer Cwynar by looking for ways to assist disadvantaged groups in rural Pennsylvania, such as children, human trafficking survivors and those without transportation to healthcare services,” Ross said. “I was therefore doubly honored to be selected for the Jennifer S. Cwynar Community Achievement Award, and to know that I could help carry on Jennifer’s dedication to helping those in need.”

The Jennifer S. Cwynar Community Achievement Award was established in memory of Cwynar, a 2008 graduate of HPA and a 2008 undergraduate intern at PORH. The award is given in recognition of Cwynar’s commitment to community service, advocacy for underserved and rural populations, and focus on public health. The award is issued to a senior undergraduate HPA student who has advanced those commitments, and is intended to encourage and foster personal and professional development.

2019 Edith Pitt Chace Award

Ross is also recipient of the 2019 Edith Pitt Chace Award, presented by the College of Health and Human Development Alumni Society. She was recognized on April 5 at the College of Health and Human Development’s Alumni Society Board awards dinner.

The Edith Pitt Chace Award, named in memory of the director of the Penn State home economics program from 1918 to 1937, recognizes an outstanding student leader and scholar in the College of Health and Human Development.

“So many people within HPA, the College of Health and Human Development, and Penn State encouraged me to grow as a leader and provided me with chances to learn what leadership truly means,” Ross said. “I learned that Edith Pitt Chace led not just for the sake of leading, but with the intention of serving others. I’m honored to be a recipient of the Edith Pitt Chase Award; her example of gracious leadership and empowerment is one I hope to emulate in my own leadership style.”

Ross is a participant in the HPA Peer Mentoring Program, where she provides guidance to mentees transitioning into the HPA major at the University Park campus, and was a teaching assistant for the course, HPA 101, Introduction to Health Services Organization.

She also serves as a resident assistant (RA), providing guidance, support, policy enforcement and campus resource information for 50 students in a residence hall. As an RA, she responds to multiple emotional and psychological crisis scenarios.

Ross has served as the president of the American College of Healthcare Administrators Club. As a Schreyer Honors Scholar, she has been active with the Schreyer Ambassador Team, representing the Schreyer Honors College on student panels and by giving tours to prospective students and their families.