9th Circuit Ruling a Temporary Win for Rural Health

Thursday evening’s 9th Circuit Court of Appeals’ 3-0 decision upholding a temporary stay on President Trump’s travel ban also marked a temporary reprieve for rural healthcare, experts say.

The issue now appears likely headed for the U.S. Supreme Court, although any ruling at that level could be somewhat moot, being as the ban was listed as having a 90-day expiration date upon its creation via a Jan. 27 executive order.

Journalist Parija Kavilanz with CNN Money reported last week that rural healthcare relies hugely on foreign doctors, especially in underserved areas.

“There could very well be a patient in a rural area who had an appointment with their doctor this week and the doctor was not allowed back into the country," Matthew Shick, director of government relations and regulatory counsel with the American Association of Medical Colleges, was quoted as saying in the article. "At a time when the United States is facing a serious shortage of physicians, international medical students are helping to fill an essential need,"

Each year, Kavilanz wrote, more than 6,000 medical trainees from foreign countries participate in medical residency programs through J-1 non-immigrant visas, according to the American Association of Medical College (AAMC). Whether J-1 visa holders who were out of the country when the ban went into effect will be able to start or finish school remains up in the air.

Once they complete their residency, the report explained, physicians can either return to their home country for two years before they are eligible to re-enter the U.S. through a different immigration pathway, such as an H1-B worker visa, or they can apply for a Conrad 30 J-1 visa waiver, which allows them to extend their stay in the U.S. – as long as they commit to serving in rural and underserved areas for three years.

In the last 15 years, Kavilanz wrote, the Conrad 30 J-1 waiver has funneled 15,000 foreign physicians into underserved communities.

"Even though this is a little known visa program, the J-1 visa waiver has done more to recruit physicians to underserved areas in this country than even the National Health Services Corps," Shick added.

CNN further reported that the American Medical Association, which represents medical doctors across the country, recently sent a letter to the U.S. Department of Homeland Security asking for clarity on the visa ban.

"While we understand the importance of a reliable system for vetting people from entering the United States, it is vitally important that this process not impact patient access to timely medical treatment or restrict physicians and international medical graduates (IMGs) who have been granted visas to train, practice in the United States," the letter read.

The AMA stressed that the ban would worsen access to healthcare in rural areas, noting that foreign medical graduates are "more likely to practice in underserved and poor communities, and to fill training positions in primary care and other specialties that face significant workforce shortages."

Janelle Ali-Dinar, vice president of rural health for MyGenetx and a regular contributor to RACmonitor’s Monitor Mondays, also expressed concern over the ban’s potential effects.

“As more rural communities become more diverse in population, often long-term policy can impact, shift, and shape social detriments (in healthcare),” Ali-Dinar said. “I think if there had been a long-term ruling (on the ban), the issue of J-1 Visa physicians providing a significant amount of primary and specialty care, especially in HPSA areas, would have severely impacted access and delivery of care for patients – and that would have caused significant barriers to care and the bottom line of clinics and systems.”

Read the CNN Money article online in its entirety at: http://money.cnn.com/2017/02/02/news/economy/trump-visa-ban-doctor-shortage/index.html

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Mark Spivey is a national correspondent for ICDmonitor and RACmonitor who has been writing on numerous topics facing the nation’s healthcare system (and federal oversight of it) for five years.

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News Alert: Price Confirmed as HHS Secretary

Despite vigorous protests by Senate Democrats, the U.S. Senate today confirmed President Trump’s nomination of Rep. Tom Price (R-Ga.) to helm the U.S. Department of Health and Human Services (HHS). 
 
Reaction was swift and candid.
 
“Tom Price’s confirmation suggests a radical departure in federal health policy,” Emily Evans said in an email to RACmonitor. “For the last 30 years, federal health policy has focused on a centrally planned system of prescriptive policies.” 
 
Evans, the managing director for Hedgeye Risk Management who regularly reports on healthcare regulatory matters, went on to say that “Price and the CMS (Centers for Medicare & Medicaid Services) nominee, Seema Verma, hope to implement more consumer-oriented policies that use a system of tax credits and HSAs (health savings accounts) to shift healthcare decision-making to the patient and/or their family.”
 
Healthcare attorney David Glaser also weighed in on  the expected changes the new secretary is likely bring to HHS.
 
“Change is coming,” Glaser said. “We don’t know exactly how much, and in what areas, but it is clear that Rep. Price has some fundamental disagreements with current HHS policy.”
 
Glaser also said that major programs like the new cardiac bundling program could be be delayed or cancelled. He further noted that existing CMS programs, such as Comprehensive Care for Joint Replacement (CJR) may be modified or repealed.  
 
“However, any astute observer of health policy knows it is impossible to predict the future with much confidence,” Glaser added. “As always, we will have to watch for new and repealed regulations, and adapt as quickly as possible once the new policy is clear.”  
 
Glaser also believes that the current state of the Patient Protection and Affordable Care Act (PPACA) should, in his words, “serve as a good reminder as to what to expect or not expect.”
 
“Even when nearly everyone is certain that some policy is forthcoming, unforeseen developments can result in the status quo being maintained,” Glaser said.
 

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Chuck Buck is the publisher of RACmonitor and the executive producer and program host of Monitor Mondays.

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Healthcare Uncertainty Continues in Washington

Senate Democrats pulled off a surprise boycott of Tuesday’s meeting of the Senate Finance Committee, which was originally scheduled to finalize the nomination of Rep. Tom Price (R-Ga.), President Trump’s pick to helm the U.S. Department of Health and Human Services (HHS).

Senate Finance Committee Ranking Member Ron Wyden (D-Ore.), who led the boycott, said in a statement that unanswered questions and misleading statements by Price led to the delay in what was to have been the scheduled confirmation of the nominee. Wyden said that the issue hinged on the fact that Price had earlier testified that he did not receive an exclusive discount on purchases of stock for an Australian biomedical company. 

Today’s Committee meeting was expected to result in Price’s confirmation prior to it going to a full Senate vote. With the Democrats having boycotted the session, the meeting will be rescheduled. Ironically, the boycott came on the last day of 2017 open enrollment under Patient Protection and Affordable Care Act (PPACA).

“Rep. Price has been critical of (the) Centers for Medicare & Medicaid Innovation (CMMI),” Rhonda Taller said in an email to RACmonitor. “(Price) doesn’t like (the) mandatory bundles they (CMS) did for joint replacement and cardiac care.”  

Taller also said that the Advancing Care Coordination (ACC) program, managed through episode payment models (EPMs) and the Cardiac Incentive Payment Model Rehab Incentive Payment Program, are among regulations that fall under regulatory freeze announced by President Trump on Monday. This pilot is due to start July 1.

“Most people think CMMI will survive, but may look different (and) have (a) different name and more Congressional oversight,” Taller said. “All the Advanced Alternative Payment Models (A-APM) under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 come today from CMMI, so to get rid of CMMI equates to cutting off the A-APM track under MACRA’s Quality Payment Program (QPP) – or the other track, which is the Merit-based Incentive Program (MIPS).”

Taller says that there is consensus for keeping MACRA, noting that it did eliminate the flawed sustainable growth rate (SGR) formula for reimbursing physicians under Medicare. 

“MACRA passed in 2015 with (a) great deal of bipartisan, bicameral support, with Rep. Price voting for the program,” Taller said.

On the other hand, she noted, there is no consensus among Republicans for repealing and replacing the PPACA. 

Taller said that different pieces of legislation can be expected to be introduced, noting that already there is a discussion draft authored by Rep. Greg Walden (R-Ore.), who chairs the House Energy and Commerce Committee. The Walden draft would maintain coverage for preexisting conditions. 

“It’s unclear what the final Republican solution will look like,” Taller said. 

And so far, there has been no rescheduling of the Senate Finance Committee on the confirmation vote for Price. 

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Chuck Buck is the publisher of RACmonitor and the executive producer and program host of Monitor Mondays.

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News Alert: Rural Health Advocates Head to Capitol Hill

With millions of rural Americans at risk of losing health insurance and direct access to care, an unprecedented number of National Rural Health Association (NRHA) members will descend upon Washington, D.C. Tuesday to advocate for preserving healthcare access and delivery of services.   

Among those attending the NRHA Policy Institute and Capitol Hill meetings will be rural healthcare leaders from across the nation advocating for the provision of regulatory relief for 62+ million rural residents. Other agenda items will include the impact of future changes to the Patient Protection and Affordable Care Act (PPACA), the need for the 340B Drug Program, the opioid and substance abuse public health epidemic, and the need for expanded telehealth reimbursements.

To drive home what’s at risk, attendees will thread impact stories with the following simple facts: 80 critical access hospitals have closed since 2010, with 673 more currently being at risk of closure; there will be a primary care shortage of 30,000 by 2025; and approximately one million nurses are expected to retire in the next 10 years.

Advocates are also expected to tell their respective congressional delegations that rural health is seeking regulatory relief, recognizing several key areas that have gone unaddressed, including the following:

  • Critical Access Hospitals (CAHs) and several Sole Community Hospitals (SCHs) should have “eligibility” for Indirect GME (IME).
  • Hospital Star Ratings treat rural hospitals unfairly, and rural relevant measurements are needed.
    • More equitable Merit-Based Incentive Payment System (MIPS) performance comparisons should be made to those of equivalent cohorts in the program, creating more of an apple-to-apple framework and offering a more level playing field for incentives.
    • The “Section 603 Site-Neutral” payment for new off-campus provider-based departments (PBD) harms rural providers.
    • A common-sense approach is needed for the “exclusive use” standard.
    • The elimination of the longstanding troublesome issue of the “96-hour condition of payment” requirement would reduce all of the unnecessary red tape, aligning with the congressional intent of designating CAHs.
    • The improper Medicare Administrative Contractor (MAC) denial of the low-volume hospital adjustment must be addressed.
    • Changing the supervision requirements for outpatient therapy services to general supervision from direct supervision would protect patient safety and access.

All of these aforementioned issues are widening the disparities in service between rural and non-rural providers.

One factor that would help enormously and would in essence act as a tourniquet limiting the bleeding of rural healthcare is “Save Rural Hospitals,” a piece of legislation known as HR3225 that was introduced by Rep. Sam Graves from the 6th Congressional District in Missouri. First introduced on July 27, 2015 and with support of 34 other members, it was enacted during the 114th Congress when its session ended on Jan. 3, 2017. Known as a “rural provider payment stabilization” effort, the bill included several high-impact provisions, including but not limited to the following. It will:

  • Provide extension of Medicaid primary care payments
  • Eliminate Medicare and Medicaid DSH payment reductions
  • Eliminate Medicare sequestration for rural hospitals
  • Provide reversal of all “bad debt” reimbursement cuts
  • Provide permanent extension of the rural ambulance and super-rural ambulance payment
  • Provide permanent extension of current low-volume and Medicare-dependent hospital payment levels
  • Provide establishment of Meaningful Use support payments for rural facilities struggling (recognizing value-based focus)
  • Reinstate sole community hospital “hold harmless” payments
    • Provide rural Medicare beneficiary equity by eliminating higher out-of-pocket charges for rural patients.

This also includes an innovative model of care for the future called the Community Outpatient Model. This new Medicare payment designation ensures emergency access for rural patients. This model also allows flexibility through outpatient care established by a Community Needs Assessment (ironically embedded within the PPACA). Additionally, primary care would be provided through a Federally Qualified Health Center (FQHC) lookalike model or a Rural Health Clinic (RHC). There would be no preclusion to swing beds, observation beds, population health models of care, telehealth services, home health services, or infusion services. The Medicare reimbursement ratio for the model is 105 percent of reasonable cost. To help implement it, there would be $50 million in wraparound population health grants.

Rural healthcare needs congressional (and CMS) support in stabilization and reconfiguration. They are vital and deserve vitality. 

About the Author

Janelle Ali-Dinar, PhD is a rural healthcare expert and advocate with more than 15 years of healthcare executive experience in many key areas, addressing critical access hospitals (CAHs), rural health clinics (RHCs), physicians, and patients. Dr. Ali-Dinar is also a sought-after speaker on Capitol Hill. A former hospital CEO and regional rural strategy executive, Janelle is also a past National Rural Health Association rural fellow, Rural Congress member, and Nebraska Rural Health Association president. She is currently the Nebraska DHHS chair of The Office of Minority Health Statewide Council. Janelle is currently the vice president of rural health for MyGenetx.  

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News Alert: During News Blackout it’s Business as Usual at CMS

It’s business as usual at the Centers for Medicare & Medicaid Services (CMS) this week in the wake of a White House order issued Wednesday creating a temporary ban on some federal agencies communicating directly with the public through news releases and social media.

On Wednesday morning, it was revealed that the Trump administration told the Environmental Protection Agency (EPA), the U.S. Department of Health and Human Services (HHS), U.S. Department of Transportation (DOT), and the National Park Service to cease and desist any form of communication with the public and the media as it pertained to their research.

On the same day, however, Politico quoted an HHS official who said "contrary to erroneous media reports, HHS and its agencies continue to communicate fully about its work through all of its regular communication channels with the public, the media, and other relevant audiences."

Indeed, Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, told RACmonitor that he had not experienced any evidence of the blackout, nor was he aware of any cancellations of CMS outreach activities, such as the agency’s open door telephone forums. Hirsch went on to report that he even received a response from a CMS official within 10 minutes of sending a query.

“It’s business as usual at CMS,” former CMS official Stanley Sokolove told RACmonitor. “There is the usual hold on regulatory implementation until the new CMS administrator gets her feet wet, as is the case with any new president taking office and setting a global agenda.” 

Sokolove said that in talking with his former colleagues, he saw no sign of a morale issue at the department, adding that “morale was as usual during a changeover, similar to the change of administrations of former presidents Bush and Obama.”

Moreover, Sokolove does not see any major changes to the provider-based clinic program.

“CMS policy people are handling provider inquiries, but any major regulatory implementations are on hold for now,” he added.

Would President Trump’s blackout be considered unprecedented? No, according to former CMS official Stanley Nachimson, who was a federal employee at CMS during the during the presidential administrations of Carter, Reagan, Bush, and Clinton.

“It’s not abnormal for a new administration to exert some control over the staff responses and websites at federal government departments,” Nachimson said. “It is reasonable to have the new (agency) websites reflect the policies of the new administration (and) to have consistency of the message coming out of the federal government.”

“While I was at CMS, we were required to get clearance to speak to the press, and were provided with guidance as to what we could and could not discuss by the CMS press office,” Nachimson added. “The concern is mostly around high-level policy statements rather than day-to-day operations. Staff is able to answer factual questions about operations and status.” 

Nonetheless, in response to the silencing of an official National Park Service Twitter account in the Badlands of South Dakota that was tweeting out neutral scientific facts about climate change, a group of “alternative” unofficial Twitter accounts sprang up with the intention of continuing to inform the public without fear of censorship or repercussion from the government.

“Although by definition unverifiable, these accounts claim to be run by scientists and employees of these government departments, members of a resistance tweeting in secret,” said Stephanie Thompson, an independent social media communication specialist. “One of the first ‘alt’ Twitter accounts to be created was @AltHHS, defining itself as ‘unofficial and unaffiliated resistance account by concerned scientists for humanity.’”

Thompson said its first tweet, posted at about 10:50 a.m. EST on Wednesday, said, “Don’t let the gov’t tell you what you can and can’t say, or who you can or can’t say it to. Solidarity in science, not oppressive regimes.” 

“Right now the new administration is getting control because they don’t federal officials speaking on issues that are contrary to the administration,” Nachimson said. “They are hoping to get consistency and have the government agencies speak with one voice.”

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Chuck Buck is the publisher of RACmonitor and the executive producer and program host of Monitor Mondays.

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