Policy and Regulatory Updates from Inside the Beltway - PowerPoint Presentation

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Policy and Regulatory Updates from Inside the Beltway

Diane Calmus, JDGovernment Affairs and Policy ManagerSlide2

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306Slide3

Historically significant election

Never has there been a President with no political or military experience.Conventional wisdom out the window. Polls, pundits, media - - all wrong.Despite President Obama’s high favorability, he lost more Democratic congressional seats than any other Democratic President.Rural vote had a significant impact.Slide4

Rural America Speaks Loudly…

“Hillary lost rural America 3 to 1. If she lost rural America 2 to 1, it would have broken differently.” Democrat inside the Clinton campaign. Politico, 11-16-16President-Elect Donald Trump never issued any specific rural policy agenda, yet captured high rural voter turnout:20% of the nation lives in rural America - - according to exit polls, rural voters made up 17 percent of the electorate. Slide5

Now is the time to make sure Washington gets the message…

The Power of RuralSignificant opportunity on Capitol Hill and with the new AdministrationOur Message: Debate will begin on how to reinvigorate economic development and infrastructure across the nation, it’s imperative that we remind our leaders that rural healthcare is the critical component to a vibrant rural economy: You can’t have a healthy rural economy without a healthy rural community. Quality rural healthcare saves lives, provides skilled jobs, attracts businesses, and reinvests millions back into rural communities.Slide6

The Trump AdministrationLots of unknownsFocus on personnel/personalities vs. policy

Use of Administrative AgenciesTransition – strong think tank influenceThe Heritage FoundationAmerican Enterprise InstituteSlide7

What will happen to ACA under President Trump

American Health Care ActRepublican repeal and replace bill using reconciliation (cannot fully repeal using this process)Process: “regular order” but notFailed to include many republican ideals such as Health insurance sales across state lines Pulled before vote…may be backExecutive orders and RegulationsSlide8

Repeal

3 step approach – (1) Budget Reconciliation Originally expected to be done immediatelyBlueprint from last year’s budget reconciliation billLimited to policies affecting permanent spending and revenuesNot limited to deficit reductionAmerican Health Care Act(2) Administrative Action – “Secretary” appears nearly 3,000 times in ACA

(3) Bipartisan lawmaking

Likely to be piecemeal

Unclear what will happen with items incidentally added to ACA

Payment transformation - volume to value

Role of state waivers (

ACA's 1332 waivers) – Importance of IndianaSlide9

The Affordable Care Act

The good, bad and not so pretty…Slide10

The Affordable Care Act

Access to CareExchangesPremium increaseLack of choiceHigh deductible

Medicaid - - non-expansion states

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340B Drug ProgramSlide11

EMS and the ACA/repeal

Medicaid expansion – expansion and non-expansionCoverage changesLoss of CoverageRole of WaiversSlide12

Trump and ACA - - Some things to remember

Tough to repeal a benefitExpensivePresident Trump: Replace then repealExpressed support: pre-existing condition benefit and parental coverage up to 26Slide13

Rural Mortality Rates. A Rural Divide in American Death

Center for Disease Control January, 2017 Study:“The death rate gap between urban and rural America is getting wider”Rates of the five leading causes of death — heart disease, cancer, unintentional injuries, chronic respiratory disease, and stroke — are higher among rural Americans. Mortality is tied to income and geography.Minorities, especially Native Americans die consistently prematurely nation-wide, but more pronounced in rural.Startling increase in mortality of white, rural women. Causes:

Risky lifestyle (smoking, alcohol abuse, opioid abuse, obesity)

Environmental cancer clusters

suicides

January 2017Slide14

“Deaths of Despair”

New California Study (The California Endowment)Death rates from stress-related conditions in rural areas up dramatically.Fresno County: rate of 40-64 year olds death by drug poisoning increased 212%Tulare County: death rate from viral hepatitis increase 166% and suicides increased by 121%Kern County: white women are most impacted. Accidental drug overdoses have increased over 250% “We cannot blame these deaths simply on the opioid epidemic. These are deaths of despair”Slide15

Opioid Crisis in Rural American

All states have demonstrated an increase in nonmedical prescription opioid mortality during the past decade, however, the largest areas of abuse are concentrated in states with large rural populations, such as Kentucky, West Virginia, Alaska, and Oklahoma.Slide16

Opioid Crisis in Rural AmericanAccess to care is a major issue in rural America

Access to care is particularly lacking for mental health and substance abuse. In 55% of all American counties, most of which are rural, there are no psychologists, psychiatrists or social workers. Expand access to substance abuse treatment services including medication assisted treatment and traditional psychosocial substance abuse treatment programs. Develop and Identify evidence-based prevention programs tailored to the needs of rural communities.Promote use of evidence-based prescribing guidelines. Expand use of substance abuse treatment as an alternative to incarceration for opioid users. Slide17

#3 Hospital Closure CrisisSlide18

80 Hospitals have closed since 2010.

The VULNERABILITY INDEX™ identifies 673 Rural Hospitals Now Vulnerable or At Risk of Closure210 hospitals are most vulnerable to closure, while an additional 463 are less vulnerable

A Catastrophic Crisis

673

since 2010

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Rural hospitals are closing where health disparities are the greatest.

At current trajectory, 25% of hospitals will close in less than a decade.Slide19

Rural Hospital Closures and Risk of Closures

35%Percent Vulnerable

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Hospital Closures and EMS

In the Tennessee Delta, a poor community loses its hospital — and sense of security (Washington Post, Amy Goldstein, April 11, 2017) County commissioners added seven paramedics and advanced EMTs and went from two ambulances available to threeThe typical call, 30 minutes when the hospital was open, is now 2½ hours – sometimes all ambulances are on runsUnexpected: how many people refuse transport (just accept treatment at the scene) since the ride is “a one-way ticket”Problem is without transport Medicaid and Medicare don’t payThough ambulance service won awards for excellence lack of payments mean they are back to two ambulance and had to cut staffSlide21

Rural Hospital Closures: 1983-97

If Congress does not act, history will be repeated…Slide22

The Politically Powerful are ListeningSlide23

Save

Rural Hospitals ActRural hospital stabilization (Stop the bleeding)

Elimination of Medicare Sequestration for rural hospitals;

Reversal of all “bad debt” reimbursement cuts

(

Middle Class Tax Relief and Job Creation Act of 2012

);

Permanent extension of current Low-Volume and Medicare Dependent Hospital payment levels;

Reinstatement of Sole Community Hospital “Hold Harmless” payments;

Extension of Medicaid primary care payments;

Elimination of Medicare and Medicaid DSH payment reductions; and

Establishment of Meaningful Use support payments for rural facilities struggling.

Permanent extension of the rural ambulance and super-rural ambulance payment.

Rural Medicare beneficiary equity

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Eliminate higher

out-of

pocket charges for rural patients (total charges vs. allowed Medicare charges.)

R

egulatory Relief

Elimination of the CAH 96-Hour Condition of Payment (See

Critical Access Hospital Relief Act of 2014

);

Rebase of supervision requirements for outpatient therapy services at CAHs and rural PPS See

PARTS Act

);

Modification to 2-Midnight Rule and RAC audit and appeals process.

Future of rural health care

(Bridge to the Future)

Innovation model for rural hospitals who continue to struggle. Slide24

Future Model: Community Outpatient Model

24/7 emergency ServicesFlexibility to Meet the Needs of Your Community through Outpatient Care:Meet Needs of Your Community through a Community Needs Assessment:Rural Health ClinicFFQHC look-a-likeSwing bedsNo preclusions to home health, skilled nursing, infusions services observation care.TELEHEALTH SERVICES AS REASONABLE COSTS.—For purposes of this subsection, with respect to qualified outpatient services, costs reasonably associated with having a backup physician available via a telecommunications system shall be considered reasonable costs.”.

$2 million in EMS grants.Slide25

Protecting Patient Access to Emergency Medications Act

Ensures that EMS personnel can administer emergency medications in a timely manner and provide needed care to patients.clarify that the current practice of physician Medical Directors overseeing care provided in the field by paramedics and other EMS practitioners via “standing orders” or via “online medical direction” is statutorily allowed and protected.H.R. 304 (Rep. Hudson (R-NC-8))– Passed the House January 9, 2017Senate hearing in HELP Committee – Wednesday April 26Slide26

Medicare Ambulance Access, Fraud Prevention and Reform Act

makes the temporary Medicare ambulance add-ons permanentImplements prior authorization program for dialysis transports (does not apply to hospital-based providers) Directs CMS to collect ambulance cost report dataTreating ambulance service suppliers more like providersSenators Roberts and Stabenow – was S. 377 last CongressSlide27

Is a Government Shutdown pending?

Current Funding runs out April 28 (Congress has been on recess previous 2 weeks)Democrats signaled that they will seek to secure payments owed to health insurers under the Affordable Care Act as part of pending negotiations over a government spending bill.President Trump threatened to use the payments to force Democrats to negotiate a replacement for the ACA.Appropriations Bills from last congress likely will form basis for funding bill – Omnibus funding bill anticipatedSlide28

NRHA Policy Paper

support of education for volunteer and paid EMS providers, support for paid and volunteer leadership training, support for community to achieve the type of emergency care and response to meet community needs – support “community self-determination”funding specific for EMSsupport ambulance services to be classified as a provider not a supplier by CMSclassify community paramedicine and other providers as eligible for reimbursement promote national and local research to study of regulatory barriers and opportunities, the efficacy of coverage and document evidence based practices of EMS response and capacity and role for shared saving models such as ACOsa joint national rural EMS Advisory Committee to advise the NHTSA and HRSA and USDA programs similar to collaborative efforts with EMS-Cpromote regulations that ensure the inclusion of EMS services in ACO projects in rural communities support a national rural EMS technical assistance resource center for rural community EMS providers to improve workforce, education, quality improvement and other needs of rural EMS providers. Slide29

THE IMPORTANCE OF TODAY

Washington is reaching out to Rural America.Both political partiesA rural voice to capitalize on this opportunity.Policy Institute - - Record attendance from Capitol Hill!Our Message: rural healthcare is critical for rural patients and the rural economy:You can’t have a healthy rural economy without a healthy rural community.

Quality rural healthcare saves lives, provides skilled jobs, attracts businesses, and reinvests millions back into rural communities.Slide30
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Thank you!Diane Calmus (dcalmus@nrharural.org

)(202) 639-0550