Rural Health Information Hub Latest News

CMS Takes Decisive Steps to Reduce Health Care Disparities Among Patients with Chronic Kidney Disease and End-Stage Renal Disease

CMS is taking action to close health equity gaps by providing Medicare patients living with End-Stage Renal Disease (ESRD) with greater access to care. Through the ESRD Prospective Payment System (PPS) annual rulemaking, CMS is making changes to the ESRD Quality Incentive Program (QIP) and the ESRD Treatment Choices (ETC) Model, and updating ESRD PPS payment rates. The changes to the ETC Model policies aim to encourage dialysis facilities and health care providers to decrease disparities in rates of home dialysis and kidney transplants among ESRD patients with lower socioeconomic status, making the model one of the agency’s first CMS Innovation Center models to directly address health equity.

“Today’s final rule is a decisive step to ensure people with Medicare with chronic kidney disease have easy access to quality care and convenient treatment options,” said CMS Administrator Chiquita Brooks-LaSure. “Enabling dialysis providers to offer more dialysis treatment options for Medicare patients will catalyze better health outcomes, greater autonomy and better quality of life for all patients with kidney disease.”

According to CMS Office of Minority Health’s studies on racial, ethnic and socioeconomic factors, disadvantaged people with Medicare have higher rates of ESRD. They are also more likely to experience higher hospital readmissions and costs, as well as more likely to receive in-center hemodialysis (vs. home dialysis). Studies also indicate non-white ESRD patients are less likely to receive pre-ESRD kidney care, become waitlisted for a transplant, or receive a kidney transplant.

CMS is improving access to home dialysis for patients of all socioeconomic backgrounds. For example, CMS is finalizing changes to the ETC Model to test a new payment incentive that rewards ESRD facilities and clinicians who manage dialysis patients for achieving significant improvement in the home dialysis rate and kidney transplant rate for lower-income beneficiaries. In addition, CMS is approving the first ever technology under a recently established policy that allows for enhanced payments for innovative technologies that represent a substantial clinical improvement relative to existing options. This approval will help ESRD facilities offer an additional option to beneficiaries for home dialysis at this critical time in the pandemic.

Consistent with President Biden’s Executive Order 13985 on “Advancing Racial Equity and Support for Underserved Communities through the Federal Government,” CMS is addressing health inequities and improving patient outcomes in the U.S. through improved data collection for better measurement and analysis of disparities across programs and policies. In response to the proposed rule, CMS received valuable feedback on potential opportunities to collect and leverage diverse sets of data such as race, ethnicity, Medicare/Medicaid dual eligible status, disability status, LGBTQ+ and socioeconomic status, to better measure disparities. CMS also received feedback on various methodical approaches to advance equity through the ESRD Quality Incentive Program (ESRD QIP). This valuable stakeholder feedback will help guide future rulemaking to improve health equity.

The rule finalizes policies for the ESRD QIP that address the circumstances of the COVID-19 public health emergency and functionality challenges relating to the implementation of a new data collection system. These challenges include a special scoring and payment policy under which no facility will receive a payment reduction under the ESRD QIP for the upcoming year, especially since such payment reductions would have been based on performance during the height of the pandemic in 2020.

CMS’ proposed rule included several requests for information (RFIs) for the agency to consider as part of its goal to increase access to dialysis treatments at home. Commenters’ responses to the RFIs included specific suggestions for improving Acute Kidney Injury (AKI) payment and the ESRD PPS.

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Pennsylvania to End Health Benefits for Certain Immigrants

Beginning October 2021, the Pennsylvania Department of Human Services (DHS) will begin terminating state-funded Medicaid coverage for individuals who are found ineligible for the program. There are roughly 2,400 state-funded Medicaid recipients at risk of termination; all will receive renewal packets giving them a chance to demonstrate eligibility before DHS takes action to terminate. It is vital that recipients complete their renewals on time and in full. State-funded Medical Assistance recipients are immigrants, and many have limited English proficiency. Many are also seniors and/or disabled. As a reminder, DHS now has many forms (PA60, application for benefits; PA600HC, application for healthcare only; and the PA 1663, Employability Assessment Form) translated into six languages—Spanish, Chinese, Russian, Vietnamese, Cambodian, and Arabic—and they can be found in the DHS Medical Assistance Eligibility Handbook.

The state’s decision to terminate state-funded coverage does not affect the majority of Medicaid enrollees, since most people are getting federally-funded Medicaid, which is still protected under the Federal Public Health Emergency (PHE) and its continuous coverage protections.

Individuals who believe their Medicaid coverage has been improperly stopped can call the Pennsylvania Health law Project Helpline at 1-800-274-3258 or email them at

Pennsylvania Office of Medical Assistance Programs Releases Telehealth Bulletin

The Pennsylvania Department of Human Services (DHS), Office of Medical Assistance Programs (OMAP) released MA Bulletin 99-21-06, “Guidelines for the Delivery of Physical Health Services via Telemedicine.” The purpose of this bulletin is to notify providers that, effective Sept. 30, 2021, the DHS is expanding the scope of services for which telemedicine may be used, expanding the scope of providers who may render MA covered services to beneficiaries using interactive telecommunication technology to include all enrolled providers, if permitted according to their scope of practice, licensure, or certification and establishing ongoing guidelines for services rendered via telemedicine. Key points from the Bulletin:

  • The MA Program will pay for MA covered services rendered to beneficiaries via telemedicine when clinically appropriate and allowable according to the provider’s scope of practice. Services rendered via telemedicine must be provided according to the same standard of care as if delivered in-person. Providers are encouraged to establish protocols for the use of telemedicine. MA MCOs may, but are not required to, allow for the use of telemedicine.
  • Providers are to obtain consent prior to rendering a service via telemedicine from the beneficiary receiving services or their legal guardian. Providers must also allow beneficiaries to elect to return to in-person services at any time.
  • Providers should fully document the services rendered and the telecommunication technology used to render the service in the MA beneficiary’s medical record. If the service was rendered using audio-only technology, providers are to document that the services were rendered using audio-only technology and the reason audio/video technology could not be used. Providers should obtain the location of the beneficiary at the time each service is rendered via telemedicine should there be a need for emergency medical services.
  • DHS added Place of Service (POS) 02 (telemedicine) for providers to identify services that are rendered via telemedicine. Providers are no longer required to utilize the GT modifier to indicate the use of telemedicine and are instead to use POS 02. Providers are to indicate in the beneficiary’s medical record when telemedicine services are rendered via audio-only.

This bulletin obsoletes MA bulletin 09-12-31 et al., Consultations Performed Using Telemedicine, issued May 23, 2012 and, Provider Quick Tips #229 and #242, Telemedicine Guidelines Related to COVID-19.

Pennsylvania Governor, Legislature Work Together to Extend Waivers

Pennsylvania Governor Tom Wolf signed HB 1861 to “allow temporary regulatory flexibilities to continue the emergency response to the COVID-19 pandemic by requiring the state agencies to issue a final report of the regulatory suspensions and terminations.” The bill allows for additional temporary extensions for regulatory statues, rules and regulations which are in effect on Sept. 30, 2021, to be extended until March 31, 2022, unless they were already terminated by the authority which initially authorized the suspension. The extension includes the following regulatory statutes:

  • Regulatory statutes, rules or regulations enforced by the Department of Health.
  • Regulatory statutes, rules or regulations enforced by the Department of Human Services.
  • Regulatory statutes, rules or regulations enforced by the Bureau of Professional and Occupational Affairs.

How Do Patients Feel about a Dental Benefit in Medicare?

According to CareQuest Institute research, more than 90% of survey respondents agreed that dental should be covered in Medicare. Survey respondents who had at least one unmet oral health need, such as a cracked tooth or swollen/bleeding gums, were 2.5% more likely to agree that Medicare should cover dental services. And those who rated their oral health as poor were 4.5% more likely to agree than those who rated their oral health as excellent.

Read the research brief.

Traffic and Mobile Phone Data Predict COVID Case Counts in Rural Pennsylvania

How much people moved around town predicted COVID-19 cases in a rural Pennsylvania county in 2020, according to a new study by researchers at Penn State. The researchers approximated movement during the initial stay-at-home orders and subsequent restricted phases by using data from traffic cameras and mobile devices. They confirmed that increases in movement preceded increases in COVID-19 cases in Centre County, Pennsylvania. The results also revealed general compliance with local regulations and suggest that these types of passive surveillance data could be used to monitor and improve behavioral intervention guidelines for outbreak management.

“With the emergence of the COVID-19 outbreak in 2019, local governments initially relied heavily on behavioral interventions like stay-at-home orders in order to limit transmission,” said Christina Faust, postdoctoral researcher at Penn State and first author of the study. “Knowing if people are willing to follow these kinds of interventions, and if these interventions do what they are intended to do, is important to future outbreak planning.”

The researchers approximated movement from March to August 2020 in Centre County, Pa, which is home to Penn State’s University Park campus, during a period when university students were primarily not residing in the area. This period encompassed the strictest restrictions in the county, including a 40-day red phase that involved a stay-at-home order except for life-sustaining businesses and activities; a 20-day yellow phase that stressed remote work and teaching and a preference for curbside retail; and the initial 78 days of a green phase that mandated reduced capacity at local businesses, mask wearing in public, and guidelines for additional businesses to reopen.

“Assessing the impact of intervention strategies is especially important in rural areas, where access to healthcare is often limited and under-resourced,” said Nita Bharti, Lloyd Huck Early Career Professor in Biology at Penn State and senior author of the paper. “Rural areas have limited health care capacity and struggle to manage the large numbers of patients we expect to see during outbreaks like this. Preventive strategies to limit transmission are critical.”

The research team used two data sources as proxies for movement. They collected real time images from 19 traffic cameras from across the county, including “connector” roads that provide links between towns and “internal” roads that measure movement within towns. They also studied anonymized location data from mobile devices from the company SafeGraph, which captured visits to over two thousand points of interest around the county, including grocery stores, coffee shops, gas stations, and locations on the Penn State campus. The team compared numbers of mobile visits recorded in the summer of 2020 to the pre-pandemic summer of 2019 to identify differences due to behavioral interventions. Their results appear in a paper published in the journal Epidemiology & Infection.

The research team found that, when moving from red phase to yellow and especially from yellow phase to green, traffic volume increased on both internal and connector roads. Although the numbers of visits to local points of interest were significantly lower than visit numbers from 2019, they increased as restrictions were lifted.

“During the strictest phases, movement was mostly internal, which is what we would hope to see in order to reduce opportunities for transmission between towns,” said Faust. “As restrictions eased, we saw a lot more traffic, particularly on connector roads, and more mobile visits to points of interest, which collectively suggests overall compliance with these intervention strategies. What is particularly reassuring is that, even though changes in phase regulations were announced 10 days before they were implemented, we did not see a change in movement until the new phase came into effect.”

Reported cases of COVID-19 in the county were related to movement collected from both data sources, with a 9 to 18-day lag depending on data type. The researchers believe this lag includes the incubation time of the virus — when an individual is infected but may not yet show symptoms — as well as in some cases considerable delays in accessing a test and receiving test results.

“Increases in movement reliably preceded increases in COVID-19 cases during the study period,” said Faust. “These results suggest that vehicle traffic and mobile visit data could be used in real time to monitor the outbreak. For example, if there is an uptick in movement, local governments could reinforce messaging and prepare to allocate resources for health care to high-movement areas.”

The researchers note the importance of using multiple types of data; individual data sources may measure different types of behaviors and reflect certain subsets of a population. For example, they believe the vehicle data may represent permanent residents while mobile visits may better reflect students. While urban areas may have more data sources available, this study demonstrates that the combination of existing data sources in rural areas — vehicle traffic and mobile data — provide important information.

“Rural areas typically experienced delayed introductions to the virus and delayed outbreaks, but statewide regulations were largely based on outbreaks in urban areas, where the bulk of cases occurred,” said Bharti. “Local oversight, when paired with federal and statewide response and relief, can more effectively serve outbreak response, management, and planning efforts. Here we show that measuring local population movements through passive approaches can help assess the effectiveness of intervention strategies and inform policies that target transmission prevention.”

In addition to Faust and Bharti, the research team at Penn State includes Brian Lambert, computational scientist; Cale Kochenour, spatial analyst; and Anthony Robinson, associate professor of geography.

Rural Doulas Support Maternal and Infant Health

The latest feature article in The Rural Monitor spotlights a New Mexico doula program that reaches American Indian, Hispanic, and other populations who lack nearby labor/delivery units, a Minnesota program helping moms experiencing incarceration, and a North Dakota program training postpartum doulas to care for families impacted by opioid use disorder and other substance use.

Read the article here:  Rural Doulas Supporting Maternal and Infant Health.

New Spanish Language App Helps Latinos With Health Care

A report from HHS shows that insurance coverage and access to care improved significantly for Latinos between 2013 and 2016, but they still have among the highest uninsured rate of any racial or ethnic group within the U.S.  To build on progress, HHS launched a Spanish version of its QuestionBuilder app, which can help Latino patients prepare for their in-person or telehealth appointments.  The Agency for Healthcare Research and Quality built the app to help users improve their interaction with clinicians, providing questions they might want to ask with links to helpful resources.  The 2020 Census reports that Hispanics are the second most prevalent racial or ethnic group in rural America, comprising 10.4 percent of the rural population.

See more at New Spanish Language App Helps Latinos With Health Care.