From Axios

After weathering the pandemic with federal COVID aid, rural hospitals are facing a convergence of challenges that could leave many facilities deep in the red and at risk of closing as soon as the end of this year.

Why it matters: Hospitals are among the biggest employers in rural communities and the only health providers in large swaths of the country. But they’ve been operating on the edge for years, tending to older, sicker patients who often can’t afford care.

Driving the news: Hospitals couldn’t persuade Congress to delay a scheduled 2% cut in Medicare payments, then were frustrated by a Medicare payment proposal for 2023 they say ignores the effects of inflation, labor and supply cost pressures.

• Many facilities have burned through federal COVID provider relief funds and Paycheck Protection Program loans that helped them cope with staffing and supply shortages and lower demand as patients deferred care.
• “The data would suggest we will see a lot more rural hospital closures at the end of this year and into 2023,” Alan Morgan, chief executive of the National Rural Health Association, told Axios.
• Closures could dramatically reduce access to care, forcing patients to travel longer distances for inpatient services, substance use treatment and other needs, per the Bipartisan Policy Center, which recommends new payment models and incentives to retain health workers to ease the crunch.
• But sympathy may be limited for an industry that recently received large sums of federal dollars to get through the pandemic.

Flashback: Rural hospital closures are not a new story — since 2010, 140 rural hospitals have closed, according to the University of North Carolina’s Rural Health Research Program’s tracker.

• The majority of closures were in the Southeast, where “you’ve got a lower-income, sicker population that is underinsured or uninsured,” Morgan said.
• The pandemic forced facilities to lay off staff and, in some cases, restrict services just to COVID patients. But Congress responded with a bailout, including $175 billion to hospitals and clinicians around the country that was particularly advantageous to rural facilities.
• While revenues might have dropped, margins at most facilities held firm, a May study in JAMA found.
• Since the beginning of 2021, just five rural hospitals have closed, compared to 19 that closed in 2020 and 18 in 2019.

Go deeper: Experts say many of the rural facilities are running on unsustainable business models.

• Some “only had one-third of their beds filled, with a low occupancy rate, and then you have to run a hospital with a lot of fixed costs and that’s a fundamental reason that hospitals are facing financial challenges,” Ge Bai, a Johns Hopkins University professor who studies rural hospital finance, said.
• The situation leaves facilities in peril without federal aid, especially since many rural residents bypass their local facilities for elective surgeries, Bai said.

Pennsylvania Governor Wolf and the Budget Secretary recently announced a new round for the Redevelopment Assistance Capital Program (RACP). The new RACP Round for 2022 opens July 25, 2022, and will remain open until August 19, 2022, at 11:59 pm. The Redevelopment Assistance Capital Program (RACP) is a Commonwealth grant program administered by the Office of the Budget for the acquisition and construction of regional economic, cultural, civic, recreational, and historical improvement projects. RACP projects are authorized in the Redevelopment Assistance section of a Capital Budget Itemization Act, have a regional or multi-jurisdictional impact, and generate substantial increases or maintain current levels of employment, tax revenues, or other measures of economic activity. RACP projects are state-funded projects that cannot obtain primary funding under other state programs. Please visit the RACP website for the link to apply and view the itemization listing, which will soon be updated with Act 27-2022, e-Application instructions, and the funding schedule. The Pennsylvania Department of Community and Economic Development’s website will start accepting e-RACP Applications for the program on July 25, 2022. All e-Applications require a $500 fee paid via credit card at the time of submission. Questions may be directed to Holli Reidlinger at hreidlinge@pa.gov, George Leach at geleach@pa.gov, and/or Ryan Nornhold at rnornhold@pa.gov.

“[I]f a physician believes that a pregnant patient at an emergency department, including certain labor and delivery departments, is experiencing an emergency medical condition as defined by EMTALA, and that abortion is the stabilizing treatment necessary to resolve that condition, the physician must provide that treatment.” The Biden administration on Monday said doctors and hospitals need to follow the federal Emergency Medical Treatment & Active Labor Act (EMTALA) law and provide abortions if there is a medical emergency and the health or life of the patient is at risk, regardless of state law. The Department of Health and Human Services (HHS) reaffirmed that EMTALA protects providers when offering legally mandated, life- or health-saving abortion services in emergency situations and that the federal government can penalize doctors or hospitals that fail to provide care in those circumstances. The law leaves it up to a physician to determine what qualifies as an emergency medical condition for a pregnant patient, but the administration listed examples such as ectopic pregnancy, complications of miscarriage or severe preeclampsia. EMTALA is a complaint-driven process and an investigation can’t occur without a complaint to the federal government. Each violation will cost a hospital $119,942 if it has over 100 beds and $59,973 for hospitals under 100 beds. Hospitals could also lose their Medicare and Medicaid provider agreements, and private citizens who are harmed by a physician’s or hospital’s failure to provide stabilizing treatment may file a civil suit against the hospital to obtain damages. Individual physicians could also face civil penalties of $119,942 per violation. Click here to access the CMS Memo.

Kaiser Family Foundation (KFF) reported on July 11, 2022, that 10% of Medicaid beneficiaries who are seniors or disabled are expected to lose coverage after the public health emergency (PHE) ends, based on responses from 14 states in a KFF survey of 50 states and the District of Columbia. States said that staffing shortages and enrollee confusion are the issues most likely to impact enrollment. Read More.

The Pennsylvania Department of Human Services Refugee Health Program (RHP) webpage provides a program overview and important resources. The RHP works with commonwealth-selected Community Health Centers and other providers to ensure that all refugees receive an initial health assessment to identify and treat health conditions or health-related issues that could get in the way of successful resettlement. The RHP also works with statewide partners to develop and implement health promotion programs that educate and empower refugees in taking charge of their own health. Connecting refugees to care and coverage is important. If a refugee is not eligible for Medical Assistance, the County Assistance Offices will determine eligibility for Refugee Medical Assistance for up to 12 months after their date of entry. RMA provides short-term medical coverage with benefits similar to Medicaid to refugees ineligible for Medicaid. For additional resources visit the PA Refugee Resettlement Program Webpage or email RA-PWREFUGEEPROGRAM@pa.gov.

The Center for Medicaid and Medicare Services Innovation Center (CMMI) published a blog entitled CMS Innovation Center Tackles Implicit Bias. The blog details the findings from an assessment of potential implicit bias in three experimental models to determine whether implicit bias may be present in the existing models’ designs, and, if so, has led to the unintentional exclusion of certain beneficiary groups. The assessment focused on three established payment and service delivery models: Kidney Care Choices Model, Comprehensive Care for Joint Replacement Model, and Million Hearts® Cardiovascular Risk Reduction Model. The results of this analysis are informing broader efforts to address bias across CMMI’s models and align with CMMI’s goals of advancing health equity and increasing focus on underserved populations. Visit the CMS Innovation Center Strategy webpage for additional information.

A bipartisan legislative package to modernize Pennsylvania’s mental health and substance use disorder laws was recently signed into law. HB 1561 amends the state Mental Health Procedures Act and HB 1563 amends the Pennsylvania Drug and Alcohol Abuse Control Act to align with federal health privacy standards to permit providers, facilities, and health plans to share patient mental health and substance use disorder-related information more easily. Under previous Pennsylvania law, mental health and physical health information could not be fully shared among providers. The new laws bring Pennsylvania in line with most states that already allow providers to share this information and are seeing improved patient outcomes. The laws leave all HIPAA protections in place, and information cannot be shared outside of a medical context.8i

On July 11, Pennsylvania Governor Wolf signed HB 2419 into law as Act 76 of 2022. The new law amends the Outpatient Psychiatric Oversight Act by removing the statutory requirement of 50% onsite psychiatric time and allows for services to be provided using telehealth technology. Psychiatrists and advanced practice professionals would use in-person or telehealth sessions with patients as specified in department regulations or waivers.

Voters in Pennsylvania could be asked as early as the spring to weigh in on five significant amendments to the Pennsylvania Constitution, including one that would require voters to show ID every time they vote and another that asserts the state’s charter does not protect abortion access. The state Senate and House, largely along party lines, passed an omnibus resolution with five proposed amendments to the state constitution that could be sent to Pennsylvania voters as soon as spring 2023. The amendments would:

• Declare the state constitution does not grant any right relating to abortion, including no right to public funding for the procedure
• Require government-issued ID to vote
• Require the auditor general to audit elections
• Allow each major party’s gubernatorial nominee to choose their own running mate, rather than holding a separate primary for lieutenant governor
• Expand the General Assembly’s power to reject regulations

The proposed amendments to the constitution must pass the state House and Senate twice, in two consecutive sessions. Both chambers need to pass the measure again during the 2023-24 session to send the proposed amendments to the voters. Each proposed amendment would appear on the ballot individually. Republican lawmakers insisted that the proposed abortion amendment would not ban abortion or change current state law, but legal experts believe it would lay the groundwork for additional restrictions or an outright ban by removing a legal foundation to challenge such laws in state courts. Proposed constitutional amendments can be sent to the voters during an election, even low turnout primaries. Since 1968, the year Pennsylvania’s current constitution went into effect, voters have rejected only six of 49 proposed amendments that reached them.

With the signing of Executive Order 2022-01 by Pennsylvania Governor Wolf, Pennsylvania joined New York, New Jersey, and Connecticut in action to protect abortion seekers traveling from other states. The states anticipate more out-of-state people seeking an abortion, as roughly half of U.S. states ban or impose restrictions on the services. The EO and its protections are set to take immediate effect. The order bars any agency, board, or commission that answers to the governor’s office from using Pennsylvania resources to help another state’s investigation into a patient seeking reproductive health services, or the providers helping them. This protection does not apply if cooperation is required by court order or if the actions being investigated broke laws in the commonwealth. The governor will also deny any request to arrest or extradite someone who received reproductive health services in Pennsylvania or assisted in these services. Unlike some states that have passed laws to protect abortion access, Pennsylvania only has the EO, which means the gubernatorial election in November will determine whether it remains in place.