(As prepared for delivery – November 19, 2020)
Thank you. It’s a pleasure to speak to you on this tenth annual Rural Health Day. Let me start by thanking all of you on the frontlines for your hard work and dedication at this difficult time in history. It’s not lost on me how much rural providers have sacrificed. You are heroes in this war. Coronavirus has not spared any part of the world, and it has been particularly challenging for rural providers, which already faced considerable difficulties going into this pandemic.
The good news is that there is light at the end of the tunnel. Recent news about impending vaccines and new treatments is heartening. Life will eventually return to normal. As we face many difficult days ahead and all the challenges of immunizing a nation, I am also encouraged by the progress CMS has made in addressing some of the most critical rural health issues.
During my first year at CMS, I traveled to a rural health center and even visited the rural health association headquarters in Kansas. Coming from Indiana I had some familiarity with rural health care, but I am indebted to those who have continued to educate me about the issues rural communities face.
I learned about the many burdensome CMS regulations that may make sense in an urban community but don’t take into account the unique challenges in rural communities. Rural Americans might live a long distance from the closest healthcare providers. These providers in turn often have limited resources and tight profit margins due to low patient volume, making it difficult to maintain robust workforces. These problems result in a systemically fragmented rural healthcare system, limited access to important specialty services, and disproportionately poor health outcomes for 60 million of our fellow Americans.
And that’s why I made rural health one of CMS’ top strategic initiatives. Over the past 4 years, we worked across the entire agency in every department to address rural health challenges. This represented a departure from established practice, as rural America’s pressing healthcare problems have been largely ignored for too long. I am proud of what the CMS team has accomplished. Their efforts have laid the foundation for rethinking rural health across the country.
During my time in office, CMS has constantly sought to bring the principles of the free market and competition to bear on the many areas of the healthcare system we oversee. We have had many successes in that effort, including some that affect rural areas directly. For example, when we came into office, insurers were fleeing the Exchanges. By 2018, 50 percent of counties in America – the majority of which are rural – had the non-choice of just one health insurer in their exchange; today, that number has plummeted to 9 percent. And our changes to Medicare Advantage have increased plan options for our beneficiaries, many of whom who have historically enjoyed limited choice due to anemic market competition. In 2021, Medicare beneficiaries in rural areas will have more than double the plan options they had in 2017.
That’s because we have given plans in Medicare Advantage – the privately administered branch of the Medicare program – flexibility and incentives to design supplemental benefits, including transportation and meal delivery that can help keep rural patients healthy. We recently allowed Medicare Advantage plans to count telehealth providers in certain specialty areas – such as Dermatology, Psychiatry, Cardiology, and more – toward our network adequacy requirements. This increased flexibility has allowed them to assemble more robust health care provider networks in rural areas using telehealth.
But the fact remains: compared to their urban and suburban counterparts, rural areas present a special challenge for a market-based approach to healthcare policy. Infusing competitive forces is more complicated – sometimes downright impossible – given the unique obstacles rural areas face.
From the beginning, we have sought to address these problems by leveraging innovation and the transformative power of technology. Our historic work to promote the seamless and secure flow of medical records is a game changer for virtually every American, but it represents a particularly important breakthrough for rural Americans. Access to electronic medical information removes geographic barriers that prevent them from accessing the most up to date medical providers, research studies, and other services that typically cluster around dense urban areas.
We expanded telehealth because of its potential for rural areas where transportation over long distances can be difficult and providers are often in short supply. Starting in 2017, we allowed for short virtual check-ins with patients in their home and expanded the number of services that could be provided via telehealth, benefits that predate and will outlast the pandemic.
During the pandemic itself, we dramatically accelerated the telehealth expansion to help patients under stay-at-home orders receive care. At President Trump’s direction, we got rid of various restrictive regulations, including those that prevented telehealth from being furnished in people’s homes, including nursing homes.
We also expanded the types of providers that can provide telehealth and removed face-to-face requirements for certain types of care. Finally, we added over 135 telehealth services, such as emergency department visits, mental healthcare, and eye exams.
Just a few months ago, thanks to a groundbreaking Executive Order from President Trump, we proposed to make many of these flexibilities permanent, including prolonged office visits, mental health services, and more. We’ve proposed extending still others, such as lower level emergency department visits, psychological testing services, and more, beyond the end of the public health emergency. The result is a veritable revolution in healthcare delivery that will be a boon for rural patients.
Before moving on from this subject, it’s important to understand that our regulatory authority is largely limited specifically to telehealth services. We cannot make telehealth available permanently outside of rural areas, permanently expand the list of providers authorized to provide it, nor allow patients to receive telehealth services from their homes. Congress, then, has an essential role to play in following through on this historic opportunity. Without a change to the statute, telehealth will eventually revert to a more limited benefit that cannot be utilized from a patient’s home. In an earlier age, doctors commonly made house calls. Congress has the opportunity bring the reinvigoration of that tradition across the finish line.
In addition, just last year, to address disparities in Medicare payment among rural and urban hospitals, we boosted Medicare payments for many rural hospitals, to bring payments on par with those in urban areas. This is helping hospitals improve their financial sustainability and attract talent, improving access in rural America.
Reducing regulatory burden has also been a key focus. We have given hospitals greater flexibility on physician supervision requirements for certain types of hospital services and eased Medicare requirements so practitioners like physician assistants and nurse practitioners can independently provide more services so long as it’s within their scope of practice. The telehealth executive order I mentioned a moment ago also directed CMS to propose extending a pandemic flexibility that allowed physicians to virtually supervise their staff as they provide care to patients. Thanks to these reforms, rural hospitals can make the most of often limited workforces while maintaining patient safety.
To further ease the burden on physicians of all stripes, we have reformed their quality program and empowered them to pick the metrics most relevant to their specialty or the types of patients they see, rather than overloading them with largely irrelevant measures. Rural providers, often stretched thin, have benefitted tremendously from these reforms with more than 98 percent of eligible clinicians in rural practices participating as of 2018. Yet more simplifications lie in store.
These reforms are significant and tangible, but our most significant move is aimed at a more comprehensive reboot strategy for rural health. Because without it, the longstanding, fundamental issues remain.
Most recently, we announced a new avenue for local and rural communities to take an active role in the transformation of their care. Called the Community Health Access and Rural Transformation model, or CHART, it represents a more flexible, grassroots approach to rural healthcare delivery than the top-down, one-size-fits-all approach that has failed rural Americans for so long.
Specifically, CHART would provide upfront funding to up to fifteen lead organizations that would bring together local parties – state Medicaid agencies and commercial payers, local hospitals, clinics, and other providers. These organizations would be eligible to receive upfront infrastructure investments, in grants of up to $5 million each for a total rural investment of $75 million, with which to organize the healthcare delivery system that works best for them. That may include explore transitioning to a “hub and spoke” model, in which one relatively large hospital serves as a kind of command and control center for smaller, more limited provider types. It may involve reducing services for some hospitals and adding more for others, like maternity and home health. It allows communities to think about what might work best for them.
It also requires rural hospitals to move to a stable, predictable, value-based payment and away from the current erratic, volume-based system that often doesn’t work for rural providers with low patient volume. It represents the first steps in a radical rethinking of how we pay for care in rural communities. Contrary to the stale approach that has prevailed for so long, simply throwing more money at the problem is not enough. In some cases, funding increases may indeed be necessary, but how we pay is just as important as how much we pay. All reimbursement systems should be structured to create incentives to produce better outcomes for patients.
Finally, we have paired these payment reforms with unprecedented regulatory flexibilities and program waivers for which rural providers have been asking for years. Specifically, the model waives certain conditions of participation in our programs, allowing hospitals to reduce unnecessary overhead costs while maintaining their status as hospitals or critical-access hospitals. Organizations can also employ value-based incentives such as reducing or waiving Part B co-insurance amounts to promote high-value preventive care.
In sum, the model’s seed funding, combined with the regulatory flexibilities and technical support will give rural providers what they have never had enough of before: breathing room to provide high-quality care to rural patients. In the months and years to come, CHART promises finally to deliver the wholesale transformation rural healthcare has needed for so long. If these local ventures fulfill their potential, they may serve as models for rural areas throughout the country.
Too often, policymakers have placated rural Americans with token solutions that fail to advance the systemic, fundamental transformation necessary to tackle these pervasive problems. Under our watch, that wildly insufficient approach has gone by the wayside. I am incredibly grateful to and proud of the CMS team that has spearheaded these reforms.
We have gone beyond merely tinkering around the edges of policy in favor of lasting, transformative change. We have disrupted the status quo for sake of the American patient and thought big and acted boldly on issue after issue. Rural Americans are already experiencing the improvements brought by our reforms, but their beneficial effects will be felt in rural areas for years to come. Thank you.