The Office of the National Coordinator (ONC) reports that nearly all hospitals provided patients with the ability to electronically view and download their personal information in 2017. However, Critical Access Hospitals (CAHs) and small rural hospitals were less likely than larger and urban hospitals to be able to transmit that data and to have view, download, and transmit (VDT) capabilities. Under the Promoting Interoperability Program (PI), hospitals are required to use electronic health records technology. Another aspect of the program is to promote patients’ ability to view and download their personal health information. The cost of electronic health record systems and limited access to broadband are two of the barriers to electronic capabilities in rural health care settings. See the Policy Updates section below for requests for comment on recent proposals on electronic health information networks.
ARC on the State of Health Disparities in Appalachia
The Appalachian Regional Commission (ARC) is a federal agency created by Congress to partner with state and local governments and promote economic development for the region. This month, the ARC released three separate issue briefs on health disparities in the 13 states of the region – Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and West Virginia. The briefs describe the factors unique to the region that contribute to disparities related to obesity, opioid misuse, and smoking, and provide recommendations and practical strategies for communities.
Nonmetro Counties Gain Population for Second Straight Year
From the Daily Yonder…
Rural America’s population grew by 0.1 percent from 20017 to 2018. The growth was small and clustered near metropolitan areas. But it reverses the trend of population loss that occurred from 2011 to 2016.
The size of the non-metropolitan population crept up for the second year in a row in 2018, adding about 37,000 residents to reach 46.1 million.
That’s a gain of about 0.1 percent, according to a report from demographer Kenneth M. Johnson at the University of New Hampshire’s Carsey School of Public Policy. The rate of growth is roughly the same as the growth rate from 2016 to 2017, when non-metropolitan counties added 33,000 residents.
The overall U.S. population grew by about 0.6 percent over the last year.
While the gains for non-metropolitan America were scant, they continue to reverse the historic drop in non-metropolitan population that occurred from 2011-16.
The map shows which counties gained or lost population from 2017 to 2018. County-level data is available a map. Or see the map in a new, full-sized window.
About half of America’s 2,000 or so non-metropolitan counties gained population, while about three quarters of metropolitan counties did.
Rural America’s net growth came from rural counties that are adjacent to metropolitan areas, Johnson said in his report. Those counties gained 46,000 residents, while non-metro counties that don’t touch a metro area lost 9,000 residents.
Johnson said non-metro counties grew from a combination of migration (more people moving into a county than leaving it) and natural increase (more births than deaths). The rate of natural increase is dwindling, Johnson said.
Growth rates in non-metropolitan American varied by region. “The fastest growing counties have recreational and scenic amenities that attract migrants including retirees from elsewhere in the United States,” according to the report. In contrast, farm counties had more people leave than move into the counties.
The Census Bureau, which released the 2018 population estimates Wednesday (April 18, 2019), noted that the South and West tended to have the fastest numerical growth in counties.
How this story defines rural: This story uses the Office of Management and Budget metropolitan statistical area system to define rural. Rural counties are defined as those that are not in a metropolitan statistical area or MSA. In this story, rural is synonymous with non-metropolitan. There are numerous ways to define rural. You can learn more (much more!) from the USDA Economic Research Research and the U.S. Census.
CMS Advances Agenda to Re-think Rural Health and Unleash Medical Innovation
On April 24, 2019, the Trump Administration proposed changes that build on the progress made over the last two years and further the agency’s priority to transform the healthcare delivery system through competition and innovation while providing patients with better value and results. The proposed rule would update Medicare payment policies for hospitals under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) for fiscal year 2020 and advances two key CMS priorities, “Rethinking Rural Health” and “Unleashing Innovation,” by proposing historic changes to the way Medicare pays hospitals.
“One in five Americans are living in rural areas and the hospitals that serve them are the backbone of our nation’s healthcare system,” said CMS Administrator Seema Verma. “Rural Americans face many obstacles as the result of our fragmented healthcare system, including living in communities with disproportionally higher poverty rates, more chronic conditions, and more uninsured or underinsured individuals. The Trump Administration is committed to addressing inequities in health care, which is why we are proposing historic Medicare payment changes that will help bring stability to rural hospitals and improve patients’ access to quality healthcare.”
The inpatient hospital wage index specifies how inpatient payment rates are adjusted to account for local differences in wages that hospitals face in their respective labor markets. It is intended to measure differences in hospital wage rates across geographic regions and is updated annually based on wage data reported by hospitals. Hospitals located in areas with wages less than the national average receive a lower Medicare payment rate than hospitals located in areas with wages higher than the national average. For example, a hospital in a rural community could receive a Medicare payment of about $4000 for treating a beneficiary admitted for pneumonia while a hospital in a high wage area (like many urban communities) could receive a Medicare payment of nearly $6000 for the same case, due to differences in their wage index.
In last year’s proposed rule, CMS invited comments on changes to the Medicare inpatient hospital wage index. Many responses reflected a common concern that the current wage index system makes the disparities between high and low wage index hospitals worse. High wage index hospitals, by virtue of higher Medicare payments, can afford to pay their staff more, allowing the hospitals to continue operating as high wage index hospitals. Conversely, low wage index hospitals often cannot afford to pay wages that would allow them to climb to a higher wage index. Over time, this creates a downward spiral that increases the disparity in payments between high wage index hospitals and low wage index hospitals, and payment for rural hospitals and other low wage index hospitals declines.
To address these disparities, CMS is proposing to increase the wage index of low wage index hospitals. This change would ensure that people living in rural areas have access to high quality, affordable healthcare. CMS is considering several ways to implement this change, and the agency looks forward to comments on the different approaches.
The Trump Administration is also announcing proposals that would ensure Medicare beneficiaries have access to a world-class healthcare system by unleashing innovation in medical technology and removing potential barriers to innovation and competition in order to expedite access to novel medical technology.
“Transformative technologies are coming to the private market, but Medicare’s antiquated payment systems have not contemplated these technologies,” said CMS Administrator Seema Verma. “I am particularly concerned about cases that have been reported to the agency in which Medicare’s inadequate payment has led hospitals to curtail access to needed therapies. We must continually update our policies in response to the rapid pace of advancement in medical science.”
To ensure that Medicare payment supports broad access to transformative technologies, CMS is proposing several payment policy changes. These include proposing to increase the new technology add-on payment, which provides hospitals with additional payments for cases with high costs involving new technologies, including potentially new antimicrobial therapies. The increase would apply to all technologies receiving add-on payments starting on October 1, 2019, so that when a physician determines that a patient needs a qualifying new therapy, the hospital at which the therapy is administered would be able to more completely cover its costs. This change would promote patient access and reduce the uncertainty that innovators face regarding payment for new medical technologies for Medicare beneficiaries.
CMS is also proposing to modernize payment policies for medical devices that meet FDA’s Breakthrough Devices designation. For devices granted this expedited FDA approval, real-world data regarding outcomes for the devices in different patient populations is often limited. At the time of approval, it can be challenging for innovators to meet the requirement for evidence demonstrating “substantial clinical improvement” in order to qualify for new technology add-on payments.
Therefore, CMS is proposing to waive for two years the requirement for evidence that these devices represent a “substantial clinical improvement.” Waiving this requirement would provide additional Medicare payment for the technologies for a period of time while real-world evidence is emerging, so Medicare beneficiaries do not have to wait for access to the latest innovations.
In the proposed rule, CMS highlights the unique challenges associated with paying for CAR-T technology in particular. CAR-T is the first-ever gene therapy and is used to treat certain forms of cancer for which no other treatment options exist. The agency is considering several changes to payment policies for CAR-T for 2020, including additional changes to new technology add-on payments for CAR-T and changes to the formula that is used to calculate payments to hospitals for CAR-T. These changes may help ensure adequate payments to hospitals administering this groundbreaking therapy while CMS continues our work to ensure that we pay for innovative therapies appropriately.
The IPPS and LTCH PPS proposed rule is one of five Medicare payment rules released on a fiscal year cycle, to define payment and policy for inpatient hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, skilled nursing facilities, and hospice. Modernizing and strengthening Medicare through rulemaking is critical to achieving CMS’s objectives, and the IPPS and LTCH PPS proposed rule is an opportunity to further advance its goals.
For a fact sheet on the proposed rule (CMS-1716-P), please visit: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acute
To view the proposed rule (CMS-1716-P), please visit: https://www.federalregister.gov/documents/2019/05/03/2019-08330/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the
NIH Funds Study in Four States to Reduce Opioid Related Deaths by 40 Percent Over Three Years
The National Institutes of Health has selected four research sites for the HEALing Communities Study in states hard hit by the opioid crisis. This ambitious study aims to reduce overdose deaths by 40 percent over three years in selected communities by testing a set of proven prevention and treatment interventions. More than $350 million will support this multi-year study. Applications included the involvement of community resources such as police departments, faith-based organizations, and schools, with a focus on rural communities and strong partnerships with state and local governments.
Medicare Advantage Enrollment Update 2018
Medicare Advantage Enrollment Update 2018 
Onyinye Oyeka, MPH; Fred Ullrich, BA; and Keith Mueller, PhD
The RUPRI Center’s annual analysis of Medicare Advantage (MA) enrollment shows that there are 2.6 million nonmetropolitan beneficiaries (24.6 percent of eligible nonmetropolitan beneficiaries) enrolled in an MA plan. The number of nonmetropolitan beneficiaries enrolled in an MA plan increased by 9.5 percent from 2017 to 2018. Nonmetropolitan MA enrollment remains significantly lower than metropolitan enrollment (24.6 percent v. 36.4 percent), but in 2017 the nonmetropolitan rate of growth in MA plan enrollment was higher than the rate of growth in metropolitan areas (4.7 v. 2.0 percent).
Among MA plans, nonmetropolitan enrollment in private fee-for-service MA plans declined sharply between 2009 and 2018, while nonmetropolitan enrollment in health maintenance organizations (HMOs) and local preferred provider organizations (PPOs) saw significant increases.
Click to download a copy: Medicare Advantage Enrollment Update 2018
New Guide Brings Clarity to the Complexities of Funding Assistive Technology
As Vernon saw it, a Pennsylvania Assistive Technology Foundation (PATF) loan was the clear choice to pay for his new hearing aids, with a low interest rate, no fees, and affordable monthly payments. But sometimes finding the right funding isn’t so straightforward.
In 2018, when Vernon’s hearing had declined enough that he was missing large chunks of conversation due to background noise at work and at home, he knew he needed new hearing aids. Vernon has worked in upper management for York Water Company for 21 years. After speaking with the Office of Vocational Rehabilitation (OVR), Vernon was referred to PATF. He found the PATF interest rate was significantly lower than that of a traditional consumer loan and it was cheaper than charging the hearing aids on his credit card. He also described the monthly payments as very manageable. In Vernon’s case, with few other funding options for hearing aids, a low-interest loan made the most sense. Now, Vernon is grateful to have his hearing aids, and says that they have significantly improved his quality of life and made a drastic difference for him both at work and in his personal relationships.
But finding funding is not always so simple. In fact, one of the leading obstacles for many people in obtaining assistive technology (AT) is finding the money to pay for it. And, there are many factors to take into account when developing a funding solution. A person’s diagnosis, age, whether or not they are a student, where they live, whether or not they work, their financial situation, and their wants and needs all come into play when determining what funding options are available.
While PATF provides loans for the purchase of AT to Pennsylvanians of all ages, all income levels, and all disabilities and health conditions, we also provide free information and assistance services with the goal of helping people navigate the complex process of finding funding. Our recent publication, Funding Your Assistive Technology: A Guide to Funding Resources in Pennsylvania, includes the information we cover most frequently with callers. Chapters include topics such as what is assistive technology, tips and considerations when choosing your AT, how to develop a funding strategy, a list of funding resources, specifics on how to access AT through waivers including Community HealthChoices, and how to save safely for assistive technology using an ABLE account and a Special Needs Trust.
“This comprehensive guide is an easy-to-use resource for Pennsylvanians with disabilities, seniors, their families, service providers, and legislators. It empowers Pennsylvanians with the knowledge to gain access to 
devices and services that make independence and autonomy possible,” says Nancy Murray, President of The Arc of Greater Pittsburgh at ACHIEVA and incoming Board President at PATF.
SIM Initiative Evaluation: Model Test Year Five Annual Report
SIM Initiative Evaluation: Model Test Year Five Annual Report. In December 2018, the Center for Medicare & Medicaid Innovation released its fifth annual report on Round 1 of the CMS State Innovation Models (SIM) Initiative, which tests the ability of the governments in six states (Arkansas, Maine, Massachusetts, Minnesota, Oregon, and Vermont) to move providers to value-based payment. A number of these states had activities involving rural providers, including RHCs, FQHCs, and CAHs. As a key finding, states used SIM awards to provide resources to providers to enable provider participation in Medicaid alternative payment models. While most state-led models supported through SIM did not realize Medicaid savings, many results were promising considering the limited provider incentives. A 2017 guide from Rural Health Value highlights the rural focus within select SIM awards from Rounds 1 and 2.
CMS Releases Care Coordination Toolkit and Series of ACO Case Studies
CMS releases Care Coordination Toolkit and series of ACO Case Studies. The Centers for Medicare & Medicaid Services (CMS) has released a public Accountable Care Organization (ACO) Care Coordination Toolkit highlighting innovative strategies that ACOs and End-Stage Renal Disease Care (ESRD) Seamless Care Organizations (ESCOs) use to collaborate with beneficiaries, clinicians, and post-acute care partners to ensure high-quality, effective care is provided at the right time and in the right setting. CMS has also released seven case studies to describe innovative initiatives from ACOs and ESRD ESCOs on a variety of topics including engaging beneficiaries, coordinating care in rural settings, and promoting health literacy. Each case study includes detailed results and lessons learned.
Report Describes Disparities in Death By Rurality, Race, and Ethnicity
Dying Too Soon: Disparities in Death By Rurality, Race, and Ethnicity. A recently released brief by the Rural Health Research Gateway finds rural counties had higher rates of premature death (defined as years of potential life lost before age 75) than urban counties. Researchers analyzed data from the 2017 County Health Rankings, and found that counties with a majority of residents identifying as non-Hispanic Black or American Indian/Alaska Native had significantly higher rates of premature death.