The Federal Office of Rural Health Policy announced that for the 2016 Marketplace insurance plan year, the Centers for Medicare & Medicaid Services have released a draft of Essential Community Providers (ECPs) and many Rural Health Clinics (RHCs) are included on the list for the first time.

From the announcement:

ECPs are providers who care for predominantly low-income, medically underserved individuals.  Under the Affordable Care Act, insurers (called Qualified Health Plan issuers) must include a minimum number of ECPs within their provider networks for plans sold on the insurance Marketplaces.  Insurers can use the list to select ECPs to include in their provider networks.  The draft list of ECPs and a description of the list are available here.

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Tuesday was another fascinating exercise in democracy and while there is much to analyze, the significant takeaway is this: Rural America continues to turn a brighter shade of red as the rural/urban electorate seemingly grows further and further apart. The expanding rural/urban divide could even be seen in not-so-rural states like Maryland who shockingly elected only their second Republican Governor in nearly 50 years. This is entirely because the voter turn-out was low in Baltimore but high in eastern and southern Maryland, the rural portions of the state. 

Yesterday’s election has two other significant underlying stories:

  1. The Hispanic vote, didn’t show-up in high numbers, but nevertheless was overwhelmingly for Democratic candidates – 63%. This means that very little inroads were made for Republicans despite the strong efforts by Reince Priebus, chairman of the Republican National Committee, to gain diversity in candidates. Without significant changes in this vast voting bloc, Republicans should be worried about losing their gains in 2016.

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As rural health care workers we are all aware of the unpredictability of what malady may enter our doors.

Through training, practice, ongoing study, reading and information from our professional organizations, we are all constantly learning and staying up to date on the latest therapies and illnesses.

To date I am not aware of Ebola’s presence at a rural site. One truism of rural medicine is that any known diagnoses, as well as evolving problems can enter our facilities at any time. We subconsciously monitor changes in our charges be they environmental, infectious, traumatic, etc.

With that same spirit and urgency, I am sure we are all monitoring and looking at how we would handle Ebola in our facilities. Obviously, the CDC website has been receiving a lot of hits from us.

NRHA has no official statements yet on Ebola.

This summer, NRHA launched a rural preparedness page on our website and has added information specific to Ebola as we receive it.  
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The National Rural Health Association participated in the “Champions of Change” event hosted by the White House on Monday, October 20th, which highlighted the Affordable Care Act (ACA) and various organizations that are working to assist with enrollment efforts.


Representatives from faith-based organizations, local libraries and other community grassroots organizations were in attendance to discuss efforts to help enroll individuals to receive health care coverage under ACA.


Health and Human Services Secretary Sylvia M. Burwell

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Four members are vying to be NRHA's president-elect and multiple others are nominated for Board of Trustees and Rural Health Congress positions.

The president-elect will serve in that role in 2015 and as president in 2016.

Please review each candidate's nomination submission in advance of the voting period beginning Oct. 28.

Tommy Barnhart

In my 40-plus-year health care career I have seen tremendous change but none as dramatic or all-encompassing as we are now experiencing or about to undergo.

In my consulting experience, I have been extensively involved with rural providers of all types and will leverage that experience in my NRHA presidency.

NRHA is the strongest voice for rural health and needs strong leadership during these changing times. NRHA must continue to advocate for sustainable payment systems while new systems are developed, tested and implemented while advocating for sustainable rural workforce and delivery programs.
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Senators Heidi Heitkamp (D-N.D.) and John Thune (R-S.D.) are currently gathering signatures for a letter to be sent to CMS asking for a more robust review of rural impacts of any new regulation. The letter, set to be sent on Thursday, asks that CMS rural impact statements are made more clearly and for better review of rural input of regulations. 

NRHA strongly encourages all NRHA members to call their Senators and ask them to join on this letter.  A copy of this letter may be forwarded by NRHA members to their Senators for review. Senators wishing to join on this letter should contact Senator Heitkamp or Senator Thune BEFORE this Thursday (October 2).  

Any questions about how to contact your Senator or about the letter may be directed to NRHA Government Affairs staff. Because of the Rural Health Clinic and Critical Access Hospital Conferences this week, please send questions via email to Maggie Elehwany, David Lee
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The Oct. 1 deadline is approaching to begin reporting meaningful use of electronic health records (EHR) for fiscal year 2015, NRHA and 16 other national associations sent a message to Patricia Burwell, HHS Secretary to implement more realistic Meaningful Use timelines.

The linked letter states, “only 143 hospitals and 3,152 Eligible Professionals have documented an ability to meet Stage 2 requirements using 2014 Edition Certified Electronic Health Record Technology.” 

If HHS chooses not to meet these requirements, hospitals and Eligible Professionals could face the loss of incentive payments and even worse, significant penalties, disproportionately harming rural providers.
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Have healthcare executives and managers considered the unintended (or intended) consequences associated with the implementation of PPACA?

  1. Radiology/Assets:  Aging Infrastructure impacts HCAHPS, Patient Safety and revenue streams.
  2. IT:  The $$$ depletion from the Balance Sheet for IT rollouts that fail to meet MU 2 attestation standards - "Buyer Beware!" - one size does not fit all.
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Congratulations to Paul Klehn, CIO of Liberty Hospital in Liberty, Missouri! 

Paul was recently elected President of the Heart of Amercica HIMSS. 

Both NRHA and Allscripts are honored to be long term partners of Paul’s and his organization. 


Allscripts Corporation

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Yesterday, the National Rural Health Association participated in the Texas Medical Association’s 9th annual Border Health Caucus Conference on Capitol Hill.


This year’s theme was “Disease Knows no Borders” and included presentations by the Veterans Administration, members of Congress and physicians working along the United States-Mexico border. The conference was geared toward legislative staff, researchers and other border health stakeholders.


As part of a panel alongside Rep. Ruben Hinojosa, D-Texas, and Juan Escobar, MD, president of the El Paso County Medical Society, I was able to discuss current issues impacting the rural health care workforce and efforts being made to help improve access and quality of care for those living along the border.

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Keep your lap bar down and safety belt strapped...we are in for a white-knuckler ride...

In a crazy, but dramatic style, two U.S. appeals courts issued contradictory rulings on health exchange subsidies within hours of each other.  The first dealt a huge blow to the president’s health law by striking subsidies down for millions of Americans covered through, the Federal Exchange.  In effect, crippling the law.  The second court ruling, a couple of hours later, sided in an opposite manner.  

No subsidies were cut off immediately as the legal fight will continue.

At issue is whether individuals can get subsidies to help make insurance affordable in both federal and state exchanges. The first ruling determined that the IRS acted beyond its authority in providing the tax credit, and that instead it should only be done under the authority of a state.  This holding would eliminate all subsidies provided in the 34 Federal Exchanges, making the insurance mandate not affordable for millions.  

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Providers of rural health care are challenged as never before. These pressures are coming from many different sources; causing leaders to juggle many balls while doing their best to keep from dropping one. The Rural Policy Research Institute (RUPRI) has identified six key areas that leaders need to juggle at the same time. They are:

  • Optimize operations within the current fee for service environment
  • Innovate
  • Efficient operations
  • Reduce variation
  • Population health, for example, implement Patient Centered Medical Homes (PCMH)
  • Engage the medical staff

While juggling innovation, the possibilities are endless. However the barriers to implementation can be high. To our surprise, CMS has assisted rural providers by promulgating regulations that can spur innovation in your rural community in two key areas: tele-emergency and tele-health.

CMS advised state survey agencies that the CAH Conditions of Participation (CoP) can allow for an emergency department (ED) to use physician services through tele-health connections. CAHs can analyze the possibility of scheduling physicians’ on-call services using this method. This could reduce ED physician costs while yielding high patient satisfaction.

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As many hospitals and health
 care providers have experienced firsthand, a natural disaster can mean financial strain, organizational confusion and increased risk for patients. 

Last week, Paul Black, interim CEO of Winston Medical Center, reported that his community is still recovering from a tornado that recently destroyed the rural Mississippi hospital.

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Hello.  I am trying to find the standard of care for patients who require Rapid Sequence Intubation at Critical Access Hospitals where there is only one provider in the Emergency Department.  Specifically, are nurses allowed to Administer (i.e. "Push") medications such as Etomidate, Propofol or succinylcholine on a Physician's order, or must the Physician push the medication?  Can a mid-level provider be the one to order and/or administer these meds?  Can anyone share a current Policy on this?

Many thanks.

Alfredo Torres, MD, FACP
River Hospital
Alexandria Bay, NY, 13607

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On cue, the data is starting to roll in regarding the impact of Medicaid expansion enabled by the Affordable Care Act (ACA). We’ve heard the political arguments, for and against, leading up to the implementation of this particular feature of the ACA, some with apocalyptic overtones. Now that we’re getting actual data on this policy matter, politicians can run, but they can’t hide.

The Colorado Hospital Association (CHA) and its Center for Health Information and Data Analytics released a report earlier this month that was important. It found that significant changes emerged in the states that expanded Medicaid in the 1st quarter of 2014 compared with those that didn’t. There was a 3.5% increase in Medicaid revenue, on average, in expansion states and at the same time the percentage of self-pay patients decreased by 1.6%. The average charity care per hospital decreased from $2.8 million to $1.9 million, or an approximate 33% decrease.  In non-expansion states, the percentage of hospital Medicaid revenues did not change; self-pay patients increased slightly, and average charity care per hospital increased by 10%. I suspect that the evidence will continue to grow that demonstrates the positive impact of Medicaid on the financial health of our rural hospitals.

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Plan now to attend the Rural Quality and Clinical Conference July 16-18 in Atlanta, Georgia.

NRHA’s Rural Quality and Clinical Conference is an interactive event for quality improvement executives and coordinators, performance improvement coordinators, infection control practitioners, rural clinicians, medical directors, information technology experts, quality improvement organizations and nurses practicing on the front lines of rural health care. The conference offers two tracks: the r

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The House Ways and Means Subcommittee on Health held a hearing this morning on hospital payments including a discussion on the two-midnight rule, RAC audits, the 96-hour condition of payment rule, and the supervision requirements for outpatient therapy services. While the hearing was not specifically called to address the 96-hour rule or physician supervision, many members of the panel expressed concern to CMS about these payment policies and the complications that various hospitals are experiencing.  Some Representatives included specific stories from rural hospitals in their districts that have contacted them about these challenges.

NRHA is thankful to the Subcommittee for its focus on these issues and to the individual Representatives that raised these important issues.  NRHA commends the various rural hospitals who have reached out to their elected officials and shared their compelling stories with them.  We encourage all rural hospitals to invite their Congressional Delegation to visit their facilities and share their concerns with these elected officials.  If you have any questions on how to contact your elected representatives, please contact
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The Journal of the American Medical Association Surgery (JAMA) misunderstood rural health again. JAMA seems to have resumed its inquiry into critical access hospitals (CAHs) in an article released today, titled “Transfer Rates and Use of Post-Acute After Surgery at CAH vs Non-CAHs,” This article won’t surprise those who have already come to expect sweeping conclusions based on minimal evidence.

Bottom line, it is time for non-rural health researchers to stop exaggerating their claims on CAHs.

The article examines the differences in transfer rates between CAHs and non-CAHs for six surgical procedures commonly performed in each (hip and knee replacements, hip fracture repair, colorectal cancer resection, cholecystectomy and transurethral resection). The data revealed that after adjustment for patient and hospital factors, three of the surgical procedures (hip replacement, colorectal cancer resection and cholecystectomy) had a higher likelihood of transfer by a CAH versus a non-CAH. Simply put, the authors describe these procedures as being "commonly performed in CAHs," but they only identified 22,543 cases in all CAHs in their sample, even using five years of data and six procedures. These 22,543 cases in CAHs only account for 2 percent of all cases for these procedures, while non-CAHs account for 98 percent of total cases.

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The Rural Health Fellows program is a yearlong, intensive training program that develops leaders who can articulate a clear and compelling vision for rural America.

Each year, NRHA selects 10 to 15 highly motivated individuals who have proven their dedication to improving the health of rural Americans through their educational or professional experience.

These Rural Health Fellows undergo an intensive yearlong skillbuilding program, including three advanced leadership training seminars, attendance at several of NRHA's educational conferences, monthly conference calls on rural health leadership, policy and strategic planning and a guided group project that will involve Fellows in the process of rural health policy analysis on a national level.

Fellows will gain valuable insights and build critical skills in three primary domains:

1. Personal, team and organizational leadership;
2. Health policy analysis and advocacy;
3. National Rural Health Association governance and structure.

These ambitious learning and skill development objectives will be accomplished through a combination of experiential and action learning, exposure to premier faculty and seasoned practitioners and reinforcement through executive coaching and structured team assignments.
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