Ron Wyden Chairs Senate Finance Committee Hearing On Improving Rural Healthcare

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On Thursday, Sen. Ron Wyden (D-DE) chaired a Senate Finance Committee hearing on improving rural community healthcare.   Fuel your success with Forbes. Gain unlimited access to premium journalism, including breaking news, groundbreaking in-depth reported stories, daily digests and more. Plus, members get a front-row seat at members-only events with leading thinkers and doers, access to premium video that can help you get ahead, an ad-light experience, early access to select products including NFT drops and more:  https://account.forbes.com/membership/?utm_source=youtube&utm_medium=display&utm_campaign=growth_non-sub_paid_subscribe_ytdescript   Stay Connected Forbes on Facebook: http://fb.com/forbes Forbes Video on Twitter: http://www.twitter.com/forbes Forbes Video on Instagram: http://instagram.com/forbes More From Forbes:  http://forbes.com

Transcript

00:00:00 We will come to order.

00:00:02 This morning, the committee gathers

00:00:05 to discuss the challenges and opportunities

00:00:07 in rural communities when it comes to health care.

00:00:10 And I'm going to be blunt.

00:00:12 Without rural health care, you cannot have rural life.

00:00:17 It is just that simple.

00:00:19 And yet, across the country, rural health providers

00:00:22 are struggling to keep their doors open.

00:00:24 Gesundheit, Senator Lankford.

00:00:27 Too many hospitals, doctors, pharmacies, and other providers

00:00:31 in our rural communities are now operating on a knife's edge.

00:00:36 They're forced to choose between balancing the books

00:00:39 and continuing to provide high quality

00:00:40 care to their communities.

00:00:42 Half of all rural hospitals across the country

00:00:44 operate in the red.

00:00:46 There is no better example of this

00:00:48 than what Oregonians in our Baker County

00:00:51 experienced over the past year.

00:00:53 In 1897, St. Elizabeth Hospital opened in Baker City

00:00:58 and began to deliver babies.

00:01:01 126 years later, after being acquired by Trinity Health,

00:01:06 the sixth largest hospital chain in the country,

00:01:09 they closed their labor and delivery unit

00:01:12 with less than 60 days notice.

00:01:15 Trinity basically said delivering babies at St.

00:01:21 Alphonsus was just a money loser.

00:01:25 Nobody saw it coming.

00:01:27 The people of Baker City thought their hospital

00:01:30 could have a brighter future by joining Trinity Health.

00:01:34 When I arrived at a town hall in Baker City last year,

00:01:36 there were hundreds of outraged families,

00:01:38 including a number of expecting mothers,

00:01:40 who had planned to give birth at St. Alphonsus.

00:01:44 The next closest hospital in that part of eastern Oregon

00:01:46 is 45 miles away, along a freeway that

00:01:49 can be closed during the winter because of icy conditions.

00:01:52 There's also truck crashes.

00:01:56 In fact, that hospital, the Grand Ronde Hospital

00:01:59 in the Grand Oregon, is here today.

00:02:02 And we're so glad that Mr. Davis made the trek.

00:02:05 I know a modest amount about most subjects.

00:02:09 But what I really know something about is airline schedules.

00:02:12 And for Mr. Davis to get across the country

00:02:15 to be with all of us today is a long trek.

00:02:17 And we appreciate him coming.

00:02:20 Despite efforts at the federal, state, and local level

00:02:24 St. Alphonsus in Baker City closed its labor and delivery

00:02:27 unit completely last August, the community

00:02:29 battled St. Alphonsus to keep basic labor and delivery

00:02:33 equipment in Baker City in the event

00:02:36 that the community can find their own solution

00:02:38 in the near future.

00:02:39 Rather than find ways to keep their obstetrics open,

00:02:44 the hospital offered essentially a modest sum

00:02:48 of money given their overall operations

00:02:51 as part of the sixth largest chain, $240,000.

00:02:56 The lump sum amounts to less than $2,000

00:02:59 for each year the hospital has been in the community.

00:03:04 What happened at St. Alphonsus is a textbook example

00:03:07 of what's happening in rural communities across the land.

00:03:11 Our view is these communities deserve better.

00:03:14 These Americans deserve better.

00:03:16 Between 2011 and 2021, one out of every four

00:03:19 rural hospitals in America stopped

00:03:21 providing obstetric services.

00:03:24 That's 267 communities across the country

00:03:27 where giving birth locally is no longer an option.

00:03:31 So make no mistake.

00:03:35 If it's not practical to give birth

00:03:37 within a reasonable distance of your home,

00:03:40 your community is facing the prospect

00:03:43 of becoming a maternity desert.

00:03:47 In these areas, aspiring parents are

00:03:49 going to be forced to make tough decisions about where they live

00:03:52 and where they start a family.

00:03:54 Now, everybody knows that it's tough to get nurses, let alone

00:03:58 labor and delivery nurses in rural areas.

00:04:02 These hospitals see often a low number of births each year,

00:04:06 yet face high costs to keep their services available.

00:04:10 So today, I'm going to begin discussing a fresh approach,

00:04:16 a fresh approach with colleagues on this committee that

00:04:20 combines steps that can address the economic realities

00:04:25 in these communities with extra financial support

00:04:30 as long as large hospital chains don't take the money

00:04:35 and run.

00:04:36 And my sense is that this is the kind of approach

00:04:41 we can come together on and deal with the times.

00:04:45 Let me mention two other areas briefly,

00:04:46 telehealth and workforce.

00:04:48 Telehealth is vital to health care in rural communities.

00:04:51 It's a game changer for seniors to contact their doctor

00:04:54 through a telehealth service instead of spending half the day

00:04:57 or more driving to the health clinic and back home.

00:05:02 It's enormously important for young families

00:05:07 who no longer have to take the day off work

00:05:09 to help their grandparent.

00:05:10 I would just mention, and I think Senator Stabenow

00:05:13 remembers it from working closely with me, Senator

00:05:16 Lankford as well, when Chairman Hatch and I came together

00:05:21 to deal with the chronic care bill, the biggest single piece

00:05:24 was telemedicine.

00:05:25 And after we got it enacted, it essentially

00:05:29 was sitting for a while.

00:05:30 And one afternoon, I got a call from the Trump administration.

00:05:34 They said, how would you feel about using our telemedicine

00:05:38 provisions for the COVID challenge?

00:05:41 And I said, you're calling from the Trump administration?

00:05:43 You want to know how we'd feel that you'd

00:05:46 like to use our telehealth provisions?

00:05:51 I said, this is one of the coolest moments I can remember.

00:05:53 I'm going to go off and have a hot fudge Sunday to celebrate.

00:05:56 Thank you very much.

00:05:57 We're in.

00:05:58 And those provisions that came from the Senate Finance

00:06:01 Committee that were written in a bipartisan way,

00:06:04 telehealth is part of chronic medicine.

00:06:06 We're the law of the land.

00:06:07 So there's still more to do.

00:06:11 I think it is just defying common sense

00:06:15 that clinicians in Idaho or Nevada

00:06:17 have to jump through extra hoops and pay for multiple licenses

00:06:21 just to provide care via telehealth

00:06:23 to a family in Eastern Oregon.

00:06:25 My friend Senator Cantwell, who's

00:06:27 been doing such good work on aviation and a host of issues,

00:06:33 I think is aware that a senior in Vancouver, Washington

00:06:36 can't receive care via telehealth

00:06:38 from a doctor across the river, across the Columbia River.

00:06:42 I heard that we've got this new thing called the internet,

00:06:45 brand new.

00:06:46 We ought to be able to figure this out.

00:06:48 Senator Cantwell's leadership will

00:06:51 be able to without mountains of bureaucracy.

00:06:55 Last point I want to mention is the workforce issue.

00:06:58 Health care jobs are so important.

00:07:00 It's an economic engine for rural Oregon.

00:07:02 But it's becoming more and more difficult

00:07:04 to attract qualified health care workers to rural communities.

00:07:08 One of the things we've got to do is update

00:07:10 the graduate medical education program in Medicare

00:07:12 to make sure rural areas and high need urban areas

00:07:15 aren't given short shrift.

00:07:17 And we have to boost primary care.

00:07:19 That's the backbone of the front line of American health care

00:07:22 center, Stabenow's done particularly important work

00:07:25 in this area.

00:07:26 And we're also, as a committee, we've

00:07:28 begun to do this looking at innovative approaches

00:07:32 like public private partnerships to get into the high schools

00:07:36 and start getting students earlier interested

00:07:40 in health care.

00:07:41 We've always talked about the community colleges.

00:07:43 Every member here knows about that.

00:07:45 I'm committed to getting more high school students,

00:07:48 particularly juniors and seniors, into these slots

00:07:51 and bringing them into the field.

00:07:53 So lots to do here.

00:07:55 And every member of this committee

00:07:57 has an interest in rural and underserved areas.

00:08:00 And we have a great panel of witnesses.

00:08:02 And Senator Lankford is sitting in for Senator Crapo.

00:08:07 We hope his health is good.

00:08:09 And Senator Lankford's been a leader

00:08:11 on this committee of a host of issues, including health care,

00:08:13 but is also known as one of our leaders

00:08:15 with respect to charity care, which has been very important

00:08:18 to all of us.

00:08:19 Senator Lankford.

00:08:19 Thank you.

00:08:20 Mr. Chairman, thank you.

00:08:21 I do want to submit for the record Chairman Crapo--

00:08:24 or Ranking Member Crapo's opening statement.

00:08:27 Without objection, sir.

00:08:27 Thank you.

00:08:28 He would definitely be here to be able to address that

00:08:31 if he was feeling a little bit better,

00:08:33 be able to take that on.

00:08:34 So let me say thank you to you as well for hosting an event

00:08:38 dealing with rural health care.

00:08:39 This is a very significant issue for Oklahoma,

00:08:41 just like it is for your state.

00:08:43 And my state has 4 million people.

00:08:44 2 million of those live in urban areas,

00:08:46 and 2 million of those live in rural areas.

00:08:48 And so we understand full well what

00:08:50 it means to have the critical needs for hospitals

00:08:54 in rural areas there.

00:08:54 We have 40 critical access hospitals.

00:08:57 We have three rural emergency hospitals.

00:09:00 We've seen several rural facilities

00:09:02 close over the last few years.

00:09:03 In fact, one of the reports done by Chartist

00:09:05 with our witnesses here shows that about a third

00:09:08 of Oklahoma's rural hospitals are at risk of closure, which

00:09:11 ranks Oklahoma as the state with the fourth highest

00:09:13 number of potential closures in the United States.

00:09:15 So this particular hearing is incredibly important to us

00:09:18 in Oklahoma.

00:09:20 Rural health care, though, I do want to remind everyone,

00:09:22 is not just hospitals.

00:09:23 It encompasses the entirety of the health ecosystem,

00:09:27 from access to healthy foods, local pharmacies,

00:09:30 the independent family physician practices,

00:09:32 emergency room access, ambulances or air ambulance,

00:09:36 insurance coverage, insurance networks.

00:09:38 All of them are part of that ecosystem

00:09:40 and are all vital access that we spent some time talking about.

00:09:44 I would argue several things.

00:09:47 Some of the issues that we face in rural health care

00:09:49 deal with things like physician practices

00:09:51 in hospitals and the administrative burdens

00:09:53 that they face.

00:09:54 Rural providers and hospitals have fewer resources

00:09:57 to be able to maintain those practices,

00:09:59 and they drown in some of the administrative paperwork.

00:10:01 So what we can do to be able to help them actually

00:10:02 put more people taking care of patients and fewer people

00:10:05 back office is helpful to them.

00:10:07 Nursing homes have a very difficult time

00:10:10 caring for patients, but rural nursing homes

00:10:12 have some of the most difficult times,

00:10:14 where they're dominantly funded by Medicaid in their community,

00:10:17 and they treat a higher level of acuity.

00:10:20 So there are some very real challenges

00:10:22 for rural nursing homes.

00:10:23 The pharmacies and the reimbursements,

00:10:26 they have some reimbursements that are lower reimbursement

00:10:30 than the actual purchase of the drugs that they stock,

00:10:32 but the rural pharmacies, especially independent

00:10:35 pharmacies, are often the only health care provider

00:10:37 in the community that they have immediate access to.

00:10:40 So allowing that rural pharmacist to be able to thrive

00:10:44 is incredibly important in rural America.

00:10:47 Most importantly, we deal with the issue of patients.

00:10:49 Rural patients have an even harder time

00:10:52 finding in-network providers, especially as more and more

00:10:54 rural hospitals stop accepting Medicare Advantage,

00:10:57 which we've had some of our rural providers do in the area,

00:11:00 or when there's a requirement for pre-authorization

00:11:03 for certain testing, and you already drove 45 minutes

00:11:07 to be able to get there, you meet with your doctor

00:11:09 and say, "We need to do a test,"

00:11:11 but you've got to come back again

00:11:12 before we can get authorization,

00:11:14 just discourages them from ever getting that test again.

00:11:17 It works out well for the insurer.

00:11:18 It does not work out well for the patient in rural America.

00:11:21 So these are the issues that we've got to be able to deal

00:11:24 with, proper oversight of Medicare Advantage

00:11:26 and the networks in rural America,

00:11:28 the long-term solutions, the physician fee schedule

00:11:31 that we continue to be able to talk about,

00:11:33 the PBM reform legislation that this committee

00:11:35 has passed overwhelmingly.

00:11:37 We need to be able to move because that is an issue

00:11:39 for rural independent pharmacies.

00:11:41 That's very significant that we should be able to get,

00:11:44 but we have got out of this committee,

00:11:46 we need to be able to get across the floor

00:11:47 and to be able to get that resolved.

00:11:49 Dealing with some of the CMS rules that are out there,

00:11:52 which are, I believe, a threat to rural nursing homes

00:11:55 with some of the staff requirements that are there

00:11:56 that are going to actually pull RNs away from hospitals

00:12:00 that are already struggling to be able to maintain

00:12:02 their RNs, to maintain some of the new rules for CMS,

00:12:05 may make for an even greater challenge for survival

00:12:08 for some of those rural nursing homes.

00:12:10 Senator Durbin and I have worked on a bill,

00:12:12 the Rural Hospital Closure Relief Act.

00:12:14 That's one that we want to be able to work through

00:12:16 in trying to deal with the critical access hospitals.

00:12:20 We have a lot of issues around the community health centers.

00:12:24 Those FQHCs have been a real solution for us in Oklahoma

00:12:27 and a lot of rural areas,

00:12:29 and what we continue to be able to do with that.

00:12:30 So I would just say, patients that are in rural Oklahoma

00:12:34 should not be punished for living in rural Oklahoma.

00:12:36 They should have access there that is consistent

00:12:39 and also to be able to face the unique issues

00:12:41 that they have in rural America,

00:12:44 to be able to both live and thrive there.

00:12:46 And for all of us that like to eat food and wear clothes,

00:12:50 we really need folks in rural America

00:12:52 that are in agriculture,

00:12:54 and if we cut off access to healthcare to them,

00:12:56 then we're also going to lose access

00:12:58 to a lot of the rest of our economy.

00:12:59 So I look forward to this conversation.

00:13:02 - Thank you, Senator Lankford.

00:13:03 I appreciate your making it clear

00:13:05 that food doesn't just fly out of the sky here

00:13:07 and land up here on the dais.

00:13:09 And I also appreciate your comments

00:13:11 about the Pharmaceutical Benefit Manager legislation.

00:13:14 It's been bipartisan, you played a key role.

00:13:17 It also speaks to this middlemen issue.

00:13:19 We spend more than $4 trillion a year on healthcare.

00:13:23 We've got to get at this middlemen question,

00:13:25 and we're looking at some of the work

00:13:26 that Senator Lankford and others did

00:13:28 in terms of trying to make sure

00:13:30 that we could really get good value

00:13:31 for the consumers on another bill

00:13:33 that Senator Crapo and I have to deal with drug shortages.

00:13:36 So I appreciate this.

00:13:37 Okay, Michael Topchick is going to be our first witness.

00:13:41 Executive Director of the Chartist Center for Rural Health.

00:13:44 He's been a specialist in these rural networks.

00:13:47 We appreciate him.

00:13:48 Jeremy Davis, who I've already tried

00:13:51 to give a send-off once to,

00:13:53 but we always like Oregon to get a little bit more attention

00:13:56 since we're 3,000 miles away.

00:13:58 He's the CEO of Grand Ronde Hospital,

00:14:00 where I've been often,

00:14:01 an independent critical access hospital in La Grande.

00:14:05 He's led the hospital in recruiting more clinicians

00:14:08 and the first urgent care facility.

00:14:10 They're doing very important work there.

00:14:12 Lori Rodefeld serves as Director of GME Development

00:14:17 at the Wisconsin Collaborative

00:14:18 for Rural Graduate Medical Education.

00:14:21 Very experienced advocate in the field.

00:14:26 And Dr. Keith Mueller is Director

00:14:28 of Rural Policy Analysis Research,

00:14:31 and he's at the Center

00:14:32 for Rural Health Policy Institute as well.

00:14:36 Rural Policy Research Institute

00:14:38 and also Rural Health Policy Analysis.

00:14:40 That's a lot of hats to wear.

00:14:41 I don't know when you sleep,

00:14:42 but thank you all for being here.

00:14:44 We'll begin with you, Mr. Topchick.

00:14:46 - Thank you very much.

00:14:49 Chairman Wyden, Ranking Member Crapo,

00:14:51 Senator Lankford, I appreciate you, your remarks.

00:14:54 And members of the committee, good morning,

00:14:56 and thank you for the opportunity

00:14:58 to discuss the state of rural healthcare

00:14:59 and the implications for the 46 million Americans

00:15:02 who call rural communities home.

00:15:04 My name is Michael Topchick,

00:15:06 and I'm the Executive Director

00:15:07 of the Chartist Center for Rural Health.

00:15:09 Chartist is a Chicago-based advisory firm

00:15:11 dedicated to helping clients create

00:15:13 and embrace solutions that make US healthcare

00:15:16 more affordable, accessible, and safe.

00:15:19 And my work with the center

00:15:20 is exclusively focused on rural healthcare.

00:15:22 America's rural communities are older,

00:15:26 they are less affluent, and they are less healthy

00:15:28 than their urban counterparts.

00:15:30 Rural Americans are more vulnerable

00:15:32 than non-rural Americans

00:15:33 across nearly all of the population health metrics

00:15:36 we measure at the center.

00:15:38 Rates of the leading causes of death

00:15:40 are all higher in rural America,

00:15:42 and the so-called deaths of despair,

00:15:45 with suicides, the opioid epidemic,

00:15:47 alcohol-related deaths,

00:15:48 are all much higher in rural America.

00:15:51 With that backdrop, recent history has been difficult

00:15:56 for the safety net serving these Americans,

00:15:59 particularly hospitals.

00:16:01 Since 2010, we've lost 170 of these rural hospitals,

00:16:05 half, half of rural hospitals are now operating in the red.

00:16:10 In states that have yet to expand Medicaid,

00:16:13 that number goes up to 55%.

00:16:16 Even when hospitals do remain open, access to care,

00:16:20 access is such an important word in this hearing today.

00:16:23 Access to care is constrained

00:16:25 as facilities are challenged to keep programs open.

00:16:28 For example, we've lost 25% of the nation's

00:16:32 rural obstetrics in the last decade.

00:16:35 The journey for labor and delivery

00:16:37 for these expectant mothers now means an additional 30,

00:16:41 45, or even 60 minutes for that important life milestone.

00:16:46 As tough as all of that sounds,

00:16:49 our research indicates that the future

00:16:51 might be tougher still.

00:16:53 Using our data and analytic capabilities,

00:16:56 we find 418 additional rural hospitals

00:16:59 vulnerable to closure.

00:17:00 Senator Lankford, you mentioned some of those in Oklahoma

00:17:03 that we're worried about.

00:17:05 This is a national threat that will send shockwaves

00:17:08 through communities if it's unchecked.

00:17:10 When rural hospitals close,

00:17:11 accessing care becomes harder, if not impossible,

00:17:14 and jobs in those communities and jobs at the hospitals

00:17:18 and related jobs, they disappear.

00:17:19 There's really three key factors

00:17:21 threatening rural hospitals today.

00:17:23 First, rural hospitals have high operating costs

00:17:26 and they have low reimbursements.

00:17:28 The unintended consequences related to

00:17:31 things like the sequestration and bad debt reimbursements,

00:17:34 for example, continue to chip away

00:17:35 at rural hospitals' reimbursements.

00:17:38 To counter operational and financial pressure,

00:17:40 nearly 60% of rural hospitals are now affiliated

00:17:43 with a health system.

00:17:45 And while affiliation with a health system

00:17:47 is shown to bring services to communities

00:17:50 and to improve the bottom line,

00:17:52 in our analysis it also is protective against closure.

00:17:56 It is not a panacea.

00:17:57 Second, rural hospitals treat a low volume of patients.

00:18:02 There are too few patients and even fewer

00:18:04 medical professionals to deliver care,

00:18:06 meaning that for many hospitals, the math just doesn't work.

00:18:09 Finally, rural hospitals are plagued by staffing challenges.

00:18:14 While rural hospital staffing shortages are not new,

00:18:17 the pandemic accelerated this crisis.

00:18:19 These shortages impact patient care today

00:18:23 and they threaten the introduction and delivery

00:18:25 of new services that communities will need tomorrow.

00:18:28 I'd like to share a quick anecdote

00:18:32 that I think is on all of our mind,

00:18:34 which comes from Walmart.

00:18:35 Within the last month announced it is leaving

00:18:37 the healthcare delivery space

00:18:38 after just five years in this business.

00:18:40 They cited staffing and reimbursement challenges

00:18:44 as amongst the chief reasons they got out of this space.

00:18:47 And so my question is, if Walmart can't figure this out

00:18:50 with their scale and their capacity,

00:18:52 how can we expect rural hospitals and their communities

00:18:55 who are struggling to see a future

00:18:57 in which their situation improves?

00:18:59 Let me finish by just saying that today's hearing

00:19:02 is important and timely.

00:19:04 I've dedicated approximately the last 20 years of my career

00:19:06 to advancing rural healthcare in America,

00:19:09 and I'm deeply invested in helping rural hospitals

00:19:11 deliver quality, affordable care

00:19:13 to some of our most vulnerable communities.

00:19:15 I would like to express my sincere thanks

00:19:17 to the Chartist leadership team,

00:19:18 including my colleague, Annalisa, who's with me today,

00:19:21 who have stood by us in this important mission-driven work,

00:19:24 and also my colleagues at home,

00:19:25 William Balfour, Troy Brown, Melanie Panette,

00:19:27 and Anna Visey of the Chartist Center for Rural Health,

00:19:30 whose research is fundamental for the testimony today.

00:19:34 I would like to thank all of the members

00:19:35 of the Finance Committee and their staffs

00:19:38 for the time and opportunity to speak here today.

00:19:40 I look forward to your questions.

00:19:41 Thank you.

00:19:42 - Thanks very much.

00:19:43 Great way to start.

00:19:44 Mr. Davis, welcome, and so appreciate your being here

00:19:48 to tell the Oregon story.

00:19:49 - Thank you.

00:19:50 Chairman Wyden, Senator Langford,

00:19:52 and members of the committee,

00:19:52 thank you for the opportunity to speak today.

00:19:55 My name is Jeremy Davis,

00:19:56 and I'm the President and CEO of Grand Run Hospital,

00:19:58 a 25-bed, not-for-profit, independent,

00:20:00 critical access hospital in the Grand Oregon.

00:20:02 Located in rural eastern Oregon,

00:20:04 the hospital was founded in 1907.

00:20:06 Grand Run Hospital serves a local population

00:20:08 of 26,000 residents in other parts

00:20:10 of frontier eastern Oregon and southeast Washington.

00:20:13 My community is located 216 miles east of Portland, Oregon,

00:20:16 and 170 miles northwest of Boise, Idaho,

00:20:19 along an interstate that frequently closes

00:20:21 due to weather or accidents.

00:20:23 On a personal note, I grew up 45 miles from this community,

00:20:26 so rural life and now rural healthcare is dear to me.

00:20:29 Union County is a mountainous area

00:20:32 with a local economy based on natural resources,

00:20:34 including farming, ranching, and timber.

00:20:37 About 15% of our population lives in poverty.

00:20:39 In our most recent needs assessment,

00:20:43 we identified chronic disease prevention,

00:20:45 social determinants of health,

00:20:47 and behavioral health services as top priorities.

00:20:49 Of the patients we see,

00:20:50 over 60% are covered by government payers,

00:20:53 with 41% covered by Medicare and 23% covered by Medicaid.

00:20:58 For rural hospitals, the substantial portion of patients

00:21:00 covered by Medicare and Medicaid

00:21:01 underscores the importance of adequate reimbursement

00:21:04 for these programs.

00:21:05 But reimbursement is only part of our challenge.

00:21:08 The aftershocks of the COVID-19 pandemic

00:21:10 shifted the ground beneath hospitals like mine,

00:21:13 forcing us to make difficult decisions

00:21:15 about the services we provide.

00:21:17 While many of the challenges we face today

00:21:18 were on the horizon, the pandemic exposed

00:21:20 the fragility of hospitals' financial foundations,

00:21:23 particularly for rural hospitals.

00:21:25 Rising expenses, workforce shortages,

00:21:27 and stalled revenue cratered hospital finances

00:21:29 and put hospitals like Grand Ronde

00:21:31 in one of the worst overall financial positions

00:21:33 seen since 1993.

00:21:34 Rural hospital administrators like me

00:21:36 have an interconnected list of worries

00:21:38 that keep us up at night,

00:21:39 including workforce safety and shortages,

00:21:41 financial stability, and more recently,

00:21:43 worries about cybersecurity.

00:21:45 And the next emergency, whether natural,

00:21:47 public health, or man-made,

00:21:49 is always just around the corner.

00:21:51 As wonderful as our rural lifestyle is,

00:21:53 it can be a trial for many rural residents,

00:21:55 particularly those living in communities

00:21:56 surrounding La Grande,

00:21:57 with no access to public transportation.

00:22:00 Patients often miss, reschedule,

00:22:01 or even cancel appointments, delaying needed care.

00:22:05 Since 2007, we made an early and significant investment

00:22:08 in telemedicine, allowing us to meet the challenges

00:22:10 of delivering care in a rural setting,

00:22:12 which has resulted in a nationally recognized program.

00:22:15 Telemedicine provides access to specialties

00:22:17 not available locally by tapping into specialty expertise

00:22:19 typically only available in larger cities.

00:22:21 This includes using tele-hospitals

00:22:23 for nightly call coverage,

00:22:24 specialty physician teams when patients present

00:22:27 to our emergency department,

00:22:28 and pediatric specialists for our youngest patients.

00:22:31 Investing in additional equipment,

00:22:32 as well as configuring exam rooms,

00:22:34 workspaces to pivot quickly, was the right thing to do.

00:22:37 By extending telehealth flexibilities permanently,

00:22:39 we can create certainty for Medicare beneficiaries,

00:22:43 and certainty for providers like Grand Ronde

00:22:46 that cannot always afford to invest in these tools

00:22:48 without a reimbursement pathway.

00:22:49 Similar to our telemedicine commitments,

00:22:52 our workforce investments have been promising.

00:22:55 We've reached out to candidates across the spectrum

00:22:57 of both primary and specialty care,

00:22:58 and through our recruitment efforts,

00:22:59 we have expanded services

00:23:01 and significantly improved access to care.

00:23:03 In 2021, our efforts to grow behavioral health services

00:23:06 program attracted additional providers

00:23:08 and meant better care for Union County residents.

00:23:11 Eight years ago, Grand Ronde Hospital

00:23:12 established a nurse residency program

00:23:14 to attract, train, and retain nurses.

00:23:17 We are firm believers in growing our own,

00:23:19 and our model has attracted nurses from across Oregon.

00:23:22 In 2019, we created a nurse residency educator position

00:23:25 to oversee the program, which has enhanced its success.

00:23:28 We also collaborate with our local high school,

00:23:30 and we are also a partner with Northeast Oregon

00:23:32 Area Health Education Center,

00:23:34 which hosts an annual health career exploration camp

00:23:36 for high school students.

00:23:38 Any federal support that provides incentives

00:23:40 and support for these types of programs

00:23:41 should be a priority.

00:23:43 Growing and supporting our workforce

00:23:45 and protecting and expanding services

00:23:46 are two sides of the same coin

00:23:47 when it comes to rural healthcare.

00:23:49 Neither can be achieved without the other,

00:23:51 and both require adequate reimbursement

00:23:53 and constant reinvestment.

00:23:55 Rural hospitals have to be especially creative

00:23:58 to foster and protect needed services,

00:23:59 and we have done as we have done

00:24:01 with our Children and Recovering Mothers program, CHARM.

00:24:04 CHARM is a confidential healthcare program

00:24:06 for pregnant women struggling with alcohol or drug addiction.

00:24:09 It collaborates with local providers

00:24:10 and public health department officials

00:24:12 to provide a program that improves care

00:24:14 and support for mothers and their infants.

00:24:16 Our maternity care investment helped us respond

00:24:18 when a neighboring hospital 45 miles away

00:24:20 closed its obstetrical unit in 2023.

00:24:22 In preparation, we quickly added two FTEs

00:24:26 and four RN positions, which proved to be necessary,

00:24:29 as we've seen a 65% increase in patients

00:24:32 from the neighboring county since the closure occurred.

00:24:35 While we are committed to meeting this need,

00:24:37 decisions like this are a constant juggling

00:24:38 of limited financial resources

00:24:40 and a balancing of our larger workforce needs.

00:24:43 Let me close by commenting that in addition

00:24:45 to extending telehealth flexibilities,

00:24:46 the following proposals would specifically help us

00:24:48 meet the substantial discharge challenges

00:24:50 we face in Oregon.

00:24:52 One, permanently remove the 96-hour rule

00:24:53 for critical access hospitals

00:24:55 to allow us to serve patients longer than 96 hours.

00:24:58 Two, reestablish the swing bed flexibilities

00:25:00 allowed during the pandemic

00:25:01 that expanded the ability of hospitals

00:25:02 to offer long-term care services

00:25:04 to patients who do not require acute care.

00:25:07 And three, permanently waive the outdated

00:25:08 three-day hospital stay rule for patients

00:25:10 requiring discharge to skilled nursing facilities.

00:25:13 It is an honor and privilege to serve my rural community,

00:25:15 and thank you for this opportunity to be here today.

00:25:18 - Mr. Davis, and thank you for your good work at home,

00:25:23 and I particularly appreciate this effort

00:25:26 to try some fresh approaches to attract nurses,

00:25:28 and your focus on starting at home

00:25:31 and in nearby communities is clearly an area

00:25:33 that has been underutilized, so good on you,

00:25:36 and look forward to some questions for you.

00:25:38 Ms. Rodefield.

00:25:41 - Great, Chairman Wyden, Senator Linkford,

00:25:44 and members of the committee,

00:25:45 my name is Lori Rodefeld,

00:25:46 and I serve as director of GME Development

00:25:48 for the Wisconsin Collaborative for Rural GME.

00:25:51 I also serve as the director of GME Development

00:25:52 for the Rural Residency Planning and Development

00:25:55 and Teaching Health Center Planning and Development

00:25:56 Technical Assistance Centers.

00:25:58 Rural healthcare has long faced challenges

00:26:00 in recruiting and retaining a qualified workforce.

00:26:02 This isn't just an inconvenience,

00:26:03 it threatens the fabric of healthcare in rural communities.

00:26:06 Rural hospitals and healthcare facilities

00:26:08 are already stretched thin,

00:26:09 serving patients around the clock

00:26:10 to meet their community's needs.

00:26:12 Unlike other industries, their hours can't be scaled back.

00:26:15 Emergency rooms, inpatient services,

00:26:17 labor and delivery units,

00:26:18 are all critical services that rely

00:26:24 on a strong, stable workforce to keep the doors open.

00:26:27 My testimony will include examples from Wisconsin

00:26:29 and across the country as we look

00:26:30 to address rural workforce shortages.

00:26:32 I'll highlight some innovative approaches

00:26:34 that help support rural physician training

00:26:36 and the training of other health professionals.

00:26:38 To address the doctor shortage in rural areas,

00:26:40 the answer is clear, invest in

00:26:41 really based residency training.

00:26:43 It's a proven strategy that's been in place for decades.

00:26:46 Unfortunately, the growth of rural training

00:26:47 has not kept pace with the growth of GME as a whole.

00:26:50 It's estimated that only 2% of residency training

00:26:53 takes place in rural communities,

00:26:54 despite nearly 20% of our population living in rural areas.

00:26:59 A common misconception is that rural hospitals

00:27:01 can't participate in GME programs

00:27:02 due to lack of interest, infrastructure,

00:27:05 volume or experience, which just simply isn't true.

00:27:08 Efforts to grow training are emerging

00:27:10 with a number of hospitals,

00:27:11 ranging from larger school community hospitals

00:27:13 with multiple programs, to critical access hospitals,

00:27:16 to even health centers,

00:27:18 stepping up to become involved in rural GME.

00:27:21 In 2013, Wisconsin launched a GME Development Grant Program

00:27:24 to help fund the launch of new residency programs.

00:27:27 One of the first hospitals to take advantage

00:27:28 of this opportunity was the SSM Monroe Hospital,

00:27:31 who launched the first family medicine program

00:27:33 in the state in nearly 20 years.

00:27:35 The program has seen amazing success,

00:27:37 retaining 50% of its graduates within the healthcare system.

00:27:42 A majority are practicing in rural areas,

00:27:44 and 90% of graduates remain in the state of Wisconsin.

00:27:48 Since launching our state strategy,

00:27:49 the total number of rural GME positions has increased.

00:27:53 We now have 27 programs up from six programs

00:27:56 just a little over 12 years ago.

00:27:58 The success of RRPD is another example

00:28:01 of growing interest in the creation of rural GME programs.

00:28:04 The program offers startup funding and technical assistance

00:28:06 to support residency development.

00:28:08 46 new programs have achieved accreditation by ACGME,

00:28:12 translating into 575 additional positions

00:28:15 when all the programs reach their full capacity.

00:28:18 With the demonstrated success of expanding GME

00:28:20 as a workforce strategy,

00:28:21 there's an opportunity to apply these learnings

00:28:23 to other health professions.

00:28:25 There are countless examples of rural facilities

00:28:27 who recognize this need and work to grow their own workforce.

00:28:30 I'll highlight a few initiatives

00:28:31 from Wisconsin and Minnesota.

00:28:33 A Wisconsin grant program was developed,

00:28:35 which mirrors our GME grant program

00:28:37 that I described earlier.

00:28:38 Funding supports site development,

00:28:40 and to date, over 50 new educational partnerships

00:28:43 have been formed,

00:28:44 expanding training primarily in rural areas.

00:28:47 This approach has also been used in Minnesota

00:28:49 with the Medical Education Research Cost Program.

00:28:52 The state uses Medicaid funding

00:28:53 to help support the training of not just physicians,

00:28:56 but other crucial health professionals.

00:28:59 The program supports training of social workers,

00:29:01 community health workers, paramedics, dental therapists,

00:29:04 and psychologists.

00:29:05 There's also an initiative

00:29:06 focused on the training of medical assistants

00:29:09 in the state of Wisconsin,

00:29:10 looking at ways that we can better meet

00:29:12 our underserved workforce needs.

00:29:14 Since this type of training can be offered

00:29:16 through an apprenticeship model,

00:29:17 our health centers statewide have collaborated

00:29:20 to develop programs that will share virtual instruction

00:29:23 and offer hands-on training at local centers.

00:29:25 MA positions are unique,

00:29:27 as they provide an entry point to other health careers.

00:29:30 Despite efforts to develop our workforce

00:29:32 in rural communities,

00:29:33 significant challenges remain.

00:29:35 As these issues are complex,

00:29:36 I will focus on only a couple of these challenges.

00:29:38 First, Medicare funding complexities

00:29:41 do create a barrier to expanding GME in rural areas.

00:29:44 An example of this is GME funding models

00:29:47 for sole community hospitals

00:29:48 and for Medicare-dependent hospitals,

00:29:50 who do not receive full support from Medicare

00:29:53 to cover the cost of training.

00:29:55 Financial projections estimate

00:29:57 that their indirect medical education payments

00:29:59 will be reduced for most of these hospitals.

00:30:02 Allowing full payments with IME for these hospitals

00:30:05 or treating them as non-hospital provider sites

00:30:07 in a manner similar to critical access hospitals

00:30:10 could be a potential policy solution.

00:30:13 THC GME supports 81 residency programs,

00:30:16 including 30% of programs who train in rural communities.

00:30:20 THC PD is supporting the startup of 93 new programs,

00:30:24 expanding this reach even further.

00:30:25 One program making an impact

00:30:27 is the Marshall University Consortium Residency Program,

00:30:30 which will begin training psychiatry residents

00:30:33 later this year.

00:30:34 The program will provide services

00:30:36 to a rural county in West Virginia

00:30:38 without any psychiatrists.

00:30:39 There's not a current THC GME funding opportunity

00:30:42 for these grantees like Marshall,

00:30:44 who are committed to training doctors in rural areas.

00:30:47 Finally, supportive state-level technical assistance

00:30:49 and clinical training infrastructure

00:30:51 and federal grants should be explored

00:30:53 to help rural facilities expand their training.

00:30:57 Assistance and support are needed for rural hospitals.

00:31:01 Thank you for the opportunity to testify today.

00:31:03 The future of rural healthcare depends on our ability

00:31:05 to cultivate a strong workforce.

00:31:07 - Thank you, Ms. Rugfeld.

00:31:09 Welcome to our final guest, Dr. Mueller.

00:31:12 - Chairman Wyden, Ranking Member Crapo,

00:31:15 and members of the Finance Committee,

00:31:17 thank you for holding this hearing on rural health.

00:31:20 Since I last spoke to this committee in 2018,

00:31:23 intractable challenges in hospital finance,

00:31:26 meeting workforce needs,

00:31:27 and addressing leading causes of death

00:31:29 in rural communities remain.

00:31:31 Yet we have seen the resilience

00:31:33 of health providers and organizations

00:31:35 as they rose to meet the challenges of the COVID-19 pandemic

00:31:39 and now keep their focus on improving health

00:31:41 for members of their communities.

00:31:43 In my brief formal comments,

00:31:45 I will focus on rural hospitals, Medicare Advantage,

00:31:48 and accountable care organizations.

00:31:51 Rural hospitals are now comprehensive care centers

00:31:53 with a much higher percentage of total activities

00:31:56 and revenues tied to outpatient services.

00:31:59 Transitioning to institutions

00:32:01 that best serve rural residents

00:32:03 may require modernizing facilities,

00:32:05 investing in new information systems and technologies,

00:32:09 and collaborating with community-based organizations

00:32:12 to address living conditions

00:32:13 related to chronic health problems.

00:32:16 Additional capital investments and information systems,

00:32:19 including cybersecurity and in new technology,

00:32:22 can stretch capabilities of small hospitals

00:32:25 who have operated on very thin total margins

00:32:29 and therefore lack reserves for large investments.

00:32:32 In a payment environment

00:32:34 shifting to the importance of addressing health,

00:32:37 rural hospitals and primary care clinics can be advantaged.

00:32:41 However, rural hospital administrators

00:32:44 and their limited senior staff

00:32:46 may lack the experience and data analytics

00:32:48 to leverage their position

00:32:50 as primary care providers in negotiations.

00:32:54 Programs providing technical assistance

00:32:56 make a difference for those institutions.

00:32:58 Shifting to Medicare Advantage,

00:33:01 the Roopry Center for Rural Health Policy Analysis,

00:33:03 with funding from HRSA's Federal Office of Rural Health Policy

00:33:07 has tracked rural enrollment since October 2000,

00:33:11 when a little over 200,000 beneficiaries

00:33:13 were enrolled in Medicare Plus choice plans.

00:33:17 As of March of this year,

00:33:18 there are nearly 4.8 million rural beneficiaries

00:33:22 enrolled in MA plans,

00:33:24 which is 45% of all rural beneficiaries.

00:33:27 Growth in rural enrollment in many states

00:33:30 has been dramatic since 2019,

00:33:32 when nationally it was at 29%.

00:33:35 What are the consequences of growth in MA plan enrollment?

00:33:38 Well, it's a two-sided coin.

00:33:41 On one side, as Roopry has shown in the annual reports

00:33:43 and periodic policy briefs,

00:33:45 there are many more choices now for rural beneficiaries.

00:33:48 This includes more widespread availability

00:33:50 of additional health benefits,

00:33:52 including vision, hearing, fitness, and dental.

00:33:55 As of 2022, all are available

00:33:58 in more than 90% of rural counties.

00:34:01 On the other side of the coin,

00:34:02 MA plan payment to rural providers

00:34:04 is set through contracts,

00:34:06 not the pricing system of traditional Medicare.

00:34:09 Consequently, strategies private insurance companies

00:34:12 use to control spending will apply.

00:34:15 Claims denial, which can be appealed,

00:34:16 prior approval, and variable deductibles and copayments.

00:34:21 This coin metaphor brings to mind

00:34:23 the term managed competition,

00:34:25 that in healthcare, there is value to competition,

00:34:28 but given compelling objectives of access and equity,

00:34:32 some public policy management may be needed.

00:34:35 The number of ACOs grew to 480 in 2024,

00:34:40 including 276 low-revenue ACOs.

00:34:44 The number of beneficiaries is holding somewhat steady

00:34:47 at 10.8 million nationally.

00:34:49 There are more than 2,500 participating

00:34:52 rural health clinics in ACOs,

00:34:54 and 513 critical access hospitals.

00:34:58 Rural changes allowing up to seven years

00:35:00 in an upside risk-only model

00:35:02 and an advanced investment payment

00:35:04 are likely to result in more rural participation.

00:35:08 RUPRE has followed ACO development in rural places

00:35:11 and impacts on rural providers,

00:35:13 including finding a somewhat positive impact

00:35:16 on rural hospital revenues.

00:35:17 The RUPRE Health Panel,

00:35:19 supported by the Helmsley Charitable Trust,

00:35:21 has written extensively on policy choices since 1993.

00:35:26 Based on our products and discussions with my colleagues,

00:35:28 I'll close with what I characterize

00:35:31 as sharp point concerns in rural health

00:35:33 that demand attention.

00:35:35 The first is securing the workforce

00:35:37 needed to sustain rural services.

00:35:39 A modern patient health team

00:35:41 includes community health workers,

00:35:42 lay health navigators, behavioral health providers,

00:35:45 and of course, medical care providers.

00:35:48 All are in short supply in high demand.

00:35:51 We need a multi-pronged approach to meet these needs,

00:35:54 from pipeline training programs

00:35:56 to better pay and benefits

00:35:57 to improving workplace environments.

00:35:59 A second sharp point is maintaining essential services

00:36:02 in rural communities.

00:36:04 As already discussed, this includes OB/GYN,

00:36:07 perinatal and postnatal women

00:36:09 who must have equitable access to high quality care.

00:36:12 Other essential services include emergency care,

00:36:15 primary care, and public health.

00:36:17 Thanks again for this opportunity

00:36:20 to discuss critical issues and policy considerations

00:36:23 that would strengthen and sustain essential health services

00:36:26 in the nation's rural communities.

00:36:29 - Dr. Mueller, thanks very much.

00:36:30 Excellent panel.

00:36:32 Let me start with you, Mr. Topchick,

00:36:35 and I know that you've spent 20 years in the field,

00:36:37 so you've really gotten a sense of how tough the math is

00:36:42 in rural communities.

00:36:44 You've gotta maintain labor and delivery services.

00:36:48 You have a low number of births each year,

00:36:50 yet you have high costs, and as people sometimes say,

00:36:55 the babies don't always decide to arrive between nine and five.

00:36:59 You've gotta show up and be there around the clock.

00:37:01 So what we are trying to do is look at a better way

00:37:05 to invest in rural maternal health

00:37:07 without letting hospitals take the money

00:37:09 only to leave a maternity desert behind.

00:37:13 What's your sense about the direction

00:37:16 that we're looking at now,

00:37:18 where we could have a fresh approach

00:37:21 that really zeroes in on the economic challenges

00:37:26 in these rural communities that I mentioned

00:37:29 and ensure that there would be a bit

00:37:31 of extra financial support for the big hospital chains

00:37:36 as long as they don't take the money and run?

00:37:39 Is that something that we can work around?

00:37:42 - I think there's a robust discussion there, Senator.

00:37:45 The tension I see is access, access, access

00:37:48 versus reimbursements and the dollars required.

00:37:50 In the case of labor and delivery,

00:37:52 I think everybody here is for motherhood and apple pie,

00:37:56 and we absolutely need to invest more in motherhood

00:38:00 if we are going to sustain it in rural America.

00:38:03 The math is not adding up.

00:38:04 We are losing it.

00:38:05 The proof is right before our very eyes.

00:38:07 So very concerning.

00:38:09 Health systems play a role in investing in rural communities

00:38:13 when very difficult decisions like the example you gave

00:38:17 in Oregon arise.

00:38:19 They are not taken lightly, and it's tough.

00:38:22 It's tough for the mothers.

00:38:23 It's tough for the community.

00:38:24 It's tough for the doctors and hospitals

00:38:26 that want to deliver those services.

00:38:28 What they're asking for in return is,

00:38:30 can you help us with the reimbursements

00:38:32 to maintain this particular vital service,

00:38:34 but others as well?

00:38:35 It could be chemotherapy.

00:38:36 It could be others.

00:38:37 - We'll want your input as we go.

00:38:41 The challenge is it's not as if the rural hospitals

00:38:46 and providers are just left to go off

00:38:49 and make the sensible decisions that you're talking about.

00:38:52 So many of the shops are being called

00:38:55 from thousands of miles away in these big chains,

00:38:58 and that's why we're gonna want your good counsel

00:39:02 as we go forward so that we can take the economic realities

00:39:07 of these rural communities and connect them to the fact

00:39:12 that often these judgments about whether,

00:39:15 particularly these big hospitals, are going to stay there

00:39:19 and gonna stay there for a significant period of time,

00:39:23 those decisions are being made thousands of miles away

00:39:27 from the rural communities where you are doing

00:39:30 such good work, and I very much appreciate your leadership.

00:39:35 We're gonna want to call on you.

00:39:37 - Thank you.

00:39:38 - Let me go to you, Mr. Davis, beyond the fact

00:39:41 that I know the community so well,

00:39:45 and you're doing such good work with nurses.

00:39:48 I think people would kind of like to hear

00:39:50 the Oregon secret sauce here.

00:39:52 How did you manage to stay independent

00:39:58 all these years when everybody even,

00:40:00 as we've been talking about in the neighborhood,

00:40:03 is getting gobbled up?

00:40:06 You stayed independent in the face

00:40:07 of increasing consolidation and ownership

00:40:10 by these big corporations.

00:40:11 How'd you do it?

00:40:13 - You know, that's a great question.

00:40:14 It's one I get asked a lot, and honestly,

00:40:16 I ask myself that question often as well.

00:40:19 You know, when you look at us, it shouldn't be the case.

00:40:23 You know, we're one of five independent,

00:40:25 non-governmental hospitals left in the state of Oregon.

00:40:27 There used to be six, and when you look at the geography

00:40:30 that we serve, very isolated, frontier eastern Oregon,

00:40:33 we have a lot of things stacked against us,

00:40:35 and there's a couple things I think add to the secret sauce.

00:40:40 One is, you know, the hospital in LeGrand

00:40:45 was started in 1907 by four local physicians,

00:40:47 and I think whatever they did back in 1907,

00:40:50 that culture and that vision that they set forward

00:40:53 has carried us through today.

00:40:55 I think there's a grit in eastern Oregon

00:40:57 that ties back to the Oregon pioneers,

00:41:00 that we've just had to figure out ways

00:41:01 to solve our own problems, and typically,

00:41:04 when we're asking for help, we're looking for a hand up,

00:41:06 not a hand out, and I think the fact that we're independent,

00:41:11 one of the reasons I think we remain independent

00:41:15 is we have really good governance.

00:41:17 We have a local board of trustees that is dedicated,

00:41:20 committed to the success of the organization.

00:41:23 Our board actually leaves LeGrand once a year

00:41:26 and goes to a conference together

00:41:28 to learn about emerging trends, emerging innovations,

00:41:31 so we can figure out ways to try to bring those back

00:41:33 into our local community, so we can, again,

00:41:36 take care of our local community.

00:41:37 We're a rare breed in the fact that it is local decisions

00:41:41 and local money, and there are some things

00:41:45 that have helped us, strong leadership.

00:41:48 We've had two CEOs now in the last 40 years.

00:41:51 Now, my predecessor was there for 35,

00:41:53 so I can't take credit for a lot of that,

00:41:55 but I bet you there's not many large or small hospitals

00:42:00 in this country that can say they've had two hospital CEOs

00:42:02 in the last 40 years, so stable leadership certainly matters,

00:42:05 not to say that we're perfect, we make mistakes,

00:42:08 but there's been a commitment in leadership

00:42:10 to stay and see the vision and see the care through.

00:42:14 We have a great team of physicians and staff.

00:42:18 Dr. Hunsaker told me when I first arrived in LeGrand

00:42:21 that we fight above our weight class here,

00:42:23 and to me, that is a testament to our medical staff

00:42:26 that they too are committed to drive decisions

00:42:30 and challenge administration in finding creative ways

00:42:34 to provide as much care locally as we can,

00:42:36 and that has carried us through.

00:42:39 And then I would say there are things,

00:42:41 when you're doing good things, good things happen,

00:42:43 and then there's a little bit of luck,

00:42:45 but Oregon certainly being a state

00:42:47 that was an early expansion state for Medicaid

00:42:49 certainly helped, and we know that the data bears out

00:42:52 that the states that did not expand Medicaid,

00:42:55 the majority of rural hospitals that are vulnerable

00:42:57 to closure in this country are in those states.

00:43:00 So I think there's a lot of things

00:43:01 that Oregon has done right,

00:43:03 and then there's a lot of great people in LeGrand

00:43:05 that have gotten us to where we are today.

00:43:08 - You really are a poster child

00:43:10 for the kind of nuts and bolts work we've got ahead of us,

00:43:13 and you're throwing bouquets to everybody in Eastern Oregon,

00:43:16 we wanna throw some your way,

00:43:18 because leadership starts at the top,

00:43:19 and good work, and we're gonna be calling on you.

00:43:21 Senator Lankford is next.

00:43:23 - Thank you, thanks to all of our witnesses,

00:43:26 I appreciate the work very much.

00:43:28 Mr. Topchak, I wanna be able to drill down

00:43:29 with you a little bit, you've been at this for two decades

00:43:31 and getting a chance to be able to research rural hospitals.

00:43:34 We were not dealing with the number

00:43:35 of rural hospital closures three decades ago

00:43:38 than we are now.

00:43:39 So what has shifted in those three decades,

00:43:42 that three decades ago we're opening rural hospitals

00:43:44 and now we're closing rural hospitals, what has shifted?

00:43:48 - Rural hospitals predominantly rely upon

00:43:52 Medicare and Medicaid reimbursements,

00:43:54 and as rural hospitals expenses have continued to climb,

00:43:58 especially recently with the inflationary pressures,

00:44:01 staffing challenges have continued to grow,

00:44:03 new technologies are required to do business today

00:44:07 that didn't exist three decades ago,

00:44:08 all of this is very expensive,

00:44:10 and the reimbursements have not kept up,

00:44:12 I think that's the simple answer.

00:44:13 We see declining reimbursements relative

00:44:16 to the fixed costs of operations.

00:44:18 - What do those reimbursements need to be

00:44:20 for a rural hospital as far as percentage increase

00:44:24 to be able to make the math work for them?

00:44:25 And I know it's gonna be different for different hospitals,

00:44:27 I understand the administrative structure,

00:44:29 so there's not a one size fits all,

00:44:30 but what are we talking about?

00:44:31 - Right, I think it was this committee

00:44:33 under Senator Baucus' leadership

00:44:35 that recognized this low volume problem

00:44:37 and we created a cost-based reimbursement system,

00:44:41 cost-based plus, and over time,

00:44:43 if my consulting peers would suggest

00:44:46 that even at the beginning of that program,

00:44:48 it was probably in the high 90th percentile

00:44:50 of the actual costs of running a hospital,

00:44:53 and today what we hear is it's probably more like 90%,

00:44:56 so what that difference is and how to make up for that,

00:44:59 I think, is something that we would need

00:45:02 to look at more carefully, but your question is spot on.

00:45:04 There's a lack of reimbursement,

00:45:06 and what that gap is, it continues to widen,

00:45:09 as we've seen, 10 years ago, Senator,

00:45:12 when I was looking at this data, a third of rural hospitals

00:45:14 were in the red, and today it's 50%.

00:45:16 - Right.

00:45:17 The challenge has been staffing for rural hospitals.

00:45:20 That's been significant.

00:45:22 There is a new CMS rule that is out right now

00:45:24 dealing with staffing for nursing homes,

00:45:26 which I think disproportionately will hit

00:45:28 rural nursing homes as well in staffing.

00:45:31 Their solution is to increase the quality

00:45:32 of nursing homes, just increase the staffing,

00:45:35 just hire more people to be able to add into it.

00:45:39 The challenge that I have is, obviously,

00:45:40 if they're gonna hire more nurses there

00:45:41 at rural nursing homes, they're gonna come take them

00:45:43 from rural hospitals to be able to get there,

00:45:46 to be able to maintain this.

00:45:47 There's a limited number of people

00:45:49 that are already there to be able to do it.

00:45:51 How do we deal with the staffing issues in rural America,

00:45:54 knowing that the D.C. solution is just,

00:45:57 if there's not enough staff, just hire more people?

00:45:59 How do we deal with that?

00:46:01 - Senator, I appreciate the question.

00:46:02 The entire panel was having a discussion

00:46:04 in the antechamber just before this

00:46:06 about threading that needle and how challenging it is.

00:46:09 I think all of us can get behind additional staffing

00:46:13 and higher quality of care for our seniors

00:46:16 in long-term care.

00:46:17 I'm comforted when I look at the final rule

00:46:20 that there were recognitions of rural challenges

00:46:23 around being in a healthcare professional shortage area

00:46:28 to begin with.

00:46:29 How can we, if we're in a shortage area,

00:46:31 meet these challenges?

00:46:32 But I saw then provisions to give a timeline

00:46:36 that was extended as well as waivers in those cases

00:46:39 where it's not possible.

00:46:41 So on the one hand, threading the needle,

00:46:43 Senator, I like the idea of increased quality of care

00:46:46 for my dad, for example,

00:46:48 but I totally understand that the hospitals whom I serve,

00:46:51 they are now facing an additional burden,

00:46:53 and that's the challenge.

00:46:55 - Yeah, it is a challenge.

00:46:56 When I went through the rule as well,

00:46:57 you've got three years to get there for an urban

00:46:59 and five years to be able to get there for a rural.

00:47:01 I think the challenge is going to be is that

00:47:03 the urban are gonna basically hire as many people

00:47:06 as they possibly can,

00:47:07 and it puts the rule behind then, even farther behind,

00:47:11 because the urban have a faster deadline

00:47:14 to be able to get there.

00:47:16 The other challenge is gonna be the waivers,

00:47:17 as you mentioned before.

00:47:19 If you request a waiver and get it,

00:47:21 you've gotta publicly display that you've got a waiver,

00:47:24 that you're operating under a waiver.

00:47:25 You've gotta tell every future family

00:47:27 that's considering that you're operating under a waiver.

00:47:29 So while you could request a waiver,

00:47:31 it seems like the first step towards closure

00:47:34 to announce that you have a waiver,

00:47:35 because now you're not gonna have families

00:47:36 take you up on it,

00:47:37 'cause they're gonna go, "Okay, you're a problem facility.

00:47:40 "You're operating under a waiver."

00:47:42 So it puts you as a stigma right at the beginning,

00:47:45 which I think would decline even faster there.

00:47:47 So there are some real challenges on the waiver process

00:47:50 that I think actually will lead to more rule closures

00:47:54 than actually more opportunities there.

00:47:56 And time will tell on that,

00:47:57 but that's one I'm hopeful that CMS will actually take up

00:48:00 and to be able to take a harder look

00:48:02 at that same issue on this.

00:48:03 For all of you, I'd love to be able to sit

00:48:05 and visit with you for hours,

00:48:06 'cause we've got lots of questions on it,

00:48:07 but obviously there's a lot of us

00:48:08 that wanna be able to drill down these issues.

00:48:10 Thanks for your testimony and for the time

00:48:12 to be able to put into this.

00:48:13 Thank you, Senator. - Important questions,

00:48:14 Senator Lankford.

00:48:15 Senator Stabenow.

00:48:16 - Well, thank you very much, Mr. Chairman.

00:48:20 And first, let me say to our acting ranking member,

00:48:25 my mom grew up in, born and raised in Oklahoma,

00:48:29 and came to Michigan when she married my dad,

00:48:32 and worked at a rural hospital,

00:48:34 was director of nursing at the hospital where I grew up.

00:48:37 - You're welcome to retire and come to Oklahoma.

00:48:39 (laughing)

00:48:41 - I keep telling her now, though she's 97 years old,

00:48:44 that 42 years in nursing,

00:48:46 she could probably get whatever salary she wanted.

00:48:49 But I grew up around the hospital

00:48:52 and around rural healthcare.

00:48:55 Really appreciate all of your work and what you're doing.

00:49:02 I do wanna say, there's so many different fronts

00:49:06 we need to work on.

00:49:06 Reimbursement is critical, and staffing, and so on.

00:49:10 I mean, there's some good news

00:49:11 around high-speed internet access.

00:49:13 We're pushing to do that so that everywhere,

00:49:17 telehealth available, and there's other things.

00:49:19 We've had a lot of recent good success

00:49:22 on creating behavioral health centers,

00:49:25 certified behavioral health centers,

00:49:27 fully funded under Medicaid,

00:49:29 getting those into rural areas.

00:49:31 That's positive.

00:49:32 But we have a lot of work to do

00:49:34 around what you were talking about today.

00:49:36 And in addition to hospitals,

00:49:37 I just also want to lift up another area

00:49:40 that I've been working a lot on,

00:49:42 and that is our home healthcare sector,

00:49:45 where disproportionately, we have seen cuts and cuts,

00:49:50 and they fall on small home health agencies.

00:49:53 And we've lost more than 1,000 home health agencies so far,

00:49:57 despite huge demand for home health.

00:50:00 So we, and I'm very concerned about what's happening

00:50:04 in rural communities for home health as well.

00:50:06 In my position as chair

00:50:08 of the Agriculture, Nutrition, and Forestry Committee,

00:50:11 I recently introduced our version

00:50:15 of a five-year farm bill,

00:50:16 the Rural Prosperity and Food Security Act.

00:50:19 And I mention this because, important to this hearing,

00:50:22 it makes critical investments in rural health

00:50:27 by expanding access to capital

00:50:29 for rural healthcare facilities

00:50:31 through the Community Facilities Program,

00:50:34 supporting access to distance learning

00:50:37 and telemedicine grants for projects

00:50:40 for behavioral health as well.

00:50:41 And we reauthorize something called

00:50:44 the Farm and Ranch Stress Assistance Program

00:50:47 related to mental health.

00:50:48 And so, Dr. Mueller, I wanted to ask you,

00:50:53 you mentioned the role of USDA's

00:50:55 Community Facilities Program in your testimony

00:50:58 in helping rural hospitals invest

00:51:01 in meeting the needs of patients.

00:51:03 I wonder if you might speak at all

00:51:05 to our efforts to extend the loan and grant flexibilities

00:51:10 in the Community Facilities Program

00:51:12 to allow wards to be used more broadly

00:51:14 for medical supplies, increasing telehealth capabilities,

00:51:19 and meeting staff needs.

00:51:21 And could you speak to the impact

00:51:24 on rural hospitals and why we need

00:51:28 an all, I think, all hands on deck approach,

00:51:31 not just our finance committee,

00:51:32 but in every committee that touches on rural health?

00:51:35 - Thank you for the question, Senator Stabenow.

00:51:39 As Mr. Davis pointed out, it takes a lot of investment

00:51:42 and new technologies to maintain the role of the hospital

00:51:46 and the community, and USDA is vital in doing that

00:51:49 with the communities program, as you mentioned.

00:51:52 I think expanding that into different realms

00:51:55 of utilization that help with the telehealth in particular

00:51:58 and making that readily available is important.

00:52:01 I think associated with that, USDA,

00:52:03 I think it was about two or three years ago now,

00:52:05 started up a technical assistance program

00:52:09 to help those hospitals who have,

00:52:12 as I mentioned in my testimony,

00:52:13 very little administrative core staffing

00:52:16 and analytic capability to come in

00:52:19 with some technical assistance to help them deal

00:52:21 with the new technologies and information systems,

00:52:25 with the new technologies in telehealth,

00:52:27 and with utilizing their information

00:52:30 in negotiation and payment contracting.

00:52:34 I think all of that is important,

00:52:35 and it's good to see that USDA and in the new farm bill

00:52:38 would continue that investment as well.

00:52:41 - Thank you.

00:52:42 Just quickly, Mr. Davis, in looking at all the work

00:52:46 you're doing in nursing and behavioral health

00:52:48 and all the important areas,

00:52:50 during the Affordable Care Act,

00:52:52 I authored a demonstration

00:52:55 for a graduate nursing education program,

00:52:59 and we found that it led to a 54% increase

00:53:02 in advanced practice registered nursing enrollment

00:53:07 and a 67% increase in graduation,

00:53:10 and we'd like to make that permanent.

00:53:11 There's a group of us who have put in legislation

00:53:14 to make a national graduate nursing education program

00:53:19 permanent, and I wonder if you might speak

00:53:21 to that as a possibility.

00:53:25 - Yeah, I think anything that you can do

00:53:27 to stabilize the workforce and create a pathway

00:53:32 instead of extending some of these avenues

00:53:34 would certainly be advantageous for rural hospitals,

00:53:40 'cause we're constantly,

00:53:41 seems like there's always a cliff.

00:53:42 There's something that's being extended,

00:53:44 and we're wondering, is it gonna be extended?

00:53:45 Is it gonna be extended?

00:53:46 And so I think making those things permanent

00:53:48 would certainly free up some of our time

00:53:50 to focus on some of the more mission-critical work

00:53:52 that we have in front of us.

00:53:54 - Thank you, Mr. Chairman.

00:53:56 - I thank my colleague, and so our panel knows

00:53:58 Senator Stabenow has been our leader

00:54:00 on these behavioral health issues.

00:54:01 So as we go forward,

00:54:03 and we're gonna have some opportunities,

00:54:05 and I'm not just talking about the lame duck session.

00:54:07 We've got a lot of healthcare work to do,

00:54:09 so your testimony and presence here today

00:54:12 is very timely.

00:54:12 Next is Senator Grassley.

00:54:14 - Dr. Mueller, we welcome you back to the committee again.

00:54:18 We appreciate your insight on rural healthcare

00:54:22 and keeping in touch with us.

00:54:24 Mr. Chairman, I wanna say,

00:54:27 share your interest in improving maternal and child health.

00:54:31 When I was chairman of this committee,

00:54:33 we sought stakeholder feedback to improve maternal health.

00:54:38 I've also introduced Healthy Moms and Babies Act

00:54:41 with Senator Hassen.

00:54:43 Our bill seeks to improve the economics

00:54:46 of rural labor and delivery units

00:54:49 through a health home model

00:54:52 that makes sure that we're using modern technology

00:54:55 in maternity care and reducing unacceptable rise

00:55:00 of maternal mortality rates.

00:55:03 I hope this committee can work in a bipartisan way

00:55:06 to advance this common sense idea.

00:55:09 Now I go to Dr. Mueller.

00:55:12 Over 600 rural hospitals send benefits,

00:55:17 or we do benefit from K.C. Grassley

00:55:20 Rural Hospital Support Act.

00:55:22 The bill permanently extends the Medicare-dependent hospital

00:55:26 and low-volume hospital programs.

00:55:29 Congress has reauthorized these programs

00:55:32 more than seven times.

00:55:34 We have other rural hospital Medicare programs

00:55:37 that offer flexibility and support for rural hospitals,

00:55:41 but those programs have been made permanent.

00:55:46 Why is it important for there to be flexible

00:55:50 and targeted rural hospital programs under Medicare,

00:55:53 and why should they be made permanent?

00:55:56 - I think it's important to have those programs,

00:56:00 as you've heard today in the testimony,

00:56:01 particularly from Mr. Davis and Mr. Topchik.

00:56:04 The current financial situation for a lot of hospitals

00:56:08 across the country,

00:56:09 including the 85 critical access hospitals in Iowa,

00:56:12 is precarious.

00:56:14 I think the reason to make those programs permanent,

00:56:17 again, Mr. Davis' comments were spot on

00:56:19 just a couple of minutes ago

00:56:20 when he talked about you get to a cliff

00:56:23 of, oh, what's gonna happen now

00:56:25 that the program's gonna run out in two months,

00:56:27 and do I need to start preparing for that?

00:56:28 And you spend valuable, precious management time

00:56:32 trying to work through scenarios

00:56:34 that you shouldn't have to.

00:56:35 You should be able to rely on

00:56:37 what the reimbursement rate will be going forward.

00:56:41 I think we also need to continue to work on

00:56:44 increased flexibility of how the dollars are used

00:56:48 by rural hospitals,

00:56:49 so that you can take some revenue streams

00:56:52 and convert the revenue from direct patient care,

00:56:56 get that funded appropriately,

00:56:58 and have a revenue stream

00:56:59 for some of the new administrative tasks

00:57:01 and the tasks of meeting healthcare needs in the community

00:57:05 through collaborations with community-based organizations.

00:57:09 - Yeah, thank you, Dr. Mueller.

00:57:12 Ms. Rodefeld, CMS is currently distributing

00:57:16 1,200 additional graduate medical education slots.

00:57:21 With the 400 slots already distributed,

00:57:23 I'm very concerned CMS isn't meeting

00:57:27 the rural and underserved thresholds

00:57:29 as required in the 2020 law

00:57:33 that I helped pass when I was chairman of this committee.

00:57:37 When I wrote CMS last year,

00:57:40 they responded that they're meeting the rural threshold

00:57:43 by counting urban hospitals

00:57:46 that are reclassified as rural.

00:57:49 The agency also cited a lack of rural hospital applications,

00:57:54 so my question, are rural hospitals getting a fair look

00:57:58 for additional residency slots,

00:58:01 and what can CMS be doing to help rural hospitals apply

00:58:06 and be competitive?

00:58:07 - Thank you for the question.

00:58:10 I was part of a team that did an analysis

00:58:12 of the round two slot distribution,

00:58:14 and we are seeing that rural hospitals are,

00:58:17 you know, not being prioritized for slots

00:58:21 because of the issue you mentioned

00:58:22 with rural referral centers.

00:58:24 The legislation used the language treated as rural,

00:58:26 which does include those non-geographically rural hospitals

00:58:32 in the distribution of slots.

00:58:35 There are a number of barriers

00:58:37 to getting rural hospitals to apply.

00:58:40 We have a relatively low number of rural residency programs.

00:58:44 I think it's around 150 in 2022,

00:58:48 so when you add in factors

00:58:50 like having to have a HPSA designation,

00:58:52 then that narrows the pool even further

00:58:55 of hospitals that are going to apply,

00:58:57 but I would like to note

00:58:58 that we had one geographically rural hospital

00:59:01 in Wisconsin, Marshfield Clinic,

00:59:03 that has applied in the first two rounds

00:59:05 of slot distributions and has not received slots

00:59:08 because CMS prioritizes based on HPSA designation.

00:59:13 Other hospitals who do not have a HPSA designation

00:59:16 have not applied.

00:59:17 I know I had a program director

00:59:20 in one of our Wisconsin hospitals

00:59:21 with a CMS MIRAS application open just a couple of months ago.

00:59:25 He was eager to apply, expand his program,

00:59:28 and I had to break it to him

00:59:29 that because he's not located in a HPSA,

00:59:31 he can't apply for those slots.

00:59:32 So I think that any future slot distribution

00:59:35 should pay attention

00:59:37 to whether there's a HPSA designation requirement

00:59:39 in order to apply.

00:59:40 I think gatekeeping programs

00:59:43 that are successful out of this process is kind of unfair.

00:59:46 They're still rural hospitals.

00:59:48 They're still doing a great job

00:59:50 in recruiting residents

00:59:52 and retaining them in their communities.

00:59:54 - I also have some questions for the director.

00:59:57 - Thank you, Senator Grassley,

00:59:58 and I just want to note for our guests and the members,

01:00:02 you and I have taken on some big healthcare giants

01:00:05 over the years,

01:00:06 and I think part of this,

01:00:08 and I think you had to be out of the room at the time,

01:00:12 is how can we respond to the changes,

01:00:17 particularly in rural communities

01:00:19 as it relates to healthcare,

01:00:20 and Mr. Topchick and all of our guests have done it,

01:00:24 and at the same time say,

01:00:26 okay, if you're gonna make a commitment to stay

01:00:29 and to work with the community,

01:00:32 you're not just taking the money and running,

01:00:33 and we may be able to give them some extra help.

01:00:36 So very good to have you here

01:00:38 and look forward to working with you.

01:00:39 Senator Cassidy.

01:00:40 - I'm sorry.

01:00:45 Mr. Davis,

01:00:47 everybody's familiar with the change,

01:00:52 the UnitedHealth issue where there's a hack,

01:00:55 and speaking to Andrew Woody, the CEO of United,

01:01:00 he said that they will only have,

01:01:03 if any software is more than two generations old,

01:01:06 so if Windows 15 is the latest version,

01:01:09 anything older than Windows 13 is replaced,

01:01:12 and exploring this with them,

01:01:15 it's my impression, though,

01:01:16 that a lot of rural hospitals would have Windows 5,

01:01:19 and I'm not blaming them.

01:01:23 I'm saying when you have thin margins

01:01:25 with a lousy payer mix,

01:01:27 there's a limit to how much you can put into reinvestment.

01:01:30 So, and frankly, there may not be the people,

01:01:35 if you need somebody on-site to service,

01:01:38 then you need to have people living in a rural community

01:01:41 to service or driving there from someplace else.

01:01:45 Any thoughts about this?

01:01:47 I mean, I was pursuing this,

01:01:51 is this a point of vulnerability for change

01:01:54 that we have people billing from places

01:01:56 that cybersecurity may not be strong?

01:01:58 He assured me that their software

01:02:00 would attempt to intercept that,

01:02:01 but the point is, you see where I'm going with this?

01:02:03 - No, it's a great question.

01:02:05 I think the reality is is that the industry

01:02:09 is heavily reliant on technology,

01:02:11 and so we have to keep up.

01:02:14 We really can't defer upgrading

01:02:17 some of our basic infrastructure

01:02:19 in terms of computing power,

01:02:21 whether it's Windows ME or Windows One or Windows 11.

01:02:25 Obviously, there's a grace period there

01:02:30 of when you update and replace,

01:02:33 but there's so much technology, whether it's imaging,

01:02:35 whether it's nuclear medicine, whether it's cardiac,

01:02:39 that we wouldn't be able to render care

01:02:41 if we did not have adequate infrastructure.

01:02:45 - Now, but, so understand the infrastructure is necessary.

01:02:48 - Yes. - Obviously,

01:02:49 if you don't have an MRI, you can't do an MRI,

01:02:52 but you're gonna have to bill no matter what,

01:02:54 and now everything is billed electronically.

01:02:56 - Right, right. - And so,

01:02:57 what is the general state, do you know,

01:02:59 or perhaps this is a question for Dr. Mueller,

01:03:03 what is the general state, do you know,

01:03:04 of rural hospital cyber infrastructure?

01:03:09 Is it like somebody just resident in the thing

01:03:14 or are they in the cloud?

01:03:15 You see where I'm going with this?

01:03:16 - Sure, sure.

01:03:17 Yeah, well, a couple points.

01:03:19 One is I can tell you that since 2019,

01:03:22 our cyber insurance premiums have gone up by 608%.

01:03:26 - Okay, but I got limited time.

01:03:28 Do you have a sense of, and let me just go to Dr. Mueller.

01:03:30 Dr. Mueller, do you have a sense of what is the kind of

01:03:33 general state of what we've been speaking

01:03:38 in the average rural hospital?

01:03:41 - Frankly, no, but that's something that I'll follow up on.

01:03:44 - Okay, thanks.

01:03:47 Now, next thing, Obamacare,

01:03:50 and we're gonna be revisiting Obamacare next year,

01:03:52 expanded Medicaid, but Medicaid,

01:03:56 absent of a program like UPL or disproportionate share,

01:04:00 when I speak to hospitals, frankly,

01:04:03 it is such a lousy payer,

01:04:06 they can't keep the doors open with it.

01:04:08 And they use 340B to subsidize,

01:04:10 they use other things to subsidize.

01:04:14 And I say that because I was just visiting

01:04:18 some urban hospital in California,

01:04:21 and they were telling me that Medi-Cal pays so poorly

01:04:24 that they're worried.

01:04:28 This is an urban hospital system

01:04:31 that Medi-Cal's paying poorly.

01:04:33 So what advice would you give to us

01:04:36 as we look to reauthorizing some of these programs,

01:04:39 recognizing that there is the essential nature

01:04:43 of an adequate payer mix,

01:04:45 and an adequate payment from that mix

01:04:47 in order to keep hospitals open?

01:04:50 Dr. Davis?

01:04:51 - Yeah, so adequate reimbursement

01:04:54 and stable reimbursement are absolutely critical.

01:04:58 Many rural hospitals have over 60% of their payer mix

01:05:01 is either Medicare or Medicaid.

01:05:03 Obviously, with the UPL, the Medicaid expansion, 340B,

01:05:09 there are a lot of programs that are meant

01:05:11 to help subsidize inadequate reimbursement.

01:05:14 So anything I think that this committee and Congress can do

01:05:17 to pay providers adequate reimbursement

01:05:20 for the cost that it takes to render the service

01:05:24 would be well-received. - Now, you're speaking

01:05:25 to providers, and the hospitals do have those subsidies,

01:05:27 but the physician typically does not.

01:05:29 - Correct. - And so the physician,

01:05:31 if she or he is attempting to do private practice,

01:05:33 say it's gonna be suckin' wind

01:05:35 if you got that kind of payer mix.

01:05:37 Dr. Chokshi, Mr. Chokshi, how would you respond to this?

01:05:41 - I would echo Mr. Davis's comments

01:05:44 in that the mix is problematic to begin with.

01:05:48 You mentioned two primary government payers

01:05:50 that drive rural reimbursements, and they have eroded--

01:05:54 - Medicare and Medicaid driving lower reimbursement.

01:05:56 - Yes, and they have eroded, sir.

01:05:58 - Yeah, and I think we could add CHIP to that, too,

01:06:01 'cause that's usually a Medicaid rate.

01:06:03 I'm almost out of time, how about you?

01:06:05 Thank you. - Thank you.

01:06:06 - Senator Johnson is next.

01:06:08 - Hey, Mr. Chairman.

01:06:09 Mr. Rodenfeld, first of all, welcome.

01:06:11 It's always nice to have witnesses from our home state.

01:06:13 You're familiar with what's happening up

01:06:15 in the Duke Hospital closures in Chippawa Falls and Eau Claire.

01:06:20 I always like to look back in time.

01:06:23 These are hospitals, I've met with their representatives,

01:06:26 I think they've served the community for over 100 years,

01:06:29 and I've met with their representatives just yesterday,

01:06:32 and the description of why they closed

01:06:34 is different than what has been provided here,

01:06:37 and again, I don't dispute your three main points,

01:06:41 but as it was described to me,

01:06:44 what happened is you had private equity-owned hospitals

01:06:47 moving the area, pretty well skim off

01:06:51 the private sector patients,

01:06:53 leaving these hospitals with Medicare and Medicaid patients

01:06:57 that, too low reimbursement, they just simply can't survive.

01:07:01 Is that an inaccurate assessment

01:07:03 in terms of your understanding of what happened there?

01:07:06 - I think the situation up in the Eau Claire region

01:07:09 is very tragic, it's very complicated,

01:07:11 and I know that there's a lot of ripple effects from that.

01:07:15 I know there's private practices

01:07:18 that now can't get privileges at the two health systems

01:07:20 that remain in that region,

01:07:22 but my understanding is that the hospital

01:07:25 that closed in Eau Claire was a safety net hospital,

01:07:27 and reimbursements were a factor in the closure.

01:07:29 I don't know that it was the only factor

01:07:32 in leading to the closure.

01:07:34 Unfortunately, it did lead to the closure

01:07:35 of two residency programs,

01:07:37 one rural track in Augusta and another in Eau Claire,

01:07:40 so that's been a really significant hit for the workforce

01:07:43 in northern Wisconsin as well,

01:07:45 so again, really sad to see that hospital closure

01:07:49 because they were meeting a huge need.

01:07:52 - So there are always multiple factors

01:07:54 in just about anything, but again,

01:07:56 as the representatives related to me,

01:07:59 that was the primary factor right there,

01:08:01 is the private equity hospitals skimming off

01:08:05 the private sector patients and leaving them

01:08:08 with government-run healthcare reimbursements,

01:08:11 and that's the point.

01:08:12 I mean, we need to take a look at this.

01:08:14 The model for rural healthcare, rural hospitals worked

01:08:17 for 100 years up to point something changed.

01:08:23 You know, one thing I've been encouraged by,

01:08:26 'cause this is not just about rural hospitals,

01:08:28 this is about rural healthcare,

01:08:30 is the growth in direct primary care

01:08:35 operations or clinics, and there's over 2,300 nationally,

01:08:40 there's 86 in Wisconsin, I've visited some of them.

01:08:43 I will say that the healthcare providers,

01:08:46 the doctors and nurses, really enjoy it.

01:08:48 What happens here is they just opt out of Medicare,

01:08:54 so they're not subject to all the rules,

01:08:56 all the regulations, they charge really reasonable prices.

01:09:00 I think it's somewhere between $50 to $100 per month

01:09:03 subscription fee, I know when I was there

01:09:05 a couple years ago, it was $55 for a half-hour visit.

01:09:08 Now, they don't have all the resources,

01:09:10 they need hospitals for testing, that type of thing.

01:09:13 But some combination of clinics that are kind of

01:09:18 outside the system that aren't harmed by the system,

01:09:23 aren't harmed by all that, together with trying

01:09:25 to figure out some way to get control

01:09:30 of our financing system, but just comment

01:09:32 just in terms of these direct primary care,

01:09:35 are you familiar with them in Wisconsin,

01:09:37 and does your hospital system,

01:09:39 do they cooperate with these?

01:09:41 - So I don't work for a hospital system any longer,

01:09:43 but I know, I'm familiar with many direct

01:09:46 primary care practices, and it does simplify everything,

01:09:51 and it's not just Medicare and Medicaid,

01:09:53 it's also working with private insurance,

01:09:55 and the paperwork, pre-authorizations.

01:09:58 There's a lot of things we need to address

01:10:00 within healthcare, beyond government payments,

01:10:04 the insurance companies also do require a lot

01:10:08 of our primary care physicians,

01:10:09 whether they're in private practice or not.

01:10:13 - The reason I keep bringing this up is,

01:10:15 I want the committee to think outside the box,

01:10:19 kind of travel back in time, and take a look at,

01:10:22 it worked then, what's changed?

01:10:24 Maybe the solution is to kind of go back

01:10:27 to the way things operated back then,

01:10:29 when doctors were independent, instead of 80% employed,

01:10:34 when you didn't have all these rules and regulations,

01:10:36 where government-run healthcare didn't drive

01:10:38 the entire bus, in terms of reimbursement rates,

01:10:41 and just how to practice medicine.

01:10:45 And again, that's what I suggest to the committee members,

01:10:47 is take a look at some of these models,

01:10:49 and think innovatively, is there some way

01:10:51 we can integrate this, because in these hearings,

01:10:54 we're always hearing, one of the solutions

01:10:56 is we have to increase competition,

01:10:59 but then nobody ever talks about how

01:11:01 to actually increase competition,

01:11:02 it's always about a new government program,

01:11:04 or a new grant program, which again,

01:11:06 I realize free federal money is great,

01:11:08 it just doesn't solve the problem,

01:11:10 I would argue it oftentimes exacerbates the problem.

01:11:12 So anyway, appreciate you coming here,

01:11:14 appreciate the testimony, thank you, Mr. Chairman.

01:11:16 - Thank you, Senator Johnson.

01:11:17 Senator Whitehouse is next.

01:11:19 - Thanks very much, Chairman,

01:11:20 thank you to the panel for being here.

01:11:23 Dr. Mueller, you talked about ACOs in your testimony,

01:11:29 and we're looking at changing the rules

01:11:34 for prior authorizations to essentially bar

01:11:39 prior authorizations requirements with respect to ACOs,

01:11:47 as long as the ACOs are operating effectively,

01:11:51 unless they go to CMS and get prior authorization

01:11:58 to have a prior authorization,

01:12:00 because it strikes me that in a fee-for-service system,

01:12:03 there is a danger to the payer of a medical practice

01:12:09 trying to run up bills by doing the most expensive

01:12:14 treatments and doing additional unnecessary treatments.

01:12:20 So one can argue that prior authorization

01:12:22 in that fee-for-service environment

01:12:24 is a necessary check on the behavior

01:12:27 of the provider.

01:12:29 We can argue that,

01:12:30 but at least it's a proposition out there.

01:12:32 To me, the proposition completely evaporates

01:12:35 when you're dealing with an ACO

01:12:36 or other value-based care model

01:12:38 where the doctor on the ground making the decisions

01:12:42 about the patient's care is just as motivated

01:12:44 to not engage in unnecessary and excessive expenditure

01:12:50 as the insurer.

01:12:52 And I'd be interested in your comment

01:12:55 on what sense it makes

01:12:58 to allow prior authorization requirements

01:13:00 for providers operating successfully in the ACO model.

01:13:04 - That's a great point.

01:13:07 And I like the way you phrased it,

01:13:09 the larger value-based payment arena

01:13:12 in which you're trying to change the incentives

01:13:14 for everyone, including the providers,

01:13:17 so that they understand if they add an additional procedure

01:13:21 that's going to cost more

01:13:22 and they'll exceed expenditure targets

01:13:24 and they'll have to pay back.

01:13:25 So they do have the incentives

01:13:27 to keep the utilization down.

01:13:30 So I think that's an appropriate way

01:13:33 to begin to think about,

01:13:34 we don't need to have prior authorization.

01:13:36 That would also create, frankly,

01:13:38 as a researcher in my mind,

01:13:40 I'm thinking that would be a great source of data then

01:13:43 for us to investigate what happened

01:13:45 when you lifted prior authorization as a requirement.

01:13:49 Did utilization spike up or not?

01:13:52 And did appropriate utilization remain in place?

01:13:55 I'm with you, I believe it would work.

01:13:58 - Not to mention an inducement and a reward

01:14:01 for particularly primary care practices

01:14:04 that go through the ordeal of becoming an ACO

01:14:08 and setting up their systems to report that way

01:14:12 and change their business model to operate that way.

01:14:15 So I hope we can get that done

01:14:18 and appreciate your thoughts on it.

01:14:20 - Okay.

01:14:21 Is it Dr. Davis?

01:14:23 Mr. Davis, I can't see, Mr. Davis.

01:14:25 I wanted to ask you about telehealth.

01:14:29 We're working on a bill, it's called the Treats Act

01:14:33 that would extend the ability that we created

01:14:37 during the COVID pandemic

01:14:39 for patients with opioid disorder

01:14:42 to get treatment and prescriptions via telehealth.

01:14:48 Makes perfect sense, seems to have worked very well.

01:14:51 It is expiring.

01:14:52 Could you comment on whether letting it expire

01:14:55 is a good idea and how the access to telehealth

01:15:00 is of particular advantage to patients in rural communities?

01:15:06 - Yeah.

01:15:07 No, I think anything that we can do to extend

01:15:10 the waivers and flexibilities around telehealth

01:15:12 would be a godsend.

01:15:16 Especially, I would say payment parity.

01:15:19 There's a significant pay discrepancy

01:15:21 between an in-person visit versus a telehealth appointment.

01:15:24 I know early on in the pandemic,

01:15:26 you probably could have heard a collective sigh of relief

01:15:28 when we saw that we were gonna be able to get paid,

01:15:31 the same for a telehealth visit,

01:15:33 as well as an in-person visit.

01:15:35 And then in terms of behavioral health,

01:15:37 substance abuse disorder, absolutely.

01:15:39 There's a shortage of behavioral health specialists

01:15:41 across this country.

01:15:43 So leveraging technology,

01:15:45 and we've also found that a lot of these patients

01:15:48 are more comfortable reaching out and seeking these services

01:15:52 when they're able to do it

01:15:53 from the comfort of their own home.

01:15:54 - I am really glad to hear you say that

01:15:57 because that is the exact same thing I have heard

01:16:00 from the treatment and recovery community in Rhode Island.

01:16:05 They did not expect that, Mr. Chairman.

01:16:07 They expected that when they got access to telehealth,

01:16:10 that would solve the COVID exposure problem,

01:16:15 and that there would perhaps be more

01:16:18 utilization of services, which in fact there was,

01:16:20 which is a good thing in that environment.

01:16:23 What they did not expect,

01:16:24 but what they've told me over and over again

01:16:26 they experienced is that the content

01:16:29 of the engagement actually improved

01:16:34 because the patient did not have to drive across town,

01:16:38 sit in the stupid waiting room,

01:16:39 fill out the stupid clipboard,

01:16:42 go into an alien office,

01:16:44 and then share what's going on with themselves.

01:16:48 They could do it from the comfort and security

01:16:50 of their own home.

01:16:51 So thank you for bringing that up.

01:16:52 Well said.

01:16:53 - Thank you, Senator Whitehouse.

01:16:55 And Senator Whitehouse, as usual,

01:16:56 is talking about important healthcare reforms,

01:17:00 and I just want to note,

01:17:01 we touched on it a little bit earlier.

01:17:04 When Senator Whitehouse talks about using

01:17:07 the COVID model for telemedicine,

01:17:10 and Senator Warner knows this,

01:17:11 the Senate basically used our model,

01:17:15 the Finance Committee's model from the Chronic Care Bill,

01:17:18 and plugged it in to what we did for COVID.

01:17:20 So we've got a lot of history,

01:17:22 and I look forward to hearing more about what you're,

01:17:24 you call it TREATS?

01:17:26 Great, good name.

01:17:28 Okay, Senator Barrasso next.

01:17:30 - Thank you, Mr. Chairman.

01:17:31 Dr. Mueller, in Wyoming,

01:17:34 our medical school works in partnership

01:17:36 with the University of Washington,

01:17:37 along with Montana, Alaska, Idaho,

01:17:39 you know, the WAMI program.

01:17:41 And what we find out is that giving students

01:17:43 rural experience and residents rural experience

01:17:46 helps them recognize early in their career

01:17:48 the benefits of working in rural clinics,

01:17:50 hospitals, hopefully then moving there

01:17:52 and practicing there full time.

01:17:54 I think it's an encouraging,

01:17:56 it's a great recruitment tool if they have that experience.

01:18:00 So research shows residents are more than five times

01:18:03 more likely to then go on and practice

01:18:05 in a rural community if their residencies

01:18:07 are in those type communities.

01:18:09 And I see, Mr. Rodfel, you agree and complete,

01:18:11 and I'm gonna have a question for you soon

01:18:12 about OBGYN in some of these areas.

01:18:15 You know, that's why I've introduced legislation

01:18:19 called the Rural Physician Workforce Production Act

01:18:21 to provide additional funds to rural hospitals

01:18:24 that train residents.

01:18:25 Right now, so much of the funding goes

01:18:27 to the larger community, the large city hospitals,

01:18:29 not the rural experience.

01:18:31 So how could a sustainable resident payment model

01:18:34 for training in rural areas,

01:18:36 and this is political, but it's bipartisan,

01:18:40 'cause if you're a senator from,

01:18:42 whether you're Republican or Democrat,

01:18:44 you're from a state that has a lot of rural areas.

01:18:47 You want to get doctors into those areas.

01:18:50 So how could a program like this,

01:18:52 this model for training in rural areas,

01:18:55 actually help training programs be more viable

01:18:57 in those locations?

01:18:58 - You hit on the answer as part of the question,

01:19:04 Senator Barrasso, in that getting that additional funding

01:19:08 is, would put a lot of the rural hospitals

01:19:10 sort of over the threshold of being able

01:19:13 to implement the program.

01:19:15 The next step would be to find a way

01:19:17 through the GME funding streams

01:19:20 to have funds flow directly to those hospitals

01:19:24 for those programs, rather than having to flow

01:19:27 through a teaching hospital,

01:19:29 which then allocates out to the rural.

01:19:31 So the direct expenditure from GME

01:19:34 would be very helpful.

01:19:35 - And Ms. Ruffo, could I go next to you?

01:19:37 In Wyoming, due to financial strains

01:19:39 and workforce shortages, maternity services are closing,

01:19:42 and you're an expert in this area.

01:19:44 Five of our counties have lost maternity services entirely.

01:19:47 Seven others have minimal access to care.

01:19:50 And it's leaving only 11 of our 23 counties

01:19:53 with adequate access to OB services.

01:19:56 Now just for reference, every single county in Wyoming

01:19:59 is larger than the entire state of Delaware

01:20:00 or the entire state of Rhode Island.

01:20:03 Some of our counties are larger than Connecticut,

01:20:05 larger than the state of New Jersey.

01:20:07 So can you imagine if the entire state of Delaware

01:20:10 or Rhode Island or New Jersey

01:20:13 lost all of their OB services?

01:20:15 You know, it would be on the front page of every paper.

01:20:18 So what I would like to talk to you

01:20:19 as the expert you are is how we can address this crisis.

01:20:22 It's a matter of health and economic viability

01:20:25 for rural America.

01:20:26 If you can't provide opportunities to deliver babies,

01:20:28 harder to recruit teachers,

01:20:31 people in small businesses, all of those things.

01:20:33 You really were successful, I thought, in Wisconsin

01:20:35 in crafting that residency program

01:20:37 to be a tool to addressing rural access.

01:20:39 So on the federal level, can we mirror the access

01:20:43 and the success that you've had?

01:20:45 - Yeah, I think maternity care is a huge issue.

01:20:48 It's an issue in Wisconsin.

01:20:49 I think we have 13 OB units that have closed

01:20:52 within the past 11 years.

01:20:53 So we are right up there with you in your state.

01:20:58 But I would say that we need to get

01:21:01 family medicine residents OB experiences

01:21:05 and encourage and nurture their interest in performing OB.

01:21:10 I will say in smaller hospitals, in smaller settings,

01:21:12 it is hard to be a physician of one

01:21:16 providing service to a community.

01:21:19 I know how difficult it can be if, you know,

01:21:21 you wanna take a vacation, who's gonna cover,

01:21:23 who's gonna deliver your babies for you?

01:21:25 Similarly, there is a dearth of OB/GYN

01:21:29 rural residency programs.

01:21:30 We have one in Wisconsin.

01:21:32 I believe that there's three others across the country.

01:21:35 But I think that hope is on the way.

01:21:36 I've talked with many hospitals that are looking at,

01:21:40 you know, creating rural track.

01:21:41 Section 127 of the Consolidated Appropriations Act

01:21:45 does allow for compliment increases.

01:21:48 And I think it's educating, you know,

01:21:51 educating OB programs that this is possible,

01:21:53 that you can, you know, do a compliment increase.

01:21:55 You can add one extra resident

01:21:56 and give them 50% of training time in a rural area,

01:21:59 which we know leads to future rural practice.

01:22:03 But again, it's not a one-size-fits-all approach.

01:22:05 We've also launched two OB fellowships in Wisconsin.

01:22:08 But that has been a long time in the works.

01:22:10 And it's not gonna get us exactly where we need,

01:22:13 but we need to support those physicians

01:22:16 who have an interest in OB and provide strong mentorship.

01:22:19 Because I think one barrier I've seen with, you know,

01:22:22 new grads from any OB program is that

01:22:24 if they're the only provider in a hospital,

01:22:26 that's very scary if you aren't as experienced.

01:22:29 - A final question for Mr. Davis.

01:22:31 Good to see you again.

01:22:32 Welcome back to, welcome to Washington.

01:22:34 You went to county where you were in Evanston.

01:22:36 I was there for the health fair many times in Evanston,

01:22:38 as well as the Uinta County Health Fair

01:22:40 at Bridger Valley just two weeks ago.

01:22:42 So I'm there in the community a lot.

01:22:45 As you know, rural hospitals,

01:22:46 clinics across the country are closing

01:22:48 at a higher rate than urban hospitals.

01:22:50 Patients are forced to travel greater distances.

01:22:52 You know, I think that telehealth has helped,

01:22:54 but how else can we strengthen rural care

01:22:56 so patients are not forced to drive hours for care?

01:23:00 - Yeah, so you hit the nail on the head.

01:23:02 Obviously, expanding telehealth

01:23:03 and making some of the flexibilities we had,

01:23:05 making those permanent would be a huge help.

01:23:08 Again, I think recruitment incentives would be very helpful.

01:23:14 Many of these providers have significant student loan debt.

01:23:17 I heard HPSA scores were brought up.

01:23:20 Having that maybe re-evaluated.

01:23:22 And then just adequate reimbursement.

01:23:24 You know, we've seen significant increases

01:23:29 in wages and compensation to keep up, to retract.

01:23:34 And it's a challenge.

01:23:36 So reimbursement would be a big help.

01:23:38 - Thank you, Mr. Chairman.

01:23:40 - Thank you, Senator Barrasso.

01:23:41 And you hit the key question,

01:23:43 which is how we can find new ways to create incentives

01:23:46 to strengthen these rural communities.

01:23:48 We'll want to talk with you.

01:23:49 Okay, Senator Bennett's next.

01:23:51 - Thank you, Mr. Chairman.

01:23:52 Thank you all for being here today.

01:23:55 When you get toward the end of the dais,

01:23:57 some of your questions have been asked already,

01:23:59 but I hope that this one has not.

01:24:02 In Colorado and across the country,

01:24:04 we're seeing entire swaths of rural counties

01:24:09 that have no obstetrics care of any kind,

01:24:14 no mental health care of any kind.

01:24:16 People coming out of COVID have used telehealth,

01:24:20 I think, in ways that has been useful,

01:24:22 but it doesn't replace having people

01:24:27 in your community doing this.

01:24:28 And increasingly, Ms. Redfield,

01:24:31 a barrier in Colorado seems to be housing,

01:24:36 places where people just cannot afford

01:24:39 to live in rural parts of the state.

01:24:42 Providers are becoming housing deliverers

01:24:47 because otherwise there's no housing for them.

01:24:51 Regions in places like the San Luis Valley in Colorado,

01:24:55 which used to be competitive, Alamosa, Colorado,

01:24:57 it was an advantage that real estate was inexpensive there.

01:25:02 Today, they have a hard time hiring doctors

01:25:06 to say nothing of something like the Roaring Fork Valley

01:25:09 between Aspen and Glenwood Springs

01:25:11 where people commonly say to me,

01:25:13 no doctor can afford to live there.

01:25:15 So I wonder if you could say a word about that.

01:25:18 I'm sorry if I mispronounced your name, Rodfield.

01:25:20 If you could say a word about that,

01:25:22 I'd really appreciate it.

01:25:23 - Yeah, we are absolutely seeing issues with housing

01:25:26 and that doesn't just impact physicians, nurses,

01:25:30 it also impacts the ability of rural residencies

01:25:32 to train and recruit their graduates.

01:25:36 I will say the rural hospital that I worked at

01:25:38 prior to coming into my position

01:25:42 did own several houses and did explore ways

01:25:45 that they could build their own housing for their workforce.

01:25:48 And I think any innovation where you can provide

01:25:51 some type of affordable housing,

01:25:53 especially for those lower wage positions

01:25:55 like medical assistants,

01:25:57 folks that work in the cafeteria,

01:26:01 they need affordable housing as well.

01:26:03 I'm impressed when I work with rural hospitals

01:26:07 launching residency programs,

01:26:08 so they've been very successful in fundraising.

01:26:11 In fact, one of the grantees that I work with

01:26:14 has actually been able to secure private funding

01:26:17 so they were able to purchase houses

01:26:18 for the new residents coming to their hospital

01:26:21 and that's a huge relief for those incoming residents

01:26:24 when they can know they have a place to live

01:26:26 and they don't have to search for a home.

01:26:28 And again, I think looking at other creative strategies,

01:26:31 I don't know if Dr. Mueller is familiar

01:26:33 with anything with USDA,

01:26:35 any infrastructure development that rural hospitals

01:26:39 could use to further build housing for their workforce

01:26:41 could be helpful.

01:26:43 - I've got a couple minutes left, Dr. Mueller,

01:26:44 would you like to use some of that?

01:26:46 And I think, Mr. Davis, you may have some experience

01:26:49 building housing for teachers,

01:26:51 so it'd be good for us to hear that too.

01:26:53 - I think that was a great summary.

01:26:55 I would just add two things to that.

01:26:57 One is there has been some creative use of Medicaid waivers

01:27:01 around the country to be able to use

01:27:03 some of the federal match in Medicaid

01:27:05 to address housing issues,

01:27:08 predominantly because when patients are discharged

01:27:11 from hospitals, if they're discharged into a homeless status

01:27:14 then they're right back in the hospital later.

01:27:17 So using some of our payment

01:27:20 through the health payment system

01:27:21 to address that is useful.

01:27:24 The other comment is whatever the investment sources

01:27:27 might be, and USDA is one, through their programs,

01:27:30 housing and urban development is one,

01:27:32 state governments and philanthropy are all

01:27:36 stepping up to the plate in isolated examples

01:27:39 that I'm aware of around the country.

01:27:41 If we could learn from those,

01:27:42 try to expand that to more communities.

01:27:45 - Yeah, I never, when I got into healthcare administration,

01:27:48 never thought I'd be managing houses.

01:27:52 And I think we've got 10 or more leases,

01:27:55 and one of the things that I think is a really neat

01:27:57 private partnership with the local school district

01:28:00 is they noted there was a shortage of tradespeople

01:28:04 that do this type of work,

01:28:05 and so they developed a CTE program.

01:28:08 We had a need for workforce housing,

01:28:09 so we agreed to buy those initial set of townhomes.

01:28:13 So they had the reassurance that those are gonna be sold,

01:28:15 they could use that funding to then perpetuate that program.

01:28:18 So we view it as a really, kind of almost

01:28:20 as a community benefit, that as we get

01:28:22 an intrinsic value out of it for our workforce,

01:28:27 but it also is investing in these young kids,

01:28:29 and hopefully creates a pipeline,

01:28:31 and helps housing construction accelerate

01:28:35 in the community in the future.

01:28:37 - Thank you, thank you, Mr. Chairman.

01:28:39 - I thank my colleague.

01:28:41 Next is Senator Carper.

01:28:42 We also have a vote on, and I think that we can get

01:28:45 all of the people here today, right here now,

01:28:50 in before we see the vote closed.

01:28:53 We'll have to see who else arrives,

01:28:55 but that's gonna be the goal.

01:28:56 Senator Carper.

01:28:57 - Thanks, Mr. Chairman, welcome.

01:28:58 I think I had a chance to shake your hands,

01:29:00 and welcome you here earlier this morning.

01:29:03 So we're glad you're still sticking around,

01:29:06 and I'll have a chance to ask you some questions.

01:29:09 In 2020, in response to COVID-19 pandemic,

01:29:14 CMS implemented what they call

01:29:16 the Acute Hospital Care at Home Waiver Program.

01:29:21 You may be familiar with that.

01:29:22 The program permits Medicare beneficiaries

01:29:25 to receive hospital-level services

01:29:28 in the comfort of their own home,

01:29:30 which is really what people prefer to do,

01:29:32 as you probably know, to allow patients and providers

01:29:35 continued access to the hospital at home program,

01:29:38 and last Congress, Senator Tim Scott and I championed

01:29:42 legislation that extended the hospital at home program,

01:29:46 waiver program, for two years beyond the duration

01:29:49 of the COVID-19 public health emergency.

01:29:53 Since then, this healthcare delivery system

01:29:56 has not only benefited patients

01:29:58 by making hospital-level care more accessible,

01:30:02 it's also been shown to do a number of things

01:30:05 that we all should seek, and one of those is reduce cost.

01:30:08 Another is to improve patient outcomes,

01:30:10 and a third is to provide high patient satisfaction.

01:30:14 That's like a hat trick.

01:30:15 Today, hospitals and healthcare systems

01:30:19 across I think 36 or 37 states,

01:30:22 including my own home state of Delaware,

01:30:24 utilize the hospital at home program

01:30:27 to provide safe, high-quality,

01:30:29 hospital-level services in patients' homes.

01:30:33 Currently, the hospital at home program

01:30:35 is set to expire in this country at the end of this year.

01:30:39 I just believe, Senator Scott believes

01:30:41 we cannot allow this to happen.

01:30:43 To ensure that Medicare beneficiaries

01:30:45 and their healthcare providers

01:30:47 have the certainty and stability they need

01:30:49 for this important care delivery option,

01:30:52 this week, Senator Tim Scott and I introduced

01:30:56 the Hospital and Patient Service Modernization Act of 2024.

01:31:00 The bipartisan legislation would further extend

01:31:03 the hospital at home waiver program for another five years.

01:31:07 As we knew, rural communities face an abundance

01:31:11 of access and quality of care issues,

01:31:14 hold alternative care delivery models like hospital at home,

01:31:20 hold potential to improve healthcare delivery

01:31:22 in rural communities.

01:31:24 Question for Mr. Topchak, colleagues, Mr. Topchak.

01:31:27 Love that name.

01:31:28 Could you please share with us

01:31:32 how the hospital at home program

01:31:34 has been beneficial to patients in rural areas, please?

01:31:38 - Senator, thanks for that and all your work

01:31:40 on the issue of hospital at home.

01:31:41 I think it is an innovative model

01:31:43 and it is proving out across the country.

01:31:47 This movement to provide a relief valve

01:31:50 and the provision of high-quality care at lower costs

01:31:53 and keeping patients at home

01:31:55 is so, I think, valuable to the patients.

01:31:57 And in rural areas, that's such a challenge,

01:32:00 keeping patients home instead of traveling great distances.

01:32:03 I think the tension here in rural areas is workforce

01:32:06 and it's the volume and the scale.

01:32:09 But I know there are experiments going on right now

01:32:11 with rural hospital at home programs

01:32:14 and I really look forward to seeing how they play out.

01:32:17 - Well, I'm gonna ask you another question for the record

01:32:19 and that is how do we as policy makers

01:32:22 address these barriers, including workforce?

01:32:24 I think it's an important point.

01:32:25 We'll ask you to respond for the record.

01:32:28 - I'm sorry, how do we directly--

01:32:30 - No, no, no, we'll ask you to respond

01:32:31 for the record in writing, okay?

01:32:33 - Okay, thank you. - Yeah, there you go.

01:32:35 When I visit healthcare facilities up and down Delaware,

01:32:38 I ask three questions.

01:32:39 I ask 'em, and I do it every day.

01:32:42 We go home, we'll finish up here later today.

01:32:44 I'll go home, tomorrow I'll be all over the state.

01:32:45 I visit businesses large and small.

01:32:47 And I ask them three questions.

01:32:48 How are you doing?

01:32:49 How are we doing?

01:32:50 Our congressional delegation, the Congress, and so forth.

01:32:53 And what can we do to help?

01:32:55 The biggest challenge I hear about consistently,

01:32:57 now for not just weeks, months, but for years,

01:33:01 has been workforce.

01:33:02 You know, having people show up for work

01:33:06 that are either trained or are trainable

01:33:08 and who are willing and ready to do a day's work.

01:33:10 But the challenge is amplified in more rural counties.

01:33:14 We have two rural counties,

01:33:16 and we have three counties in Delaware,

01:33:17 the southernmost county is a very rural county.

01:33:19 And throughout, we have that challenge

01:33:22 throughout the healthcare industry.

01:33:24 Two of Delaware's healthcare counties

01:33:26 are considered health professional shortage areas.

01:33:30 We simply don't have enough healthcare providers

01:33:32 choosing to practice in these rural communities.

01:33:35 It's critical that our rural communities

01:33:38 are able to recruit and retain a qualified workforce

01:33:41 to ensure patients have access to high quality care.

01:33:44 And I have one last question.

01:33:46 And Mr. Davis, this would be for you, please.

01:33:48 What have you learned from the healthcare facilities

01:33:51 that are doing well at recruiting and retaining staff?

01:33:55 What did you learn from those?

01:33:57 If I know it works, do more of that.

01:33:59 - I think in terms of workforce training,

01:34:02 doing good onboarding, training programs,

01:34:06 we do a lot of leadership development.

01:34:08 Our strategic plan that we just adopted,

01:34:11 we're gonna be investing a lot in our middle management

01:34:12 to kind of grow our own.

01:34:14 At one point, we had 220 open positions during the pandemic.

01:34:18 So we were kind of up against the ropes.

01:34:20 And thank goodness for our workforce and our staff,

01:34:23 we've clawed back, and now we're back

01:34:25 to about 60 open positions, which is kind of pre-pandemic.

01:34:28 And it's just continuing to create a culture

01:34:31 and an organization that people wanna be a part of.

01:34:35 - As much as I agree with Senator Carper,

01:34:37 we're gonna have to move on to get everybody in.

01:34:38 Senator Warner.

01:34:40 - Thanks to all of you.

01:34:41 - Thank you, Mr. Chairman.

01:34:42 I wanna echo what Senator Bennett said.

01:34:43 Sometimes you're into the dais,

01:34:46 your question's been asked.

01:34:47 I do wanna mention the fact that I thought

01:34:51 Senator Whitehouse was doing such a good job on telehealth

01:34:54 and raising the important issue

01:34:56 of how telehealth actually did with opioid abuse

01:34:58 and the notion that we can use this tool

01:35:01 in a dramatic way for things like suboxone

01:35:05 and there were no abuses.

01:35:08 I said, boy, how is he so smart?

01:35:09 And my staff said, well, actually,

01:35:12 you and he are working together as co-leads on that bill.

01:35:14 So I was glad to be informed that we were jointly smart.

01:35:18 And in that same context, Senator Barrasso's comments

01:35:22 about the lack of OBGYNs.

01:35:24 I mean, in my state, in the Commonwealth of Virginia,

01:35:28 we've got the area between Richmond

01:35:29 and North Carolina border, it's called Southside.

01:35:31 We've had five OBGYN practices leave hospitals

01:35:35 and we have a wide swath, maybe not as big as New Jersey,

01:35:38 but a wide swath of our state

01:35:40 where people literally have to travel hours and hours.

01:35:42 And that's why, Mr. Chairman,

01:35:44 I'm glad that you and I and others

01:35:46 are going to introduce the labor and delivery support

01:35:50 to try to increase the Medicaid reimbursement issue.

01:35:55 I think one that maybe not has been asked,

01:35:57 and this is for Dr. Mueller,

01:35:58 is the questions around pharmacy services.

01:36:02 Again, one of the things that we saw during COVID

01:36:06 was better utilization by pharmacies

01:36:11 of things like COVID tests, tests for flu, for strep.

01:36:16 And in Virginia, we have been pretty good

01:36:20 about trying to look at the evolving nature

01:36:23 of pharmaceutical services

01:36:24 and the fact that pharmacists are now providing

01:36:27 a lot of services that they used to have to go

01:36:29 to either an actual provider or an urgent care center.

01:36:34 The thing is, we've worked on employer plans,

01:36:38 we've worked on Medicaid,

01:36:39 but those Virginians on Medicare

01:36:41 can't get the reimbursement through the pharmacy.

01:36:44 Dr. Mueller, you wanna make a comment on that?

01:36:48 - I think you're correct that that set of services

01:36:52 is critical and available in a lot of rural communities

01:36:56 only through the pharmacy, as you point out.

01:36:58 And we did some early work during the pandemic

01:37:00 to call attention to that

01:37:02 when it came to distribution of vaccines,

01:37:04 that the only way to get that out

01:37:05 across all of rural America was to get it out

01:37:07 through the local independent pharmacies.

01:37:10 So everything that we do in reimbursement policy,

01:37:13 including Medicare, the gap that you mentioned,

01:37:16 is something that we need to pay attention

01:37:18 to keep that vital service there.

01:37:21 And to point out, finally, that the pharmacy service

01:37:24 is part of the health team.

01:37:26 And to think of it that way, rather than only,

01:37:29 well, that's just dispensing drugs.

01:37:30 No, there's a lot more to the local pharmacy services.

01:37:34 - Yeah, I think it is, again, a lesson learned from COVID

01:37:38 that we oughta continue.

01:37:39 And if we've got employers,

01:37:41 if states are using their Medicaid plans,

01:37:43 I again hope we can work on that reimbursement on Medicare.

01:37:47 I wanna raise one other,

01:37:48 shall stick with you, Dr. Mueller, on this.

01:37:50 Something that I think has been indirectly talked about

01:37:55 a lot is how we make sure we keep rural hospitals

01:37:59 alive and vibrant.

01:38:00 I was proud that we, in Virginia,

01:38:02 were actually, after seven years, six years,

01:38:05 able to reopen one of our most rural hospitals

01:38:08 in far southwest Virginia, Lee Hospital.

01:38:11 But working with my colleague Senator Blackburn,

01:38:13 we have introduced for a number of years

01:38:16 what we call the Save Rural Hospitals Act,

01:38:18 which would try to go ahead and look at the

01:38:22 average wage index and bump it up

01:38:25 to a base minimum across rural communities.

01:38:28 And I think what we've seen,

01:38:30 particularly for MedPAC, is that we've carved out

01:38:34 so many exemptions in that formula

01:38:37 that I just really question whether it's working.

01:38:42 I obviously, for the rural hospital standpoint,

01:38:44 and before Senator Blackburn,

01:38:46 I worked with Senator Lamar Alexander on this,

01:38:48 our rural hospitals gotta have that minimum floor

01:38:50 or they're not gonna be able to compete.

01:38:51 But maybe we should just go ahead and look at this whole

01:38:55 tool, which frankly, in many ways,

01:38:58 I think has been so chopped up and carved out

01:39:01 that it doesn't meet basic needs.

01:39:04 And I know the whole panel would like to weigh in,

01:39:06 but I'm gonna stick with you, Dr. Mueller,

01:39:07 to try to make sure that I adhere

01:39:09 to the chairman's five-minute rule.

01:39:11 - Quick answer, yes.

01:39:13 We should be looking at the wage index issue

01:39:15 with what you have in mind of,

01:39:18 are we doing it the right way?

01:39:19 And then secondly, why are we doing it?

01:39:21 Why are we saying that there's such variability

01:39:23 in that when we're hearing about the cost

01:39:26 of workforce recruitment and retention?

01:39:28 - And Mr. Chairman, I am more than willing

01:39:31 to wave back my remaining 11 seconds.

01:39:34 So Senator Hassan, who's been so patient,

01:39:36 gets her, or whoever's next.

01:39:37 - Collegial as always.

01:39:40 Thank you, Senator Warner.

01:39:41 I'm next to Senator Blackburn,

01:39:43 but we're gonna get everybody here on,

01:39:45 and we'll see if anybody comes in and tries to juggle it.

01:39:48 But thanks for being so helpful.

01:39:51 Senator Blackburn.

01:39:52 - Yes, thank you so much.

01:39:53 And I'm going to pick up right where Senator Warner left off

01:39:57 because several years ago,

01:39:59 I developed what's the rural health agenda.

01:40:02 It was important for my state of Tennessee.

01:40:05 And Senator Durbin and I have worked together on workforce

01:40:09 and have legislation that would beef up that workforce.

01:40:14 As you mentioned earlier, Miss, is it Redefield?

01:40:19 Redefield?

01:40:21 Getting people to work in a rural area.

01:40:23 So if you do this for a period of five years,

01:40:27 then your loans would be forgiven.

01:40:29 Your student loans would be forgiven tax-free.

01:40:32 And so Senator Durbin and I are working on that.

01:40:35 Senator Hickenlooper and I are working

01:40:38 on innovative delivery models

01:40:41 so that you carry that access into the rural areas.

01:40:45 And as Senator Warner said,

01:40:47 he and I have worked on this area wage index.

01:40:50 You know, having these differentiations made sense in 1968,

01:40:55 they don't make sense today.

01:40:57 Healthcare delivery is technology.

01:40:59 I'm reminded of this as I go through my community every day

01:41:05 with healthcare innovators that are there in Nashville.

01:41:07 I do wanna talk, let's see, Mr. Davis,

01:41:12 let me talk with you about telehealth.

01:41:14 Because this is something, when I was in the House,

01:41:17 we worked on telehealth.

01:41:20 And we have seen tremendous promise with this.

01:41:24 I think we've got 90% of the healthcare centers

01:41:28 are now offering this.

01:41:30 And of course, we decoupled it

01:41:34 from the emergency health order.

01:41:37 Permanency is going to be important.

01:41:40 Stopping this thing of having to go back and reauthorize

01:41:43 is going to be important too.

01:41:46 But the disparity in the reimbursements,

01:41:49 our rural centers are getting $95 for a telehealth visit.

01:41:54 Urban and in-person visits are $195.

01:41:59 Now we know this is expanding.

01:42:01 I recently went through the technology that is,

01:42:05 the doctor is a hologram, it's in the box,

01:42:08 it's in the room with the patient.

01:42:10 So that's the next evolution of this.

01:42:14 So talk to me about the difference in reimbursement rates

01:42:19 from the telehealth to the in-person,

01:42:23 the way you get better compliance

01:42:26 with adding in the telehealth,

01:42:29 and the difference that makes for people in rural areas.

01:42:32 - Sure.

01:42:33 That's a great question.

01:42:34 And I think you kind of bring up a great point.

01:42:37 I think we're at an inflection point in this country

01:42:39 where we've been advancing telehealth

01:42:42 and then the pandemic hit.

01:42:44 And we really saw a lot of providers and patients

01:42:47 who actually learned to love it,

01:42:49 where they were really reluctant to use it prior to,

01:42:51 and now they don't want to go back.

01:42:53 They see it as a great tool to improve access.

01:42:57 And really for some of those patients

01:42:58 that are really hard to get in,

01:43:00 they have transportation issues,

01:43:01 they have mobility challenges,

01:43:03 they're busy, maybe they're working professionals.

01:43:06 So to be able to leverage technology is huge.

01:43:08 But there's a misaligned incentive

01:43:11 whereby these rural health clinics and FQHCs,

01:43:15 we don't get the equal payment.

01:43:17 And so it's to our advantage

01:43:19 for those who run these clinics to prioritize and prefer

01:43:24 and almost push these patients to come in for a visit.

01:43:28 And so absolutely anything that we can do

01:43:31 to increase that payment parity.

01:43:33 For us, we have a couple of rural health clinics

01:43:36 and we have to carve out any space in the building

01:43:41 that is being used for telemedicine.

01:43:43 We can't recoup those costs,

01:43:45 which to me, it shouldn't matter

01:43:47 whether we're rendering that service via a camera

01:43:51 or a microphone or whether in person.

01:43:53 We're taking care of rural Americans

01:43:56 and therefore the payment should be on par.

01:43:59 - Well, I agree with that.

01:44:01 And the area wage index,

01:44:04 I wanna add just one more thing on this

01:44:06 and the work that Senator Warner and I are doing,

01:44:09 trying to establish that floor

01:44:13 and get it at an 85% floor.

01:44:16 Because technology is where it is now

01:44:20 and we have to make certain

01:44:22 that you preserve that access to care in these rural areas.

01:44:27 And unless we address this wage index,

01:44:31 we're not going to be able to guarantee that.

01:44:34 I'll yield back my 19 seconds.

01:44:36 - More collegiality.

01:44:37 Thank you, Senator Blackburn.

01:44:39 Senator Haston, you're next.

01:44:40 - Thank you very much, Mr. Chair

01:44:43 and to you and the ranking member for this hearing.

01:44:45 To the witnesses, thank you for being here,

01:44:47 but also for the work you do.

01:44:49 And I wanna add on to the line of questions

01:44:54 about maternity obstetric care.

01:44:57 I recently toured the birthing unit

01:45:00 at Speer Memorial Hospital in Plymouth, New Hampshire.

01:45:03 It's the only birthing unit left in that area of the state.

01:45:06 11 maternity wards have closed in New Hampshire

01:45:09 in the last two decades.

01:45:10 The average time now to get to a birthing unit

01:45:15 in New Hampshire is about 40 minutes

01:45:17 and you add bad weather and mountains to that

01:45:19 and it can be pretty dicey.

01:45:22 So the situation in rural New Hampshire

01:45:25 is certainly not unique,

01:45:27 as we have heard from this dais this morning.

01:45:30 Since 2011, around one in four

01:45:33 or more than 260 rural hospitals

01:45:35 have shut down their obstetric services.

01:45:38 Mr. Davis, this is a question for you.

01:45:40 We've talked about how we can make sure

01:45:43 there are obstetric services available,

01:45:45 but what I'm concerned about specifically

01:45:48 is how do we make sure that all hospitals

01:45:51 are ready to provide urgent obstetric care,

01:45:54 such as labor and delivery,

01:45:55 even if they don't have an obstetrics unit

01:45:59 but somebody appears at the emergency room?

01:46:01 - Yeah.

01:46:02 No, it's a great question

01:46:03 because you think about healthcare,

01:46:05 you've got pre-hospital, you got acute,

01:46:08 and you got post-discharge and post-acute.

01:46:11 And given the maternal crisis we have in the country,

01:46:15 we've gotta think upstream

01:46:16 and we've gotta make sure that EMS,

01:46:18 certainly the emergency room can be a safety net,

01:46:23 but they're not doing deliveries every day.

01:46:25 And so adequate training, adequate equipment.

01:46:28 I know in the case of Grand Run Hospital,

01:46:30 when we learned that the nearby hospital in Baker City

01:46:32 was closing their maternity program,

01:46:35 I was really proud of our emergency department

01:46:36 and our OB providers.

01:46:38 One of our ER docs serves as the medical director,

01:46:40 and so he went out

01:46:41 and did some refresher courses with EMS.

01:46:45 And then same with our OB/GYNs.

01:46:47 And your case in point,

01:46:49 I actually just learned recently in the last month and a half

01:46:52 that there was a mother in Baker County

01:46:55 who, of course, I think it was late at night,

01:46:59 all times of the day, didn't make it to the hospital

01:47:03 and ended up delivering in her car across, in a canyon.

01:47:06 And luckily it was this time of year

01:47:08 instead of December or November or January.

01:47:12 And so that pre-hospital preparation for EMS

01:47:15 is gonna be absolutely critical.

01:47:17 - Absolutely, and I just wanna make the chair

01:47:19 and my colleagues aware that Senator Britton and I

01:47:21 have the Rural Obstetrics Readiness Act

01:47:24 with Senator Collins and Smith

01:47:26 that will help rural healthcare facilities

01:47:29 train their staff, purchase equipment,

01:47:33 and then one of the other things we're looking at

01:47:35 is a nationwide telehealth service

01:47:37 so that if you're dealing with an obstetric emergency,

01:47:39 an emergency room you can hook in 24/7

01:47:42 to an obstetric expert who can guide you through

01:47:45 that particular emergency.

01:47:47 Mr. Topchick, as we've heard today,

01:47:49 Medicaid covers nearly half of all rural births

01:47:52 across the country.

01:47:54 It covers prenatal visits and labor and delivery,

01:47:56 but providers often can't get reimbursement

01:47:59 for the time they need to spend coordinating care,

01:48:02 such as developing a care plan for a pregnant woman

01:48:04 or coordinating with community resources

01:48:07 to get her the support that she needs.

01:48:08 How can we help doctors and hospitals

01:48:11 provide the consistent, coordinated services

01:48:13 that women need to stay healthy during

01:48:15 and following pregnancy?

01:48:17 - Right, from prenatal care through birth

01:48:20 and postnatal care, we need to support mothers

01:48:23 and their children, and the biggest payer of that

01:48:25 in this country is Medicaid.

01:48:27 This body has done a great deal of work with seniors

01:48:30 through the Medicare program,

01:48:32 Medicaid, of course, being a federal-state partnership,

01:48:34 it's a little bit more challenging,

01:48:36 but I think similar types of investments

01:48:38 are going to be needed to be made

01:48:40 in order to sustain what is an eroding aspect

01:48:43 of the American health safety net,

01:48:45 which is maternal care.

01:48:46 - Well, I appreciate that, and Mr. Chair,

01:48:48 I know that this is an area of great interest for you.

01:48:50 Senator Grassley and I have the Healthy Moms and Babies Act,

01:48:54 I know Senator Grassley has mentioned it,

01:48:56 which would create an option for states

01:48:58 to reimburse for highly-coordinated maternal health care,

01:49:01 so I hope it's something we can consider

01:49:03 as we're moving forward on this topic.

01:49:04 - We will definitely be interested in working with you.

01:49:07 - Okay, and I will not ask this question

01:49:10 'cause I think it will elicit a long answer,

01:49:12 except I will ask it for the record later on,

01:49:14 but I am working on, obviously, site neutrality

01:49:17 as an issue in our health care system.

01:49:20 As we work on that, we also have to make sure

01:49:22 rural hospitals are appropriately reimbursed,

01:49:25 and so I'll look forward to submitting that question

01:49:27 for the record as well, thank you.

01:49:29 - Very good, Senator Cortez-Mastos, next.

01:49:31 - Thank you, Mr. Chairman.

01:49:32 Thank you also to the panelists for being here.

01:49:35 Excuse me, I've been focused on, in my state of Nevada,

01:49:39 expanding opportunities for health care providers

01:49:42 to train there because we know once they train,

01:49:44 they usually remain, and that's the key,

01:49:47 I think, for many of us, and that's why I have been part

01:49:50 of a bipartisan working group with my colleagues here

01:49:52 on the committee to advance additional medical,

01:49:55 or excuse me, Medicare graduate medical education proposals,

01:49:58 as you all are very familiar with that.

01:50:01 Congress recently approved

01:50:03 Medicare-supported residency positions

01:50:05 and specified that these slots should go to hospitals

01:50:08 serving health professional shortage areas, HPSA.

01:50:12 I support this policy because in Nevada,

01:50:14 all 17 of our counties, all 17 of our counties

01:50:17 are designated shortage areas.

01:50:18 However, listening to the testimony today,

01:50:21 you've highlighted that some rural hospitals in Wisconsin

01:50:27 have not applied for slots

01:50:28 because they do not have that designation.

01:50:31 My aim is to make sure that these new slots

01:50:33 are allocated to the areas where there's a greatest need.

01:50:35 So I guess, Ms. Rotherfeld, my question to you is,

01:50:39 you talked a little bit about why rural areas in Wisconsin

01:50:42 lack HPSA designation despite experiencing

01:50:46 this health care workforce shortage.

01:50:49 Do you believe we need to clarify current law

01:50:53 regarding the GME allocation formula

01:50:55 to better identify and support our rural communities

01:50:57 with those critical health care needs?

01:51:00 - Yeah, that's a great question.

01:51:01 And I think, as you look at, again,

01:51:04 the relatively small pool of rural hospitals that host GME

01:51:09 and then those who are located in a HPSA area,

01:51:14 it's gonna be even smaller.

01:51:15 I would say, in Wisconsin, our hospitals,

01:51:18 I actually have four hospitals

01:51:20 that are looking to expand their rural programs

01:51:22 that are training not only for their local community,

01:51:25 but what I've seen time and time again is, when they're full,

01:51:28 they feed the nearby counties that are HPSA.

01:51:30 So again, while you may not have a residency program

01:51:33 located in a HPSA, they may be attracting those residents

01:51:36 because all the data shows residents typically stay

01:51:39 within 100 miles before they do their training.

01:51:41 And if they can't stay in that HPSA,

01:51:43 they'll go in the neighboring county.

01:51:44 And I've seen, right now, we're at about 70% of retention

01:51:48 of residents in-state.

01:51:51 And again, we've done a lot of really great work

01:51:54 to partner together to meet our workforce needs in the state.

01:51:57 But I think looking at prioritizing HPSAs

01:52:02 in slot distribution, absolutely,

01:52:04 hospitals with HPSAs should get slots first.

01:52:06 But if there are remaining slots,

01:52:08 could we look at those residency programs

01:52:10 in rural hospitals that are doing great work

01:52:12 and allow them to expand as well?

01:52:13 - Okay, thank you, that's helpful.

01:52:15 And Dr. Mueller, Seoul Community Hospitals.

01:52:19 Nevada has two of them.

01:52:22 Seoul Community Hospitals and Medicare-dependent hospitals

01:52:25 are well-positioned to host the residency programs.

01:52:29 However, those compensated based

01:52:34 on their hospital-specific rate face financial constraints

01:52:38 due to a lack of independent medical education adjustment

01:52:42 leading to inadequate financial support

01:52:44 for training programs from Medicare.

01:52:46 In contrast, Seoul Community

01:52:48 and Medicare-dependent hospitals paid under the federal rate

01:52:51 receive both direct medical education

01:52:54 and indirect medical education payments

01:52:56 when starting teaching programs.

01:52:57 So, Dr. Muriel, my question to you is,

01:52:58 do you believe that Seoul Community

01:53:00 and Medicare-dependent hospitals,

01:53:02 which actually represent 80%

01:53:04 of eligible rural training hospitals,

01:53:07 should receive fair incentives for teaching programs?

01:53:10 - Yes, that's a fairly easy answer.

01:53:15 - And can I ask, would addressing this Medicare payment gap

01:53:21 contribute to securing the workforce need

01:53:25 to sustain these rural service areas?

01:53:28 - It would certainly be very helpful.

01:53:31 We're always hesitant to say a single lever

01:53:34 is going to change a lot of behavior,

01:53:37 but it seems like it would be a necessary,

01:53:39 and in many cases sufficient condition,

01:53:41 yes, to get them to change.

01:53:43 - Good, thank you, 'cause I agree with you 100%.

01:53:46 And then finally, let me just say to the panelists,

01:53:50 telehealth, it's a game changer.

01:53:51 We all know that, particularly in our rural communities

01:53:54 and our frontier communities across this country,

01:53:57 including in Nevada.

01:53:58 I'm curious, though,

01:54:01 which specific Medicare telehealth flexibilities

01:54:03 do you believe are most essential

01:54:05 for addressing the healthcare needs of rural communities?

01:54:08 We talked a little bit about payment parity.

01:54:10 Are there other things that we should bring attention

01:54:12 to this committee to make sure that we're prioritizing

01:54:16 or making permanent when it comes to telehealth services?

01:54:19 - I can take that one.

01:54:20 So a couple that I wrote down just in case.

01:54:24 There's no geographic restriction from originating site

01:54:28 for non-behavioral health

01:54:29 or mental health telehealth services.

01:54:31 Some non-behavioral health mental health telehealth services

01:54:33 can be delivered using audio-only communication platforms.

01:54:37 And then the big one is an in-person visit

01:54:39 within six months of an initial behavioral health

01:54:40 mental telehealth visit,

01:54:41 and annually thereafter is not required.

01:54:44 So there's just some little, I think, tweaks

01:54:46 that can be done that will make this much more efficient.

01:54:49 - Thank you.

01:54:50 And I know my time is up.

01:54:51 Audio-only, is that something you would support?

01:54:54 - Well, given that many of the rural communities

01:54:59 can't meet the broadband requirements,

01:55:00 and it's at this point, then yes.

01:55:04 But we wanna get to video. - Thank you.

01:55:05 That's the answer I want.

01:55:06 Thank you so much.

01:55:07 Thank you, Mr. Chairman.

01:55:09 - The Senator from Nevada and I both know when to quit

01:55:11 while we're ahead, and well said.

01:55:13 Thank you.

01:55:14 The chair of the subcommittee, the health subcommittee,

01:55:15 and expert on these issues is here, Senator Cardin.

01:55:18 - Thank you, Mr. Chairman.

01:55:19 Thank you for holding the full committee hearing

01:55:21 in regards to rural healthcare.

01:55:23 The subcommittee has been actively engaged in this issue,

01:55:27 and this hearing very much helps us

01:55:30 in filling in some of the additional information

01:55:33 for us to adjust policies to deal with the gaps

01:55:36 we have in rural America.

01:55:38 I represent the state of Maryland.

01:55:40 Most people think the state of Maryland's a pretty urban state.

01:55:43 We have rural communities that have challenges

01:55:45 with access to healthcare.

01:55:47 The western part of our state,

01:55:48 the eastern part of our state,

01:55:50 it can be a challenge to be able

01:55:52 to get access to healthcare.

01:55:55 I know there's been a good deal of discussion

01:55:57 on two areas that have been extremely important

01:55:59 in our state.

01:56:00 Telehealth has been a real game changer.

01:56:03 I've been to Pocomoke City in the eastern shore of Maryland

01:56:06 seeing the direct benefits of telehealth

01:56:09 and being able to get healthcare needs met.

01:56:12 And we invested a long time ago in broadband

01:56:15 so that we have, most of our communities now

01:56:18 have access to high-speed internet.

01:56:20 So we have been able to put in the infrastructure

01:56:23 for rural Maryland that has helped us a great deal

01:56:27 to deal with these challenges.

01:56:28 But there are at least two areas

01:56:31 that we find to be a real challenge.

01:56:33 One more thing about Maryland.

01:56:34 Maryland has the total cost of care model,

01:56:36 the only one in the country where we have

01:56:38 an all-payer rate structure,

01:56:39 so we can use our rate structure

01:56:41 to provide equities to rural hospitals

01:56:44 that would otherwise be at a disadvantage

01:56:47 because of the volume that is in these facilities

01:56:51 compared to our urban centers.

01:56:53 But there are two areas that we find challenging

01:56:56 that I'd like to get your comments on.

01:56:59 And they're both related.

01:57:00 It's preventive healthcare, which at many times

01:57:03 requires a person to travel in order to have

01:57:06 the follow-up necessary for the preventive

01:57:08 healthcare services, and that can be a challenge

01:57:11 in rural America.

01:57:12 The second is oral healthcare.

01:57:15 Oral healthcare has been an area of particular concern

01:57:18 to us in Maryland.

01:57:19 I mention this frequently.

01:57:21 When I came to the Senate in 2007,

01:57:23 we had the tragic loss of DeMonte Driver

01:57:25 'cause he couldn't get access to healthcare.

01:57:28 All we needed was a simple extraction.

01:57:31 It didn't get treated.

01:57:33 His mother tried, couldn't get access.

01:57:36 There was no facilities available.

01:57:38 In the rural parts of our state

01:57:39 and rural parts of our country,

01:57:41 it's not as easy to get access to oral healthcare.

01:57:45 And I hate to, at times, we don't think

01:57:48 that's quite as important, and it's critically important

01:57:52 for oral healthcare.

01:57:53 So can you tell us what strategies have worked

01:57:56 in rural America, what we can do better

01:57:59 to be able to put a priority on access to oral healthcare,

01:58:03 particularly for our children, which is now

01:58:05 covered service under all of our healthcare plans,

01:58:08 but also for the adult population,

01:58:10 as well as how we can better serve

01:58:13 in dealing with the extraordinary technologies

01:58:16 that have developed in detecting diseases early,

01:58:19 which is not always available as easily

01:58:21 to people who live in rural America.

01:58:24 Who wants to take a stab at that?

01:58:26 Everybody's volunteering.

01:58:28 I appreciate that very much.

01:58:30 I'll call on you then.

01:58:31 Dr. Moller, you're up first.

01:58:35 (audience laughing)

01:58:36 - Okay.

01:58:37 - You give short answers.

01:58:37 That's why I'd like to call you first.

01:58:40 - The short answer is I think a comprehensive health team,

01:58:43 which I mentioned in my oral testimony,

01:58:45 has to include preventive health services

01:58:48 and oral healthcare.

01:58:49 Once we establish that, as this is part of the health team,

01:58:53 I think we'll start dedicating more resources

01:58:55 to figuring out how do we get that everywhere,

01:58:58 where we're saying that we're serving populations.

01:59:01 And the answer for that in rural is some combination

01:59:04 of telehealth, where we can use it,

01:59:07 but different levels of professional services

01:59:09 with preventive care, what can we utilize.

01:59:12 We talked about pharmacy earlier.

01:59:13 How can pharmacies play a role in that?

01:59:16 In oral healthcare, how can we utilize dental hygienists

01:59:20 as effectively as possible?

01:59:22 And how do we utilize oral health clinics

01:59:26 that can be mobile and serve multiple communities

01:59:30 rather than thinking we have to have one in each community?

01:59:33 - Mr. Rogfell, I see you're in the GME issue.

01:59:39 One of our areas that we've been able to do

01:59:42 is expand the qualified health centers

01:59:43 to include oral healthcare,

01:59:46 and had them located in rural communities,

01:59:50 not just in the urban centers.

01:59:52 A lot of that deals with having the personnel.

01:59:57 So how do you incentivize getting the medical personnel

02:00:02 in rural communities through the graduate medical programs?

02:00:05 - Yeah, I think that there's a couple of initiatives.

02:00:08 One is the Family Medicine Residency Programs

02:00:10 have a Smiles for Life curriculum,

02:00:12 and trying to get them to approve that

02:00:15 and implement that is a big approach,

02:00:18 because primary care can make referrals to dental.

02:00:21 I've been involved with efforts

02:00:23 with teaching health centers,

02:00:24 and we have a number of teaching health center

02:00:27 planning and development grantees that are dental

02:00:29 that are, even if they're located in an urban area,

02:00:33 a lot of them have mobile units.

02:00:34 And actually, I was just a few weeks ago

02:00:37 at a NAC conference where they were talking about

02:00:40 ways that they could get their dental residents

02:00:42 out into rural communities with mobile units.

02:00:46 So very similar to what Dr. Mueller just shared,

02:00:48 but I think supporting any incentives

02:00:50 to get dental residents or even dental students

02:00:53 into rural communities is a great strategy

02:00:56 to help address some of these issues we're seeing.

02:00:58 - Thank you, thank you, Ms. German.

02:00:59 - Thank you, I'd just say to our friends

02:01:01 and people following this,

02:01:03 Senator Cardin has been the go-to person in the Senate

02:01:07 using his chairmanship on the subcommittee of health

02:01:11 for oral health care, and I so appreciate it.

02:01:13 And we're gonna have to find a way to fill his big shoes,

02:01:16 and it won't be easy.

02:01:17 Senator Warren.

02:01:19 - Thank you, Mr. Chairman.

02:01:21 Oral health care providers face a slew of challenges,

02:01:25 low patient volumes, high operating costs,

02:01:27 staffing shortages, and this threatens health care access

02:01:32 and quality of care for millions of people

02:01:35 in rural communities.

02:01:37 In April, CMS took a big step to improve quality of care

02:01:41 in nursing homes by putting in place

02:01:43 minimum staffing standards, including ensuring

02:01:47 that facilities have a registered nurse on duty 24/7.

02:01:51 Mr. Topchick, you are an expert on rural health care needs.

02:01:56 So can you tell us, what will this new staffing rule mean

02:02:00 for quality of care, particularly at nursing homes

02:02:04 in rural communities?

02:02:06 - Senator, I appreciate the question.

02:02:07 Just evaluating nursing homes a couple months ago

02:02:11 from my father and was shocked to learn

02:02:13 that there was not a nurse on staff 24 hours a day.

02:02:15 So the idea of elevating staffing requirements

02:02:19 to better serve our seniors,

02:02:21 to provide higher quality care, thrills me.

02:02:24 I do note the tension that the committee noted

02:02:28 in the final rule by referencing the challenges rural faces

02:02:32 and by offering a five-year ramp in

02:02:35 to meet those challenges, as well as a variety

02:02:38 of opportunities for waivers if they happen to be

02:02:41 in a health professional shortage area.

02:02:42 So I appreciate that.

02:02:43 - Good, thank you.

02:02:44 You know, I think this is a good rule

02:02:46 that's going to help millions of nursing home residents.

02:02:50 And it's made even stronger by the fact that CMS listened

02:02:54 and they addressed the concerns

02:02:56 of rural nursing home providers.

02:02:59 I think that's an important part of it.

02:03:01 Fortunately, CMS also had the good sense

02:03:04 to ignore the biggest nursing home companies' claims

02:03:08 that they can't afford to increase staff.

02:03:11 Last week, I wrote to three

02:03:13 of the biggest publicly traded nursing homes

02:03:15 about a new analysis that my office did

02:03:19 that found that these homes had paid out

02:03:21 over $600 million in stock buybacks,

02:03:25 dividends, and CEO pay since 2018,

02:03:29 which sounds to me like they actually have the resources

02:03:32 to implement this rule.

02:03:34 Mr. Chairman, I would like to make those letters part

02:03:36 of the hearing record.

02:03:38 - I'm looking forward to reading it.

02:03:39 - Okay. - I'm so honored.

02:03:40 - Good.

02:03:41 So now I want to talk about another healthcare challenge

02:03:44 facing rural communities.

02:03:46 In just the past decade, over 160 rural hospitals

02:03:50 have closed, while over half of all rural hospitals

02:03:53 are currently operating in the red.

02:03:56 Rural hospital operators have identified the same program

02:03:59 as the biggest hospitals have.

02:04:02 Their threat is to survival is Medicare Advantage, or MA,

02:04:07 which allows private health insurance companies

02:04:10 to administer Medicare coverage

02:04:12 for over 31 million Americans.

02:04:15 Mr. Topchick, do you agree that Medicare Advantage

02:04:20 is the biggest threat to rural hospitals?

02:04:22 - Senator, I work with hundreds of rural health executives

02:04:25 who tell me that it is keeping them up at night.

02:04:27 It is one of their single biggest concerns,

02:04:29 and I ask them about this.

02:04:32 And what they tell me is they cite more challenging

02:04:34 environment with pre-authorizations.

02:04:36 They tell me they cite differing net reimbursements,

02:04:39 especially around the critical swing bed program

02:04:42 with critical access hospitals.

02:04:43 They cite higher rates of denials and delays

02:04:46 and reimbursements, and they tell me they're falling behind.

02:04:48 - Right, so basically, they delay payments,

02:04:51 they deny payments.

02:04:52 That boosts profits for Medicare Advantage

02:04:55 and leaves our rural hospitals in the red.

02:04:59 Private insurers in Medicare Advantage

02:05:03 are routinely delaying and denying payment to providers,

02:05:06 and they make it increasingly difficult

02:05:09 for rural hospitals to get reimbursed.

02:05:11 For example, in 2022, investigation by

02:05:15 the Health and Human Services Inspector General

02:05:18 found that nearly one in five payment denials

02:05:22 by insurers in Medicare Advantage

02:05:25 violated Medicare coverage rules, one in five.

02:05:29 And this is particularly devastating for rural hospitals,

02:05:33 which rely more on public payers like Medicare.

02:05:38 So that's why I've called on CMS

02:05:40 to aggressively increase its audits

02:05:43 of private insurers in Medicare Advantage

02:05:46 and to terminate contracts

02:05:48 with those wildly profitable corporations

02:05:51 when they are in violation of Medicare law.

02:05:54 It is past time that we protect taxpayer dollars

02:05:58 and at the same time ensure that rural hospitals

02:06:01 can stay open for the millions of seniors who rely on them.

02:06:06 Thank you.

02:06:07 Thank you, Mr. Chairman.

02:06:08 - I thank my colleague,

02:06:09 and I just wanna say, as we've talked about before,

02:06:11 I think that the Senator is right

02:06:13 that we need additional audits

02:06:15 as it relates to Medicare Advantage.

02:06:16 I'm very supportive of it.

02:06:18 Okay, to our guests,

02:06:20 thank you for giving us this kind of on-the-ground

02:06:23 assessment of what's going on in rural health in America.

02:06:27 Mr. Davis, I think you really gave us a chance

02:06:30 to kick this off.

02:06:32 It was the Oregon way, especially.

02:06:34 But what you said, and I wrote it down exactly,

02:06:37 is in rural health,

02:06:39 communities are looking for the hand up and not a handout.

02:06:42 And that's what we're gonna build on.

02:06:45 I think everybody heard us discuss the fact

02:06:48 that the committee feels strongly

02:06:50 that we've been able to take some steps

02:06:52 to be helpful in rural areas.

02:06:54 The telehealth model came from the Chronic Care Act

02:06:58 that was written in this room.

02:07:01 In this room, the late Orrin Hatch led a big group of us.

02:07:05 We said, look, I remember Medicare,

02:07:09 when I was director of the Great Panthers,

02:07:11 was largely about acute care.

02:07:13 It was about, it broke your leg

02:07:16 and you went to the hospital,

02:07:17 that was A, and you had health problems,

02:07:19 and then you went to the doc, and that was B.

02:07:22 Now it's chronic disease.

02:07:24 And what we're using is the importance of telemedicine

02:07:29 to deal with a lot of those kind of conditions.

02:07:34 So we are going to take what we've done

02:07:38 in telehealth so far and extend it,

02:07:40 and particularly look to using it across state lines

02:07:43 with some of the flexibility we were talking about.

02:07:47 I do think that we've gotta zero in on this question

02:07:50 I started something like two and a half hours ago

02:07:53 with Mr. Topchick.

02:07:55 We want to help rural communities

02:07:58 with their conditions on the ground.

02:08:00 And we talked about not very many babies

02:08:03 and you have to have something 24/7 and the like.

02:08:06 I'm prepared to help in those kinds of issues

02:08:09 as long as the big guys don't take the money and run.

02:08:13 And we need all of you to kind of help us

02:08:16 get the nuts and bolts right.

02:08:18 It's always one thing to say it in a hearing,

02:08:20 it's another thing to actually write it in language

02:08:23 so you get it right, and we're gonna wanna do that.

02:08:27 And my colleagues all through the morning

02:08:31 had suggestions and ideas they were working on.

02:08:33 You can see there's tremendous passion

02:08:35 for this cause here in the Finance Committee.

02:08:37 And I didn't hear a lot of people say,

02:08:39 well, there's only a Democratic way and a Republican way

02:08:41 and go back and forth.

02:08:44 They were talking about sensible ideas.

02:08:46 And for me, this comes back to the proposition,

02:08:50 and Mr. Davis knows this.

02:08:52 We have 36 counties in Oregon,

02:08:55 and a lot of them are such a far distance

02:08:58 from Washington, D.C.

02:09:00 They think that for all practical purposes in their lives,

02:09:03 D.C. might as well be Mars

02:09:06 for all the connection it has to 'em.

02:09:08 And what you do is you bring us

02:09:10 the kind of view on the ground, all four of you,

02:09:14 that this is what we're dealing with.

02:09:15 And these wonderful people sitting in back of me

02:09:18 try to take those ideas

02:09:20 and turn 'em into good and sensible policy.

02:09:23 We talked about maternity deserts.

02:09:25 I mean, I think that's really what we're looking at.

02:09:27 And I just want you to know, on my watch,

02:09:30 as long as I'm chair of this committee

02:09:32 and a tremendous honor representing Oregon

02:09:35 in the United States Senate,

02:09:37 we're gonna fight that kind of concept.

02:09:39 We're not going to let rural healthcare

02:09:43 in these communities become sacrifice zones.

02:09:45 We can do better than that.

02:09:47 And Oregon is mostly rural,

02:09:48 and you could hear from my colleagues

02:09:50 that many of their states are largely rural.

02:09:53 So you gave us a great kickoff

02:09:55 to the cause of taking some significant reforms

02:10:00 as it relates to strengthening rural healthcare in America.

02:10:03 We're gonna follow up with all of you.

02:10:05 For the senators, we're following the wrap-up questions.

02:10:09 For the record, you're due one week from today at 5 p.m.

02:10:12 Thanks to all of you.

02:10:13 We're adjourned.

02:10:14 - Thank you.

02:10:15 [BLANK_AUDIO]

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