The American Hospital Association has made improving access to rural health care a top priority, and its 2024 AHA Rural Advocacy Agenda lays the groundwork to improve the system as a whole. In this conversation, three AHA experts drill down on specific steps needed to help rural health care stay financially sound and ready to serve.

This discussion took place at the 2024 Rural Health Care Conference in Orlando, Florida.

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Tom Haederle

Some 57 million rural Americans depend on their hospital as an important source of care, as well as a critical component of their area's economic and social fabric. But many rural care providers have faced and continue to face a rocky road ahead. Attracting and retaining workers. Financial stresses. Dealing with complicated and sometimes conflicting regulations. These are among the factors that can jeopardize the ability of rural hospitals to provide patient access to care.

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Tom Haederle

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Tom Haederle

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Lisa Kidder

Good day. I'm Lisa Kidder, senior vice president, AHA advocacy and political affairs. I am joined today by my two colleagues, Travis Robey, vice president of political affairs, and Shannon Wu, senior associate director, AHA payment policy, two of the experts on rural health care. Welcome, Shannon. Welcome, Travis. We all know rural hospitals continue to experience ongoing challenges that jeopardize the ability to provide local access to care and essential services to their patients and community.

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Lisa Kidder

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Lisa Kidder

Travis, let's start with you. As AHA continues to work with Congress and the administration to support these rural hospitals. We're also looking to support a public policy environment that will protect access to care, innovation and invest resources in new rural communities. Could you talk about those five areas, please?

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Travis Robey

Absolutely. Our first priority in our updated rural advocacy agenda is commercial insurer accountability. It continues to be an issue that we hear as a top tier issue of concern for our members. Second is supporting flexible payment options. Third is ensuring fair and adequate reimbursement. Fourth is bolstering the workforce. And fifth is protecting the 340B program.

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Lisa Kidder

Great. Thanks. I will dig into some of those issues here in just a minute. Shannon, as Travis mentioned, the number one he first mentioned and maybe even number one on our priority list this year is commercial insurer accountability. Can you talk a little bit about what's been happening with the administration and some of the actions they've taken to address this issue?

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Shannon Wu

Sure. We've already seen some moves in the right direction from the administration, from last year and the beginning of this year. So first, we are carefully monitoring compliance and the recent Medicare Advantage rules that were finalized last year, which went into effect last month in January. Many of these rules hold plans accountable for covering services and for their marketing tactics, among other requirements.

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Shannon Wu

So we're keeping a close eye on how this Medicare Advantage plans are complying with those rules for the upcoming year. Second, the administration also finalized just last month in January again, prior authorization rules that the AHA advocated heavily on. These will go into effect in the next few years and are really aimed at streamlining and reducing burden associated with prior authorization and at promoting greater transparency.

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Shannon Wu

Of course, our work here is not done, and we continue to advocate for ways to reduce administrative burden and help our rural hospitals navigate through the changing Medicare Advantage landscape.

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Lisa Kidder

Thanks, Shannon. It sounds like lots of good work is being done. Travis, let's talk about another issue that has getting a lot of attention in Washington, D.C. right now from both sides, both those who are for it and against it. Can you tell us about site neutral and what is happening right now in Congress on the issue?

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Travis Robey

Absolutely. Hospitals and health systems play a critical role in preserving access to care for patients and communities throughout rural America. They've increasingly stepped up to fill the voids in care by reinvesting through access points like hospital outpatient departments. These sites of care are essential services in so many rural and low income communities across the country. Our emphasis right now is trying to push back on congressional efforts to impose site neutral payments, particularly for drug administration.

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Travis Robey

But their longer term vision is far more expansive than that. And the impact on rural communities is particularly acute. We've recently put out data that shows that disproportionately rural patients access care at hospital outpatient departments. And we want to ensure that that access continues going forward by opposing the site neutral cuts.

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Lisa Kidder

And, Travis, I hate to put people on the spot, but I'll put you on the spot. What do you think the chances are that Congress takes action this year on the issue?

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Travis Robey

Well, right now we've got, in the short term, the March 1st and March 8th government funding deadlines that put us at risk on these issues. The hope is that we can stave off any pending cuts in that government funding package that's going to move in the next month, but then we'll still have the lame duck session of Congress in November and December, where this will be a top tier issue.

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Travis Robey

So we need to make sure that our rural members and all of hospital leaders across the country are engaging with their legislators to make sure that the message gets delivered, that the current payment model is essential to maintain access to care, particularly given the financially vulnerable position of so many rural and safety net hospitals.

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Lisa Kidder

Great. So that sounds like a call to action as well as an update. The next issue I know is one that really hospitals and hospitals really across the country are dealing with that definitely peaked during Covid. But can you talk about workforce challenges? So Travis, I'll send it to you. But then, Shannon, you may have thoughts as well of some of the issues you've worked on.

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Lisa Kidder

So, Travis, why don't you go first and then you can turn it over?

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Travis Robey

Yeah. This is a key area where there is the potential for possible bipartisan support over the coming months. The National Health Service Corps is up for reauthorization. We're also advocating for an expansion of graduate medical education residency slots. Over the last several years, we've seen investments in more GME slots after nearly a couple of decades where there had been a freeze on those slots.

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Travis Robey

But there are also rural specific proposals, like the extending the Conrad state 30 program, which allows J-1 visa waivers for physicians who train in the U.S. to be able to stay here if they practice in an underserved or rural community. So there are a variety of key workforce provisions that are specifically focused on rural, but I want to highlight one additional area: the SAVE Act. That's focused on workplace violence,

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Travis Robey

such a key issue for employees and administrators at hospitals to take this issue head on. We just had a very successful - almost 100 congressional staffers attend a briefing on this issue that really, I think, drove home to congressional staff the importance of this issue, and we're looking to make progress on that over the coming months as well. And that's a bipartisan piece of legislation in the House and the Senate.

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Shannon Wu

Great. Well, on the regulatory front, we've been really focused on the proposed nurse staffing minimum rules that were released by the Centers for Medicare & Medicaid Services last year. We strongly oppose these rules. So while we agree that staffing is an integral part of providing safe, high quality care, we believe that the proposed rules from last year really are an overly simplistic approach to a complex issue and that, if implemented, would have serious negative consequences not just for nursing homes but across the continuum, especially with ongoing workforce challenges that are preventing hospitals and rural hospitals especially, from discharging their patients in a timely manner to subacute or post-acute places.

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Shannon Wu

So we are currently awaiting the final rule and in the meantime, have supported legislation that would prohibit the agency from finalizing those proposed requirements.

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Lisa Kidder

Great, thanks. Going to turn to Travis again for an issue that has perennially gotten a lot of attention. And this is the 340B drug pricing program. Travis, I know that there's some interest in it right now on Capitol Hill. Can you bring us up to speed?

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Travis Robey

Yes. The House of Representatives has had some hearings on this issue, trying to make changes that we think are problematic for the program. There's also been some legislation, a draft legislation put forward by some of the members of the Senate who have been champions of the 340B program. We're currently evaluating that to provide comments as they continue to refine that legislation moving forward.

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Travis Robey

But I think the key message is that we want to make sure that all 340B hospitals are reaching out to their legislators to continue to explain the importance of the 340B program, how it ensures that you can stretch scarce federal resources further, and particularly for our rural members, how important it is to maintain access to care in your communities.

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Lisa Kidder

Great,thanks. And just in the last couple of minutes, let me open it up to you. I know this is a question we sometimes ask our CEOs, but you know what's keeping you up at night? What's the unfinished business of rural health care that you'd like to see tackled? Shannon?

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Shannon Wu

Well, I'll just continue on the 340B theme. And I want to mention here, obviously the AHA continues to oppose any efforts to undermine the 340B program, but in particular contract pharmacies. And we know how important that is for rural communities. So we know that there are still legal actions pending in the federal courts. And much of that action has moved to the states, which the AHA is very supportive and poised to help states in protecting access to contract pharmacy.

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Shannon Wu

So that is something that we continue to monitor and continue to be engaged on for this year.

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Lisa Kidder

Thanks, Travis. Anything from you?

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Travis Robey

It really is site neutral for me. That's the issue that I think is front and center in Congress right now. There are certainly important provisions, like extending the Medicaid DSH cut moratorium that is essential for protecting the financial stability of the field. But I think right now, the number one threat to the hospital field are site neutral payment cuts.

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Travis Robey

And that's what keeps me up at night, concerned that at a time of continued financial challenges for the field, that Congress might unwisely try to pass that legislation. So again, one last call to action on that. Please continue to reach out to your legislators on that issue.

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Lisa Kidder

Great. Thank you so much to both of you. Lots of hard work being done. And again, thanks, Travis and Shannon for all your help. I am Lisa Kidder, and thanks for listening. This has been an AHA Advancing Health podcast.

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Tom Haederle

Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.