Rural hospitals say they're stuck between a rock and a hard place


Happy Tuesday, and thanks for reading. Let’s dive in.

Today’s edition: David Kessler, a leader in the Biden administration’s coronavirus vaccination effort, is stepping down. Federal officials concluded it’s “very unlikely” that Pfizer-BioNTech’s coronavirus booster carries a stroke risk for seniors. But first …

Some rural hospitals want funding help without a requirement to slash inpatient services

The federal government rolled out a new payment model on Jan. 1 aimed at helping America’s struggling rural hospitals survive, but with a catch: They must agree to give up their inpatient services.

Hospital administrators say the unusual condition has them stuck between a rock and a hard place — balancing community needs for inpatient care against their facility’s long-term viability. The National Rural Health Association supported the model because of the need to maintain emergency services in rural areas, but acknowledges it doesn’t solve all the financial challenges facing rural hospitals.

More than 600 rural hospitals, representing nearly 30 percent of all rural hospitals nationally, are at risk of closing in the near future because of persistent financial losses on patient services, inadequate revenue to cover expenses and low financial reserves, according to a recent study by the nonprofit Center for Healthcare Quality and Payment Reform.

The Rural Emergency Hospital designation aims to curb those closures by offering struggling rural hospitals greater Medicare reimbursements and monthly facilities payments for providing emergency care, observation and other outpatient services. In exchange, a patient’s stay cannot exceed 24 hours.

The program’s aim: Keep hospitals open

Historically, Medicare has required hospitals to furnish inpatient services to keep their hospital status and the reimbursements that go along with it. The new model is designed to preserve some access to care in communities where rural hospitals wouldn’t otherwise be able to survive by converting them into a new type of stand-alone emergency room and outpatient service center.

“This is an attempt to be more than a primary care clinic but less than an inpatient facility,” said George Pink, deputy director of the North Carolina Rural Health Research Program. The model “has been urged by the rural health community for a long time, but without these specific details.”

Congress created the new rural hospital designation in a sweeping government funding bill passed in December 2020. Under the program, the Centers for Medicare and Medicaid Services pays critical access hospitals or rural hospitals with fewer than 50 beds an additional 5 percent for their covered outpatient services. Hospitals that convert can also receive a monthly facilities payment of $272,866 — totaling more than $3 million each year.

For a state to enact the program, its legislature must pass legislation regulating the new provider type before hospitals can apply. So far, just four states have done so: Kansas, Nebraska, South Dakota and Michigan, per the National Conference of State Legislatures. Lawmakers in Iowa and Texas are also pushing to license the hospitals.

Some hospitals have already announced their intention to make the switch. In a letter to community members, St. Margaret’s Health in Illinois said it intends to convert one of its two facilities into a rural emergency hospital once the state’s legislature passes licensing for the new designation.  

Other hospital administrators say that while the government’s offer is appealing, the requirement to cease inpatient services could hurt their community’s access to health care. That’s because bigger hospitals are increasingly reluctant to accept rural transfer patients as they struggle to contend with their own financial constraints, staffing shortages and overcrowding due to surging rates of covid-19, influenza and RSV.

“You don’t want to remove that as a health-care option in your community if you don’t have to unnecessarily,” said Jed Hansen, executive director of the Nebraska Rural Health Association. Hansen noted that while Nebraska has more than 60 critical access and rural hospitals, he doesn’t expect any to apply for conversion this year.

Carrie Cochran-McClain, chief policy officer and head lobbyist for National Rural Health Association, acknowledged that the new provider type still leaves rural hospitals with financial problems — but said that’s not the point.

“From my perspective, that’s not the intent of this model,” Cochran-McClain told The Health 202. “It’s for very specific communities that doesn’t or can’t sustain inpatient capacity to still maintain an access point for emergency services.”

Rep. Jodey Arrington (R-Tex.)

‘The traditional myth’

Some critics of the new provider type argue that it’s based on a long-standing misconception about inpatient services and fails to address the root of rural hospital’s financial woes.  

“What I would call the traditional myth is that the reason why small rural hospitals lose money is because they’re providing inpatient care to a very small number of patients. Therefore, if you could somehow relieve them of that responsibility, then everything would be fine,” Harold Miller, president and CEO of CHQPR, told The Health 202. “The problem is that’s not necessarily true.”

Miller said that if hospitals eliminate their inpatient unit, they usually can’t recoup all of the costs that are associated with it, but they do miss out on its revenue. For example, a nurse working in the inpatient unit at a small rural hospital will typically also tend to the emergency department. So, even if inpatient care is eliminated, the hospital still needs that nurse. 

“That means they would lose money by closing their inpatient unit as well as not providing the service that the community needs,” he said. 

White House prescriptions

Biden official key to coronavirus vaccine effort steps down

David Kessler, an early adviser to President Biden on the coronavirus pandemic, is leaving the administration, The Post’s Laurie McGinley and Tyler Pager report.

Kessler — a former head of the Food and Drug Administration — emerged as a key player in the administration’s quest to vaccinate Americans and deliver covid-19 treatments, overseeing the spending of billions of federal dollars to speed up the manufacturing and the distribution of both. 

He joined Biden’s 2020 presidential campaign as it was scrambling to adjust to the virus with little information, helping dispense advice on how to keep Biden and staff members safe. After the election, he was named chief science officer for the coronavirus response. While he was based within the federal health department, Kessler’s West Wing connections helped grant him sweeping authority to manage key parts of the nation’s coronavirus response. 

Here’s one way to look at it: Kessler’s departure signals the last chapter in what was formerly known as Operation Warp Speed, the initiative originally started by the Trump administration to accelerate the development of vaccines and therapeutics. He’s the latest Biden official to exit a top post, with longtime infectious-disease expert Anthony Fauci, who served as Biden’s chief medical adviser, stepping down last month.

A vaccine safety monitoring system in late November picked up a signal that the updated Pfizer coronavirus booster shot was possibly linked to an increased risk of strokes for those 65 and older. But a deep dive into several large databases failed to confirm the preliminary information, leading federal health officials to conclude the risk is extremely low, and probably nonexistent, Laurie and Lena H. Sun report. 

What happened: The Centers for Disease Control and Prevention and the Food and Drug Administration have decided there is no need to change the recommendation that everyone 6 months and older should stay up to date with their coronavirus vaccinations.

Government vaccine safety experts combed through databases containing millions of records, such as the Vaccine Safety Datalink system and databases for Medicare, the Department of Veterans Affairs and Pfizer’s global surveillance network. They also consulted with regulators in other countries, including Israel, but haven’t found any indication that there’s a clinical risk to patients.

  • A statement from the two agencies noted that the government uses multiple systems to detect potential issues, and that “often these safety systems detect signals that could be due to factors other than the vaccine itself,” Laurie and Lena report.

China released new covid-19 data — but the WHO is pushing for more

The World Health Organization is ramping up pressure on China to continue sharing data on its latest coronavirus outbreak after the government revised the nation’s death toll in hospitals from 37 to nearly 60,000 linked to covid-19 since early December, The Post’s Adam Taylor reports. 

By the numbers: Hospitals recorded at least 59,938 coronavirus-related deaths between Dec. 8 and Jan. 12. Of those fatalities, 5,503 involved respiratory failure caused by the virus and 54,435 were the result of cancer, heart disease and other underlying diseases combined with covid-19, according to data released Saturday by China’s National Health Commission.

The numbers appear to show an outbreak similar to the waves of omicron that washed over other countries a year ago and suggests the new surge in infections has peaked. But significant gaps remain, including detailed regional data. It also lacks the detailed genome sequencing that WHO and others have requested to track any new variants, Adam notes. 

The announcement follows weeks of criticism by international health experts and global leaders that Beijing hasn’t been transparent about the extent of its outbreak despite widespread reports of overwhelmed hospitals and funeral homes since the country lifted its “zero covid” policy on Dec. 7. 

Tedros Adhanom Ghebreyesus, WHO’s director general:

  • Pregnant women infected with the coronavirus are seven times more likely to die than expectant mothers who haven’t contracted the virus, according to a new study of more than 13,000 patients from 12 countries, per our colleague Sabrina Malhi
  • Starting today: Veterans experiencing acute suicidal crisis are eligible to receive emergency health care at any Department of Veterans Affairs medical facility or outside provider at no cost, even if they aren’t enrolled in VA benefits, the department announced.  
  • Supreme Court investigators have narrowed their search for the alleged culprit behind last year’s leak of Supreme Court Justice Samuel Alito’s draft opinion overruling Roe v. Wade to a small number of suspects, but officials haven’t conclusively identified who leaked the document, the Wall Street Journal reports. 

For long covid fatigue, a strategy called ‘pacing’ helps, but at a cost (By Amanda Morris | The Washington Post)

Medical Residents Unionize Over Pay, Working Conditions (By Dominique Mosbergen | The Wall Street Journal)

Why nurses say they are striking and quitting in droves (By Lauren Kaori Gurley | The Washington Post)

Thanks for reading! See y’all tomorrow.

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