What Role Should Providers Play in New Rural Emergency Model?
November 1, 2022 7 minutes read
By Dorothy Brooks
The first Rural Emergency Hospitals (REH) will debut in 2023. These are a new type of provider created by Congress to help preserve acute care services in rural areas served by hospitals that are struggling financially and face potential closure.
Beginning on Jan. 1, 2023, at least some of these financially stressed hospitals will be able to convert to the REH model rather than close their doors completely and deprive area residents of needed healthcare services. This is a potential lifeline for the communities involved as well as a way to preserve the healthcare workforce in areas of high need.
The REH model also should present a new opportunity for emergency medicine providers, although much depends on the final Conditions of Participation (CoP) that will govern these facilities. The American College of Emergency Physicians (ACEP) has been actively involved in trying to ensure the interests of emergency providers and patients are reflected in these rules. The Centers for Medicare & Medicaid Services (CMS) seeks to ensure the care provided under the REH model is safe and high quality while not making workforce demands that rural communities may not be able to meet.
As described in the statute, it appears REH facilities will operate much like EDs, offering emergency and observation care, but they also will be allowed to provide some additional outpatient services, such as maternal care (including low-risk labor and delivery services), behavioral healthcare (including outpatient treatment for opioid addiction), and outpatient rehabilitation. Also, importantly, REHs will receive enhanced reimbursement under Medicare for services provided, along with a monthly facility payment.
There are a few noteworthy stipulations. For instance, an REH cannot provide inpatient care services, and the average patient length of stay (LOS) cannot exceed 24 hours. Instead, REHs must create a transfer agreement with a level I or level II trauma center where patients requiring inpatient hospitalization can be sent. Also, REHs must be able to provide service at their facilities 24/7. However, in the proposed CoP, CMS gives wide latitude to facilities regarding what type of personnel will be providing and overseeing care.
This is an issue ACEP takes strong issue with. They detailed their positions in a July 2022 online post and more formally in a letter sent to CMS in August.1,2 Jeffrey Davis, ACEP’s director of regulatory and external affairs, wrote in July, “All services delivered in REHs should be supervised by emergency physicians, either in-person or virtually via telehealth. While we prefer that all services delivered in REHs be overseen by board-certified emergency physicians, we acknowledge that this is not always possible due to existing workforce challenges in rural areas.”
If a board-certified emergency provider is unavailable, Davis argued CMS should require a physician with training or experience in emergency medicine to provide the care or oversee such care provided by non-physician practitioners. “The level of training and education of physicians far exceeds that of non-physician practitioners, and emergency patients represent some of the most complex and critically ill patients in medicine,” Davis wrote.
Davis also contended a standard of training for all practitioners delivering services in REHs must be established. ACEP strongly opposes the CMS proposal that such facilities do not need a physician, nurse practitioner, clinical nurse specialist, or a physician assistant available on the premises to provide care 24/7. Rather, CMS suggests clinicians can be on call and immediately available by phone or radio, and be present on site within certain periods. “If finalized, this provision would pose significant patient safety concerns,” Davis wrote. “It could also increase the chances that REHs violate the Emergency Medical Treatment and Labor Act (EMTALA) in scenarios where a trained clinician is unable to arrive in time to treat or stabilize a patient.”
Meanwhile, ACEP is pleased CMS recognizes the important role telemedicine plays in the delivery of care in rural areas and has taken steps to streamline the credentialing and privileging process for clinicians who will perform these services for REHs. For instance, rather than going through the burdensome process of credentialing and privileging providers offering telemedicine services from a hospital at a distant site, an REH can choose to make these determinations based on information from the providing distant hospital.
“Overall, ACEP supports these proposals, as we appreciate CMS’ efforts to reduce regulatory and administrative barriers to telehealth,” Davis wrote. “ACEP believes that telehealth can serve as a method for physicians to deliver services or to oversee care provided by non-physician practitioners in REHs when in-person care and/or supervision is not possible.”
That said, ACEP is seeking clarification on several related matters, including whether distant site hospitals and providers that are providing telemedicine services from those hospitals need to be enrolled in Medicare. “CMS should also clearly articulate the existing Medicare regulations regarding the supervision of non-physician practitioners and how telehealth can be a platform by which physicians can supervise care being delivered by non-physician practitioners,” Davis wrote.
Davis tells ED Management applications of telehealth technology could reshape the way care is provided in many underserved regions. “Improving the way telehealth is used in rural communities can help meaningfully address some of the longstanding barriers to access and challenges facing rural care teams and patients,” he says.
Margaret Greenwood-Ericksen, MD, MSc, is an assistant professor in the department of emergency medicine at the University of New Mexico in Albuquerque. As both a practicing emergency physician who has worked in rural EDs and a researcher focused on rural healthcare delivery and outcomes, she has been watching the development of the REH model closely. “It is very exciting to think of a rural hospital being able to transition to a facility that best matches the community’s needs,” she says.
However, some of Greenwood-Ericksen’s initial excitement about the REH model has dimmed as more information about how such centers will operate is revealed. “It’s increasingly clear that without any capital investment, these hospitals will have to operate this model out of their same facilities, which will prevent them from realizing much of the efficiency gains and clinical innovation that free-standing EDs and microhospitals may achieve,” she says. “Of course, the big difference is that an ED clinician [operating in an REH] can no longer admit a patient to the hospital as an inpatient. Those patients will need to be transferred to another hospital where they can be admitted. This may increase rural hospital bypass and/or increase interhospital transfers, which could be an additional strain on rural EMS systems, which already are underfunded and understaffed.”
Greenwood-Ericksen believes the goal of the REH model appears to be providing an opportunity for small, rural hospitals and critical access facilities with few inpatient admissions to right-size themselves. However, she notes innovative delivery models typically require significant investment up front. “They start by first building a facility designed to meet their goals, be that efficiency, communication, or co-location of services,” Greenwood-Ericksen says. “That is different from the REH model, which will have to operate out of the same [hospital] facility.”
Under this scenario, Greenwood-Ericksen fears REH facilities will have to endure all the costs associated with operating a large facility. Further, REH operators might be unable to design the kind of centers that best match their needs. “It increasingly seems to me that the only thing that may change will be the financial model, not the delivery [model],” Greenwood-Ericksen says.
Further, Greenwood-Ericksen echoes the staffing concerns Davis highlighted in July. “The field of emergency medicine cares deeply about rural health. A new model that proposes to stabilize or reduce rural hospital closures is welcomed,” she says.
“Specifically, [ACEP] has long advocated for [an REH-like] concept as a way to expand access to emergency care in areas impacted by rural hospital closures. However, ACEP and emergency physicians are concerned that CMS has not required physician support and oversight of non-physician practitioners.”
Some rural, non-physician practitioners are experienced, Greenwood-Ericksen says, but she notes others are new graduates and require a great deal of support and guidance from a supervising physician.
Despite all these concerns, the American Hospital Association (AHA) has voiced strong support for the REH model. In a letter to CMS, the AHA stated the REH model will help preserve healthcare services in areas already underserved.
“Rural hospitals and CAHs [critical access hospitals] struggle to attract and retain sufficient numbers of physicians, nurses, and other healthcare providers. They frequently are the only available source of urgent and emergent care for many miles. They have to stretch available resources due to financial constraints, especially for the past several years, and they face new challenges as a result of unprecedented workforce burnout. These difficulties, compounded by the COVID-19 pandemic, played key roles in a record number of rural hospital closures in 2020, with 19 rural hospitals closing in that year alone,” AHA wrote.3 “We appreciate CMS’ efforts to assist rural providers as they navigate these exceptionally difficult times.”
However, in further comments, the AHA asked CMS for some changes. In particular, the group wants CMS to include two exceptions to the 24-hour LOS requirement. First, while AHA supports allowing REH facilities to provide labor and delivery services, it noted it would be impractical to expect these patients to be discharged within 24 hours, particularly in cases that require surgical intervention.
Second, the AHA noted it may be difficult to discharge patients requiring behavioral health or psychiatric care within 24 hours. Instead, the group suggested REHs be given the opportunity to provide documentation of their efforts to discharge and/or transfer a patient to another facility.
CMS is expected to finalize CoP rules for the REH model before the end of 2022, along with payment policies and provider enrollment procedures.
REFERENCES
1. Davis J. CMS releases first summer reg: Rural Emergency Hospital Conditions of Participation. July 7, 2022.
2. American College of Emergency Physicians. ACEP response to CoPs for Rural Emergency Hospitals. Aug. 18, 2022.
3. American Hospital Association. AHA comments on CMS-proposed Conditions of Participation for Rural Emergency Hospitals. Aug. 26, 2022.
In 2023, remote, financially stressed hospitals could convert to a new model and remain a critical part of small communities. This is an exciting opportunity for emergency medicine providers, although much depends on the final regulations that will govern these facilities.
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