Remarks to the National Rural Health Association

Alex M. Azar II
The Rural Health Association
February 5, 2019
Washington, D.C.

We should set our standards high: As America becomes a wealthier, prosperous, more interconnected nation, there is no reason that we should not expect rural health to be improving—not just staying steady, but catching up to outcomes seen in the rest of the country.

Thank you for that introduction, Dr. Putnam—it’s always a pleasure to be introduced by a fellow Hoosier.

Good morning, everyone, and thank you for welcoming me here today.

I’m delighted to be here because the work of this gathering, and of the National Rural Health Association, is vital to the mission of the department I lead, the Department of Health and Human Services. Our mission is to improve the health and well-being of every American, and that includes a special focus on the health and well-being of the 57 million Americans who live in rural areas.

I’m also glad to be here because the issue of rural health has been an interest of mine for a long time.

I grew up in a rural area, on the eastern shore of Maryland, and I’m the son of two rural healthcare providers.

Now, Maryland isn’t always the first place that comes to mind when you think of rural America, but my town was definitely rural.

We did have two McDonald’s in my town in my early years growing up—but it was small enough that, when a Wendy’s finally opened, that was a very big deal.

Surgeon General Jerome Adams, whom you’ll hear from later today, is from rural Maryland too—we can safely say the administration has easily met and exceeded its rural Maryland quota.

The Surgeon General and I are also both transplanted Hoosiers, so we have some interest in rural health from that perspective, too.

In my professional life, now, the question of how to provide quality, affordable healthcare to rural areas has become a deep interest.

Certainly, it is of great interest to HHS and the Trump administration. Eighteen percent of Americans live in rural areas, spread across 80 percent of the country’s land mass. Approximately 2,000 of the country’s 5,000-plus acute care hospitals are located in rural America.

And we know that many rural hospitals are in crisis: The Government Accountability Office found that 64 rural hospitals closed from 2013 to 2017. This represented about 3 percent of all the rural hospitals we had in the country in 2013. We closely track these hospital closures and the factors behind them through a HRSA-funded rural research center at the University of North Carolina.

In addition, HHS has a special responsibility to provide healthcare in Indian Country, often in areas so remote that they are more properly called frontier than rural.

But rural health challenges are not just about healthcare infrastructure. Rural communities can also face particular social risk factors, such as limited employment and education opportunities.

We’ve also seen particular health challenges burden rural areas. The opioid epidemic, unlike past drug crises, has hit rural areas harder than urban ones. That is one reason is why the Trump administration has proposed rural-specific programs to tackle the crisis, through the Rural Community Opioids Response initiative, which has produced a two-year investment of $265 million to target the epidemic in rural areas.

The opioid crisis is one of the four priorities I have identified as Secretary, alongside value-based transformation of our healthcare system, addressing the cost and availability of health insurance, and bringing down the high price of prescription drugs.

Each of these priority areas has important implications for rural providers and the communities they serve. But they’re also important to mention because the reason I picked them as priorities is the same reason that rural health is a priority for HHS.

When you’re selecting priorities as a leader, you don’t pick particular challenges just because they are pressing problems—though certainly that’s a criterion. You also pick something as a priority because it requires more than just continuing business as usual—it requires transformation.

So, for example, we aren’t going to beat the opioid crisis without significant transformation in how our country treats pain, mental health and addiction.

We’re not going to bring down the price of prescription drugs without transforming the landscape of how these drugs compete with each other and are paid for.

That’s why we have identified rural health as a priority, too. Better meeting the needs of rural communities is going to require transforming how we meet those needs.

For that reason, last year I pulled together a rural health task force at HHS, with key leaders and stakeholders from across the department. The goal of the taskforce is to bring together disparate efforts across HHS and develop the best understanding of where policy changes can help bring about the needed transformation.

So what have we been thinking about so far?

Our goals for rural healthcare are simple: We need care in rural areas, as everywhere, to be affordable. We need care to be as accessible as possible. And we want that care to be high quality.

We know where we want to go. Today, I want to lay out three key strategies for how we can get there: sustainability, innovation, and flexibility. I’ll address each of them in turn.

Sustainability

First, we need to think about how to deliver care in rural areas in a sustainable manner—sustainable for providers, for patients, and for the taxpayer.

There is no reason to invest new resources and stretch existing ones to prop up models that are not going to be economically sustainable long-term.

As I mentioned, we are concerned about the closure of rural hospitals, and we’re working to understand how we can support them. But we also need to think broadly about what rural healthcare may look like in the future: the right sustainable model for healthcare in an area may not always be the traditional 1960s hospital model. Other models may offer better care, at a more sustainable cost.

We do know there are some longstanding, structural challenges in payments for rural hospitals, which we want to address. As our CMS Administrator, Seema Verma, has discussed, we’re thinking about how we can adjust our wage index formula to avoid exacerbating the already stark disparities between urban and rural providers.

We know the wage index can present challenges for rural hospitals.

It’s an enduring enough problem that, during my Senate confirmation process, a little over a year ago, someone came to me and said: So we need to get you briefed up to meet with Senator X on a particular issue, I said, “ah, could this perhaps be the rural floor?”

It wasn’t my first rodeo with the rural wage index—I understand how much it matters.

But addressing something like the wage index isn’t the endgame—we all know that. The rural health task force is examining all aspects of our rural health policies, looking closely at how payments are affecting rural hospitals, and considering where the most sustainable models may not be hospitals at all.

One tool we have is experimenting with wholly new payment models—not just tweaks around the edges but bold experimentation that can improve efficiency, quality, and access. We have extensive powers to do that within the Center for Medicare and Medicaid Innovation, which is run by Adam Boehler, who is also my senior advisor for advancing value-based transformation.

It’s important to understand that our thinking about sustainable models for rural health is informed by how we are thinking about our larger work on value-based care.

We all want care to be delivered at the lowest cost possible. But unless that care is also accessible and of high quality, the low cost you paid for it could come back to bite you in the future.

Patients need access to care to prevent and manage illnesses. High quality care, whether because it’s curative or enables the patient to live a more active, healthy life, can sometimes pay for itself in the long run.

But accessing high quality care doesn’t necessarily have to mean going to what we think of today as a hospital.

A truly sustainable model for rural healthcare is going to require thinking about where we absolutely need traditional hospitals, and where we can provide the same quality of care or even better through some other model, which may not yet exist.

One model for sustainable, low-cost, high-quality care is HRSA’s community health centers.

Most health centers are located in rural areas or urban areas with other challenges, and yet they have shown success in beating the national averages with their patients’ results in blood pressure control, diabetes treatment, and more.

Innovation

Sometimes, however, complicated medical conditions require not just going to a hospital, but actually getting really advanced medical expertise.

This brings me to the second principle I want to discuss, innovation: We need to think innovatively about how to bring the best care to as many patients in rural areas as possible.

This is an interesting challenge when it comes to something like cancer care.

As we’ve ventured into the world of precision medicine, academic medical centers are playing a more and more important role in cancer care. Providing follow-up care for a unique treatment regimen is quite complicated.

But new technology also offers ways to improve access to top quality doctors and diffuse knowledge and best practices across the country.

There is no reason why we shouldn’t be able to extend the reach of, say, incredible cancer doctors at Johns Hopkins to help improve care where I’m from, in Salisbury, a couple hours southeast.

This is especially important when it comes to cancer, because rural communities continue to have noticeably worse cancer outcomes than urban areas. We actually see lower rates of cancer in rural areas, but higher rates of cancer mortality.

Last year, the National Cancer Institute put out a funding opportunity specifically focused on improving cancer prevention and care in rural areas. One particular area for exploration specifically mentioned is pioneering new technology-enabled, team-based care models that could offer more high-quality cancer care among rural populations.

Improving cancer care in rural settings is a focus for the cancer institute’s director, Ned Sharpless, and we hope to expand this work in the future.

With modern technology, your survival rate should not depend on your ZIP code.

On other health challenges, we have already seen some promising ways to extend expertise to rural communities. The state of Mississippi, for instance, has just one academic medical center, the University of Mississippi Medical Center in Jackson.

In 2003, with support from USDA, they began equipping ambulances and emergency rooms across the state with more sophisticated diagnostic equipment and telehealth capabilities. This allowed specially trained EMTs, nurse practitioners, physicians in rural areas to communicate in real time with emergency medicine physicians in Jackson.

The Center currently provides expertise in more than 35 medical specialties for adults and children. In 2017, HRSA named the Mississippi project one of the two centers of excellence for telehealth in America.

Still, for all the innovation going on, we know that there are a number of regulatory and payment barriers that have held back telehealth. The Medicare fee-for-service system currently pays for telehealth services only in a limited range of circumstances—typically, rural areas with a shortage of healthcare professionals.

We believe that can sometimes be a penny-wise, pound-foolish restriction, and we want to continue searching out areas where technology, including telehealth, can increase access to care and decrease costs.

Late last year, for instance, we created two new ways for Medicare to pay providers specifically for forms of “virtual care,” delivered remotely.

Providers can now be reimbursed for remote patient monitoring visits and for assessments of electronically transmitted images.

Previously, a physician’s phone or video check-in with a patient was not payable by Medicare separately from an in-person visit.

I think we would all agree, if we’re trying to get the best out of modern communications technology, only paying for remote interactions that involve someone having to go into the doctor’s office isn’t going to do the trick.

We’ve started paying separately for physicians to consult with their patients remotely, using technology, without the patient being in a doctor’s office or other health facility.  In many circumstances, patients can just now check-in with their doctors from home. For someone in a city or suburb, that’s convenient; for a patient in a rural area, it could be life-changing.

In addition, we have continued to conduct an annual review to identify services we can remove from statutory limits on telehealth so that these services can be reimbursed by Medicare regardless of whether they originate in areas that are designated as rural shortage areas.

Allowing telehealth to flourish everywhere across the country is going to be good for the rural places that need it most. We also know that the technical definitions of which communities are rural and which communities face provider shortages can sometimes be a confusing barrier in and of themselves.

Finally, we have also proposed using new flexibility provided by Congress to allow Medicare Advantage enrollees to enjoy even more telehealth flexibilities, including the ability for plans to offer telehealth services as part of their basic benefit.

This would remove disincentives for telehealth in Medicare Advantage and allow beneficiaries to receive any service covered by their plan from their home, or any other location, at any time they choose. Even better, this work in Medicare Advantage could be an important innovation model for us to draw lessons to apply to Medicare fee-for-service.

It is remarkable what telehealth can accomplish in some of the most rural communities in America. Last year, our deputy secretary at HHS, Eric Hargan, led a delegation up to tribal communities in Alaska, where they learned about some remarkable innovations.

In Hughes, Alaska, a town of less than 100 people, our HHS team saw how community health aides can use a two-way diagnostic tool to examine a patient and then confer with care providers and pharmacists in Fairbanks, about 250 miles away. Medicine can then be prescribed by the doctor in Fairbanks and then dispensed through a “vending machine” at the clinic back in Hughes.

This is remarkable work, and understanding the perspectives of tribal communities and our Indian Health Service facilities is a key piece of improving rural health.

There are even innovative solutions sitting out there that we just need more people to know about. Last year, for instance, we put out a guidance from our assistant secretary for health, Admiral Brett Giroir, alerting prescribers to how they can use telehealth to prescribe buprenorphine as part of a medication-assisted treatment regimen for opioid addiction.

Many practitioners assumed this was infeasible or impossible, because buprenorphine is a controlled substance. But practitioners in rural areas who don’t have a buprenorphine prescribing waiver can offer the drug by connecting, via telehealth, with those who do have the waiver anywhere else in the country.

But again, some real, significant barriers to telehealth do exist: Some states, for instance, require practitioners to have met the patient in person before treating over telehealth.

These kinds of well-meaning regulations can make some sense on their face, but they can also impede access to the right solutions for patients and providers in unique and challenging rural circumstances.

Flexibility

That brings me to the third principle I want to discuss, flexibility.

Earlier this year, a number of components from across the Trump administration released a report on choice and competition in American healthcare.

It laid out a number of places where existing regulations, from the federal to the local level, may be raising the cost of healthcare and reducing the supply of practitioners, and many of these issues are especially relevant to rural areas that face provider shortages.

I’ll give you just one example: There’s a category of nurses technically known as advanced practice nurses, which, as many of you know, includes nurse anesthetists, nurse midwives, clinical specialist nurses, and nurse practitioners. They are explicitly trained to offer primary care and certain specialized care.

Yet, as the administration report notes, more than half of states impose on them either supervision requirements or “collaborative practice” requirements, which can have the same cost and inconvenience. These nurses are specifically trained to offer specialized care, and yet these regulations make it costly or even impossible to practice to the top of their license.

We know the supply of providers in rural areas can be a serious challenge, and I encourage all of you interested in this issue to take a look at the administration’s choice and competition report, and see where there may be regulations impeding supply in the areas where you work.

There is potential not just to empower advanced practice nurses, but also physician assistants and other health professionals.

We also want to think about how we can expand the knowledge and practice areas of clinicians in rural areas. One great example of this, which many of you may be familiar with, is Project ECHO, which works to disseminate training and knowledge to physicians in rural areas. It’s a revolutionary approach to medical education, which expands the capacity to provide specialty care in places that would never otherwise have the relevant expertise.

Local clinicians around America are put together with specialist teams at academic medical centers in frequent virtual clinics, to share knowledge and expand treatment capacity. Currently, Project ECHO is providing clinicians with the knowledge and support to treat conditions from hepatitis C, HIV, and TB to chronic pain, dementia, and serious mental illness.

Project ECHO has also helped share knowledge about prenatal and maternal care. We know prenatal care and labor and delivery is a serious challenge in rural areas. Better dissemination of best practices and better use of non-physician health professionals can both help address this particular challenge.

Project ECHO has been so successful that the CDC has even adapted its model for medical education within PEPFAR, including in partnership with the Ministry of Health in Namibia—the world’s second most sparsely populated country.

If your innovation is so adaptable that CDC is using it to expand capacity in the second-most-sparsely populated country in the world, I think you’re onto something.

Conclusion

Successes like Project ECHO show how much reason we have to be optimistic about the future of rural healthcare.

I hope all of you are excited about this future, because I’m excited about the future of rural healthcare.

For any area where there is this much dedication to patients and this much openness to innovation, you can’t help but be optimistic.

We should set our standards high: As America becomes a wealthier, prosperous, more interconnected nation, there is no reason that we should not expect rural health to be improving—not just staying steady, but catching up to outcomes seen in the rest of the country.

Meanwhile, lack of healthcare access should never undermine our rural communities and drive urbanization in our country.

Even as our country changes, the health and well-being of rural America is just as important important today as ever before. Rural America, rural health, and rural healthcare are and will be a priority for this administration.

With your hard work, cooperation between HHS and all of you, and a sustainable, innovative, flexible approach, we can deliver a new era of quality healthcare in rural America—and better health for every rural American. Thank you for having me here today.

This information was originally distributed by the U.S. Department of Health & Human Services.

Remarks to the National Rural Health Association from the U.S. Secretary of Health and Human Services