HJNO Jan/Feb 2025

HEALTHCARE JOURNAL OF NEW ORLEANS I  JAN / FEB 2025 41 federally- designated primary care short- age areas are rural or partially rural 10 , and that rural communities experience “extreme levels of poverty and low life expectancies” 11 with “higher rates of certain chronic con- ditions and health risk factors.” 12 “Distance and time are two variables that lead to lower health status of populations,” said National Rural Health Association Chief Operating Officer Brock Slabach. ENHANCING PAYMENTS FOR RURAL ACCESS To protect local rural access, Congress established enhanced reimbursements under the CAH payment system for low- volume rural hospitals that have high fixed- staffing costs. 13 According to the Medicare Payment Advisory Commission (Med- PAC), after Medicare sequestration pay- ment reductions, CAHs can recover 99% of their costs for services for “outpatient, inpatient, laboratory and therapy services, as well as post-acute care in the hospital’s swing beds.” 14 MedPAC recently found that even with these payment enhancements, “the small- est hospitals lack economies of scale, and if their patient volumes fall far enough, they may close.” 15 While Louisiana has largely been spared from rural hospital closures, 16 researchers have tracked 109 complete clo- sures in the U.S. since 2005. 17 GAMING THE MA BENCHMARKS Critics have called for significant reforms in how CMS pays MA plans for rural care. To update payments for MA plans, the agency calculates a county-level bench- mark or maximum it will pay based on aver- age spending for that county’s traditional Medicare enrollees. 18 These calculations include the enhanced reimbursements for local care provided by CAHs and other small rural hospitals. “The higher costs of rural care are in the benchmark,” said MedPAC member Lynn Barr, who clarified that her private com- ments were not the official opinion of the commission. “If traditional Medicare pays and allowing MA plans to lower it to 65% by using waivers. During rulemaking, CMS said it did “not believe that this reduction will result in leaving some rural communi- ties without appropriate access to essential services.” 6 Kaiser Family Foundation (KFF) researchers recently found that rural MA enrollment has nearly quadrupled since 2010, with an average of 27 MAplans in each rural community. 7 MA rules also explicitly permit companies to enroll rural beneficia- ries without offering access to any providers in the same parish (county) or state. 8 Since 2020, policy leaders have raised concerns about access barriers that prompt rural MA enrollees to switch back to tra- ditional Medicare. A Health Affairs study found that “rural MA enrollees switched to traditional Medicare at substantially higher rates than nonrural MAenrollees. This phe- nomenon was more pronounced among those who required the use of costly ser- vices, such as facility stays or hospitaliza- tions, those with poor self-reported health, and those who reported lower satisfaction with their access to care. If the quality of MA networks in rural areas is a concern, CMS can consider implementing more stringent network adequacy standards for rural coun- ties in a plan’s service area.” 9 “Eliminating people from access by cut- ting out whole markets is not the solution,” said Pratt, noting that rural Medicare enroll- ees “are just as important as every other Medicare recipient across the country.” West Feliciana Parish Hospital CEO Lee Chastant said his CAH serves as the only behavioral health provider that accepts Medicare patients in its parish, and Peo- ple’s Health terminated its MA contract for all non-emergency services without nego- tiation. He said local leaders were already focusing on transportation challenges within the parish for these patients. “If they can’t get to us in the same community, how are they going to get to Baton Rouge or beyond?” he asked. Reducing rural patient access might seem counterproductive considering that most us a chance to ask questions,”she said, add- ing that her doctor’s rural health clinic and SJPH are only two blocks from her home. With experience in national Medicare shared savings activities, 2 SJPH provid- ers improve local patient outcomes every day by recommending smoking cessation, mammograms, and colonoscopies, and helping patients control their diabetes and hypertension. 3 Jacob recalled feeling upset when Humana told her it had assigned her a new physician without fully explaining why. After switching MAplans, she still worried about learning where to refill medications under her new insurance company. “I can’t wait until the last minute,” she said. “The loophole here is ‘we are not drop- ping you, but we’re leaving your local pro- vider,’”said former HumanaMApatient Mai- tland “Spuddy” Faucheaux, who expressed concerns that other MA insurer networks might also drop SJPH and that some local seniors might forgo needed care due to new transportation challenges. “Many of us feel we were misled,” he said, discussing how Humana’s webpage for 2025 MA enrollees still falsely listed SJPH as in-network during the open enrollment period. 4 Will Freeman, MD, who works in several Louisiana CAHs, agreed that Humana’s pro- vider lockout exacerbates existing rural provider shortages and undermines invest- ments in physician recruitment. “Sending patients far away to get labs, X-rays, and MRIs makes it less convenient for doctors to practice in those communities,” he said. WEAKENING RURAL ACCESS PROTECTIONS Before 2020, MA plans were required to ensure that 90% of their total enroll- ees could reach an in-network acute care hospital within 75 minutes and reach a pri- mary care provider within 40 minutes. 5 After reporting “existing failures in MA plans meeting the time and distance stan- dards,”the Centers for Medicare &Medicaid Services (CMS) reduced these rural patient protections by cutting the threshold to 85%,