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In Texas, Americans Highlight Need for Access to Emergency Care in Rural and Underserved Communities

March 21, 2024

Five Key Moments from Ways and Means Hearing on Emergency Care

DENTON, TEXAS – At the site of an air ambulance service provider, patients, doctors, and emergency medical personnel shared their stories about access to emergency medical care in remote, rural, and underserved communities. Many of the stories shared by witnesses highlighted how the lack of access is especially dangerous for Americans living in remote communities, while also highlighting how innovative care delivery models like the Rural Emergency Hospital (REH) designation, community paramedicine, and freestanding emergency departments (FSED) can help bring emergency care access to more patients.

Medical providers testified about the benefit of federal programs aimed at keeping emergency rooms open in rural communities and urged Congress to consider doing more to help patients, including expanding eligibility for the REH designation, allowing FSEDs to participate in Medicare and correcting the Biden Administration’s flawed implementation of the No Surprises Act.

Hosted by Global Medical Response, the hearing included witnesses who serve as a former EMT, a REH administrator, an Emergency Medical Services company’s medical officer, and a former emergency cardiovascular care patient now advocating for better access to such care.

Medicare Regulations Prevent Emergency Care in Rural America

A frequent topic at the hearing was how current Medicare rules and regulations hinder new innovative ways to preserve and expand emergency care. One example is FSEDs – a low barrier to entry way to bring emergency medical care to patients. Ways and Means Committee Chairman Jason Smith (MO-08) highlighted how more Americans would have quicker access to emergency care if FSEDs were more widespread.

Chairman Smith: “Mr. Morris, I think it’s important that we get to the freestanding emergency departments. They can be a lifeline. With the exception of the recent public health emergency, they are ineligible for Medicare reimbursement. This means these facilities are reliant solely on private insurance, private pay, effectively preventing them from spreading into rural and underserved areas where government payers are more common. Can you describe the potential impact freestanding emergency departments could bring to rural emergency care access, if they are allowed to participate or continue to participate in Medicare?”

Robert Morris, FSED administrator: I think [FSEDs] have so much untapped potential if we’re given the opportunity, but when you look at the demographics in [rural] areas, it’s majority Medicare and Medicaid [patients]. We cannot make a go of it without the government reimbursement.

American People to Secretary Becerra: Start Enforcing the Law

Ahead of a Ways and Means hearing with Health and Human Services Secretary BecerraRep. Beth Van Duyne (TX-24) asked the witnesses what they would ask Secretary Becerra about his failed implementation of the No Surprises Act. An emergency care provider highlighted that the Biden Administration’s approach has led medical providers, including emergency care providers, to not receive fair reimbursement, from insurance companies. A chief concern among medical providers is that the process for determining the qualified payment amount is opaque and unclear, skewing payments downward.

Rep. Van Duyne: “Mr. Morris, Congress wrote the No Surprises Act with very intentional and specific guidance, yet we have continued to see the Administration ignore congressional intent during the implementation. Secretary Becerra is going to be in front of this committee on Wednesday in Ways and Means. If you were in my seat, what questions would you ask him?”

Robert Morris, emergency care provider: “Probably the top of the list would be, ‘How are you monitoring, enforcing how qualified payment amounts are determined?’It appears there’s a lot of opportunity there for enforcement on working with payers to make sure that they’re honoring the way that statute was intended and the way those QPAs are being calculated is appropriate. That would be at the top of my list.”

Rural Emergency Hospital Designation Off to Promising Start, But Could Be Improved

Four years after Congress created the REH designation during the Trump Administration, the results show the designation is promising, with Texas leading the nation in the number of rural hospitals with the designation. Nineteen hospitals have switched to the designation, allowing rural communities to keep their hospital open and emergency and outpatient services in their community. Rep. Jodey Arrington (TX-19) asked the administrator of a small hospital in his district how the REH designation could be improved. 

Rep. Arrington“I was proud to lead the Rural Emergency Hospital designation…For Anson, Mr. Matthews, it’s been a lifesaver. You’ve implemented it – you and 19 others in the country – but there are 389 rural hospitals that would qualify for this designation…I’d like more stories of turning around a hospital that would have otherwise shuttered and would not be saving the lives that you and I talked about before this hearing. What can we do to improve upon the REH designation?”

Ted Matthews, REH administrator: “Honestly, I’m surprised also that more rural hospitals in Texas have not converted. We have 19 on a national basis. We have 12 that are in the application process. So shortly, we’re going to have 31 REHs on a national basis… I believe that the primary factor is the loss of services. And that has to do with the inpatient and the swing bed program. We were a Prospective Payment System hospital, but many of the critical access hospitals have huge reimbursements on the swing bed side. If you have a strong swing bed, then you’re able to recoup financially and flow those dollars toward operations.”

Air Ambulances Can’t Get Off the Ground

For air ambulance companies, the flawed implementation of the independent dispute resolution (IDR) in the No Surprises Act has hurt their ability to maintain the readiness needed to respond in an emergency. Rep. Brad Wenstrup (OH-02), co-chair of the GOP Doctors Caucus, highlighted how patients could lose access to emergency care in the future if emergency care providers cannot receive a fair reimbursement.

Rep. Wenstrup: “Dr. Racht, maybe you can talk about how this flawed implementation of the No Surprises Act impacted patient access to air ambulance services in rural and underserved areas?”

Dr. Ed Racht, emergency care provider: “Substantially, and the potential is greater moving forward. If we can’t sustain those resources, that cost of readiness, because of the struggles with payment, in a post-IDR environment, we’re not going to be able to sustain everything that we’ve been talking about today…We finally got an approach to managing the unexpected, the high severity in a way that was fair to the patient, that allowed them to heal. Unfortunately, because of the challenge in collection, we’ve not seen that come to fruition. An important thing to remember from all of us on the emergency care side – we don’t know if you can pay or not. We don’t know if you have insurance or not. We may not even be able to talk to you. But we do the same thing to stabilize your anatomy and physiology and get you to the point where you maximize your chance of survival.”

Paramedics Make a Difference for Rural Patients

The community paramedicine model allows paramedics to provide assistance at the point of care to stop health problems from escalating into an emergency. Though not widely adopted because the service is not covered by Medicare, this approach has been shown to reduce emergency room visits and reduce health care spending. In response to Rep. Lloyd Smucker (PA-11), one witness who oversees a community paramedicine program shared how Medicare’s lack of coverage has a cascading effect on other types of insurance which in turn discourages investments in this innovative model.

Rep. Smucker: “Have you seen the paramedicine program hindered by reimbursement models? Can you talk a little bit more about how that’s worked for you and what could we do to ensure that these programs could continue to start and grow in communities?”

Matt Zavadsky, emergency care provider: The economic model for a community paramedic program is fundamentally flawed in that Medicare does not recognize it as a covered benefit. Therefore, Medicaid typically does not as well; commercial insurers typically do not as well. Many community paramedic programs started with grants. Medicare did health care innovation award grants, and there were six of them that were community paramedicine programs. Then as soon as the grant program ran out, they closed because there was no sustainable funding mechanism for it