CREJ

April 2021 — Health Care & Senior Housing Quarterly — Page 3 www.crej.com I n the fall of 2018, one of my best friend’s proposed we embark on the ultimate week- end. One of his corporate part- ners invited him to a private event at Lambeau Field that includ- ed drinks, dinner and a tour with Packer legend LeRoy Butler; after- ward we made the roughly 70-mile trip to my family’s Northwoods cabin to fish before returning to Green Bay for the game on Sunday. The event at Lambeau was incred- ible, but it was the next morning that I remember the most. After breakfast, my friend calmly asked me where the nearest hospital was. He was experiencing chest pain and the closest hospital was nearly 45 minutes away. Knowing that call- ing an ambulance to our remote area would take considerable time, I chose to drive him to a rural hospi- tal I knew was operated by a larger system with a renowned cardiol- ogy center. Thankfully, we arrived at the rural hospital and he began receiving treatment in time; he was transferred to the larger center to have a stent inserted into his 95% blocked artery. The following day, we watched the game from my liv- ing room instead of Lambeau Field. I’ve had the privilege of delivering architecture and planning services to the health care industry for the past 25 years in a variety of com- munities. In my personal life as well as my career, I have witnessed the impact different payment mod- els can have on communities and developed a passion for under- standing how the built environment can connect the delivery of care to diverse popula- tions, while being financially sus- tainable, efficient and effective. Accessibility, ade- quacy and afford- ability of health care continue to be three primary con- cerns for Ameri- cans. Having worked for facilities in rural and urban areas, I’ve noticed the disparity of the various pay- ment models regulated by Health and Human Services as well as the impact the Affordable Care Act has had on both demographics. Though the 2010 legislation has come with challenges for all health care providers, I’ve observed that rural communities have an even greater uphill battle that often is not considered. Factors such as longer travel distances, difficulties in attracting medical talent at all levels and various socioeconomic realities present real barriers for rural health facilities to strike the balance between delivering appro- priate services to their unique pop- ulations while also being financially sustainable. n An alarming trend in rural health. According to the National Health Council, rural areas cover over 90% of the nation’s land area but con- tain somewhere around 20% of the total population (about 60 million). This underserved and remote popu- lation has gone unnoticed for far too long. The challenges for rural health have been pretty much the same for many years with reali- ties like higher poverty rates, large numbers of uninsured people and older adults with chronic health problems, in addition to heightened exposure to environmental hazards. Despite enhanced payment mod- els for some rural hospitals over the last 20 years, a Feb. 24, 2020, Forbes article cited that 120 facili- ties had closed in the 10 years prior, accounting for 7% of the 1,844 rural hospitals at that time. Forbes also claimed that 1 in 4 rural hospitals were at risk of closure – an espe- cially shocking number consider- ing this was prior to the pandemic. Fortunately, this alarming trend has started to drive increased attention from policymakers and advocates in recent years – but not enough yet. To demonstrate the disparity in attention between communities, we can look to the COVID-19 pan- demic as a recent example. Since the beginning of COVID-19, health reform conversations and data on the effects of this health emer- gency have been primary focused on urban areas. However, a recent study on rural health in the West- ern states confirms the importance of increased focus on rural health care facilities. The research indi- cates that the effects of the COVID- 19 pandemic on rural populations have been severe, with significant negative impacts on unemploy- ment, overall life satisfaction, men- tal health and economic outlook, and that rural recovery policies risk being informed by anecdotal or urban-centric information. n Legislative measures for rural health. Although far from receiving the attention and resources needed, there has been some traction in Congress for improving rural health. The Rural Emergency Acute Care Act has been around in various forms since 2015 in an attempt to provide relief, but it did not address two important areas: reimburse- ment around telehealth and the promotion of partnerships between rural hospitals and their closest larger health systems. So, it ended up serving as more of a springboard than a solution. On Dec. 21, legislation on year-end COVID-19 relief was approved by Congress, establishing Rural Emer- gency Hospitals as a new Medicare provider type effective Jan. 1, 2023. REHs – defined as providers that furnish certain outpatient hospital services in rural areas, including emergency department services – will be reimbursed at a rate 5% higher than the otherwise-appli- cable payment under the Medicare Outpatient Prospective Payment System. This enhanced reimburse- ment undoubtedly will provide major financial relief for many struggling hospitals. Facilities wanting to enroll as REHs will need to meet certain requirements and conditions placed by the Centers for Medicare & Med- icaid Services. According to the act, REHs are required to: • Not provide acute care inpatient services (beds); • Not exceed an annual per patient length of stay of 24 hours; • Have a transfer agreement in place with a Level I or II trauma center; • Maintain a staffed emergency department, including staffing 24/7 by a physician, nurse practitioner, clinical nurse specialist or physician assistant; • Meet critical access hospital- equivalent conditions of participa- tion for emergency services; and • Meet applicable state licensing requirements. At the time of this writing, the U.S. Senate has just passed the American Rescue Plan. The Sen- ate version provides $8.5 billion for rural hospitals and facilities for health-care-related expenses and lost revenues attributable to the COVID-19 pandemic. This is another positive sign the federal govern- ment is taking action to help our rural population and health care providers. n What the future will hold for rural health. There still are a lot of open questions and the next two years will be filled with lively discussion and debate as CMS digs deeper into detailing future rulemaking and guidance while rural communi- ties grapple with potential changes to their local health care system. Questions will be raised, such as: How will local jobs be affected? Will people adapt to only receiving pri- mary and emergency care close to home with travel required for sur- gery and other complex procedures? With more flexible work models and HEALTH CARE — MARKET UPDATE Ed Anderson, MBA, EDAC Health care market leader, EUA A lack of density does not equal a lack of need Following a master plan, renovations and an addition allowed this regional medical center to provide the surrounding community with a much-needed new emergency department, birthing center, wellness/rehab department, and a transformed dining and nutrition experience for the campus. To minimize operating costs, this new construction rural hospital incorporated a geo- thermal system to achieve payback in less than five years. To meet the needs of its rural population, this provider is undergoing a phased approach of first expanding a clinic with an emergency department and then expand- ing to include inpatient care to make a full-scale rural hospital. Please see Anderson, Page 15