american history tv, on real america, archival films of world war one. sunday at c-span at 6:30 p.m., former new jersey governor chris christie at the new jersey institute of politics. at 9:00 p.m., afterwards, former intelligence director james clapper. american artifacts. memorial day on c-span at 11:00 a.m. eastern life coverage of the wreath laying ceremony at the tomb of the unknown soldier. in american history tv on c-span three, programs marking the centennial of world war one.

go to c-span. org. >> potential changes to medicare payments coming up next. the hearing is shared by you utah senator. it's two hours and 15 minutes. 15 minutes. >> the hearing would come to order. i would like to welcome everyone to today's hearing. the topic today is rural healthcare which is a critical issue for

virtually every member of this committee and so many others. many of our nations urban counterparts enjoy, representing the western state i understand the challenges of rural hospitals and providers face. in the senate rural healthcare policy boasts a long history of cooperation. the mma, included a comprehensive healthcare package taylored specific with healthcare providers in mind. the mma finally put rural providers on a level playing

field with their neighbors. it helped isolated under served areas in the country, to provide access to medical care as close to home as possible. however, in the years following these temporary provisions became known as medicare extenders. as many know, the debate over necessary funding for the future, although some healthcare policies and medicare payments, many rural and frontier healthcare providers still face significant obstacles attempting

to successfully participate in medicare system reforms and bundle payment arrangements. while this continues knew ways, medicare existing strategies to preserve healthcare in rural areas still rely on special reimbursement programs that either supplement in patient hospital payment rates or provide cost base hospital payments. now, these special payment structures may work just fine insert parts of the country, but with a wide range of special medicare payment programs, some smaller communities still find it hard to achieve financial stability. the reasons as we will learn landlord the panel today are

complexity and multifaceted. when compared to their urban counterparts on average, the 4 million beneficiary people living in rural and frontier areas suffer from more chronic conditions and face higher mortality rates. to make matters worse, small rural hospitals continue to be more heavily developed. at the same time we're seeing a steady nationwide shift from in patient care to providers offering more out patient services it seems to me. some struggle to keep their

facilities operating in the black in order to meet local demands for a full range of in patient and outpatient services. clearly for some communities medicare special rural payment structure -- structures i guess i should say, they stifel innovations for rural healthcare delivery systems. one consistent theme that we will hear from our witnesses today is the need for flexibility. they're not asking congress for a one size fits all federal policy, they want the flexibility to design innovative ideas. they want the federal

golf him to government to increase excess to basic medical care, lowering costs and improving patient outcomes. but the federal government cannot tackle this challenge alone. i was pleased to see this released, this rural health strategy area this month, i believe that this administration still needs to improve coordination across the agencies who have been in the department to help prioritize new payment models, while also reducing regular motive of rural and frontier providers. state and local officials must be aggressive in their efforts for program that meet their unique rural healthcare needs. and the federal government really needs to listen.

we should listen to what these folks have to say and how we can -- what some of the solutions really are. in my view states should be the breeding ground to test new ideas, however it is not sustainable for every small town to have a full service hospital with every type of special tee provider at it's disposal. that's why it's important for rural communities to work together, share resources and develop network. there is a difference between rural delivery. in response, by pulling our knowledge, we can protect medicare beneficiaries

and american taxpayers. i'm looking forward to hearing some of those innovative ideas. but before we do that i want to bring would be important item to the attention of the committee. the medicare advisory commission, otherwise known as mac, outlining the state's access to emergency development services for beneficiaries, people living in all communities, and ask it be made part of the official hearing record. with that let me now turn turn it over. >> i want to take it right out of the gate.

i think it is very doable to create a bipartisan product here. we did that with respect for ten years, we did it by the way in the rural area. it's headed to medicare expenditures, we were talking about ambulance, but i think it is very doable to come up with a bipartisan product. each year i hold town hall meetings and they tell me that there are a few potential healthcare communities. first, they feel that there's a wrecking ball heading their way because the trurp administration plus

congress has spend the last $15 in orthopedic to make enormous cuts to medicaid. >> the principle's budget indicates another assault could be coming. the fact is medicaid is a life line for rural hospitals and patients. if you want to turn real america into a sacrifice zone. the way to do it is by flashing medicare. local people feel their hospital is already on the brink of lobing acknowledging those doors. if the local hospital goes on, now

this is. decades ago getting routine healthcare, you spent more times. rural hospitals much more. they told me to maintain the emergency department because you recall hospitals are under senior huge financial pressure, i keep that emergency room open is extraordinary expensive. at the same time more and more americans are -- who sheriff's office l3 rural hospitals have closed their door and reno. the bottom line when you

leave in a big city, like chicago, los angeles, you take it. there's alleges going to be a, they will be. i heard exactly that kind of concern just a couple weeks ago in you recall original or. -- in rural oregon. keeping these hospital emergency departments open is a key challenge. where people can't get the care they need. i'll just close by this point.

i've already indicated i think we can produce a bipartisan product here. the country as well they as ours looks like we spent about $3.5 trillion last year object healthcare. for that amount of money you could practically send every family of four in america a check for $40,000 and say here, get healthcare. it ought to be possible to guarantee that rural americans are not on the outside looking in. thank you. i'm looking forward to working with our colleagues and getting the bipartisan product. >> thank you, senator. let me just set the record straight that the decline to rural hospitals started long before medicaid expansion, after the trump administration of course. rather than blaming trump i hope

we can set politics aside and value whether medicare, medicaid are yeelg and the h. communities. the purpose of this bipartisan hearing, you can't just -- i look forward to continue talking to our expert witnesses to be sure federal dollars are being spent judicially and wisely to help our rural hospitals and providers. we need to do that. i would like to extend a warm welcome to each of our five witnesses today. today we will briefly introduce you and you're set to testify. first we will hear from dr. george a pink, distinguished professor in the department of health, policy and

management at the school at a school i. all -- the university of north carolina, chapel hill. prior to receiving this ph.d. dr. if i think sent doubt servicend planning: a ph.d. incorporate finance from the university of tractor-trailer. i -- i think senator grassly you can proceed with your introduction. >> before i do that, since you recall hospitals have been

brought up i would like to point out and senator widen she i have about i might be a could he sponsor of it. i hope people will look at it and it is a the also five tore position. dr. mueller is an expert about rural healthcare. he is the interim deem of the college of public health and a professor of health management and policy at the university of iowa. he directs the ruppe, which is the center for held policy analysis at the university of iowa.

the doctor has public rishgd for his rural healthcare research. welcome, dr. miller. >> next to speak? >> next to speak.. >> senator benefit. >> thank you, mr. chair man and thank you so much for holding this hearing, communities have long been struggle with exact at the bags and challenge. the rural would sit, tiply hard. so many, the chief exec i've officer, an interest. prior to

being named ceo in 2013 she served as chief operating officer. she completed advanced regional training due to help and environmental leadership at the university of colorado. that heft look at her necklace. ms. march tim also place a pillar in the world. she is the search committee committee's language. i look forward to hearing ms. martin's testimony. thank you, mr. chairman. >> thank you, ten at been. our first witness will be susan j could go nant and, so senator trace. >> she is senior vice-president of integration and optimal

decision. she was also the ceo ask thing point, a nurse by training and she's the first eye juan sfal. no chooses professional akeef him, i would like to say a part of her legacy is sitting behind her take, so i'm going to in involve myself in her family. nate thomas a sue answer son. actually tom sued his daughter-in-law and nament, evenly if there's naw take --

she is sue's son-in-law, chat is the director of operations for unity point planning. or welcome to the committee. >> well, thank you censor storl nchlths i found out where this would be dr. ken and murphy who will be introduced by our good friends. thank you, mr. chairman. privileged to introduce dr. mur tee, dr. mur tee is chief innovation officer at guy certificate health systems. i know her from our home town and she has a long report of service. she served with the pa.

she was. she was nchlths we ask the dr. philosophy, and ab mba, my mother and my sister wanted me to mention i got maerpt /á /á /á . >> whether there's a real commitment to the reform in the healthcare delivery system, in so many ways karen has brought a passion and a degree of excellence to these issues that i think is unmatched. karen, welcome. >> thank you for rounding up our introductions. thank you for the witnesses for being here today and thank you in their testimony

as to, in advance of their patients and their flexibility, and we'll be moving in and out of today's hearings because we have other mark ups going on right now, so i have two or three mark ups going on right now. certainly, i may have to return the judiciary committee. and now with her all the way. >> chairman, thank you very much for the opportunity to testify today on behalf of my colleagues at the north carolina rural health research program and the school of global public health at the university of north carolina chapel hill. we research problems in healthcare, rural healthcare delivery and are funded primarily by the federal office of rural health policy. i am hear to discuss what we know about rural hospital closers and i will start with an all too common

story. cora ring go medical center in coral ringo. on may 1st it announced 14 months, it is in solvent and we'll close all services i believe june. it will leave, without an merge room, and nearest hospital is at dentist health in sanford which is over 40 miles away. coral rip go will be the second to. original rel nag melt call center closed six months ago. across the country 125 rural hospitals have closed since '2005. why is this happening? many reasons but wrong term unprofitability is an important

factor. years of losing money results in little cash, those payments that can't be move, four different facilities and outdated technology. why did combine this with reimbursement reductions, professional shortages and many other challenges and you can see why i prefer being a prove prove to a real hospital executive. what happens to a closure? some convert to another type of healthcare facilities but no healthcare services, they are barking lots. patient travel an average of t 1/2 highlies more

or new or no, this address without such vice. who is the most affected. we have vest gauges during by. these communities have significantly higher percentages of people who are black, unemployed, lacking a high school medication, in other words, vulnerable people. until. we'll be at increased risk. what can be done? we have tried to explore ways that target medical care, and the

closure would have all the greatest comments on the communities. prep per plea we should develop something new. at at math innings is the most common frustration i have here is a lack of a model to disdries, okay real, in patient p. we need something in between. there is no child support acknowledge of innovative ideas. eight to ten roll p florida. we need to step up the pays of innovation and new medicare policy. thank you again for the opportunity to discuss these issues with us today, particularly because during the past 35 years some of the most

innovative and affect developments have emerged from the senate finance committee. thank you so much, we appreciate you having here and having yield we'll turn it over to you know. thank you, for this opportunity to share my speaker scientific insurance on key issues. while some things have changed in the 30 years i have been conducting rural health research and policy analysis, the underlying dynamics remain much the same. but we have new tools both in healthcare delivery and public policy to help us continue our request to establish a hyper form answer health system in form america. we have had an interesting ride including whethering the after made in the late 1990s, considering healthcare reform in those changes, major changes in

medicare payment or truck. now are we knew and welcome about what we should be doing the best signed from the best certified our knee. i started with a koven that mr. roberts is brought up as that, we provided analysis of five reform proposals including the health security act by assessing their impacts on key remember says. does it and i'm sure i follow load. check can give me the confidence to continue, bringing forward what we added to poll. -- the we pal in 1992, to bring world did he men shas front and center in public

discussions. it was a program of if the snm. >> the act she referred to in 2003 and of course tee pack in 2010. we provided feedback to this committee and motor and followed up with an analysis, new poll say sal ease, other congress at the bbaa. i've got to appreciate the ex just of what we do in the research come indy sfam nchlths the association in '96. i rent the needs. a policy was provided. they were working with develop nchlths i mult mother choice, more phone.

my research involves visits to real health. engagement in that, the rupee and the rough center based and in coreration with others covers a whole list of other subjects. we're all pharmacy, implications of changes in healthcare delivery and organization, delivery system reform initiatives and the ef evolution. i would like to share some important questions to consider for the future offed medicare aco program. are there benefits other than savings related to changes and delivery models that help achieve the aaa of basin experience, loather health and there's low cost.

should variations of social media advanced patient? perhaps global budgeting that we'll hear about later. i further. we'll 4561 organized cyst tommy to kate in did he. four, a lying medicare payment and dispushing nils. s in general policies shut be sensitive to the real crafting environment, acknowledged the need for intra structure and investment. new models can build on the strength of your system. notably primary care. thank you for this opportunity and i look forward to your questions.

>> thank you. we appreciate you have your testimony here today. >> thank you for the opportunity to share our healthcare story. i'm a ceo of a small melt care system in southern colorado. we serve six counties, an area roughly the size of massachusetts. two of our counties are the poorest in colorado. near 70% of our pashlths are covered by medicare or medicare. with this challenging remain, we will help and the rural under around the country is world communities and it's helpful immediate yum help is on the way.

it is 17. we operate five rule health clinics two of which are provider base. the surprise sheer we provided 25 hospital visits, 58 thousand ,000. we are a level 3 trauma center and the and we have any type of specialty care for 120 miles in any direction. we serve vetter rans veterans. we are the largest employer in our region with a staff of over 800. maybe of them have lived in the community their entire lives and there familiar lazy for generations. as for me i moved to the valley in 1985, and i began my healthcare career in an in tree

i, and i have worked my way into the current c cnr.e. our system must report on dozens of of our private insurer is asking you us to rove but using a different definition. this complexion confruiting data reporting takes time away from what amy mat terts which is deliver open our healthcare pro seft: -- protect. we have multipill grow your own programs from paramedic training

to hosting medical students, in nor. we do have our work force success stories to celebrate as well with two family physicians in our system who returned to their childhood homes to care for friends and neighbors and we have a physician who came during college to serve as a volunteer in a local shelter and today he's a surgeon in our organization. world communities pride themselves on hard work and taking care of their own, however federal payment systems and delivery models must recognize the unique circumstances of providing care in a rural community and they must be updated to math the reality and challenges of how healthcare is delivered today and in the future. about ten years ago, they approached us

for help. nearing closure and in dire financial condition we entered into a partnership to provide management services and financial support. in 2013 this critical hospital fully merged into the system that it is today san luis valley health. this type of arrangement prevented a hospital closure. such partnerships are not available to many rural hospitals. we see the results of that and some are operating in the red. so what i'm asking for is including the creation of 24-7, and senator graphly -- and i ask you to provide appropriate resources if, innovate and work hard and

meet the challenges for caring for our friends and neighbors. a corn tree such as ours where you life and how you. nchlths thank you so much. we turn it to you now. >> thank you, and good morning. thank you for this great opportunity to address the committee on several of the challenges facing healthcare in rural america and also some ideas or potential solutions. i would be remiss if i did not take this opportunity to thank senator grassly for everying you do for iowa and your country. before i sending my job, i was the ceo in forth doing, including clinics and home care

services that over the years have health the designations of a did poll p bet, in rural health in clicks and most recently a queener: so there was five critical access hospitals, the system mark et cetera including des moines. but possibly the experience has purchase the the date, as a medical care, an a co. pi on neat. she took responsibility for improving the quality. the total cost of care for approximately 10,000, and medicare. they did this consist assistantly andity to do so.

it is through the work challenges have become so clear to us. the first challenge to highlight is the dichotomy in seen tifts these programs, and the rural counterparts that operate under fee for service, hospital based reimbursement business. while the former looks to keep members healthy and out of the hospital, the ladder is rewarded when all the beds have medicaid patients. the beneficiaries attributed to the trinity pioneer, when regarding value based payment models the rural groups would ask where do we fit in. and to date the

answer to that question has been you don't. the policy approach has been to exempt them from value based policy all together. we submit this approach is not working and needs to change. rural healthcare can fit into value based payment models. so you wonder, if did you at any point add vocation the be did he coninstructioned and to that we answer no. we are requesting it be renovation. thigh brings me to the second challenge, access to healthcare services in rural areas. bringing quality care to rural americans comes at a cost, and the cost is distinction the from the actual provision of the medical certificate vials. these additional costs relate to the time and major service centers.

we propose the renovation of healthcare delivery in rural areas include a value based component tied to expenditures and a separate and distinction payment structure is developed for reimbursement, the pays for the cost associated with access in rural areas. or does it go into greater detail how such a system can be structured as we design this type of system. the dues. do encourage the cms innovation to develop pi lots that test that program designed to work in rural march kelths like iowa. we see great even taken. design a bench mark to accommodate for the official cost of bringing access to world

market. and do support bills like the reach act but allow rural hospital to transition designed to mead not names, and do along to fit did it northeast practice extent the reach of our in person, it allows free standing ambulatory centers and cherry pick patients by procedure, further strange the. i want you to have them all in an emergency room. we need our rural. we need them to make the transition to rural healthcare access center. we know they can by come. though you this opportunity. i thank you, ms.

murphy you'll be our first all west. -- i i spent two years with my roll as secretary of health. today i would like to share the development of an innovative payment and delivery model that was developed when i served as secretary of health in pennsylvania. i began my tenure as secretary of health assessing the status of the healthcare delivery systems in pennsylvania. i was struck by the financial instability of the rural hospitals. i found that in research i found the situation in pennsylvania was being copied across the country. 67 of our 169 hospitals in pennsylvania are in rural communities.

more than 58% of those hospitals in rural areas have mounting financial pressure resulting in break even or negative operating margins. they began to look for a solution. after working and seeing the impressive results we decided to define a similar models. we worked with them on designing the matter and i would like to acknowledge senator casey in his office as we designed this model. the design was launched in january of 2017. the objective of the model are to provide a pass to improving health and healthcare delivery in rural communities. the model changes the way how it's reimbursed. a multibudgets

based. however, it was necessary to develop a new methodology since maryland has the authority to establish hospital rates and pennsylvania does not.

. >> such as united way area agencies on aging, drug and alcohol treatment centers to develop services based on their community needs. to provide purchasing hospitals with transportation support, pennsylvania plans to create a

redesign center. to support all participating hospitals. pennsylvania is planning to engage six hospital in the initial performance year, gradually expanded to 30 hospitals in pennsylvania. we are a participant in the initial face.