Hillsdale Hospital News

Episode 83: Telehealth and NRHA Advocacy Update

Telehealth was brought to the forefront of healthcare delivery models during the COVID-19 pandemic as patients were hesitant to leave their homes and the need for isolation and social distancing required more virtual care. During the public health emergency, telehealth has been reimbursed, but the future of that reimbursement is uncertain as the expected end of the public health emergency looms. So, how do rural hospitals understand and advocate for reimbursement to sustain telehealth as a standard care delivery option.

On today’s episode, hosts JJ and Rachel talk with Josh Jorgensen, Government Affairs and Policy Director at the National Rural Health Association, to discuss payment models that support rural healthcare’s needs for their patients and their communities.

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Audio Engineering & Original Music by Kenji Ulmer




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Rachel: Telehealth was brought to the forefront of healthcare delivery models during the COVID-19 pandemic, as patients were hesitant to leave their homes, and the need for isolation and social distancing required more virtual care. During the public health emergency, telehealth has been reimbursed, but the future of that reimbursement is uncertain, as expected. End of the public health emergency looms. So how do rural hospitals understand and advocate for reimbursement to sustain telehealth as a standard care delivery option?

JJ: With an understanding of policy, direct advocacy efforts, and sheer determination.

Rachel: I’m Rachel Lott.

JJ: And I’m JJ Hodshire.

Rachel: And this is Rural Health rising.

JJ: Welcome to episode 83 of Rural Health Rising. I’m JJ. Hatcher, president and Chief Executive officer at Hillsville Hospital.

Rachel: And I’m Rachel Lot, director of Marketing and Development.

JJ: All right, Rachel. Obviously, telehealth has been extremely, extremely instrumental for patients and their families since the start of the pandemic and has become a commonplace among healthcare providers right now in their ability to get reimbursement for such changes has impacted the way that we operate. So, I want to take you through a little journey. We’re going to discuss that today. We are constantly striving to provide superior care, and you’re going to hear our story today about how we can accomplish that in a rural community where technology is a challenge and where we have some limitations. But also, today we’re going to talk about what the COVID-19 post pandemic environment looks like and obviously how we can make this a viable option for healthcare providers as we move forward. So obviously, we’re looking at how our destiny looks into the future. And I’m excited today to discuss this topic.

Rachel: That’s right. And we are keeping a very close eye on this right now, in particular as a public health emergency comes to a close in January. And today we’re talking with someone who has been advocating for telehealth policy and payment models that support rural health care’s needs for their patients and their communities.

JJ: Absolutely. Our guest today is Josh Jorgenson, government affairs and Policy Director for the National Rural Health Association. And we had the distinct privilege of meeting with Josh in Washington, DC. When we were there advocating for rural health and for Hillsboro Hospital. So, Josh, we’d like to welcome you to Rural Health Rising today.

Josh Jorgensen: Hey, thanks for having me. A second time seeing you all this week and second time being on the show. So, I must be doing something right, right?

Rachel: One week ago today, we were in. How cool was that?

JJ: That’s cool.

Rachel: So, to start, Josh, why don’t you quickly reintroduce yourself to our audience for those who did not hear the last episode or maybe who are new listeners to the show, tell us a little bit about your background and your work at NRHA.

Josh Jorgensen: Yeah, thank you. Well, Josh Jorgenson, I serve currently as the Government Affairs and Policy Director at the National World Health Association. And quick background on NRHA before I talk about myself just for folks who might not be overly familiar or listening for the first time. National World Health Association is a membership organization of about 21,000 folks nationwide. And we really have advocacy, in my opinion, in all the nooks and crannies of what is rural health care. So, we have folks like yourself, right, at Hillsdale Hospital health System, critical Access hospitals, rural health clinics, but we also have folks in academia and research, state offices of rural health, rural health associations, and then doctors, patients and nurses, and just kind of your grassroots want to advocate type individuals. So that can make finding consensus on the issues that we work on sometimes a little bit difficult. But largely speaking, we put our work into three big buckets. It’s rural health equity, it’s preserving the rural health safety net, and then it’s growing that rural health workforce and pipeline to ensuring that we have folks here moving forward. So that’s a little bit about NRHA. As for myself, I’ve been with the association now two and a half years, which is crazy, flown by, and it’s all been during the Pandemic or now the public health emergency, as we call it, that’s kind of coming into an end. I guess I’ll transition into a post public health emergency life at NRHA. But before me, being at NRHA, I worked on Capitol Hill for a senator from South Dakota, which is where I’m from, Senator Mike Rounds, and did his healthcare portfolio, amongst a couple of other items, and made the transition after doing that for about four years with a constituency that really felt close to home. Because South Dakota is about as rural as it can get. And so, working on rural health care with NRHA kind of felt like a natural transition. So that’s what I do now, is advocate on the other side of things to ensure that we have our hospitals staying open and that the resources they need are provided to them. So, thanks for having me and looking forward to the conversation.

JJ: Well, welcome again, and certainly your advocacy is much appreciated by rural hospitals like Hillsdale. Now that we’ve established who you are and what you do, let’s start with the why, and we do this on each of our podcasts to get to know our guests just a little bit better. So, Josh, I want to ask you this question. What motivates you? What gets you up out of bed in the morning to do what you do? What’s your why?

Josh Jorgensen: Yeah, I mean, I guess we’ll have to go back and compare the tapes to see how similar they are. But I think my why is just that I’m from South Dakota. I’m from a rural area, and I like to think that I understand the complexities of these issues. And really the way I look at it is if you don’t have health care in a community, that community is not really a community anymore. I look at it as not only is providing the health care to the population, which as we know, oftentimes has higher prevalence of underlying health conditions and have lower socioeconomic standards compared to their urban suburban areas, but just being that hospital in the area is a community source, it’s an employment source. And so, I look at the work that I do as kind of keeping that rural community alive that I grew up in and meant a lot to me and still does to my family. And whenever I go home understanding that if the hospital’s not there, the hardware store is not going to be there. And so that’s kind of me up in the morning. It’s just making sure that we continue to have access to health care in those communities and not only for the community to thrive, but for the patient to thrive and ensure that they have good health care outcomes as well.

JJ: If you’re listening today to the podcast and you’re not familiar with the work that is done by the National Health Association, I want you to know that what Josh does is very instrumental. Rachel and I have participated on many of his calls in which he talks about advocacy. And that is so critically important because to Josh’s point just a minute ago, whatever happens here at our hospital, whether we’re successful or if it fails, has a dramatic impact on this community in communities across America. And we see that, Rachel. It’s why we started the podcast. When hospitals close and shut down or move out of their communities or have a merger and an acquisition, loss of jobs, loss of economy, so goes the community, right? So, the work that Josh and his team are doing and we got to see that first hand, it’s incredible. And I would encourage those listening today to participate in those calls. If you’re a rural hospital and you’re really trying to understand all the dynamics involved in pairs and what’s happening on Capitol Hill, I would encourage you to log in and to go to their website and sign up for those grassroots calls. They are very helpful. Very helpful. So, Josh, let’s start with background on telehealth. That’s something that during the Pandemic, we all heard about it and we had to live it. Rachel and I had about 24 hours to develop a product and we did in a marketing really advantage, along with.

Rachel: Seth Gibson, our director of outpatient services.

JJ: He moved so quick. He did. And we had to, right. We had another choice. But for our discussion with Josh today, what was the state of telehealth before the Pandemic, if you could really set that stage for us and how was it perceived and utilized in the healthcare industry?

Josh Jorgensen: Yes, I was working on Capitol Hill at the beginning of the Pandemic and I think for years there was this desire from folks in the industry as well as folks on Capitol Hill, I think, to expand telehealth and kind of look at the utilization and try to move forward with it. There was significant progress happening building up to the pandemic, kind of with those Medicare flexibilities and distant site regulations that I’m sure we’ll talk about a little bit more that were really expanded overnight via the cares act and some of those other critical pieces of legislation at the beginning of the pandemic. But it’s kind of was just sitting in limbo for the longest time because I think there was this really DC speak way of saying, how much is this going to cost and what’s it going to look like and how efficient will telehealth be? And what the pandemic did as a true silver lining, because I don’t want to say anything really good came out of the pandemic, but it allows for telehealth to just expand virtually overnight. And now we have some really good case studies and the patient satisfaction is there. I think the provider satisfaction is there. And really the healthcare industry as a whole has had the opportunity to take a look at this over the last couple of years in a manner that I don’t know we would have gotten to if it wasn’t for the pandemic. It might have been a more gradual approach, but I don’t think we would have had rural health clinics and federally qualified health centers being distant site providers within a week if it wasn’t for what happened with COVID-19 back in march of 2020.

JJ: Absolutely right.

Rachel: So, like you said, things changed with the pandemic, with telehealth, and I myself have used it. There was a Sunday, it was actually easter Sunday, but I woke up on a Sunday morning and I had an infection and I was in pain, and I was like, I have got to get something prescribed ASAP. And telehealth was the way that I was able to get that care and to do that. And so that’s, I think, one of those examples of the patient satisfaction and the patient experience of not having to leave the house when you’re dealing with something like that and to be able to just, you know, jump on your phone or your device and have that interaction with your provider is so helpful and to your point, very efficient. Right. But during the pandemic, we know things changed. What exactly changed? Who changed it, and what authority did they have to do it? Right, because part of me wants to say, oh, wow, if it was just that easy to flip the switch, we should have done this years ago. Right, but this was a unique circumstance.

Josh Jorgensen: Yeah, I mean, I think what exactly changed? You can look at this from two ways. So, I’ll start with kind of the mindset towards telehealth, which I think for lawmakers just haven’t been around it at the time. And kind of looking back was there was a directive essentially nationwide that we were going to have to pause elective surgeries and elective procedures and elective conversations and consultants with your doctor. And essentially that changed the mindset pretty quickly because folks still needed to receive care. Like you said. I mean, easter Sunday of 2020, if you have an infection, you still need it, but you might not be able to go into the hospital in the same manner you would have two months previously. So, what changed was right away, the first couple of weeks, there was a few big pieces of legislation on capitol hill that moved forward, but the biggest of which was the cares act, which was signed towards the end of March of 2020. And that really provided the spark for telehealth. I think, as we see it today, when we look back at some of the waivers that we’re looking at, those distances status for federally qualified health centers and real health clinics, the ability to utilize audio only telehealth, the ability to get rid of geographical restrictions when it comes to telehealth, those all part were part of the Cares act. And that’s kind of what we’re going to be talking about later on in the conversation on ways to make that move forward. But that was all changed by lawmakers on capitol hill. So, some of the flexibilities came from CMS centers for Medicare and Medicaid services, but a lot of it came from elected officials working on capitol hill to really tweak the law as we know it, the Medicare law, and kind of how telehealth was able to fit in there. Of course, then some of the private insurers followed suit and it kind of became the understanding way to move forward as doing telehealth. So, the authority was right there, but they tied everything to the public health emergency. That’s why this conversation becomes more important today. They tied everything to a date in which the secretary of HHS gets to decide when the public health emergency comes to an end. Obviously, it’s not just a unilateral decision, there’s a lot of factors that come into it, but right now it’s extended to about mid-January. It looks like we might get another extension, we might not. Usually they’re 90-day extensions, which means that it goes until about next April. But some of the issues we see, whether it’s telehealth policy, whether it’s some of the Medicaid policies that we’ve been talking about over the last couple of years in healthcare, they’re all tied to this date. That’s kind of a moving target, I think. If you recall when I was on this podcast before, we were thinking that the public health emergency might have ended in July. Well, it didn’t now January, and now it might be here until April, and it might be here till next July, but we don’t really know. So that’s one of the things that we’re talking about now, and we’ll talk about a little bit more. And you guys were out in Washington advocating is there’s a lot of policy tied to the public health emergency that’s coming to an end over the next four to six months. And it’s kind of our job to kind of lift that up. But telehealth is, I think, first and foremost on everybody’s mind. The one thing I’ll mention about telehealth is in March, they did extend telehealth for 151 days beyond the public health emergency, which is an exact number for a really technical reason, which was that they did it thinking that the public health emergency was going to come to an end in July. 151 months or 151 days, excuse me, is about five months. And that would push it until mid-December, which is when typically, these big legislative vehicles are considered on Capitol Hill. Right now, though, we have telehealth for whenever the public health emergency happens to end, plus 151 days. So that was a really long answer of hopefully kind of the background setting up the stage for where we are today within telehealth policy.

Rachel: Right. The 151. That’s funny. I was going to ask you about that, like, why such a specific time? But now it makes sense. And it would have made more sense, of course, if the original target was met with the public health emergency.

JJ: Yeah, it’s very true. So obviously, as you’ve indicated and as we have shared, we’re at a much better place right now for the utilization of telehealth than we were, let’s say, in 2019. And I will tell you from our perspective and this is what I hear across our healthcare community here as well as in the state of Michigan is that providers want this to continue. And you’ve answered very clearly the why and in terms of why it exists and what we’re looking at into the future. But I guess I want to focus on connectivity. There is a lot of concern and a lot of issues surrounding rural communities that do not have connectivity. And so that’s a huge piece of this. Right, but I understand that there’s some legislation pending and some funding. Maybe it’s maybe not so much legislation, but funding for infrastructure. Could you talk to us a little bit about that? Because you can have all the best laid plans. You can have all the great ideas of having telehealth, but if you can’t connect to the end user, it’s ineffective. And this is our problem, Josh, in our community, and I often share this with folks throughout Lansing as well as Washington. We have here at Hillsboro Hospital some of our own management member teams that have no connectivity at their home. So, they can’t work remote. Honestly, they’re in a rural area.

Rachel: They live remote. They can’t work remote.

JJ: Yes, they live so remote that they can’t they can’t work remote, if that makes sense. And so, this is where we’re at today. But I am not unique. Several counties around this area face the same challenges, and there were allocated dollars to provide funding. Obviously, for connectivity, but it seems to be in this gray holding area. So, can you talk to us a little bit about that?

Josh Jorgensen: Yeah, I appreciate you bringing that up because I think when we talk with folks on Capitol Hill, or you all do, whether it’s state capitals or out here in Washington, I think when you’re talking about it from a rural standpoint, you can’t talk about telehealth without talking about broadband within about two or three minutes. And it’s really important to continue that conversation. I had a meeting about a year ago before the bipartisan infrastructure law passed, which is some of the funding you were talking about, and we can get into that. But somebody made the good point. It was Senator Shelley Moore capital from West Virginia. We were on a call with her and she said back in the day there was a time where utility poles weren’t everywhere nationwide. And now we do have that. It’s just time and it’s going to take a lot of effort both from folks in state houses and on Capitol Hill here in Washington. And so, I think they made a step in the right direction last year. So, they passed the bipartisan infrastructure law, which was signed into law about a year ago, this time in November of 2021. And I think it provided about $47 billion to the Commerce Department to put out and build out broadband infrastructure nationwide, including some really good language to have preference to rural, doing a few things that mean not overlapping services. So, if you have a provider in your part of rural Michigan, not give dollars to a competitor to just overbuild that and have competition, let’s just build it out and get the last door connectivity everywhere in the country. But to your point, it’s going to take time. There are a lot of parts of our country, whether it’s just outside of a town, ten minutes, that’s a town of 300 that doesn’t have WIFI or looking way out into the rural parts of Montana or Wyoming, it’s not even rural at that point. It’s frontier. It’s going to take some time to get broadband built out there. And I say that because while we’re making the inroads, while the funding is pending and it’s being pushed out the door, and I think some of these projects are starting going back to the telehealth policy side of it. We got to continue the audio only piece. Because in the meantime, the one thing that a lot of these communities do have is the opportunity to talk via phone. And in the world, you need for them to be able to have the same access to the telehealth services that you might in Detroit or in Lansing. You would have to do it via phone. Maybe it’s not via audio video technology. So that’s something that we’re really pushing for the continuation of that we have that included in telehealth policy. But we bring it up in every conversation just to say, hey, if we’re looking at tweaking anything in broadband or in telehealth policy, excuse me, don’t cut out the audio only piece because that’s really important just to do the talk over the phone and connect with your provider.

JJ: So, Josh, let me ask this question. Individuals that are listening to this podcast may be questioning where are the barriers? In other words, is it the payers? Is it the federal government? And no offense, because they just don’t know because it’s so new. I mean, truly, where are the barriers for the allowance of the reimbursement? If you could shed some light onto that. I mean, we don’t typically hear Blue Cross, Blue Shield, or Medicaid saying it’s inappropriate, right?

Josh Jorgensen: Yeah, I don’t think there’s a lot of barriers to it. It’s two parts, and it’s the same thing with any policy in the world right now when we’re trying to talk about it on Capitol Hill is how much does it cost and what vehicle for it to move and how much does it cost piece is kind of interesting. I think that was the biggest barrier to telehealth at the beginning, right. Was we don’t really know what the sample size is. Well, they expanded it overnight. The issue is that we’re just now starting to see data from 2021 that wasn’t 2020. So, I say that because 2020, there was a huge spike in telehealth because there was no other alternative. Right now, you’re looking at it as a model where it’s supplementing care, right. It’s not something where we’re duplicating care, but in a way, it’s an opportunity to transition an in person visit to telehealth. So, I think in the long run, how it scores on Capitol Hill will ultimately be a benefit, but it just comes down to cost. They haven’t quite figured out how much it will cost in a legislative vehicle, which is why you only saw 151 days back in March. We’re hopeful to see about one year included in a year end package. But that gets to the timing, which is we’re getting to a point in Washington where you can take the elephant or donkey out of the room for a minute, and there’s only so many legislative vehicles that move in Washington, DC. And usually, they’re called Consolidated Appropriations Act of pick the year. And that means that because oftentimes the budget does not pass on time like it didn’t this year, which is typically since 30th, they pick the can down the road until around mid-December. So right now, that date is December 16 of 2022, where they’ll have to come together and pass a bill. That bill will usually fund the appropriations that we think of every year. So that’s things like the National Health Service Corps Nurse Corps Loan or payment program, some of those good rural health programs that we look to for just regular appropriations year in and year out, but to help that legislative vehicle move and get more votes. They often tie non budgetary provisions to it. So that’s something like a telehealth flexibility package that could move along with that package. And that’s where we’re hopeful to see telehealth included. So that’s kind of the timing. It doesn’t really answer the barrier because I don’t think there’s opposition. Nobody’s up on Capitol Hill really saying, hey, telehealth is bad. I think there’s an overwhelming consensus that it’s good. It’s just finding the right time for it to pass and finding how much it’s going to cost. And that will ultimately determine the cost piece, will determine how long of an extension we get, just to determine how much money they feel comfortable spending in a year end package.

Rachel: So, with that said, that kind of tells us why is this important right now is because this is coming up and we have this hopefully appropriations will come to the 16th or right after that. But how can rural hospitals get involved to advocate for continued reimbursement for telehealth, especially with the Audio Only piece? Because my understanding right now is that CMS has basically said we don’t have the authority to continue Audio Only. And of course, you know, the players often will follow what CMS does, all the commercial payers, even though it’s been done all this time, right? So, what should rural hospitals be doing? How can we get involved to not only ensure the continuation of telehealth reimbursement, but that critical audio Only piece?

Josh Jorgensen: Yeah, it’s reaching out and telling your story. I mean, simply put, I was up on the Hill this morning with a meeting from a couple of representatives from Minnesota. I can talk about these issues until I’m blue in the face, but if it’s not coming from their constituents, the tie to the district or to the state just isn’t there. I can talk about the policies, the need for Tweaks, but it’s the everyday story, right? It’s the impact that Audio Only has in your community where your management doesn’t have the ability to even work from home, let alone have a doctor’s appointment from the comfort of their home, and the need to continue Audio Only or the need to continue investment in broadband, just given that you’re a constituent. So, I think the first thing is just telling your story. It’s so important you can’t underscore the impact that rural health has in our communities because back to the beginning of our conversation, we’re the biggest employers in our community. We are the central point for care and kind of keeping that community moving forward and ensuring that folks don’t get sick and that they stay well. So, knowing that we have kind of that tie and importance to the community, using that voice to push for change or push for the continuation of telehealth is critically important here. And I think not seeing these reimbursements lapse is something that folks know, but they need a little encouragement and make sure that they’re going out on the front lines and say, no, this is really important to me in rural Michigan or in rural Idaho, we need to have this flexibility here, moving forward, and here’s why.

JJ: Partisan issues that impact Congress, whether they’re social issues or spending issues, are oftentimes clearly defined, and there’s a line in the sand, and we know that from each side. I guess the question that I have is, as you look into the Josh Jorgensen’s crystal ball and what would you see in the next five years that policy, regulation or what’s necessary for telehealth to continue. And the reason I talked about the partisan is, I think, generally speaking, this is pretty nonpartisan stuff, right? I mean, it’s access to healthcare. I don’t know how it could have a side. Maybe I’m wrong. Maybe you could help understand that a little bit. But if not, what is that five year forecast in your mind look like? And or what should it look like?

Josh Jorgensen: Yeah, I don’t think there is much opposition to it on Capitol Hill. Frankly. It’s something where folks recognize that it’s just been a benefit. It’s been a benefit to folks in rural areas. I talk about that because that’s the constituency we work with. But we also know it’s a benefit to folks in urban Detroit, in urban New York City. It’s a benefit in urban rural in suburban areas. And that’s something that really is unique in healthcare because it’s tying everybody together, and it’s a really good bedroom. I think the biggest key, in my opinion, is removing the language from the public health emergency, picking a date, I hope it’s December 31 of 2024. That would be about two years from now, which would be a lot of guarantees for telehealth, at least for two years, we wouldn’t have to deal with this. But even if it’s December 31 of 2023, it’s no longer tied to the public health emergency plus 151 days. Let’s get rid of that and just have the policy kind of move on its own. You talked with Kerry, I think, on a previous episode about the low volume hospital and Medicare dependent hospital, which is critically important, that’s no longer tied to the public health emergency plus X amount of days. Or pick a piece of legislation plus X amount of days. No, it’s now December 16 of 2022. Well, it kind of gives a hard deadline for folks on Capitol Hill to make a movement on, and it removes it from everything else within the public health emergency, which, for better or worse, has become politicized a little bit throughout the country. So, I think that would be really important. The only thing I would quickly add that we are hopeful to see in telehealth policy is while we’re making these changes, is trying to make any tweaks that we want to see happen early on, because as we see, it gets harder and harder to tweak policy when you get. Into a one- or two-year cycle. For example, if you’re trying to make changes to the Conrad 30 j one visa program, I know there’s a bill to kind of expand those waivers and ensure that we have more visas for rural hospitals and hospitals across the country. It’s harder to do once it’s set in stone and law because it costs money later on, so it’s better to make these changes earlier. So, the one thing that we’re really making a push on, besides emphasizing the need for audio only, is payment parity between in person and virtual care for rural health clinics and federally qualified health centers. Because the way they are reimbursed is such a significant gap in the Reimbursement that by 2028, it’s going to be about $100 discrepancy between in person and virtual services. So ultimately, if you’re the rural health clinic, you might not invest in telehealth knowing that the reimbursement will be better if the patient comes in to receive care. So that’s one thing that we’re trying to do, just to ensure that there’s payment parity not only for just virtual and in person, but between rural health clinics and rural PPS hospitals or urban and suburban hospitals moving forward. So, we’re working on that tweet too, because as we get later on and it’s going to be harder to tweak the policy, but I think the first and foremost thing that we can do in telehealth policy is just moving the can away from the public health emergency. Get rid of that language, pick a date, so that way they just act on that in a silo moving forward and not tied to all the other issues that are tied to the public health emergency.

Rachel: In your mind, is there a future where telehealth becomes just like all these other services that we provide, where it’s not a continual, oh, we got extended or it goes away, we got an extended or it goes away. It becomes kind of like a contract where it renews automatically unless you cancel kind of thing like a subscription where we don’t have to every year or two years fight again to say, hey, don’t let this go. Make sure this stays. I mean, obviously everything is always being looked at and the new rules and the prospect of payment system rules come out every year and there are changes, but there are a lot of things in there that we never really question if those certain things are going to be reimbursed still. So, is there a future when telehealth looks like that?

Josh Jorgensen: I wish I could say yes, but I don’t know. Right? I mean, it’s taken the low volume hospital or Medicare dependent hospital. I’ve had 45 meetings over the last month. Nobody says that they’re opposed to those designations. Why are they? Because it makes it easier for people to vote on it on capitol hill when they need to pass the budget. Because you can’t let those expire. Otherwise, rural hospitals are damaged. And it’s not just those provisions. They’re everywhere in every industry. That’s why there’s sunset in a lot of ways. So, I don’t know if we’ll ever see it. The only alternative that the alternative world in which I kind of view things, is if you have a never-ending provision, let’s say we just permanently extend telehealth next month and we all celebrate, which we would, it would be fantastic. But the issue would be it’s really hard then to tweak the policy to go back and say, how do we make changes to this later on? So, it’s kind of a plus and negative to doing it permanently versus a continuous cycle. The thing I always look to is when it’s something like telehealth, it’s so bipartisan, it’s so popular that although it’s coming up for renewal every so often, I think there’s a pretty wide acknowledgment that this needs to move forward. And I think that would just continue well into the future as well.

Rachel: Yeah, right.

JJ: Josh, you indicated and mentioned two items that I really just want to touch briefly on because it does impact hospitals like mine. It’s the low volume adjustment, so LVA and the Medicare dependent hospital, and those designations are important to hospitals like mine due to the volume and the fact that we have a disproportionate number of government payers versus commercial insurance. For example, 70 plus percent of my population is Medicaid, Medicare. And so, we really rely and depend on these programs to provide additional reimbursement in upwards of millions of dollars. Right. And so, a removal of these programs would equal major devastation for hospitals like Hillsdale. And we’re not alone. Obviously, in rural communities, the majority of the payers typically are the government. So, this has a significant advantage across the country. And so, I guess my question to you is, as we have listeners across the country and hospitals are listening, just absolutely holding on to every word you’re saying is how does this look for us in the next Congress? Is there hope that LVA will continue in your mind?

Josh Jorgensen: Yeah, I feel pretty good about it being included. So back to the September 30 day, which is when typically, government funding is supposed to be renewed, or they’re supposed to address it and pass a new budget for the next fiscal year. Unfortunately, if you’ve tracked it in Washington, I don’t think since I’ve moved to Washington, they haven’t done it on time, which is like seven years, and I think it’s been 20, 30, 40 years before that. So anyway, they typically have to pass a continuing resolution for a couple of weeks or a couple of months, and then they address it later on. The reason why I bring that up is because included in that continuing resolution was the low volume and Medicare dependent hospital designations, bringing it with the continuing resolution until December 16. To me, that signals the mindset on Capitol Hill recognizing that these hospital designations can’t lapse. Otherwise, it could have lapsed, right? Because it was supposed to be a really clean, continuing resolution, and that’s not a clean provision. That costs money to bring that along with it. So that to me, acknowledges the need to extend it longer term. They just didn’t do it in that legislative vehicle. So now we’re looking at how do we do this in December? There’s piece of legislation that have been introduced to make those designations permanent. And Rachel, it’s kind of similar to what we were talking about with Telehealth, where doing it in a five-year increments seems to be what they like to do on Capitol Hill. I think they did it for five years back in 2018 or 17. And that brought us too today, right? If I had my Josh Jorgensen and Crystal Ball, I think we’ll see anywhere between one to five years, and I think it will be closer to that five-year number because that’s what a lot of folks have kind of pointed to on Capitol Hill or in piece of legislation that have been introduced. But if you talk to all the lawmakers, whether it’s in Michigan, South Dakota, Minnesota, I’ve talked with folks all across the country, there’s nobody saying we need to end these programs. It’s just finding the time. And the time is really this end of year package in December. And that’s why I’m here today talking about these issues and why the need for advocacy is so important to share the story about the importance of these programs and so many others to be continued in that package.

Rachel: Do we have any updates on travel nursing agency regulations at the federal level? I know last time you were on, we talked about how do you even look at that? Do you use consumer price index, what’s normally looked at for things like price gouging, but is there any movement on the federal level? I know some states are doing some things. Michigan has a bill on the table, but what about Congress?

Josh Jorgensen: You know, the federal level for items that have a lot of teeth. I don’t know if we’ve seen it. I think a lot of the state houses are taking more actionable items that should hopefully kind of clamp down on some of the actions that have been taken by traveling nurse agencies. There’s a few pieces of legislation, one bill introduced in the House and one in the Senate to do a study on what happened over the last couple of years with traveling nurse agencies and kind of examine the toll. And it has a really good call out to rural communities and kind of the toll that this has happened and this has had it in access to care or in the workforce shortages that we’ve seen due to kind of the price gouging as you talked about. But the prospects for that, I’ll be frank, I don’t know if it’s something that’s moving it might just be something that’s kind of floating out there, but that’s kind of the best piece. I don’t know if in the new Congress there might be oversight hearings looking into something like that. That could be something as we kind of remove ourselves from the kind of plunge of the pandemic policy and kind of examine what happened over the last couple of years, hopefully that’s something that’s examined, but for true regulatory burdens on those agencies to impose them from stopping doing that. I haven’t seen anything.

JJ: Yes, the last item that we want to just really talk about quickly is heavy on the minds of many hospitals across this country. Again, an impact of millions of dollars is 340 B. And wow, that’s just a challenge, obviously, because there are some major pushbacks pharma and some other things. But the impact to local hospitals like ours who participate in contract pharmacies and as we look at building an oncology program is again, millions of dollars. And in a time in which most of your hospitals specifically rule, are operating on no margin to remove any dollar is devastating. So, what’s your outlook and your forecast for 340 B? You’ve got a lot of people on Capitol Hill talking about it lately.

Josh Jorgensen: Yeah, there’s a lot of people talking about it, but there aren’t a lot of true legislative packages or pieces of legislation that folks are kind of looking at in that vein. The one bill that we look to is called the Protect 340 B Act, which would essentially prohibit PBMs and health insurers from taking discriminatory actions against the 340-b program or 340 b covered entities. But that doesn’t really solve the contract pharmacy piece or some of the other limitations that have been imposed by pharmaceutical manufacturers over the last couple of years. So, I think we look at the Protect 340 B Act, which is a really strong bipartisan bill in the House, as kind of a stepping stone to conversations, hopefully, in the 118 Congress, which, you know, we just had a midterm. We haven’t talked about that yet, which is shocking. But we had our midterm last month or earlier this month, and the new Congress starts in January. And I think, you know, 340 B is going to be something that our association, I think a lot of other associations are going to want to continue having conversations with lawmakers on to try to bolster that program. But I can’t give prospects just because it’s so hard when there’s not a lot of pieces of legislation or legislative proposals out there to really point to and say, hey, this is moving through X Community Committee. That’s just not really happening right now in the telehealth or mental health spaces. That other, you know, some of these other priorities are moving.

JJ: We’ll continue to advocate for us, as I know you do well.

Rachel: And also, this episode is airing on December, and on December 6, NRHA is doing something pretty important related to advocacy. Correct. Do I have the date right?

JJ: Yeah.

Josh Jorgensen: Well, it’s the whole week. So, it’s December 5 through the 9th. We are doing advocacy virtual fly in. You can find all of the information on our website and you’re more than free to sign up. And we have state contacts, I think in like 37 out of the 50 states, which is pretty strong and we’re hopefully growing that to a little bit higher. But if you sign up, you’ll be put in touch with your state contact who’s going to be setting up meetings with elected officials and you’ll be able to have those conversations and advocate on all the priorities we’ve been discussing today.

JJ: Excellent. And so, this is on December 1. We have four weeks until the end of the year. What’s it look like in Washington DC? It’s just commentary today. What’s it look like in DC? Is everybody going to be home? Is a workover. Obviously, what’s dependent on that is the continuation of government running. But leadership is going to go through some changes here, we understand. So, is it an exciting time in DC in December?

Josh Jorgensen: Over two years in December. It’s actually just one of those things where I think every year, I’ve lived out here, it’s a December package is dropped and there’s like 2000 pages and you have to sift through what’s the good, the bad and the ugly and then they vote on it. And I think, for better or worse, what we’re coming towards mid-December here, I wouldn’t be shocked if they have to pass a one week or so continuing resolution to kind of iron out the details. That’s pretty common. But I would assume before New Year’s will have funded the government. That’s the only projection I have. And if I’m wrong, then I guess we’ll have to deal with it in the New year.

JJ: Exactly. Well, Josh, once again, we’ve thoroughly enjoyed this time together and we could spend hours talking about all the issues that impact rural health care in America. I just want to on behalf of Hillsborough Hospital, thank you for your advocacy efforts and for what you’re doing for us as rural hospitals, as our voice. We can’t get to Washington, we do maybe every once, five years, but you’re there every day and you’re rubbing elbows and you’re in committee meetings and we truly appreciate that because you’re our voice on the ground. So, on behalf of Hillsborough Hospital, on behalf of rural health across America, we want to say thank you for your advocacy work and thanks for joining us for your second appearance on Rural Health Rising. We truly appreciate your time today.

Josh Jorgensen: Absolutely, I appreciate it. Thanks for having me.

JJ: And before we close, we love to do a segment with each of our guests. We want to know what is your most unique rural experience or one of your favorite memories that is unique to rural life or maybe your second most.

Rachel: Since you’ve been on that from rural America?

Josh Jorgensen: I was thinking about that because I think the last time I was on, I shared that I went to the Lore Angle Wilder pageant.

Rachel: Oh, yeah.

Josh Jorgensen: I guess I’ll pick this past summer; my parents have a lake cabin up in northeastern South Dakota. So, my girlfriend and I went back, and it was one of those horrible lake days where it just decides to rain all day, and it’s like 70 degrees in July, and it’s awful. And so, we ended up just kind of going from small town to small town and going to some of their different restaurants and bars and just kind of popping around. And I don’t know, there’s something about it that just reminds you of how much fun rural and small-town life is because everybody in there just has a different story, and it’s always really fun. So, I think that was the most recent fun experience I had, was just kind of driving through northeastern South Dakota, which is about as sparsely populated as it gets, and stopping into different water and holes along the way.

JJ: Yeah, that’s fun times. Well, once again, thanks for joining us today, Josh. We appreciate your time.

Josh Jorgensen: Thank you.

JJ: Next time on Rule Health Rising, we’ll have another great conversation with another great guest, so be sure to tune in.

Rachel: And with that, don’t forget to subscribe wherever you get your podcast. And if you like what you hear, leave us a five-star review on Apple podcasts and tell others why they should listen to your feedback helps more listeners find Rural health Rising.

JJ: And you can now find us on Twitter. I’m at Hillsdale. CEO JJ. Rachel is at rural health Rach. And you can also follow the podcast at rural health pod. Until next time, stay safe, stay healthy, and stay strong.

Rachel: Rural Health Rising is a production Hillsdale Hospital in Hillsdale, Michigan and a proud member of the Health Podcast network hosted by JJ. Hodshire and Rachel Lott. Audio engineering and original music by Kenji Olmer. For more episodes, interviews, and more information, visit rural health rising.com.