September 6, 2022, 3:35 p.m. News Staff — Family physicians already delivering essential care in rural areas should be integral to rural emergency hospitals, the Academy told CMS in a recent letter offering feedback on a proposed rule.
“Given the significant value family physicians can and will bring to rural emergency hospitals, the AAFP strongly urges CMS to acknowledge the vital role family physicians currently play in ensuring access to emergency care in rural areas and ensure the final rule enables family physicians to continue practicing in REHs, including serving in REH leadership roles,” the Academy said in its Aug. 17 letter.
Rural emergency hospitals, a Medicare provider type established by the Consolidated Appropriations Act of 2021 — and among that law’s family medicine wins — are meant to ensure continued care access for patients in areas affected by hospital closures. Medicare-participating critical access hospitals or rural hospitals with 50 or fewer beds can apply to convert to REHs; redesignated facilities will begin receiving Medicare payment for REH services on Jan. 1.
The Academy’s letter recognized that the proposed rule would better position family physicians to improve access to high-quality care in rural communities, but registered concern about elements of the rule involving certification, supervision and staffing.
The letter was sent in response to a proposed rule to establish conditions of participation for rural emergency hospitals, published July 6 in the Federal Register.
“Family physicians are an essential source of emergency services, maternity care, hospital outpatient services and primary care in rural areas,” the AAFP said. “Twenty-two percent of family physicians practice in rural areas, while 20% of the U.S. population lives in such areas.” The letter also cited a 2019 study indicating that more than 15% of family physicians in small rural areas, and more than 10% percent in frontier areas, practice primarily in emergency department settings.
However, family physicians are not permitted to take the American Board of Medical Specialties emergency medicine specialty board exam — a barrier CMS must bridge, the Academy said.
“CMS must ensure federal regulations do not exclude or discount the contributions of family physicians providing emergency care by encouraging, emphasizing or requiring board certification in emergency medicine,” the letter said. “Emergency department staffing in small community hospitals by family physicians allows more efficient use of resources in the hospital and in the community.
“Family physicians are also well positioned to track a patient’s progress following care provided at an REH and ensure follow-up,” the letter added. “Family physicians live and work in the communities where REHs will be located, providing them with a unique understanding of the needs of their communities and enabling them to establish long-term trusting relationships with their patients.”
To safeguard these relationships, the Academy called on CMS not to finalize the proposed rule’s “streamlined credentialing and privileging process for REHs” as written.
And to prevent direct-to-consumer telehealth companies from undercutting local physicians while maintaining adequate federal oversight, the letter said, “REHs should not be permitted to use telemedicine to provide all physician services and supervision when a local physician is otherwise available and willing to provide the care.” The final rule should not allow REHs to replace local physicians with clinicians who provide care to REH patients exclusively through telemedicine, the AAFP added.
The Academy expressed strong approval for the proposed rule’s allowances for REHs to provide common outpatient medical and health services. “Enabling REHs to fill gaps in rural communities’ access to outpatient services could prevent high utilization of emergency department care and improve care continuity and quality,” the letter said. “Family physicians are the ideal clinicians to provide other comprehensive outpatient services,” the Academy added, including maternal and behavioral health care. Women from rural communities who stay within their community to deliver have better outcomes than women who travel from rural communities to metropolitan areas to deliver, the letter noted. And family physicians practicing in REHs “could help improve access to comprehensive behavioral health services, including medication-assisted treatment (for substance use disorders).”
To avoid care delays and poor outcomes, the Academy called on CMS to emphasize physician-led care teams in REHs and require compliance with existing Medicare supervision requirements. With scope of practice in mind, the AAFP last month also co-signed a letter with the American College of Emergency Physicians calling on CMS to modify its proposed rule to ensure that “a physician with training and/or experience in emergency medicine provide the care or oversee the care delivered by non-physicianpractitioners.” Rural patients, said that letter, “should not be subjected to a lower quality of care solely because of their location.”
Repeating previous AAFP advocacy, the AAFP encouraged the use of real-time telehealth technology to meet the supervision mandate. “Family physicians have reported this flexibility has improved access to care in rural areas during the COVID-19 public health emergency,” the Academy’s letter said.
The Academy also urged CMS to alter language in the proposed rule that encourages REHs to have an emergency physician serve as medical director, modifying the wording in the final rule to include family physicians.
“The language in the proposed rule fails to acknowledge that many family physicians already provide emergency care in rural areas, including areas without a board-certified emergency physician,” the letter said. “CMS should note in the final rule that having a family physician with experience in emergency medicine serve as medical director would benefit REH patients and further encourage REHs to have family physicians serve as medical directors if possible.”