Celebrating National Rural Health Day

Speaker 1 (00:04): Welcome to 340B Insight from 340B Health. David Glendinning (00:11): Hello, from Washington, DC., and welcome back to 340B Insight, the podcast about the 340B drug pricing program. I'm David Glendinning with 340B Health. This episode is sponsored by RxStrategies, a clear choice for 340B program management. RxStrategies provides intuitive 340B solutions, including robust analytics, high-touch service, maximum savings, and unwavering 340B program compliance so their customers can achieve more. David Glendinning (00:44): As we record this episode we are still analyzing the results from the polls last Tuesday. In our next episode we'll break down the election takeaways for the 340B program. Our guest today is Alan Morgan, Chief Executive Officer for the National Rural Health Association. With National Rural Health Day coming up on November 19th, we spoke with Alan on topics important to rural hospitals. This included how the providers he represents are fairing under the latest COVID-19 surge, recent manufacturer actions against contract pharmacies and additional rural health challenges. We also discussed provider strategies to take on these challenges, in many cases with the help of 340B savings. But before we go to that interview, let's take a minute to cover some of the latest news about 340B. David Glendinning (01:33): The number of drug manufacturers taking unilateral action to cut off 340B pricing for drugs dispensed to contract pharmacies increased to four recently. Novartis, the third largest drug company in the world announced that starting next week it no longer will offer discounts to hospitals unless the contract pharmacies are within a 40-mile radius of the hospital's parent's site. As you know, many pharmacies that 340B hospitals partner with are outside of that radius, especially if they're a mail-order or specialty pharmacies. You can find out more about this development and our response to it in the show notes. David Glendinning (02:18): At the same time, the list of organizations opposing these manufacturer actions against 340B is growing larger, broader, and more vocal. A group of more than 60 organizations advocating on behalf of patients, health, consumers, and civil rights and social justice sent a letter to HHS Secretary Alex Azar urging him to block these companies. They include such prominent organizations as the NAACP, AIDS United, the American Federation of Teachers, and two of the nation's largest workers unions. David Glendinning (02:52): And did you light a candle or 28 candles to be more precise the day after the November 3rd election? Because marks the day back in 1992 when president George H. W. Bush signed into law the bill that would implement what would become known as the 340B Drug Pricing Program. Check out the show notes for a special 340B birthday message from our CEO, Maureen Testoni. David Glendinning (03:24): Now for today's feature interview with Alan Morgan, CEO of the National Rural Health Association. Alan has more than 30 years of experience in federal and state health policy and he has been recognized among the top 100 most influential people in healthcare by Modern Healthcare magazine. Prior to NRHA he spent time as a staffer to a congressman and a governor as well as a healthcare lobbyist. Our own Myles Goldman sat down with Alan recently to discuss how things are going in rural America. Let's hear that conversation. Myles Goldman (03:58): Thanks, David. I'm Myles Goldman from 340B Health and I'm joined today by Alan Morgan, the CEO of the National Rural Health Association. There is a lot happening in rural health right now and we're excited to have you join us, Alan, welcome to 340B Insight. Alan Morgan (04:15): Thank you so much Myles, it's great to be on the program with you today. Myles Goldman (04:18): One of the reasons we're excited to have you join us is to preview National Rural Health Day on November 19th. Tell us about this day and how it highlights the important role rural hospitals play. Alan Morgan (04:31): National Rural Health Day is the opportunity for us that are advocates of American rural health to come together to celebrate what works in a rural context. Myles, you know this, we spend 364 days a year highlighting the challenges, the obstacles, and the problems that we deal with this is that one day that we just focus in on what works and so it's a great day for all of us. Myles Goldman (04:59): Are there specific ways they can join NRHA in the celebration? Alan Morgan (05:04): Oh my gosh, yes. Well, for most of your listeners I know that they're active on several social platforms, whether it's LinkedIn, Twitter, Facebook, we're just asking our members to just share what's working in their community, highlight best practices and just highlight the relevance and the importance of rural health care delivery in a rural context. I know it sounds crazy but it's just people don't talk about rural health and being able to have it trending at that time is a great opportunity to remind people there is a rural America out there. Myles Goldman (05:42): With more than 130 rural hospitals closing since 2010, how does 340B help rural hospitals overcome some of their challenges? Alan Morgan (05:53): Yeah, right. It's just the fact that the public and even a lot of people in the healthcare system don't realize how central the 340B Program is to the overall success of rural hospitals. It's crazy to think that back in early April, the first week in April, 48% of our nation's rural hospitals were operating at a loss. The ability for those rural hospitals to stay afloat is directly attributable to the 340B Program. It has been a lifeline and a savior to maintaining access in rural communities, Myles. Myles Goldman (06:35): We've heard the same thing, Alan. We did a research report earlier this year where more than 75% of rural hospitals told us that 340B is helping them keep their doors open. Alan Morgan (06:47): Oh my gosh, yes. And I have to drive home the fact that that is exactly the congressional intent of this program. The intent was to make sure we maintain access for the nation's safety net providers and no greater example of that can be found in the nation's rural community health centers, rural health clinics that are connected to the rural hospitals, particularly for the critical access hospital program, that's those rural hospitals who have 25 or fewer inpatient beds which are among the smallest across the nation. Myles Goldman (07:23): And I imagine those hospitals are facing even more challenges with COVID-19. Alan Morgan (07:30): I mentioned to you that 48% were operating at a loss on April 1. Well, that was when they shut down their outpatient and elective procedures which represents up to 75% of their revenue. So I'm telling you these rural hospitals that were facing closure, operating at a loss, then immediately shut down 70 to 75% of their income. It was apocalyptic. Even hospitals that were doing well were not making payroll, were struggling to make payroll, were looking to furloughs and were facing the possibility of closing their services in the midst of a pandemic. Myles Goldman (08:11): And some of these hospitals, they didn't see cases initially so that made it even more difficult in some ways, right? Alan Morgan (08:18): This is what's unique really in a rural context. At the beginning of this crisis when we were shutting down really rural hospitals across the United States because we had cases primarily in New York City, that cleared out all the revenue coming in the door. And I want to say about the second week in May is when we we've started to see rural take center stage when it comes to the COVID story. In mid May, Myles, the cases percentage per population were increasing at a higher rate than urban, hospitalizations have increased at a higher rate than urban, and unfortunately mortality has increased per population much higher than you see in these urban areas. Myles Goldman (09:06): And of course when they do have COVID patients come in they have a limited number of beds. I know you just mentioned they have 25 beds and that is in ICU beds, that's just beds overall. Alan Morgan (09:20): You're absolutely right, Myles. Nationwide they're just under 2000 rural hospitals. 1300 are critical access hospitals, those facilities with 25 or fewer inpatient beds. There really is no room for air when you're talking about surge capacity in this context. And it's really important to note that our system is exactly as we designed it to be, which is, efficient. Myles, efficiency doesn't work well in a global pandemic. And the payment structure really mandates that we keep heads in beds and that's how we're paid. The ER needs to be full, on average they'd got one ventilator on site. Alan Morgan (10:09): And I'll be honest, for most of these rural hospitals, they don't have an ICU room, they have a room or rooms that are hardwired to the nursing station. These rural hospitals are designed for primary care general surgery, they were never designed for global pandemic response. But what's happening is as these communities surge and recede, it's next to impossible to plan to make sure that we have an adequate supply and we are positioned to do both outpatient services and elective procedures while still maintaining a level of beds necessary to face oncoming surges of COVID. Myles Goldman (10:52): And what are you telling them in order to how they can prepare for this new wave of COVID-19 cases, are they learning from each other? Alan Morgan (11:01): Yeah. Now let's talk about some good things that are happening out there in a rural context. One of the main differences in a rural context is the ability to collaborate and network among peer organizations. Throughout this crisis what we've learned is the ability for large systems to be able to share staffing which is so vitally important and to triage where we have these surges. We've actually seen multiple cases particularly in the State of Texas where you've had a rural hospital surge and surrounding pure hospitals will pitch in and bring in supplies, PPE, and in some cases even ventilators just to meet that need there locally on staff and on onsite. Alan Morgan (11:49): And I got to tell you there's a lot of shortcomings, obviously, but from what I'm hearing from our membership, FEMA has done a fairly good job of dropping into these sites and being able to assist with the transfer of patients. Because again, these rural hospitals standard protocol is once you need to be in ICU you're transferred. That's not always the case sometimes when the surrounding urban areas are surging at the same time. Myles Goldman (12:15): Are there government regulatory flexibilities that have helped rural hospitals? Alan Morgan (12:20): Oh gosh, yes. That's one of the great success stories, I think. It's been a terrible tragedy and I hate to even talk about successful things in such a horrible situation. But within the regulations that have been released by HHS and CMS, most notably for telehealth applications, I think it has allowed us in rural to demonstrate that telehealth can expand access, improve care and not break the bank if you will when it comes to the Medicare program. And I don't see that we will ever go back to the regulations pre-COVID, just the ability to deliver specialty care and now even primary care through telehealth, it's going to make a huge difference as we move ahead. And, oh, my word, the advances and the utilization of telehealth and behavioral health are enormous. Myles Goldman (13:21): Are there non-telehealth related innovations that have stood out to you? Alan Morgan (13:26): Yeah, I want to say two things that I'm really happy and encouraged to hear from our membership as a result of this. Number one, probably the biggest one which may not sound that way is the ability of rural hospitals and rural hospitals CEOs to be communicators and connectors of care within their communities. This pandemic has forced a lot of rural hospital CEOs to be the information hub and source in their rural community, which I think is going to position them extraordinarily well as we move out of this. I think rural communities are now recognizing that these rural hospitals are community assets, that they are anchor institutions and that they need to be supported by the community, number one. Alan Morgan (14:16): Number two, it has forced the team-based approach of healthcare that we've often and long talked about. And in particular, Myles, it's forced healthcare practitioners to practice to the upper limits of their training and educational competence which is great. I mean, the ability to have nurse practitioners, physician assistants, working in a team-based approach and handling aspects of care that they might not have handled pre-pandemic, I think that's going to help us be a better position system coming out of this. Myles Goldman (14:54): I think that's a great segue to looking ahead to the future of rural hospitals. Some have suggested having these hospitals focused solely on providing primary care services. What are your thoughts on this idea? Alan Morgan (15:08): Well, we could spend a lot of time talking about this. I will say that across the board, rural hospitals are designed for primary care general surgery but it really depends on the community. Some communities, the community need demonstrates that they need to have a specialty care approach. One thing that I am a little concerned about at the National Rural Health Association our greatest concern is access to 24/7 emergency room services and the ability to expand OB care and maternity care. Alan Morgan (15:44): And the reason, Myles, is if you don't have that 24/7 emergency room service, it's not safe to have senior citizens living in your community. If you don't have maternity care and OB care you're not going to attract young families into that community. So the challenge is when you lose a rural hospital you're losing the ability to retain your citizens and attract new ones in. Alan Morgan (16:08): There have been some people that have pushed for looking at just standalone ER facilities. From a volume standpoint it just isn't practical, it's not going to work. Now for our organization we are advocating for a new delivery model which would have only outpatient services attached to a 24/7 ER utilizing telehealth appropriately linked up for the specialty care teleconsultations and doing a real community needs assessment to determine what are those services most needed by your community. This would eliminate inpatient bed requirements from these facilities. Let me say, I think this model could work and help maintain access in these rural communities. Myles Goldman (16:58): Switching gears, a group of drug manufacturers are refusing to provide 340B discounts to hospitals when drugs are dispensed at community pharmacies. What does this mean for rural care providers? Alan Morgan (17:12): Oh, it's a terrible, terrible development and a terrible trend that has to be stopped. The ability for covered entities to utilize contract pharmacies in a rural setting has to be maintained. We've talked at the beginning of this about the important role that the 340B Program, the important role that it is in maintaining access of these hospital facilities, but also just the ability for residents to be able to utilize pharmacy services within their community. I can't stress that enough. Alan Morgan (17:52): I get the opportunity to go out and travel to our rural hospitals across the U.S. and so many times I'm in communities that sometime may have a telepharmacy application there. It's just not practical for that point of care not to be in that community from a geographic standpoint and even some cases where it may not seem that long of a distance, but with inclement weather these residents just are cut off, it's not safe. And we're seeing pharmacies close across the United States. This is absolutely not the time to be decreasing access to care. Myles Goldman (18:33): We've heard that drug manufacturers actions are not only impacting access to medications but also access for safety net providers to 340B savings. At 340B Health we have found more than 50% of 340B savings for rural hospitals come from community pharmacies. Alan Morgan (18:52): I firmly believe if you're the only provider in that community, you are a safety net provider. And these rural hospitals you can't think of them as just doing inpatient care. In fact, that's not even the majority of their revenue, they're doing long-term care, they're doing EMS, they're doing the chronic care management, any and every aspect in the community they're doing, they are the hubs. And this 340B program is a lifeline to maintain that access. Alan Morgan (19:26): Myles, before this pandemic began, sometimes I'd hear people in D.C. say, "Well, rural America it's getting older, it's dying away what can you do? During this pandemic I think we all know people are moving away from urban areas as quickly as they can. You have to have access to care for these families moving in. It's not the case that rural America is fading away, it's a case of we need to maintain this access as we do this national shift in how people view work and where they work from and where they live. Myles Goldman (20:03): And when you're speaking to policy makers, what are some of your top messages that you want them to know about the pharmacists and other caregivers working in rural communities? Alan Morgan (20:15): Yeah, we have been working directly with members of Congress and obviously communicating directly with the administration on the important role that key community pharmacists play in a rural context. And also of paramount concern is the 340B Program and what it means to rural communities as well going ahead. We have to maintain the access to community pharmacists, we have to maintain as well access to pharmacy services. And we want to make sure any efforts at a national level that might counter this important service are addressed head on. Myles Goldman (20:56): Well, certainly there is a lot of work to be done in terms of advocacy and working on all these issues. Thank you, Alan, for providing us with important insights into the challenges and successes rural hospitals are experiencing in this current environment. Alan Morgan (21:13): Myles, I appreciate to join your program and the ongoing partnership that the National Rural Health Association has had with 340B and will have in the future. Working together I think we can ensure that we maintain access to care for rural communities as we move forward. David Glendinning (21:29): Our thanks again to Alan Morgan for his service to rural health providers and their patients all over the U.S. we fervently hope that they start seeing some more light over the horizon very soon. What questions about rural health do you still have following today's episode? As always if you have any questions or comments about any of the items we cover here at 340B Insight, please email us at podcast@340bhealth.org. David Glendinning (21:56): It has not escaped our attention that the results of the recent elections are still sinking in for many of us as we look ahead to 2021 and beyond. Our government relations team is busy analyzing the results of the races and planning outreach to all those chosen to represent constituents starting in January. For more intelligence on what the outcomes mean for 340B providers and patients, please join us on Thursday, November 19th, for a 340B Health election webinar. And as we mentioned earlier we will be diving deeper into what you might expect from Capitol Hill and the White House on our next episode in a couple of weeks. Until then, thanks for listening and be well. Speaker 1 (22:41): Thanks for listening to 340B Insight, subscribe and rate us on Apple Podcasts, Google Play, Spotify or wherever you listen to podcasts. For more information visit our website at 340bpodcast.org. You can also follow us on Twitter @340Bhealth and submit a question or idea to the show by emailing us at podcast@340bhealth.org.