Rural health clinic

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The RHC serves a vital role in the U.S. healthcare system.

A rural health clinic (RHC) is a special facility designation of the U.S. Centers for Medicare and Medicaid Services (CMS), defined as a clinic in a non-urbanized area designated by the Health Resources and Services Administration as being in a health professional shortage or medically underserved area.

In September 1999, nearly 3,500 RHCs were operating across 45 states.[1] By January 2013, that number rose to nearly 3,800.[2]

Qualifying as an RHC

Upon creation, the RHC must be located in an area that has the following characteristics[2]:

  • defined as non-urban by the United States Census Bureau; and
  • defined as medically underserved by one of the following characteristics:
    • exists in a primary-care health professional shortage area (HPSA) under Section 332(a)(1)(A) of the Public Health Service Act;
    • exists in a primary-care population-group HPSA under Section 332(a)(1)(B) of the Public Health Service Act;
    • exists in a medically underserved area under Section 330(b)(3) of the Public Health Service Act; or
    • exists in a governor-designated and secretary-certified shortage area under Section 6213(c) of the Omnibus Budget Reconciliation Act of 1989.

Certain exceptions to the general location requirement for "essential providers" exist, including those for sole community providers, major community providers, and specialty clinics.[3]

RHCs must also follow strict regulations, including[2]:

  • employing a nurse practitioner or physician assistant who works at the clinic at least 50 percent of its operational time;
  • directly offering routine diagnostic and laboratory services, including pregnancy testing, urinalysis, stool testing, and specific blood tests;
  • directly offering drugs and other substances necessary for the treatment of emergencies;
  • creating arrangements with one or more hospitals to furnish medically necessary services that are not available at the RHC;
  • annually evaluating the effectiveness of their operations; and
  • clearly posting days and hours of operation.

The RHC must also not operate primarily as a rehabilitation agency, a mental health treatment facility, or a federally qualified health center (FQHC).

History

RHCs were established by the Rural Health Clinic Services Act of 1977, otherwise known as Public Law 95-210.[2][4][5] The program was established to address an inadequate supply of physicians serving Medicare beneficiaries and Medicaid recipients in rural areas and to increase the utilization of non-physician practitioners.

The RHC program was criticized in the 1990s for allowing enhanced reimbursement to remain for RHCs, even if that clinic is no longer in a rural or underserved community. The Government Accountability Office and the Department of Health and Human Service's Office of the Inspector General both released studies that showed that RHC status was being used by non-rural clinics to retain enhanced reimbursement. Congress changed this in the Balanced Budget Act of 1997 (BBA) by eliminating a grandfather clause for RHCs that had allowed them to retain their status despite no longer qualifying for the program.[6]

CMS released final regulations more than three years after a proposed rule to implement the BBA requirements eliminating the grandfather clause. Before the rule could take effect, lobbying groups, such as the American Medical Association (AMA), National Rural Health Association (NRHA), American Academy of Family Physicians (AAFP), and the National Association of Rural Health Clinics (NARHC) put pressure on Congress to change the law. Within the Medicare Modernization Act of 2003 (MMA), Congress included a requirement that CMS finalize any rule within three years of releasing a proposed rule to effectively kill the proposed rule.[7]

On June 26, 2008, CMS released a second proposed rule to implement the BBA-required elimination of the grandfather clause and to make changes to the RHC and FQHC conditions of participation.[7] These changes to the conditions of participation included a new quality assessment program, infection control, and changes to the Medicare payment program. Advocacy groups responded again with opposition to the changes in payment.[6]

References

  1. Gale, John A.; Coburn, Andrew F. (January 2003) (PDF). The Characteristics and Roles of Rural Health Clinics in the United States: A Chartbook. Edmund S. Muskie School of Public Service. p. v. http://www.idph.state.ia.us/IDPHChannelsService/file.ashx?file=414721DF-ABE8-46B3-8E7D-BE38B4328B80. Retrieved 15 April 2014. 
  2. 2.0 2.1 2.2 2.3 "Rural Health Clinic - Rural Health Fact Sheet Series". Centers for Medicare and Medicaid Services. January 2013. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf. Retrieved 15 April 2014. 
  3. "42 CFR 491.5 - Location of Clinic" (PDF). Code of Federal Regulations. U.S. Government Printing Office. 1 October 2011. http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5-sec491-5.pdf. Retrieved 15 April 2014. 
  4. "Public Law 95-210" (PDF). United States Statutes at Large, Volume 91. 1977. http://www.gpo.gov/fdsys/pkg/STATUTE-91/pdf/STATUTE-91-Pg1485.pdf. Retrieved 15 April 2014. 
  5. Silver, Henry K.; McAtee, Patricia R. (September–October 1978). "The Rural Health Clinic Services Act of 1977". Nurse Practitioner 3 (5): 30–32. http://journals.lww.com/tnpj/Citation/1978/09000/The_Rural_Health_Clinic_Services_Act_of_1977.9.aspx. Retrieved 15 April 2014. 
  6. 6.0 6.1 "NRHA Regulatory Guide". National Rural Health Association. 15 April 2008. http://www.ruralhealthweb.org/index.cfm?objectid=9416A73D-3048-651A-FE41FBFAA9805507. Retrieved 15 April 2014. 
  7. 7.0 7.1 "CMS Issues Proposed Changes In Conditions Of Participation Requirements And Payment Provisions For Rural Health Clinics". Centers for Medicare and Medicaid Services. 26 June 2008. http://www.cms.gov/apps/media/press/factsheet.asp?Counter=3175. Retrieved 15 April 2014.