Accompanied by the Disparities in Rural and Urban Mortality: New York State Chartbook by Adrienne Anderson
Policy Brief:
Chartbook:
Combined Documents:
Table of Contents
See Part 1 for:
Introduction
A Note on the Chartbook
Rural Mortality Compared to Urban
Background
Key Takeaways from the New York Data
Findings from the New York Data
The State of Hospitals and Healthcare Services in Rural Areas
The National Experience
The Rural New York Experience
Population, Land Area, and Premature Death Rate of Rural New York
Social, Economic, and Infrastructure Characteristics of Rural New York
Poverty in Rural New York
Access to Broadband Service in Rural New York
Access to Fluoridated Drinking Water in Rural New York
Access to Healthcare Services in Rural New York
Hospitals
Primary Care
Dental Care
Behavioral Healthcare
Pharmacy Services
North Country Health Systems Redesign Commission
In Part 2:
Core Essential Healthcare Services
Rural Hospitals
Special Classifications
Recommendations of the AHA Future of Rural Health Care Task Force
Public and Private Funding for Core Services and Improved Business Operations
Examples in New York
State Funding Programs to Support Rural Hospital Operations, Infrastructure, and Transformation
Global Budgets
Strategic Partnerships and Affiliations in Rural New York
Maternity Care
Highlighting Models in Rural Primary Care, Dental Care, Behavioral Health, and Cancer Care
Models of Primary Care, Behavioral Healthcare, Maternity Services, Dental Care, and EMS in Rural New York
Workforce Solutions
Recommendations
Physical Infrastructure
Collaboration
Reimbursement/Business Operations/Information Infrastructure
Workforce
Conclusion
Acknowledgments
Appendix: Leading Causes of Mortality, Key Terms, Methodology
Continued from Part 1...
Core Essential Healthcare Services
In 2021, the American Hospital Association (AHA) published Final Recommendations from its Future of Rural Health Care Task Force. The charge of the Task Force was to envision a range of “bold solutions and promising practices to … ensure the financial stability of rural hospitals and access to care for rural residents” (p. 4). A crucial element of the Task Force’s report is the identification of a set of “core essential services” in rural areas. Potentially, some essential services related to acute and primary care can be provided at home through remote patient monitoring, such as the Hospital at Home program.[1] These core essential services are:
Primary Care
Psychiatric and substance use treatment
ED, EMS, and observation care
Maternal Care
Transportation
Diagnostics
Home Care
Dental
Robust referral system
Telehealth
We will use these core services as a reference as we examine rural hospital operating models, as well as models for primary and specialty care in rural areas. We recommend considering pharmacy as a core service because in many rural areas, pharmacies have become an essential site through which to access healthcare services.[2]
Rural Hospitals
Special Classifications
There are several hospital models designated by Medicare that are intended to support the sustainability of rural hospitals and thus maintain access to healthcare services in rural communities. Critical access hospitals (CAH), sole community hospitals (SCH), and the more recently established rural emergency hospitals (REH),[3] among others, are all special federal classifications that reimburse services differently from most hospitals. New York has 21 CAHs, 18 SCHs, and no REHs as of yet.
These designations are determined by considerations related to the distance and type of geography between the designated hospital and other hospitals, the number and type of beds, and the types of services provided. Several of the classifications were established in the 1980s and 1990s in response to large numbers of rural hospital closures nationally. Each of the classifications includes special payment provisions to support the sustainability of rural hospitals.
Their impact is likely not what policymakers had hoped for when the policies were established. A. Maxwell and colleagues, in their Findings Brief, compared the 2016-18 profitability of urban (prospective payment system (PPS)) hospitals to that of rural hospitals (PPS and Medicare payment classifications) and found that the profitability of rural hospitals decreased while the profitability of urban hospitals increased between 2016 and 2018. They summarize the context as such,
Compared to urban hospitals, rural hospitals serve older, poorer, and sicker communities where higher percentages of patients are covered through public insurance programs and higher percentages are uninsured. Additionally, because of their smaller size and lower patient volumes, rural hospitals are particularly vulnerable to shifts in the economy and demographics of their markets as well as to state and federal policy changes. This puts rural hospitals at higher risk of financial distress, complete closure, or conversion of the hospital to some other type of non-inpatient health care facility. All of these outcomes may have implications for the communities served by rural hospitals. (2016‐18 Profitability of Urban and Rural Hospitals by Medicare Payment Classification, April 2020, pg. 4)
Some of the basic elements of the federal hospital classifications are summarized below.
For some rural communities, CAHs are an alternative to sole community hospitals. SCHs receive cost-based payments for inpatient services only, whereas CAHs receive cost-based payments for inpatient, outpatient, lab, therapy, and post-acute services in swing beds.[4] One challenge, though, is that CAHs are only permitted a maximum of ten inpatient psychiatric beds. In the discussion below, we’ll see how two hospitals in New York developed a solution that balances the need to preserve inpatient psychiatric beds and access the benefits of converting to a CAH.
New York State does not yet have an authorized rural emergency hospital (REH), although the FY 24 Enacted Budget established an array of notification requirements for facilities applying to CMS to convert from a hospital with inpatient beds to a rural emergency hospital. However, Clifton-Fine Hospital, a 20-bed critical access hospital in Star Lake plans to convert into a rural emergency hospital, as does Ira Davenport Memorial Hospital, a 35-bed critical access hospital in Bath.[5]
There are certainly pros and cons to the establishment of an REH. However, if the decision is between having no hospital facility at all and having a hospital that has no inpatient beds, many communities may opt for this alternative operating model.
The mortality data summarized above and included in the accompanying Chartbook present details on the worsening health outcomes for rural New Yorkers. There are many challenges related to operating hospitals in rural areas, and we have discussed some of them above. Additionally, reimbursement models that focus on volume pose challenges for rural hospitals because of the standby costs (for ensuring the availability of healthcare services) in the context of low patient visit volumes.
We recognize that access to high-quality healthcare services is not the only factor that affects health outcomes. Certainly, the physical environment in which people live, the social and economic context of their lives, and their personal health behaviors (acknowledging that these are often limited by circumstances outside of one’s control) also contribute to health outcomes. Our intent is to explore options related to the numerous modifiable factors that impact the sustainability of New York’s rural healthcare delivery.
Recommendations of the AHA Future of Rural Health Care Task Force
The American Hospital Association’s Future of Rural Health Care Task Force (“AHA Task Force”), mentioned above, convened in 2019 and produced a set of final recommendations in 2021. They recommended four “innovative solutions” and eight “promising practices.” The four innovative solutions included:
Creating a system of public-private funding for core services
Establishing flexible funding programs to support rural hospital infrastructure transformation
Launching a rural design center within the Center for Medicare and Medicaid Innovation (also known as the CMS Innovation Center)
Supporting rural facilities’ ability to apply for and manage grants through the creation of an online platform to match rural hospitals with grant writers and technical expertise in grant management
The Task Force also identified eight “promising practices,” some of which have been piloted and could be scaled or replicated. These practices included:
Expanding the adoption of global budget payment models in rural hospitals
Establishing a rural hospital federal tax credit program
Addressing remaining regulatory barriers to the utilization of telemedicine
Fostering strategic partnerships and affiliations
Increasing the availability of broadband and high-speed mobile networks
Investing in leadership development for healthcare leaders
Developing relationships between philanthropy and rural communities
Focusing on maternal health outcomes and disparities among racial and ethnic groups
This Brief discusses some of the core essential healthcare services, the recommendations, and how they may be being implemented in New York, below.
Public and Private Funding for Core Services and Improved Business Operations
The first of the AHA Taskforce recommendations is to establish a funding system, “by which public and private payers pool funds to pay for a defined set of essential services to a community.”[6] This solution would bring together providers, payers, and the community to identify healthcare priorities, address health-related social needs, and promote community investment in improving population health outcomes. Payers and rural hospitals have specific responsibilities in this solution and, as the AHA Taskforce explains, “[P]ayments to the fund would be tied to each payer’s market share in that region.”[7]
Examples in New York
A variation on this concept is happening in New York with a collaboration between Cayuga Health System, Arnot Health (under the same parent entity), and Excellus BlueCross BlueShield. Cayuga Health System is a clinically integrated network that delivers services at multiple locations throughout the Finger Lakes and Central New York. The health system and its partners have been engaged in a joint venture using State and private payer funding to develop an information infrastructure that includes 1) the efficient use of a shared Epic electronic health record system across multiple organizations, 2) an enterprise resource planning system to support the transformation of administrative operations such as finance, supply chain, and human resources, and 3) centralized data warehouse legacy electronic data systems, into a unified platform. The purpose is to develop an information infrastructure that is more consistent and standardized. With this, they can develop a deeper understanding of patient and population health outcomes, the cost of healthcare service delivery, and operations, to facilitate more sophisticated value- and risk-based models of care.
Taking a different approach to ensuring essential services in the community, North Star Health Alliance, which is the passive parent of both Carthage Area Hospital in Carthage (Jefferson County) and Claxton-Hepburn Medical Center in Ogdensburg (St. Lawrence County), is focused on improved business processes and overall “back office” efficiency. They are pursuing efficiency through collaborations with local providers and with a national provider of shared services. The North Star Health Alliance’s founding members include Carthage Area Hospital, Claxton-Hepburn Medical Center, North Country Orthopaedic Group, and Meadowbrook Terrace Assisted Living Facility. The Alliance uses the services of a national company that offers solutions related to supply chain management, pharmacy, health information technology, and revenue cycle management, among others, with the goal of maintaining healthcare services in their community.
State Funding Programs to Support Rural Hospital Operations, Infrastructure, and Transformation
In the Step Two Policy Project’s Policy Brief titled, The Challenge of Financially Distressed Hospitals in New York, we noted that by FY 24, gross State operating subsidies had grown to approximately $3.1 billion going to more than 50 hospitals. Hospitals in rural areas of New York, if they received State subsidies, generally received relatively modest subsidies through the Directed Payment Template Program (DPT) established exclusively for critical access hospitals and sole community hospitals, i.e., the CAH/SCH DPT Program, because they did not meet the Safety Net DPT Program threshold requirement of 36% of both inpatient discharges and outpatient visits being attributable to Medicaid patients. The supplemental reimbursement rates in the CAH/SCH DPT program, and thus the level of subsidies, are much lower than in the Safety Net DPT program.
As discussed in the Policy Brief mentioned above, “[T]he State generally defines “operating subsidies” as being limited to “supplemental payments” to a hospital under three programs: enhanced Medicaid rates under the Directed Payment Template (DPT) program, federally matched Vital Access Program (VAP) payments, and State-only Vital Access Provider Assurance Program (VAPAP) payments.” A few rural hospitals receive VAPAP subsidies, which are essentially limited to hospitals that need such subsidies to “keep the lights on.”
In addition to operating subsidies, the State has programs to provide capital funding for critical infrastructure improvements as well as to facilitate transformation. The Essential Health Care Provider Support Program and the Capital Restructuring Financing Program were originally established in 2014 to support the State’s DSRIP goals. The Health Care Facility Transformation Program (HCFT) was established in 2016 and has had several rounds of statewide funding as the contours of the program have evolved over the years. Earlier rounds of the HCFT Program included a requirement of regional balance, and this continues to be a criterion for awards. Nevertheless, regional balance was mostly satisfied by funding projects of hospitals in upstate cities, rather than rural areas. New in the FY 25 Enacted Budget is the Safety Net Transformation Program, which will facilitate strategic initiatives between financially distressed hospitals and other healthcare providers by providing both operating and capital funding, as well as regulatory flexibility related to transformation.
The Empire Center has created a NY Health Care Capital Funding (2014-2023) database. They explain that,
The new database itemizes 529 grants issued by the Health Department from 2014 through January 2024. The grants authorized funding worth a total of $4.3 billion, $2.3 billion of which had been disbursed so far. Twenty-two of the grants were declined.
Rather than reproducing the information included in the Empire Centers’ database, readers can review the data by county and see the applicant, the original grant amount, the amount disbursed as of January 2024, the description of the project, and the grant program the funds were awarded through. Despite the regional balance built into these capital programs, healthcare facility applicants in New York’s rural counties have been awarded just $6.5 million, and as of January 2024, $4.2 million had been disbursed, or .1% and .2% of the total, respectively.
As mentioned above, New York provides grant funding specifically to rural hospitals through several other programs, based on New York-specific scoring criteria. One such program, the Rural Health Care Access Development Program, seeks to help rural hospitals reduce duplication of services and develop affiliations with healthcare partners in their communities. The goals of the funds, which are derived from New York State’s Health Care Reform Act (HCRA), are to, “plan for or implement the conversion or diversification of underutilized acute care beds; plan or implement projects that diversify hospital services; plan and/or implement activities for improving cost efficiencies; develop long-term finance or resource plans for the hospitals; integrate services with other hospitals and community-based providers; and further strengthen rural health networks statewide.”[8]
The funding for these and the other rural hospital-focused grants has declined over the years, however, from a FY 16 combined appropriation of $16.2 million, to a FY 20 combined appropriation of $12.7 million, to FY 25’s combined appropriation of $10.5 million.
Global Budgets
The first of the “promising practices” recommended by the AHA Task Force is to expand the adoption of global budget payment models in rural hospitals. CMS established such a model in Pennsylvania that currently includes 18 hospital participants and six payers.[9] The Pennsylvania Rural Health Model, which started its Performance Year Zero (PY0) in January 2017 and anticipates ending the performance period in December 2024, was implemented to test whether the predictability of having a global budget will enable rural hospitals to invest in quality and preventive care, and align the services they deliver to better meet the needs of their communities. The context and assumptions for establishing the model, as described by CMS, include:
Pennsylvania hospitals in rural areas often do not have the financial resources or workforce necessary to maintain and expand access to care needed in the community, or to make investments that may improve quality of care and patient experience. As a result of these challenges, many rural Pennsylvanians have seen their local hospital close.
The Pennsylvania Rural Health Model (PARHM) pays participating hospitals a fixed amount upfront, regardless of patient volume, empowering these hospitals to invest in high-quality primary and specialty care that addresses the specific needs of the communities they serve. Model benefits may include: better coordination and linkage of medical and social needs services, chronic disease management, preventive screenings, and substance use disorder treatment. These fixed payments may also give participating hospitals financial stability, given the steady flow of payments they receive through the model.
Ultimately, through the model, rural Pennsylvania residents may experience greater access to high-quality care and live healthier lives.
The activities of Performance Year Zero (PY0) illustrate the planning and funding needs of implementing global budget models. PY0 involved CMS funding distribution to begin model operations, gain participation from rural hospitals and payers, aggregate data from participating payers, and calculate global budgets. During PY0, Pennsylvania secured final commitments from participating rural hospitals and participating payers. The participating rural hospitals developed Rural Hospital Transformation Plans describing how they intend to improve quality, increase access to preventive care, and generate savings for the Medicare program, which they submitted to Pennsylvania and CMS for approval.[10] The targets for the model include payer and hospital participation, financial, and population health, access, and quality targets.[11] It remains to be seen, though, whether this model will yield improved sustainability for rural hospitals as well as improved population health outcomes.
In New York, hospital global budgets are under development with the availability of incentive funding as part of the New York Health Equity Reform (NYHER) 1115 Waiver in conjunction with the federal All-Payer Health Equity Approaches and Development (AHEAD) Model. Even though the AHEAD model was significantly informed by the Pennsylvania Rural Health Model, the NYHER 1115 Waiver is currently available only to financially distressed, Medicaid-dependent safety net hospitals in five downstate counties (Bronx, Kings, Queens, Richmond, and Westchester).[12]
Interestingly, one of the early efforts on the part of the State to adopt hospital global budgets was in 1995, when New York established regulations to support Central Services Facility Rural Health Networks (CSFRHN), which will be discussed in additional detail below. The Administration section of the regulations provides that,
CSFRHNs may, pursuant to the provisions of section 2952 of the Public Health Law and guidelines developed by the commissioner, directly receive grants and reimbursement for planning and coordination of services and may also directly receive global budgets, pooling arrangements and/or capitation payments on behalf of participating providers (Section 408.3 (d)).
Strategic Partnerships and Affiliations in Rural New York
In January 2024, the University of Rochester Medical Center in Rochester, NY, initiated a pilot to improve healthcare access in three rural communities in the Finger Lakes area of New York using telemedicine. To accomplish this goal, they partnered with Five Star Bank, a community bank, and other partners to install telehealth stations in local bank branches in the communities, many of whose residents lack broadband internet at home. The telehealth stations are available on a first-come-first-serve basis for most of the hours when the bank branches are open, and users are connected to University of Rochester Medicine providers to treat non-emergent conditions.
In June 2024, Gov. Hochul announced plans to build a new hospital in Fredonia, NY (Chautauqua County) through a strategic partnership between Kaleida Health and Brooks-TLC Health Systems.[13] The effort to replace the Brooks Memorial Hospital in Dunkirk, NY, has been in development for many years. Brooks-TLC Health Systems used to be two separate entities, i.e., Brooks Memorial and TLC Health Network, which each had a management agreement with the larger, Buffalo-based Kaleida Health.
Brooks-TLC Hospital (formerly Brooks Memorial Hospital) has a large and outdated physical plant, and while there have been efforts to modernize where possible, the financial position of the hospital has been deteriorating for years. It has received tens of millions of dollars in State financial support through the State’s CAH/SCH DPT and VAPAP funds, as well as federal COVID-19 relief funds, but has been experiencing the same challenges as most other hospitals in New York and elsewhere, with the rising costs of supplies, workforce, and revenue declines.[14]
The Governor’s announcement regarding Brooks-TLC Hospital credits the State’s newly established Safety Net Transformation Program[15] as the context in which the Department of Health will disburse the previously committed State support of $74 million. The Safety Net Transformation Program, established in the FY 25 Enacted Budget, encourages strategic partnerships between safety net hospitals and partner organizations while offering funding and regulatory flexibility to, “… improve access, equity, quality, and outcomes while increasing the financial sustainability of safety net hospitals.” The new hospital will provide emergency services and will include a helipad, 15 inpatient beds, an observation unit, a four-room surgical suite, two procedure rooms, imaging, lab, pharmacy, and support services. Although it is not being described as such, this service configuration is similar to what are generally known as “micro-hospitals.”
Another example of a strategic partnership and supportive State funding involving a New York rural hospital occurred in 2018 with the merger of Moses Ludington Hospital in Ticonderoga (Essex County) with Elizabethtown Community Hospital in Elizabethtown (also in Essex County). Elizabethtown Community Hospital is an affiliate of the University of Vermont Health Network. The project, which included a $9.1 million State grant to Moses Ludington, involved a conversion of the Moses Ludington Hospital into an outpatient campus of Elizabethtown Community Hospital. The new Moses Ludington campus in Ticonderoga now has a fully renovated free-standing emergency department with larger and more efficient ambulance bays and lab and pharmacy space, a new radiology and physical therapy/sports rehabilitation space, as well as a newly renovated specialty clinic area. All of this enabled the community to have enhanced access to more health services than before the affiliation with Elizabethtown, without needing to travel.
In a previous cross-NYS-border merger in 2015, WCA Hospital in Jamestown (Chautauqua County) signed an agreement to merge with the Pittsburgh-based University of Pittsburgh Medical Center (UPMC) system. The agreement was approved by the NYS Department of Health’s Public Health and Health Planning Council (PHHPC) in June 2016 and then by the NYS Offices of Mental Health and Office of Alcoholism and Substance Abuse Services (now the Office of Addiction Services and Supports [OASAS]), in August 2016. UPMC committed to a minimum of $25 million over the next ten years to support upgrades at WCA Hospital, such as improved electronic medical record systems and physician recruitment. UPMC will clear their debt and pension obligations in order to redirect funds for WCA capital improvements. The merger will also enable UMPC specialty services to be available through WCA Hospital.[16],[17] The integration, the first New York hospital to merge with UPMC, was fully finalized in December 2016 with the formation of UPMC Chautauqua WCA.
The SUNY Upstate Medical Center (“Upstate”) in Syracuse (Onondaga County) is not a rural hospital, but it is a referral center for many of the rural hospitals in central New York, as well as the western portion of the North Country. Upstate is leading an effort to develop a “virtual hospital network” to facilitate collaboration and efficiency among the 11 or so health entities they frequently interact with. The network will not necessarily include formal affiliations but will focus on regional capacity management and patient load balancing, coordinating and improving the quality of care, and enhancing shared support services and institutional initiatives that support patients and workers. The effort seeks to reduce the time to treatment and to improve patient outcomes by keeping care as local as possible and enhancing capacity at the regional hospitals. These goals will be accomplished through clinical and quality support using telehealth, mobile health services, remote patient monitoring, and the use of satellite facilities and specialty clinics. With the virtual network, the members hope to disseminate best practices and address shared challenges, enhance workforce recruitment and retention, and align the standardization of care, metrics, and reporting, thereby creating an improved information infrastructure.
Samaritan Health, headquartered in Watertown, NY (Jefferson County), includes Samaritan Medical Center with maternity care and cancer care among other hospital services, five family health centers providing primary care, two nursing homes, an assisted living facility, home care, and 15 specialty clinics. Clifton-Fine Hospital in Star Lake, NY (St. Lawrence County) is also affiliated with Samaritan Health. Watertown, NY, is home to the U.S. Army’s Fort Drum. Fort Drum does not have a hospital; instead, residents of the base access many of their healthcare services in the surrounding community. Samaritan Medical Center has been able to maintain robust maternity services, delivering over 1,500 babies per year – more than twice the level of many large urban safety net hospitals.[18] This volume is driven in part by the residents of Fort Drum. Samaritan Health has been engaged in regional health planning efforts facilitated by the Fort Drum Regional Health Planning Organization (FDRHPO), which “works to strengthen the System for Health for all individuals living in Jefferson, Lewis, and St. Lawrence Counties....” FDRHPO brings the healthcare community together in these counties to focus on population health, behavioral health, health information technology, the healthcare workforce, and emergency medical services.
Significantly, Clifton-Fine Hospital, which is a 20-bed critical access hospital, is one of two hospitals in New York that are applying to convert to a rural emergency hospital.[19] Based on the declining population surrounding the hospital, the declining inpatient volume, and the projected financial losses if Clifton-Fine remains a CAH, the decision to convert to a rural emergency hospital is the alternative to closing the facility altogether.[20] In fact, the evolution of Clifton-Fine Hospital represents a familiar trend among rural hospitals across the nation.
Similar to the 2018 service changes at Moses Luddington in Ticonderoga described above, which was not designated as an REH (the designation was established in 2023), the outpatient services at Clifton-Fine will continue to include emergency care, observation care up to 24 hours, lab and radiology, primary care, physical and occupational rehabilitation, behavioral health, and specialty services via telehealth. As an REH, they will expand mobile mammography, provide early intervention pediatric rehabilitation, expand the emergency department and observation areas, as well as establish a new radiology suite.
Two other hospitals in rural New York are also in the process of transformation – seeking collaboration in the context of financial challenges related to low inpatient volume, inflation, and workforce shortages, similar to many hospitals across the State. Mentioned earlier as participants in the North Star Health Alliance, Carthage Area Hospital, a 25-bed critical access hospital, and Claxton-Hepburn Medical Center, a 127-bed sole community hospital and regional referral center that includes a 40-bed inpatient psychiatric unit, are undertaking a strategic sustainability plan.
The intent is to convert Claxton-Hepburn Medical Center from an Article 28 DOH-regulated hospital to an Article 31 OMH-regulated inpatient psychiatric hospital that will ultimately also include a Comprehensive Psychiatric Emergency Program (CPEP).[21] Claxton-Hepburn Medical Center’s acute medical services will move to a new 25-bed critical access hospital that will be operated by Carthage Area Hospital. Carthage will also assume operations of all of Claxton-Hepburn’s acute care, emergency, and outpatient services (including its five rural health clinics). The newly established Carthage-operated CAH will be co-located with the newly established Claxton-Hepburn inpatient psychiatric hospital and CPEP. The practical aspects of the “co-location” will require architectural specifications to adhere to the CMS Guidance for Hospital Co-location with Other Hospitals or Healthcare Facilities[22] and the staff will be separate.
As we see from this discussion of strategic partnerships, the importance of collaboration in planning and implementing healthcare service delivery in regions with scarce resources is crucial. The NYS DOH sought to support this when they adopted the regulations establishing Central Services Facility Rural Health Networks mentioned above, defining them as,
… a not-for-profit corporation established pursuant to article 28 of the Public Health Law, and representative of health care providers within the network through board representation, membership and written agreements or any combination thereof, for the purpose of operating a rural health network. Such network board shall also include representatives of the general public residing in the area served by the central services facility rural health network.
The regulations specify the minimum services to be delivered, as well as other services that may also receive approval from the Health Commissioner. They specify administrative requirements and define service areas. The section devoted to Network Operational Plans provides additional detail on the necessary components of a Network’s plan, its relationship to the Health Service Agencies with jurisdiction in the region, provides for, “the efficient and effective coordination of affiliated network providers in planning and evaluating both the integration and provision of services” as well as the “pooling and sharing of existing resources to facilitate greater system efficiencies.”
The details of operations and reimbursement were never finalized following the adoption of the regulations, and no Central Services Facility Rural Health Networks were ever approved, but they present an opportunity, with updated language, for rural healthcare providers in New York to collaborate on both a service delivery and a business operations level.
Maternity Care
Focusing on maternal health outcomes is another key activity identified by the Future of Rural Health Care Task Force. Earlier in this Policy Brief, we presented a map from Chartis that shows the state-by-state percentage of rural hospitals that stopped offering obstetrics services between 2011 and 2021. Per the U.S. Government Accountability Office, as of 2018, over half of all rural counties lacked hospital-based obstetrics services. Rural hospitals have difficulty recruiting and retaining obstetrics and gynecology (OB/GYN), among other types of healthcare providers.[23] Nationally, in rural areas, it is more common for family physicians to deliver babies compared to in urban areas where babies are generally delivered by OB/GYNs and midwives, although there is variation by state.[24]
Part of the challenge for the sustainability of rural obstetrics units is the older skewing of the rural population due to younger residents moving away and the (nationwide) declining birth rate.[25] Related to the small numbers of babies being delivered at rural hospitals is the potential for poor outcomes when complications occur, because it is challenging to maintain proficiency in low-volume environments, which creates a cycle that hampers recruitment and retention. The authors of a Site Report from the Rural Maternity Innovation Summit held in 2024 compiled the following list of reasons why nationally, hospitals stop providing maternity care, or close completely, in their Table 1, below,
Katy Backes Kozhimannil and colleagues explored the association between a hospital’s obstetric volume and severe maternal morbidity[26] in U.S. rural and urban hospitals. They found that the risk of severe maternal morbidity was increased for both “low-risk and higher-risk obstetric patients who gave birth in lower-volume rural hospitals, compared with similar patients who gave birth at rural hospitals with more than 460 annual births. No significant volume-outcome association was detected among urban hospitals.”[27]
The authors do not, however, recommend closing low-volume obstetric units because closure and too much consolidation lead to higher risk “associated with increases in emergency birth and preterm birth, and travel distances are associated with adverse infant and maternal outcomes.” Instead, they recommend “rural-tailored” quality improvement activities, increased investment in rural clinician training, and establishing referral and transfer networks. They point out that perinatal care quality collaboratives (such as the New York State Perinatal Quality Collaborative discussed later in this Brief)[28] are promising initiatives, but caution that they must include rural “tailoring” to accommodate low birth volume and precarious financial sustainability. Kozhimannil, et al. suggest that modifications to some existing programs could help to address the increased risk they identified as associated with giving birth at low-volume rural hospitals. For example,
Medicaid finances more than half of births at rural hospitals, and low-volume payment enhancements could address resource constraints, clinician availability and training, and financial viability concerns faced by small-volume rural hospitals.6 Additionally, the Centers for Medicare & Medicaid Services (CMS) recently launched a plan to establish a Birthing-Friendly Hospital designation.34 Such a designation holds potential to improve obstetric services in rural settings if it incorporates rural-specific resources and investments to help low-volume rural hospitals achieve and maintain evidence-based support services and an adequate workforce, as well as simulation and other training to maintain staff skills.6,35
The report from the rural maternity innovation summit mentioned earlier provides descriptions of six innovative rural models. These innovative approaches are succinctly summarized in a recent piece from the Milbank Memorial Fund called, Innovations in Rural Obstetrics to Maintain Access to Care. As characterized by the authors, the strategies of the models include developing: hospital-FQHC partnerships to optimize finances, community engagement, and a focus on equity; a culture of continuous learning and quality improvement implemented with a physician- and nurse-led approach; the prioritization of patient experience and providing culturally competent care; a multi-state, rural facility consortium that uses physician-midwife partnerships to implement standardized models of care; and rural regional care hubs staffed with multi-disciplinary, integrated teams that include community health aides. Each of the models a worth exploring to identify which aspects could be adopted in rural New York.
Highlighting Models in Rural Primary Care, Dental Care, Behavioral Health, and Cancer Care
Primary Care
Accessing primary care is often a challenge in rural areas due to a lack of providers; lack of access to broadband services; transportation challenges; inadequate health insurance coverage; and competing priorities such as family care, lack of paid time off from work, or seasonal responsibilities, for example, in farming communities. In recent years, beyond calls for enhancing the primary care workforce (whether by recruitment or enabling health professionals to work to the maximum extent of their license), investing in health centers and rural health clinics, addressing financial barriers to care, enhancing reimbursement for primary care services, expanding telehealth, and promoting health education and prevention, there have also been calls to focus on rural areas as the next hubs of innovation.[29]
One opportunity for innovation in primary care within rural populations is in diabetes management. In the accompanying Chartbook, we examined mortality rates among rural and urban New Yorkers for 15 leading causes of death, stratified by rural and urban populations and sex, and compared between two time periods. Among all ages during the period from 2017 to 2019, we see significant disparities in mortality rates related to diabetes, with rural females experiencing a 45.2 percent higher mortality rate from diabetes than urban females,[30] and rural males with a 22.4 percent higher mortality rate than urban males.[31] Among prime working-age female New Yorkers, the disparity in rural mortality due to diabetes increased 4.3 times between the two time periods, from 13.9 percent higher than urban, female peers during 1999-2001, to 60 percent higher than urban, female peers during 2017-2019.[32]
Diabetes is approximately 17% more prevalent in rural areas, and a key component of successfully controlling the disease is self-management.[33] Medicare[34] and NYS Medicaid[35] cover Diabetes Self-Management Training, but the challenge in rural areas is accessing qualified providers. One intervention that has radically changed individuals’ ability to understand and manage their blood sugar levels is continuous glucose monitoring (CGM), which uses a wearable device to track an individual’s glucose levels in real-time. Continuous glucose monitors have been available since the early 2000s, but they have become increasingly accurate and easy to use, and they sync with a mobile phone. The American Academy of Family Physicians has described how primary care practices play an important role in managing the health of patients with diabetes (Type 1 and Type 2) and how CGM can reduce and even eliminate the need for a fingerstick for blood glucose testing and provide much more comprehensive data for patients to understand and respond to their glucose levels.[36]
Research shows that children in rural areas with type 1 diabetes are less likely to use CGMs. A study from The University of Kansas Medical Center[37] demonstrated that,
Those living in rural areas were significantly less likely to use a CGM than those in urban areas, even after adjusting for sex, race or ethnicity and insurance type. Specifically, compared with youth living in urban areas, the use of CGMs was 31% lower for children and adolescents living in small rural towns, and 49% lower for those living in isolated rural towns. The gap between rural and urban patients persisted across the four years of the study, even as the use of CGMs increased for all patient types during this time. These results are also relevant to people with type 2 diabetes who require insulin.
The reasons for these disparities among children will equally apply to CGM use among rural adults, i.e., cost of the devices (Medicaid-contracted pharmacies may not be easily accessible in rural areas), lack of or inconsistent internet service, and long transportation times if troubleshooting devices is needed, but the opportunities for positive impact health outcomes from increased use of CGM in rural environments are significant.
Dental Care
Rural populations face significant challenges in accessing oral health care, which result in rural populations having higher rates of dental issues, fewer dentists per capita, and lower dental care utilization. To address these disparities, a variety of innovative models and state-level policies have been developed.
Programs like Iowa’s Mouth Care Matters focus on training caregivers and healthcare workers to provide essential oral care for elderly and homebound individuals, helping to bridge the gap in areas with limited access to professional dental services. Tooth BUDDS, a school-based program in Arizona, utilizes portable dental equipment and teledentistry to deliver screenings and fluoride treatments directly to children in rural areas.[38]
State-level initiatives are also critical in addressing these challenges. Connecticut’s HB 7122 supports mobile dental clinics by extending Medicaid reimbursement for services provided within 30 to 50 miles of a fixed clinic location, which is particularly beneficial in rural counties.[39] The Rural Health Information Hub offers evidence-based toolkits that provide information on how to develop and implement healthcare services in rural areas. They have a seven-module Rural Oral Health Toolkit that 1) provides an overview of oral health in rural communities, 2) describes models of oral healthcare and how they can be adapted to rural areas, 3) includes examples of oral health programs that have been implemented, 4) identifies resources to support implementation, 5) presents methods for program evaluation, 6) discusses strategies that support program sustainability, and 7) offers methods for communication the results of successful oral health programs in rural communities.
Another important innovation is the integration of oral health into primary care settings, as demonstrated by the Medical Oral Expanded Care (MORE) Care initiative in Oregon and the Pennsylvania Rural Primary Care Oral Health Initiative. These models incorporate services such as oral health risk assessments and fluoride varnish applications, as well as some restorative services, into routine primary care visits in rural areas. The introduction of dental therapy in some states has further expanded the dental workforce to positive effect in rural areas.
Behavioral Healthcare
The Atlantic magazine has described behavioral health as The Hidden Crisis in Rural America.[40] The author writes:
It’s prohibitively difficult to access mental-health services in rural America. That’s because, relative to urban areas, rural counties have so few mental-health professionals. The majority of nonmetropolitan counties in the U.S. don’t have a psychiatrist, and almost half lack a psychologist. The paucity has resulted in a public-health crisis—rural Americans suffering from a psychiatric condition are more likely to encounter police than receive treatment.
Behavioral healthcare in rural areas in New York faces exactly these challenges, with provider shortages and limited access to a variety of levels of care, as well as populations experiencing social isolation due to geographic isolation, which is a major factor contributing to poor mental health. Community-driven models have emerged to offer expanded service types and more flexible access. The National Academy for State Health Policy (NASHP) produced a Brief titled, The Rural Behavioral Health Crisis Continuum: Considerations and Emerging State Strategies. It describes some of the innovations that states are employing to overcome the challenges of distance, workforce shortages, and limited resources.
In addition to the NASHP examples, there are other rural-focused innovations emerging. For example, Appalachian Regional Behavioral Health (ARBH) Hospital in North Carolina is the first critical access hospital to co-locate with a behavioral health hospital.[41] In response to a growing demand for psychiatric services and an increasing number of mental health crises in the region, ARBH expanded its psychiatric bed capacity with the help of a $6.5 million grant. The hospital also developed a walk-in behavioral health assessment option, allowing patients to bypass emergency departments for faster, more direct care. This model has improved patient access to behavioral health services while simultaneously enhancing the financial sustainability of the rural hospital.
A recent white paper by NORC at the University of Chicago highlighted findings from a listening tour about mental health in rural New York.[42] It recommends improving broadband access to enhance service availability, especially for telehealth, expanding state funding for transportation, and promoting ride-sharing programs. The report also encourages investment in peer support services and non-clinical support options to reduce isolation, such as mobile app platforms and peer groups. To combat stigma, integrating behavioral health screenings into primary care settings and using models like SBIRT (Screening, Brief Intervention, Referral to Treatment) are recommended. Additionally, it is critical to address workforce shortages by raising provider salaries and offering incentives to attract professionals to rural areas.
Cancer Care
Cancer care introduces significant challenges for rural populations due to geographic isolation, financial burdens, and limited access to specialized oncology services. The centralization of cancer care in urban centers often requires rural patients to travel long distances for treatment, exacerbating disparities. Innovative models like Rural Huntsman (i.e., Huntsman Cancer Institute in Salt Lake City, UT) at Home[43] and the Rural Oncology Home[44] have been piloted. The Rural Huntsman at Home program targets patients who are a two- to five-hour drive from the Cancer Institute and offers acute and subacute cancer care in patients' homes, utilizing nurse practitioners, telehealth, and remote monitoring to manage symptoms and prevent emergency department visits. The Rural Oncology Home model provides a community-based, team-oriented approach, integrating advanced practice practitioners and telehealth to improve access to specialized care, including clinical trials, for patients in rural areas. Both models focus on reducing travel demands, improving care coordination, and enhancing outcomes for rural cancer patients by decentralizing cancer treatment and bringing care closer to home.
Models of Primary Care, Behavioral Healthcare, Maternity Services, Dental Care, and EMS Collaborations in Rural New York
Primary Care
Hudson Headwaters Health Network is an FQHC that cares for approximately 162,000 patients and serves a geographic area that’s roughly the size of New Jersey (approximately 7,900 square miles). They are a network of 25 community health centers and serve all of Warren County and parts of Clinton, Essex, Franklin, Hamilton, Saratoga, and Washington counties.[45] Hudson Headwaters collaborates with hospitals to reduce redundant services, support regional health planning strategies, and enhance essential healthcare services by expanding into areas with high need but limited resources. In many cases, they co-locate with hospitals to provide better access to care and make the delivery of care more efficient for both providers and patients. Their scale enables them to function as a safety net for primary care, obstetrics (delivering a projected 850 babies in 2024), and dental services in the region – often securing primary care in a community when private practices are no longer sustainable. Hudson Headwaters has built a sustainable network through regional efforts such as the Adirondack Medical Home initiative, which brought enhanced reimbursement for population health services, and the community impact investments available through the 340B drug discount program. Although, the recent restrictions related to single pharmacy contracting[46] have been challenging in the rural counties where they provide services. This supplemental revenue helps to offset the relatively low reimbursement for their primary care and other services— deliveries and dental care in particular.
Hudson Headwaters is increasingly embracing innovative and more integrated models of care. They recently established a Program of All-Inclusive Care for the Elderly (PACE) that they plan to have operationalized by the end of 2024. The PACE day center will be adjacent to one of their FQHCs. They are part of the Adirondack Accountable Care Organization (ACO) and they have created an Independent Physician Association (IPA) to explore more advanced value-based models of care. As they build their services and explore innovative methods for delivering care in rural New York, they are establishing the John Rugge Center for Community Impact, which will focus on addressing health-related social needs such as housing, childcare, and transportation.
The Bassett Healthcare Network, headquartered in Cooperstown (Otsego County) and providing services across eight counties, has a history of offering robust primary care services to its largely rural service area. The Network currently includes 33 primary care centers (family medicine, internal medicine, and pediatrics) and 21 school-based health centers (SBHC).[47] It also includes three locations for family dentistry. The SBHCs provide an entry point into Bassett’s integrated healthcare system. They provide physical healthcare services including immunizations by nurse practitioners or physicians, dental services by dental hygienists using portable equipment, and mental health services by social workers or mental health counselors, all using the same electronic health record as the hospital, centralized billing, and access to hospital-based services such as lab, radiology, pharmacy, and specialty care. The SBHCs are open throughout the year, including summer, have extended hours, offer video and telephone visits, bill insurance, and students can be seen at any of the SBHCs if they are enrolled in one SBHC. The map below shows the breadth of Bassett’s network,
Behavioral Healthcare
There are several models in New York that seek to integrate primary care and behavioral healthcare services. These programs can be accessed by rural providers as well as those in urban and suburban areas of the state. The NYS Office of Mental Health (OMH) administers the Collaborative Care Medicaid Program (CCMP) and Project Teach. CCMP is a program for OMH-approved primary care practices to enable them to receive enhanced Medicaid reimbursement for addressing common behavioral health issues such as anxiety and depression. In the model, there must be a specially trained team that includes a behavioral health care manager as well as a psychiatric consultant (physician or psychiatric nurse practitioner), utilizing specific screenings and protocols. The training and technical assistance are provided by OMH, and the psychiatric consultant is not required to be on-site. Some practices have expressed concerns with the billing requirements, reimbursement rates compared to fee-for-service, and the need for practice change to meet the requirements of the program.[48] Some of these concerns can be addressed through effective leadership and change management; the billing and reimbursement concerns, however, may require program policy changes from the State.
Project Teach is a program that helps child, adolescent, and perinatal healthcare providers access psychiatric expertise to better care for their patients. The clinician-to-clinician consultation is fully funded by OMH so there are no fees, and it is available to any New York clinician caring for these populations. Specifically,
Prescribers can ask questions about any case involving children and adolescents up to age 21 or perinatal patients who are in the preconception planning phase to 3 years postpartum. Questions can be specific to a particular patient; diagnosis and treatment for a specific mental health disorder; use of a particular medication or other treatment strategy; or general questions about topics in psychiatry and/or behavioral health. Project TEACH Liaison Coordinators (LCs) can assist in identifying appropriate specialty referral resources and linkages for patients and families. Project TEACH does not provide crisis services or evaluations for emergencies but can refer severe or urgent cases to appropriate emergency services.[49]
Project Teach also provides referrals to services such as community mental health services and supports when necessary, online continuing mental health education for primary care/perinatal providers, as well as other resources. The accessible, no-cost consultation model is particularly helpful for rural clinicians who may not have ready access to colleagues specializing in child, adolescent, or perinatal psychiatry.
Maternity Care
In addition to the support offered by the State to primary care and perinatal providers related to behavioral healthcare services, there are also resources that rural hospitals and other clinicians can access related to perinatal care in general. The NYS DOH established a system of perinatal regionalization that works to ensure each geographic region, “… includes hospitals that can provide a full range of services for pregnant women and their babies.”[50] Hospitals are designated at different levels, reflecting the types of care they are able to provide. When an “affiliate hospital” has a patient whose needs exceed the hospital’s level of care, the affiliate hospital can coordinate with the regional perinatal center for either consultation or to transfer the patient’s care.
In addition to the perinatal regionalization, the DOH also operates the New York State Perinatal Quality Collaborative (NYSPQC). The quality initiative began in 2010 and seeks to improve infant and maternal outcomes. The initiative also works to disseminate best practices and guidelines and its projects are free for healthcare teams. One of the recent projects released by the Quality Collaborative is the New York State Obstetric Hemorrhage Project Toolkit. The purpose of the project is to, “… reduce maternal morbidity and mortality statewide by translating evidence-based guidelines into clinical practice to improve the assessment for and management of obstetric hemorrhage.” The toolkit focused on the following aspects of the issue,
The Toolkit is 350 pages and includes materials and methods related to quality improvement; data collection; education; hospital policies, tools, and forms; references; and additional resources.
Although the CDC Wonder mortality data for rural New York do not identify obstetric-related hemorrhage as one of the leading causes of mortality for rural females, we do know from the earlier discussion, that obstetrics units with fewer than 460 deliveries are associated with increased maternal morbidity. This toolkit, and the other resources available from New York’s Perinatal Quality Collaborative, can provide essential technical assistance and support to rural hospitals that have a low volume of deliveries, to help ensure the best possible outcomes.
Dental Care
The University of Rochester’s Eastman Institute for Oral Health (EIOH) has a long tradition of community dentistry – providing mobile dental services in city schools and Head Start programs, working with nursing home residents and individuals with complex medical conditions, providing teledentistry services for rural communities surrounding Rochester, and providing education and training for dental residents. EIOH is one of only two pediatric dentistry residency programs in New York, outside of the New York City metro area.
The Eastman Institute offers a robust teledentistry program which provides access to dentists for children and adults in areas where the dental workforce is limited. Teledentistry visits enable remote patients to consult with the dentist before travelling to the office or as a follow-up visit. In some instances, they may use a specialized camera or the patient’s mobile phone camera. The EIOH has a long-standing partnership with Finger Lakes Community Health headquartered in Penn Yan (Yates County) to provide teledentistry services in their eight dental services sites. The partnership has a specific focus on pediatric care and EIOH provides pediatric dental specialists for patients with extensive caries due to various factors. One research study that emerged from the program, identified “[T]he travel distance from the children’s homes to the EIOH in Rochester varied from 19 to 90 miles (M = 49.1 miles). A quarter of children resided more than 58 miles from the pediatric dentist.” The pediatric teledentistry program uses special video equipment at the remote site with the patient and site staff and is live (i.e., synchronous teledentistry) with a pediatric dentist in Rochester.
New York would benefit from better collaboration across the State’s health and human services agencies to develop a comprehensive and coordinated approach to improving access to and the delivery of dental services, particularly for special populations like frail individuals, nursing home residents, and those with intellectual or developmental disabilities.
EMS Collaborations
The Home Care Association of New York State (HCA-NYS) and the Iroquois Healthcare Association (IHA), with the support of grant funding, have embarked on a set of multi-year pilots in “five rural and small community regions.” These pilots established models of care to bring together hospitals, home care agencies, physicians, and EMS organizations. The goals of the collaborative models are 1) to reduce hospital readmissions, and 2) to avoid preventable hospitalizations and ambulance transports through enhanced collaboration and communication among “core health sector partners.” Each pilot model is somewhat different, reflecting the different needs and resources of each community. The role of EMS organizations in non-emergency care, activities often referred to as the practice of community paramedicine,[51] is generally restricted by current New York law; these pilot models are meant to explore the different roles that each health sector partner could play to better serve their communities.
Gov. Hochul’s FY 25 Executive Budget proposed to incorporate collaborative pilots, such as those underway through HCA-NYS and IHA into the constructs of Public Health Law and the DOH. The proposal was an amendment to the existing Section 2805-x; it expanded and more explicitly identified the types of healthcare facilities and providers who could apply to the DOH to undertake innovative healthcare delivery models to meet the evolving needs of communities across New York. The Executive’s proposal was rejected by the Legislature.
Gov. Hochul’s FY 25 Executive Budget also included a package of proposals aimed at shoring up EMS services in New York that would have resulted in support for rural areas. Those proposals were omitted from both one-house budget proposals, and none of them were included in the FY 25 Enacted Budget. As the 2024 Legislative Session closed in early June, there was a push from the NY Association of Counties and others to pass a set of bills to “rescue EMS.”[52] EMS-related bills passed the NYS Senate[53] in late May 2024, and several of the bills also passed the Assembly at the very end of session. On September 18, 2024, the Governor signed two of the EMS bills, one to authorize Medicaid reimbursement for treatment services even if the patient is not transported or if they are transported to a non-hospital facility, and the other, to expand the types of ambulance services and personnel permitted to store, administer, or distribute blood.[54]The other proposals, if enacted, will permit, among several other actions, medical emergency response and emergency medical dispatch to be determined as essential services in New York, which would facilitate a uniform and coordinated response to emergencies across all counties.
Workforce Solutions
As mentioned earlier in this Brief, the J-1 Visa Waiver Program is administered on both the federal and state levels and allows graduates of non-U.S. medical schools who have had their residency training in the U.S. to waive the requirement to return to their home country for two years, providing an H-1B visa that permits the individual to live and work in the U.S., in return for practicing medicine in a federally designated health professional shortage area or medically underserved area for a minimum of three years. After three years, the individual becomes eligible for permanent resident status. Any federal government agency may recommend J-1 Visa Waiver placements in cooperation with the State, and states also have the opportunity to recommend up to 30 waiver placements to the federal Department of State, through the Conrad 30 program— the New York “State 30” Program.
Two of the federal-state regional economic and community development commissions, the Appalachian Regional Commission and the Northern Border Regional Commission, include New York counties in their service areas.[55] Federal agencies can request J-1 Visa Waivers directly, but the two Commissions that serve New York have developed programs focused on physician recruitment to complement the number of physician placements beyond the State-specific allocation. The North Border Regional Commission announced its J-1 Visa Waiver program in December 2023 and modeled it on the Appalachian Regional Commission’s, which had been in place for many years. Together, these two Commissions are contributing to the recruitment of physicians into rural New York counties. Not all of the physicians remain after their service obligation, but the J-1 Visa Waiver program provides a crucial physician pipeline for rural New York.
Many of the hospitals and other healthcare providers discussed earlier in this Policy Brief are focused on growing their own healthcare workforce. For example, Bassett has a partnership with Columbia University’s Vagelos College of Physicians and Surgeons called the Columbia-Bassett Program.[56] This offers medical students an opportunity to split their medical school training between New York City and Cooperstown to experience a broader context in which care is provided and to potentially become involved in research and management in diverse communities. Also at Bassett Healthcare Network, A.O. Fox Hospital and Otsego Northern Catskills Board of Cooperative Educational Services (ONC BOCES) have developed a partnership to educate and train LPNs. Samaritan Hospital has a physician GME program with 12 slots for Internal Medicine and Family Medicine. Hudson Headwaters has physician residency programs for Family Medicine, in partnership with Albany Medical Center and Saratoga Hospital, and in some cases with Champlain Valley Physicians Hospital in Vermont. They also have internal medicine training experiences for medical students, a dental residency program, and training rotations for pharmacy and nursing students.
In addition to the FY 25 Executive proposals mentioned above, there was also a package of proposals related to health professions’ scope of practice and national licensure compacts. The rationale for less restrictive scopes of practice for physician assistants, dental hygienists, medical assistants, EMS providers, (and pharmacists[57] and nurse anesthetists that were not included in the Executive proposals), and for New York to join the interstate licensure compacts for nursing, medicine, and other professions, is to better align the health workforce to the needs of patients and the evolving healthcare delivery system, and to enhance access to care. As B.K. Frogner, et al. explain,[58]
Ongoing payment reforms are pressing health systems to reorganize delivery of care to achieve greater value, improve access, integrate patient care among settings, advance population health, and address social determinants of health. Many organizations are experimenting with new ways of unleashing their workforce’s potential by using telehealth and various forms of digital technology and developing team- and community-based delivery models. Such approaches require reconfiguring of provider roles, but states and health care organizations often place restrictions on health professionals’ scope of practice that limit their flexibility....
Over the past decade, numerous reforms have been implemented by the federal government and by states to expand health insurance coverage, change payment models, motivate organizations to reconfigure the ways they deliver care, modify eligibility for Medicaid, and better prepare the health workforce for pressing behavioral care, primary care, geriatric care, and community care needs. To realize the potential of these laudable reforms, we believe that states should eliminate overly restrictive scope-of-practice regulations that they impose on the health professions. Doing so would allow us to unlock the full potential of the country’s health workforce.
Recommendations
Physical Infrastructure
Build a dedicated “rural hospital/healthcare facility pool” into any State healthcare funding program.
Because rural hospitals are anchor institutions in their communities and their closure has a significant ripple effect on community infrastructure, incorporate rural healthcare as a theme in State economic development initiatives, similar to the Health Across all Policies Initiative launched in 2017.[59]
“Impact of Approved Projects on Distressed Urban and Rural Communities, Small- and Medium-sized Businesses, and Strategic Industries” is a standard section in the NYS ESD Quarterly Reports and “Health Care and Social Assistance” are considered “Strategic Industries,”[60] but given the worsening healthcare outcomes in New York’s rural communities, healthcare and health-related social needs should have a higher profile as an organizing principle for project awards.
Facilitate technical assistance for rural hospitals on better leveraging federal funding through the CAH and RHC programs.
Some providers in rural New York are maximizing this opportunity and the State can assist in disseminating corresponding best practices.
Create a $4-$6 billion Healthcare Transformation Financing Fund as a new public authority financed by inflation-adjusting the Covered Lives Assessment to its 2009 level and build in a dedicated “rural hospital/healthcare facility pool.”
Successful implementation of the strategy to facilitate the transition of financially unsustainable full-service hospitals to a more sustainable operating model is likely to require significantly more capital than the State has appropriated for hospitals in recent years, with the caveat being that this strategy holds the promise of significantly reducing ongoing operating subsidies for the affected hospitals. The State should finance this investment with a new Healthcare Transformation Financing Fund that is supported by inflation-adjusting the Covered Lives Assessment (CLA). At one time, the State’s CLA assessment for individuals covered by commercial insurance or self-funded plans amounted to approximately 2.0% of such expenditures. Because of inflation, the CLA now amounts to approximately 1.40% of such expenditures. Inflation adjusting the Covered Lives Assessment by restoring it to the 2.0% level would generate approximately $500 million per year. This amount of revenue could support debt service for capital funds as large as $4-$6 billion.[61]
Capital grant funding is important for many rural hospitals because of their relatively low revenue base and, even if they have positive operating margins, they aren't large enough to support the level of capital infrastructure investment necessary to undertake major transformation and/or facility replacement.
Incentivize and coordinate the utilization of teledentistry through State grants for partnering facilities, to support the purchase of equipment and the personnel to operate and maintain a teledentistry program.
Collaboration
Modernize NYS Codes, Rules, and Regulations Title 10, §600.9 - Governing Authority or Operator (established in 1989) to facilitate collaboration between healthcare providers by permitting revenue sharing between qualified providers, even when a collaborator is not an established operator of the facility.
Consider including reporting requirements to the State related to the revenue sharing arrangements between qualified providers, so there is transparency about the partners and their activities.
Continue advocating to CMS to modernize the “co-location” prohibitions.
The current co-location guidance, revised in November 2021, maintains significant barriers to the collaboration of healthcare providers by forcing inefficient and expensive requirements related to shared spaces, services, personnel, and emergency services.
CMS maintains these prohibitions in the name of establishing clear areas of provider responsibility, monitoring safety and quality, and ensuring billing integrity. The reality of modern service delivery, however, with the drive toward more integrated and coordinated care, as well as the sharing of resources between providers, renders these prohibitions on the co-location of providers a barrier to care, particularly in rural areas.
Modernize NYS Codes, Rules, and Regulations, Title 10, Part 408 – Central Services Facility Rural Health Networks (CSFRHN) (established in 1995) to facilitate rural healthcare providers’ and health-related entities’ efficient collaboration within network operations with coordinated community planning, administration, regulatory flexibility, and innovative reimbursement models.
Restore resources for the NYS DOH Rural Health Programs to facilitate network development, regional coordination, and sharing of best practices.
Reimbursement/Business Operations/Information Infrastructure
Support alternate payment models that are not dependent on patient volume, e.g., global budget models, for rural healthcare care providers.
Reimburse Article 28 FQHCs at the full, in-person reimbursement rate for telehealth visits when both the provider and patient are located offsite, as is done in the case of Article 31 behavioral health clinics and Article 32 substance use disorder outpatient clinics that receive nearly full payment, regardless of where the patient and provider are located.[62]
Ensure the work of NY ESD’s ConnectALL office proceeds efficiently to ensure access to broadband services for all of New York.
Add oral health products like toothbrushes, toothpaste, and dental floss to the Medicaid formulary and exempt oral health products from State and local sales tax.
For NYS sales tax, oral health products should be re-classified as tax-exempt “…products (other than food) that are intended to affect the structure or a function of the human body…,” rather than as cosmetics and toiletries, as they are currently.[63]
Allow professional service fees to be an allowable cost on New York Medicaid cost reports, recognizing that clinical providers such as physicians, nurse practitioners, and physician assistants in rural areas are generally employed by a rural hospital system and there are few independent providers available.
Consider adding professional fees as an eligible service for add-on payments to Medicaid managed care plan rates in the Rural Directed Payment Template (DPT) program.
Implement an NYS Medicaid quarterly bonus program for physicians, dentists, nurse practitioners, physician assistants, and nurse midwives practicing in rural health professional shortage areas, similar to the CMS physician bonus program for delivery of Medicare services.
Support projects to incentivize networks of rural providers to focus on improved business practices through a network-wide resource planning system that modernizes administrative operations such as finance, supply chain, and human resources.
Support projects that assist rural hospitals to centralize, integrate, and secure their data; rationalize their legacy systems; and where possible, share the use of electronic health records systems.
With an improved and standardized information infrastructure that produces a deeper understanding of patient and population health outcomes as well as of spending, these hospitals will be better positioned to engage in higher-level value- and risk-based models of care.
Through technical assistance and network development, support projects that implement and expand remote patient monitoring.
Through technical assistance and partnerships with professional associations, ensure the awareness and implementation of evidence-based tool kits for primary care providers in rural areas, e.g., Evidence-Based Toolkits for Rural Community Health.
Explore pilots that involve artificial intelligence, such as machine learning, natural language processing, robotic process automation, delivery and transport robots for use within facilities, and delivery drones to improve the efficiency and accuracy of care.
Workforce
Ensure that hospitals and healthcare practices in rural areas that are located within federally designated shortage areas are leveraging the associated federal and State health workforce programs.
Ensure sufficient funding for the State-funded healthcare profession service obligation programs to expand the workforce.
Consider establishing a companion program with NY ESD to support the spouses/partners of healthcare professionals who agree to practice in New York’s rural, health professional shortage areas, with employment opportunities.
Join the Nurse Licensure Compact (NLC) and the Interstate Medical Licensure Compact (IMLC).
The NLC allows nurses to have one multistate license that enables them to practice in all member states, including NYS. The IMLC provides an expedited pathway for physicians licensed in a member state to obtain a full and unrestricted license to practice medicine in NYS and other member states.[64]
Consider establishing a “special purpose telehealth registry” that would enable certain groups of out-of-state clinicians to become licensed to provide telehealth services to in-state New Yorkers, as Utah, Vermont, and Florida have.[65]
Establish registered nurse, licensed practical nurse, and other “high-demand healthcare occupation” apprenticeship programs through the NYS Department of Labor.
Adopt changes to scope of practice (and permitted activities) for pharmacists, physician assistants, certified registered nurse anesthetists, dental hygienists, emergency medical technicians and paramedics, and recognize dental therapists and medical assistants, to maximize available workforce resources and promote team-based care, particularly in rural New York.
Enhance Medicaid Graduate Medical Education (GME) funding to establish residency programs in rural settings.
Establish a Medicaid Graduate Nurse Education (GNE) pilot for advanced practice nurses, e.g., nurse practitioners and nurse midwives, to train in rural settings.
Conclusion
In this Policy Brief we’ve discussed challenges and solutions for several aspects of the healthcare delivery system in rural New York. We have not gone into detail on long-term care or emergency medical services. These are two areas that are significantly challenged and require considerable attention. Regarding EMS, the New York State 2023 Evidence Based EMS Agenda for Future report and the forthcoming report from the NYS Rural Ambulance Services Task Force are important resources as we consider solutions.
The population health model below provides a visualization of the multiple factors contributing to health outcomes and to the rural-urban mortality gap.
As M.C. Garcia and colleagues explain in their Preventable Premature Deaths from the Five Leading Causes of Death in Nonmetropolitan and Metropolitan Counties, United States, 2010 – 2022,
Extensive literature on social determinants of health has established the importance of community context in shaping all aspects of health (6). Structural factors (e.g., lower socioeconomic status, limited access to health care professionals, and limited job opportunities) increase the risk for premature death among rural residents (7) … the population’s age structure alone does not explain the disparity in mortality. Instead, differences in social circumstances, socioeconomic characteristics, health-related behaviors, and access to health care services affect mortality and potentially contribute to approximately half of all preventable premature deaths (10).
In a Commentary on rural health that appeared in Health Affairs in June 2024, A.N. Sosin and E.A. Carpenter-Song, describe how “[d]ecades of underinvestment in rural communities, health care, and public health institutions left rural America uniquely vulnerable to the COVID-19 pandemic.” However, they also discuss how the pandemic brought forth creative responses to meet the health and social needs of rural Americans and provided insight into addressing the “long-standing rural challenges.” They propose five principles to “reimagine” rural health equity and to inform research, practice, and policymaking:
Incorporate rural health equity as a distinct aspect of health equity, that focuses on addressing rural disadvantage.
Explicitly consider “rural disadvantage” in policy and practice; acknowledge underserved rural communities’ designation as “population with health disparities” by the National Institute of Health.
Consider rural disadvantage across the lifespan. While rural populations may be older on average, we see in the New York and the national mortality data that non-elderly rural populations, particularly females between the ages of 25 and 54, are seeing significantly declining outcomes.
Expand methods to address rural disadvantage. Specifically, the authors report that, “we see the need to expand the use of rigorous community-based qualitative methods that are ideally suited to illuminating the health needs and experiences of smaller populations and groups within rural regions that may be missed by traditional public health methods.”
Focus on rural leadership and assets – identifying and building on rural strengths and assets is key to addressing rural disadvantage. Investments that protect and revitalize rural health care and bolster the rural workforce need to be accompanied by measures that empower rural institutions and actors.
The authors conclude that,
Systematically attending to rural disadvantage and strengths reframes rural disparities as amenable to action instead of inevitable consequences of geography, poverty, or demography. Achieving thriving rural communities requires attention to the complex forces shaping health at the geographic margins and commitment to specific action to narrow the sharp gradient of rural health disparities.
By addressing the challenges of delivering healthcare services in New York, and pursuing the solutions identified throughout this Policy Brief, New York policymakers have an opportunity to positively impact the health outcomes of rural New Yorkers. To be successful though, it is not just the healthcare delivery system that needs attention. The infrastructure of rural New York is in need of support - from internet service, accessible transportation, community drinking water systems, affordable housing, education and training, childcare, and job opportunities. Improvements in these social and economic needs, combined with healthcare services, can create an environment where populations thrive and where individuals have more opportunities to make positive choices for themselves, their families, and their communities.
Acknowledgments
Thank you to the following individuals for sharing their time, experience, and expertise:
Brandon Bowline, Chief Operating Officer, Claxton-Hepburn
Thomas Carman, President and CEO, Samaritan Medical Center
Robert Corona, CEO, Upstate University Hospital
Douglas DeLong, Chief, Division of General Internal Medicine, Bassett Healthcare (retired)
Jill Denny, Director, Hospital Strategic Affairs, Upstate University Hospital
Richard Duvall, CEO, Carthage Area Hospital & Claxton-Hepburn Medical Center
Gary Fitzgerald, President and CEO, Iroquois Health Alliance (retired)
Nathan Graber, Pediatric Medical Director, Office of Health Insurance Programs, NYS DOH
Bea Grause, President, Healthcare Association of New York State
Gene Heslin, First Deputy Commissioner & Chief Medical Officer, NYS DOH
Karen Madden, Director, Center for Health Care Policy & Resource Development, NYS DOH
Tracy Mills, Executive Vice President, Network Strategy, Hudson Headwaters Health Network
Tracy Raleigh, Senior Advisor, Manatt Health Strategies, Manatt, Phelps & Phillips
Dan Sheppard, Senior Advisor, Brown & Weinraub
Tucker Slingerland, CEO, Hudson Headwaters Health Network
Martin Stallone, CEO, Cayuga Health System
Kelsey L. Thomas, Research Agricultural Economist, Rural Economy Branch, Resource and Rural Economics Division, USDA Economic Research Service
Staci Thompson, President and CEO, Bassett Healthcare Network
Bridget Walsh, Senior Policy Analyst for Health and Public Health, Schuyler Center for Analysis and Advocacy
Henry Weil, President, Bassett Medical Center
Appendix
Leading Causes of Mortality - Leading causes of natural and external mortality among New Yorkers vary by the sex of the individuals, the times periods examined, whether in rural or urban areas, and depending on the age grouping, with some of the natural causes related more to advanced age, than others. The tables in the Chartbook explore some of the leading causes of mortality in rural areas – in comparison to those same causes in urban areas and compared between female and male New Yorkers— and examine change between the two time periods.
Key Terms
Urban and Rural: For the purposes of this Policy Brief, the term rural is synonymous with non-metropolitan or non-metro, and the term urban is synonymous with metropolitan or metro. The CDC WONDER data used the National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme for Counties. NCHS’s six-category, urban-rural classification scheme for U.S. counties and county-equivalent entities is based on their population and commuting patterns (Ingram & Franco, 2014). In this Brief, we collapse the NCHS urban-rural classification scheme into two categories: urban, which includes the four NCHS sub-categories of large central metro, large fringe metro, medium metro, and small metro; and rural, which includes the two NCHS sub-categories of micropolitan and noncore.
Crude mortality rate: a measure of the number of deaths in a population, typically expressed as X deaths per 100,000 population.
Age-adjusted mortality rate: a mortality rate that is statistically processed, or weighted, to allow for standardized comparison of two or more populations with different age demographics without bias. Also expressed as X deaths per 100,000 population.
Note: The accompanying chartbook only presents age-adjusted mortality rates.
The NYS Department of Health has a useful primer on age-adjustment, which includes a relevant example using prostate cancer mortality rates.
All-cause mortality rate: unlimited to any particular cause(s).
Natural-cause mortality: limited to causes related to illness and disease.
External-cause mortality: limited to causes not related to illness or disease. See Chartbook page 11.
All-ages: encompasses the overall population.
Working-age: captures people 15-64 years of age, understood to reflect the broader working-age population.
Prime working-age: captures people 25-54 years of age, used in many federal labor analyses to represent a group that is especially critical for economic productivity.
Methods
Data Source:
This study utilized data from the Centers for Disease Control and Prevention (CDC) Wide-ranging Online Data for Epidemiologic Research (WONDER) system to analyze trends in natural-cause mortality (NCM) and external-cause morality in the United States. We specifically used the Multiple Causes of Death (MCD) dataset, which is publicly available on the CDC WONDER platform (https://wonder.cdc.gov/mcd.html). The dataset includes information from death certificates, which the CDC collects annually, allowing for a comprehensive analysis of mortality trends. Our analysis covered the period from 1999 to 2020.
An example query is reproduced on pages 8-10 of the accompanying chartbook.
Primary Statistic: Age-Adjusted Mortality Rate
We utilized age-adjusted mortality rates to compare health outcomes in regions with different age distributions by eliminating the bias of age in the populations being compared.
Age Cohorts and Stratifications
The analysis included three primary age cohorts to capture trends across different stages of life:
All-Ages
Working-Age (15-64 years)
Prime Working-Age (25-54 years)
To further understand rural/urban health disparities, we ran specific queries within the CDC WONDER system to identify age-adjusted mortality rates by various stratifications, including:
Metro Status: Differentiating between urban and rural populations.
Sex: Comparing mortality rates between males and females.
Age: Analyzing trends across different age groups.
Leading Causes of Death: Focusing on the 15 leading causes of death to provide a detailed understanding of the factors contributing to mortality rates.
Endnotes
1] Bringing Hospital Care Home: A Revolution in Rural Healthcare, HealthTech, July 24, 2024.
[2] Rural Pharmacies Fill a Health Care Gap in the US. Owners Say It’s Getting Harder to Stay Open, AP, June 7, 2024.
[4] Differences in Community Characteristics of Sole Community Hospitals, NC Rural Health Research Program, November 2017.
[6] AHA Future of Rural Health Care Task Force | Final Recommendations, May 2021, p. 5.
[7] Ibid, p. 10.
[9] Participating Hospitals: Armstrong County Memorial Hospital (Kittanning, PA), Barnes-Kasson County Hospital (Susquehanna, PA), Clarion Hospital (Clarion, PA), Endless Mountains Health Systems (Montrose, PA), Fulton County Medical Center (McConnellsburg, PA), Geisinger Jersey Shore Hospital (Jersey Shore, PA), Highlands Hospital and Health Center (Connellsville, PA), Indiana Regional Medical Center (Indiana, PA), UPMC Kane (Kane, PA), Meadville Medical Center (Meadville, PA), Monongahela Valley Hospital (Monongahela, PA), Olean General Hospital/Bradford Regional Medical Center (McKean, PA), Punxsutawney Area Hospital (Punxsutawney, PA), Washington Health System Greene (Waynesburg, PA), Tyrone Hospital (Tyrone, PA), Washington Hospital (Washington, PA), Wayne Memorial Hospital (Honesdale, PA), Chan Soon-Shiong Medical Center at Windber (Windber, PA); Payers: Geisinger, Highmark Blue Cross Blue Shield, University of Pittsburgh Medical Center, Aetna, Highmark Wholecare, and Medicare fee-for-service.
[11] Financial Targets: PA commits to achieving $35 million in cumulative Medicare hospital savings over the course of the Model. In addition, the growth rate of rural Pennsylvania total Medicare expenditures per beneficiary must not exceed the growth rate of the rural National total Medicare expenditures per beneficiary by more than a certain percentage for Performance Years 2 through 5. Population Health Outcomes, Access, and Quality Targets: PA commits to achieving targets related to population health outcomes and access under this Model, and may tie financial incentives for participating rural hospitals to Pennsylvania’s performance on the following three goals: 1) increasing access to primary and specialty services; 2) reducing rural health disparities through improved chronic disease management and preventive screenings; and 3) decreasing deaths from substance use disorder and improve access to treatment for opioid abuse.
[12] The 2024 Medicaid Conference: Shaping the Future of Care Integration, United Hospital Fund, July 31, 2024.
[13] Included in the map of rural counties in New York on p. 11.
[14] Brooks-TLC in Dunkirk Pushing for a New Hospital in Fredonia, The Buffalo News, February 12, 2023.
[15] FY 2025 Enacted Budget, Health and Mental Hygiene Article VII, Part S.
[16] Merger Receives Two Approvals, The Post-Journal, August 26, 2016.
[17] UPMC's takeover of WCA Hospital moves forward, Becker’s Hospital Review, June 13, 2016.
[19] Rural Emergency Hospital Conversion, Clifton-Fine Hospital.
[20] Presentation Slides, Rural Emergency Conversion, Clifton-Fine Hospital.
[21] Critical Access Transition FAQ, Claxton-Hepburn Medical Center.
[22] Guidance for Hospital Co-location with Other Hospitals or Healthcare Facilities (Revised), Centers for Medicare & Medicaid Services.
[23] Adding to the existing challenges with OB/GYN recruitment in rural areas is the current climate for OB/GYNs in states that have enacted strict abortion laws, including potential criminal penalties for the healthcare provider. For example, in Sandpoint, Idaho, a town of 10,000 people, two hospitals stopped providing labor and delivery services in the 15 months after Idaho criminalized abortion in 2022. According to KFF Health News, during the same 15 months, the number of OB/GYNs practicing in Idaho dropped by 22 percent. This is not the case in New York, which has strong reproductive health protections and policies.
[24] Maternal Health: Availability of Hospital-Based Obstetric Care in Rural Areas. GAO-23-1055515, October 19, 2022.
[25] Rural Hospitals Built During Baby Boom Now Face Baby Bust, KFF Health News, July 15, 2024.
[26] Severe maternal morbidity is defined by the CDC as, “includes unexpected outcomes of labor and delivery that can result in significant short- or long-term health consequences.”
[27] Obstetric Volume and Severe Maternal Morbidity Among Low-Risk and Higher-Risk Patients Giving Birth at Rural and Urban US Hospitals, JAMA Health Forum, June 24, 2023.
[28] NYS also has New York’s Perinatal Regionalization designations.
[29] Rural America Is Fertile Ground for Healthcare Innovation, Experimentation, Tech Leaders Say, Fierce Healthcare, August 24, 2022.
[30] Chartbook, p. 28
[31] Chartbook, p. 29
[32] Chartbook, p. 52
[33] Diabetes Self-Management: Rural Policy Brief, CDC, May 16, 2024
[34] Diabetes Self-Management Education and Support (DSMES) Toolkit, CDC, May 15, 2024
[37] Research shows rural children with type 1 diabetes less likely to use continuous glucose-monitoring devices, KU Medical Center, June 5, 2024.
[40] The Atlantic Magazine, “The Hidden Crisis in Rural America,” by James Burns, December 6, 2019.
[41] https://www.aha.org/system/files/media/file/2022/07/members-in-action-case-study-co-located-critical-access-behavioral-health-hospital.pdf
[42] NORC Working Paper Series: “Mental Health in Rural New York: Findings and Implications of a Listening Tour with Residents and Professionals.”
[43] Nicholson, B., Sloss, E. A., Fausett, A., Davis, C., Dumas, K., Littledike, M., & Mooney, K. (2024). Rural Access to the Cancer Hospital at Home Care Model. NEJM Catalyst Innovations in Care Delivery, 5(3), CAT-23. https://catalyst.nejm.org/doi/full/10.1056/CAT.23.0336
[44] Swenson, W. T., Lindow, M., Reycraft, J., Bjerga, L., Schroeder, Z., Swenson, A. P., & Westergard, E. (2024). The Case for Decentralizing Cancer Care: The Rural Oncology Home. NEJM Catalyst Innovations in Care Delivery, 5(5), CAT-23. https://catalyst.nejm.org/doi/full/10.1056/CAT.23.0344?query=CON&cid=DM2338505_Catalyst_Subscriber&bid=-2039027071
[46] C.A. Gu, K. Rodenmeyer, T.M. Shirly, K. McGolgan, K. O’Reilly, L. Cooper, S. Dargon-Hart, M. Curry, K. Valentin, P.M. Garabedian, A. Rui, C.R. Clark. Protecting Federally Qualified Health Centers Amid Drugstore Closures and Threats To 340B , Health Affairs, July 14, 2024.
[48] E. LoPoire, M. Joseph, A. Heald, D. Gadbois, A. Jones, J. Russo, D.J. Bowen, Barriers and Facilitators to Collaborative Care Implementation Within the New York State Collaborative Care Medicaid Program, BMC Health Services Research, April 2024.
[49] Project Teach, Frequently Asked Questions.
[51] Community Paramedicine, Division for Heart Disease and Stroke Prevention, CDC, March 2023. There is a community paramedicine demonstration program in New York, established in Article 30 §3018 of PHL that goes through July 2025, though it does not expand scope of practice.
[53] New York state Senate passes measures aimed to support emergency medical service providers, State of Politics, May 29, 2024.
[54] Governor Hochul Signs Legislation to Expand Health Care Access for New Yorkers, September 18, 2024.
[55] Appalachian Regional Commission: Allegany, Broome, Cattaraugus, Chautauqua, Chemung, Chenango, Cortland, Delaware, Otsego, Schoharie, Schuyler, Steuben, Tioga, and Tompkins counties. Northern Border Regional Commission: Cayuga, Clinton, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Montgomery, Niagara, Oneida, Orleans, Oswego, Rensselaer, Saratoga, Schenectady, Seneca, St. Lawrence, Sullivan, Washington, Warren, Wayne, Yates counties.
[58] Modernizing Scope-of-Practice Regulations - Time to Prioritize Patients, NEJM, February 2020.
[59] Health Across all Policies, 2017.
[61] Step Two Policy Project, The Challenge of Financially Distressed Hospitals in New York, December 2023.
[62] Ensuring Long-Term Equitable Access to Telehealth in New York State Opportunities and Challenges, Manatt, July 2024.
[63] Drugstores and Pharmacies Tax Bulletin ST-193 (TB-ST-193), NYS Department of Taxation and Finance, 2014.
[64] Ensuring Long-Term Equitable Access to Telehealth in New York State, Manatt, July 2024.
[65] Ibid.