San Bernardino Mountains Community Hospital District Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule

WASHINGTON, Feb. 8 -- Charles H. Harrison, CEO of the San Bernardino Mountains Community Hospital District, Lake Arrowhead, California, has issued a public comment on the Centers for Medicare and Medicaid Services' proposed rule entitled "Medicaid Program: Medicaid Fiscal Accountability Regulation". The comment was written on Jan. 31, 2020, and posted on Feb. 4, 2020:

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San Bernardino Mountains Community Hospital District (the Hospital) appreciates the opportunity to comment on the Medicaid Fiscal Accountability Regulation proposed rule. Because the proposed changes would have a devastating effect on the health care safety net in California, and on the lives of many of our patients, we urge CMS to withdraw the rule.

The Hospital is owned and operated by the San Bernardino Mountains Community Healthcare District. In California, Healthcare districts have been created generally in rural settings. A Healthcare District is a small governmental agency with defined boundaries. Our District is in the San Bernardino Mountains 5,000 feet above the city of San Bernardino.

We ask CMS to withdraw the proposed rule because:

* CMS has not conducted the required analysis of how the rule would impact access to care and quality.

* CMS has overstepped its authority by proposing broad discretion with no clear criteria for decision making.

* It puts pressure on our local community to increase taxes to fill the gap created by funding shortages.

Most concerning to San Bernardino Mountains Community Hospital is that CMS has failed to conduct any analysis of the proposed rule's impact on Medicaid beneficiaries in our community. We believe these policies will dramatically cut Medicaid funding (MediCal in California), which would reduce or eliminate care for the low-income beneficiaries in our community who rely on it for coverage and, specifically, the care provided by our hospital.

The District operates a Critical Access Hospital as well as a Rural Health Clinic and Rural Dental Clinic in Lake Arrowhead and another Rural Health Clinic in Running Springs (approximately 8 miles to the east). The payor mix of the District's facilities are as follows:

See tables here (https://www.regulations.gov/contentStreamer?documentId=CMS-2019-0169-2975&attachmentNumber=1&contentType=pdf)

Our Mission Statement is as follows:

"Mountains Community Hospital makes possible essential medical services to the residents and visitors of the local mountains"

For services that we cannot perform, we rely on the County Fire Department to transfer such patients via ambulance down the hill to hospitals in San Bernardino or other communities. For extreme emergencies we can air evacuate via helicopter, using our FAA approved heliport.

State flexibility in funding the non-federal share of Medicaid is essential in making the Medi-Cal program work. Without it, the Medi-Cal program would not be able to provide coverage to 13 million Californians. CMS should not adopt a one-size-fits-all approach and restrict the legitimate use of local governmental funds, health-care related taxes, or provider-related donations in a manner that gives the agency unrestrained authority, using overly broad standards that could lead to arbitrary decisions and an uneven application across state Medicaid programs.

Due to the high percentage of Medicare and MediCal (78%) we normally have an operating loss which is somewhat offset by a parcel tax that the residents of the district pay.

In recent years, MediCa1 has allowed us to utilize various reimbursement methods to obtain reimbursement which is close to but not covering our costs.

Historically the Affordable Care Act has allowed us to help our patients to enroll in MediCal. Such enrollment has nearly eliminated self pay (which really turns out to be "no pay" or bad debts) and made MediCal our largest "insurer.

If we were to have a significant reduction in MediCal coverage and related reimbursement, the revenue shortfall would be disastrous to the well-being of the residents of our mountain community as well as to our operations. We would have to trim, or even cut out essential services and as a Critical Access Hospital essential services are just about all that we provide.

The current proposals far exceed the agency's statutory authority. Additionally, we are extremely concerned with the adverse impact that the proposed rule's administrative requirements will have on CMS and Medicaid agencies. The provisions outlined in the proposed rule are excessive and will cost the state of California millions to implement, without sufficient time to do so. Those costs will inevitably be passed on to providers in various forms.

Further, CMS proposal to limit intergovernmental transfers to state or local taxes will create additional pressure on counties and states that rely on these arrangements. In California, this effectively puts every county in a position to increase local taxes in order to maintain funding for the Medi-Cal program. In San Bernardino County with the second largest number of MediCal recipients in the state and where 39.04% of the population is covered by the Medi-Cal program, we expect our legislators will have no choice but to seek tax increases in our community, which is unacceptable.

San Bernardino Mountains Community Hospital District disagrees with CMS' premise that, in order to improve the program's fiscal accountability, states should force local communities to raise additional or create new health care-related taxes to support the existing programs. If finalized, these policies will be devastating to our most vulnerable patients. We urge the agency to withdraw the proposed rule and work with stakeholders on policy solutions that will ensure access to care for all who need it.

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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2019-0169-0001

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