NRHA 2022 Recap

Talk of 340B looms large over NRHA Critical Access Hospital Conference

When you combine critical access hospitals (CAHs) and the home office for the National Rural Health Association in Kansas City, you have a great gathering of leadership with a bit of BBQ!

The CAH conference is one of my favorite venues because it provides an opportunity to engage with rural hospital leadership on their strategies for not only 340B, but also their overall business of healthcare and serving vulnerable patient populations. It was exciting to showcase The Craneware Group to those who know us for 340B and those who know us for revenue integrity and make the connection we bring to the entire value cycle.

State and federal 340B buzz

340B was a major buzz as a topic. As a conference attendee and speaker for over a decade, I remember when 340B was not familiar to the C-suite at CAH conferences. Contrast that with today’s attendees, who said things like, “340B has kept our doors open;” “Without 340B, we would have joined the 136 other hospitals long ago that have closed their doors;” and “340B is essential.”

Discussions covered both the state and federal levels. The American Hospital Association’s policy update showed the depth and breadth of challenges facing all hospitals and their continued legal battle to protect 340B. The fight is not over.

One critical access hospital in Nebraska shared their state’s journey to passing anti-discriminatory legislation to protect 340B covered entities from PBM profiteering. 340B Health covered the broader reach of other states taking similar actions — 22 and counting — including protections from manufacturers excluding contract pharmacy access. The 340B manufacturer mayhem has caused additional burden and resource constraints, including wrestling over the question, “To submit data or not to submit data?” A common response was, “We don’t have a choice,” though many added, “It isn’t right,” and “We can’t wait for the government.” Some said they were letting the feds know they were submitting data against their will.

We remain aligned with NRHA on preventing further attacks on 340B by manufacturers and pharmacy benefit managers and focusing on reforms that protect the program.

New challenges on the horizon

A more recent challenge facing critical access hospitals relates to the new rural emergency hospital (REH) designation in the proposed Medicare outpatient prospective payment system regulations that closed for comment on Sept. 12. The REH designation, which resulted from legislation passed by Sen. Chuck Grassley of Iowa in 2019 and will begin Jan. 1, 2023, will be reserved for current eligible CAHs and prospective payment system hospitals with 50 beds or fewer. It’s meant to allow struggling rural hospitals to continue operating with only outpatient and emergency services, rather than having to close altogether.

The Craneware Group provided comments on our concerns. Eligible critical access hospitals will lose valuable access to 340B if they change their designation to REH. This designation was borne out of the closure of 136 rural hospitals in the last decade, eliminating life-saving access to emergency care and leaving some residents having to travel over 90 minutes to the nearest hospital.

We know that critical access hospitals have relied on the 340B program savings to keep their doors open. When I spoke with the federal partners from HRSA, they said the 340B law would need to be re-opened to add this new designation. The technical assistance contractor confirmed that eligible CAHs considering switching designations will receive a guide to help them understand the financial implications of losing 340B access, echoing my recommendation.

If you need technical assistance, contact or visit to speak with the National REH Technical Assistance Center, which is funded through Aug. 31, 2027.

Federal and state resources

Rural health has a unique infrastructure, including federal partners through the Health Resources and Services Administration (HRSA), the Federal Office of Rural Health Policy and the state offices of rural health, which provide technical assistance, in addition to funding streams that support rural hospitals through the U.S. Department of Agriculture. Critical access hospitals continue to face clinical staffing shortages, limited funding for capital equipment, and challenges with social determinants of health, all amid a gnawing need for healthcare in the communities they serve.

The Washington Update provided a perspective on the future of rural healthcare funding, including additional hospital closures, future legislation and rule-making process. There is still much discussion over the midterm elections and how the tables may turn. It was clear that we should expect to see more requests for information from the federal government as we head into a new Congressional year. NRHA reiterated their support for the Protect 340B Act. Clearly, rural communities and stakeholders have a vision for improving quality, health outcomes and the financial viability of rural providers.


As a previous judge for the NRHA Rural Recognition program, it was great to see the overall top 20 CAHs celebrated, followed by those in the top 20 for quality and patient satisfaction. This year’s competition between the states was led by Iowa, followed by Wisconsin and the Dakotas. I was delighted to see our customers recognized for their efforts from a pool of more than 1,400 hospitals.

Kudos, as we say at The Craneware Group, for the work your staff, management and leadership do every day to care for our rural communities.

Closing thoughts – rural voices matter

The voices of rural providers are what make the event energizing and focused us on why we do what we do: help patients. The Craneware Group continues to support our rural hospital customers. We encourage our rural customers to utilize resources provided by organizations such as NRHA, network with other rural hospitals to share ideas, and reach out to The Craneware Group with any concerns you may have. Whether your needs are 340B-focused, or you need a solution to support transparency and revenue integrity, The Craneware Group can help. We recognize that rural health systems’ resources are limited and having an expert like The Craneware Group on hand can make all the difference in keeping your doors open another day to support your communities.

We look forward to joining the rural voice matters campaign on Nov. 17. We hope you will join us Oct. 12-14 at our Performance Summit, where we will amplify the #powerofrural by unlocking the power of your data. Click here to register.