4. ďą More likely to report fair to poor health
ď§ Rural counties 19.5%
ď§ Urban counties 15.6%
ďą More obesity
ď§ Rural counties 27.4% VS urban counties 23.9%
ď§ Less likely to engage in moderate to vigorous exercise: rural
44% VS urban 45.4%
ďą More chronic disease (heart, diabetes, cancer)
ď§ Diabetes in rural adults 9.6% VS urban adults 8.4%
Rural Health Disparities
5. Workforce Shortages
⢠Only 9% of physicians
practice in rural America.
⢠77% of the 2,050 rural
counties are primary care
HPSAs.
⢠More than 50% of rural
patients have to drive 60+
miles to receive specialty
care.
6. Rural is Different
ď§ Strong sense of community responsibility,
propensity toward collaboration (unique ways to
develop and provide services needed.)
ď§ Creation of regional networks to provide greater
access to state-of-the-art health care.
- IOM 2005
7. Rural is Different
ď§ Rural areas score higher than urban on
appropriate provision of preventative services
related to breast exams/family history of
cancer, influenza immunization...
â Pol et al., 2001
8. Rural is Different
ď§ Rural hospitals have lower risk-adjusted rates
of potential safety-related events.
â Jolliffe 2003
9. Rural is Different
ď§ Rural hospitals have significantly lower
adverse event rates than urban counterparts.
â Whitener and McGranahan, 2003
10. Rural is Different
ď§ Rural hospitals have significantly lower rates
of postop hip fracture, hemorrhage, and
hematoma.
â Cromartie, 2002
11. Rural is Different
ď§ Rural critical access hospitals performed as
well as or better than urban hospitals in four
of the five pneumonia-related indicators.
â International Journal for Quality Healthcare,
2007
12. Rural is Different
ď§ Hospitals in rural areas have significantly
higher ratings on HCAHPS measures than
those located in urban areas.
â Casey and Davidson, 2010
13. Delivering Value
⢠Quality
⢠Patient Safety
⢠Patient Outcomes
⢠Patient Satisfaction
⢠Price
⢠Time in the ED
Data sources include CMS Process of Care, AHRQ PSI Indicators, CMS
Outcomes, HCAHPS Inpatient/Patient Experience, MedPAR, HCRIS
Study Area C â Hospital Performance
Source: Rural Relevance Under Healthcare Reform 2014, Study Area C.
Rural UrbanWho has the edge?
Rural hospitals match Urban hospitals on performance at a lower price
16. A Rural Hospital Closure Crisis
⢠58 Rural Hospitals have closed
since January 2010;
⢠Rate of closures are escalating;
⢠283 rural hospitals are vulnerable.
0
3
6
9
12
15
18
2010 2011 2012 2013 2014 2015 2016
17. ⢠Usually based upon low/very low ADC
⢠Lack of available workforce (i.e., physicians and
ancillary staff)
⢠Need support
⢠Debt
⢠Average age of physical plant
⢠Factors for determination: net margin/cash flow/debt
ratio
At Risk and Stable (soon to
be at risk)
18. Percent of Hospitals with Negative Operating and Total Margins by Medicare
Payment Classification, 2013
0%
10%
20%
30%
40%
50%
60%
CAH MDH PPS RRC SCH
Operating Margin Total Margin
19. Financial Crisis for CAHs
⢠41% of operate at a financial loss.
⢠Average operating margin 0.7% (Flex Monitoring Team)
⢠Cuts in Effect:
⢠Medicare Sequestration cuts
⢠Medicare Bad Debt Reductions
⢠Coding
⢠Uncompensated care provided in states that have not expanded Medicaid
⢠Many for cuts threatened
⢠79% of CAHs will be in financial distress if Congress acts on current
proposals for Medicare cuts.
20. Research indicatesâŚ
⢠Most closures in South
⢠Annual number of closures increasing
⢠Most are CAHs and PPS hospitals (vs MDH and SCH)
⢠Most are in states that have not expanded Medicaid
⢠Patients in affected communities are probably traveling
between 5 and 25 more miles to access inpatient care
⢠Most hospitals closed because of financial problems
23. Rural Hospital Closures Escalating
Source: Rural Relevance Under Healthcare Reform (2014 HCRIS)
In each year from FY11 to FY13, rural hospitals posted a median operating profit
margin that was at least 1.66 percentage points lower than that of urban hospitals,
and the gap is widening.
24. Impact of 283 Hospital Closures
Source: Hospital Strength Index- Vulnerability Index
25. Vulnerability Index: Rural Closures and Risk of Closures
The Vulnerability Index⢠identifies 283 rural hospitals statistically clustered in the bottom tier of performance
35%Percent VulnerableXHospital Closures Since 2010
25
27. Â âOnly four days after the Pungo District Hospital in
Belhaven closed its doors for good on July 1, Portia Gibbs, 48,
suffered a heart attack and died just as the chopper arrived to
airlift her to a hospital. . âIn that hour that she lived, she would
have received 35Â minutes of emergency room care, and she very
well could have survivedâ Belhaven Mayor Adam OâNeil.
(The nearest hospital is now 75 miles away.)
Itâs about the patientsâŚ
â[It] ends up with rural
communities, such as
Hancock County
(Georgia), where 39
percent of the folks who
have a stroke or have a
heart attack die. Thatâs a
lot higher than in counties
with hospitals close by.â
David Lucas, Georgia
State Senator.
28. Itâs about access to careâŚ
⢠5,700 hospitals in the country; only 35 percent are located in rural areas.
⢠640 counties across the country without quick access to an acute-care
hospital. - UNC Sheps Center
⢠âAccess to care remains the number one concern in rural health care.â
-- Rural Healthy People
⢠[The closings] âare a growing problem of âmedical desertsââŚit is much
like the movement of a glacier: nearly invisible day-to-day, but over
time, you can see big changes.â
- Alan Sager, Boston Univ. professor of health policy
29. Four hundred ninety rural communities that had one or more
retail pharmacy (including independent, chain, or franchise
pharmacy) in March 2003 had no retail pharmacy in
December
2013.
* A loss of 924 independently owned rural
pharmacies in the United States.
32. Greatest challenges to CAHs since
program established
⢠ACA â challenges in Health Exchanges; Challenges in Medicaid expansion
⢠Continued cuts in Medicare
⢠Continued threats of cuts in Medicare
33. Sequestration â mandated 2% cuts to
Medicare providers extended
AGAIN.
â˘Result:
* Rural Job losses;
* Rural revenue lost
* Rural patient services cut
* Possible rural hospital closures
34. Medicare Cuts Enacted
⢠Sequestration cuts â 2% for nine years
⢠Bad debt reimbursement cuts
⢠Documentation & coding cuts
⢠Readmission cuts
⢠Multiple therapy procedure cuts
⢠ESRD reimbursement cuts
⢠Super rural laboratory extender â expired
⢠Outpatient hold harmless payments (TOPS) â expired
⢠508 reclassifications â expired
35. Affordable Care Act
1. Rural implications in Medicaid Expansion
2. Rural implications in Federal and State
Exchanges
36. Disclaimers:
⢠NRHA did NOT take a position on the ACA
⢠NRHA sought for inclusion of rural-relevant
funding and programs in the ACA
⢠Since passage, NRHAâs Rural Health Congress has
passed policy encouraging states to expand
Medicaid
38. Are Health Exchanges Working in
Rural Areas?
⢠58.3% of rural counties only
had 1 or 2 plan options
⢠23.7% of rural counties vs.
5.5% of urban counties had
only 1 plan option
⢠Over ž of urban plans had
three or more choices of
coverage
Rural areas appear to have lower rates of plan
selection, suggesting that improving outreach and
enrollment efforts in these communities may be
particularly warranted. Sept. 2014
41. How NRHA is Fighting Back
Our Campaign:
1. Stop the bleeding. Halt additional proposed cuts to rural hospitals
from the Administration and Congress immediately. Support pro-rural
provisions such as Medicaid expansion, elimination of the 2%
sequestration cuts and 101% reimbursement for CAHs to stabilize the
rural safety net.
2. Build bridge to the future. Promote new provider payment models to
create a new rural reality.
42. To accomplish our goalsâ
Three strategies:
⢠Raise public awareness: launch national media campaign.
⢠Develop and introduce new legislation to stabilize rural
hospitals.
⢠Develop and promote the future of rural health proposals.
43. The headlines are already hereâŚ
âAnother Rural Hospital Closesâ
-Georgia Health News Feb. 13, 2014
âRural Hospitals are on Life Supportâ
-Insurance News Net April 1, 2014
âMore Rural Hospitals Face Closureâ
-Fierce Health News April 3, 2014
âRural Hospital Closure Creates Challengesâ
-Deerfield Valley News April 10, 2014
44. âRural America is Losing its Hospitalsâ
-Newser July 12, 2014
âRural Hospital Closures Strand Many in Needâ
-News and Observer July 28, 2014
âRural Hospitals Pressured to Close as Healthcare
System Changesâ
-Reuters Sept. 3, 2014
âMore Critical-Access Hospital Closings Likelyâ
-Modern Healthcare Sept. 30, 2014
45. Health Affairs Report:
⢠Conclusion: Minimum-Distance Requirements
Could Harm High-Performing Critical-Access
Hospitals And Rural Communities
⢠Presidentâs Budget continues to include eliminating
CAH designation if < 10 miles
⢠This idea has NOT gained any traction on the hill
⢠âWe conclude that establishing a minimum-distance
requirement would generate modest cost savings for
Medicare but would likely be disruptive to the
communities that depend on these hospitals for their
health care.â
46. Save Rural Hospitals Act
Rural hospital stabilization (Stop the bleeding)
⢠Elimination of Medicare Sequestration for rural hospitals;
⢠Reversal of all âbad debtâ reimbursement cuts (Middle Class Tax Relief and Job
Creation Act of 2012);
⢠Permanent extension of current Low-Volume and Medicare Dependent Hospital
payment levels;
⢠Reinstatement of Sole Community Hospital âHold Harmlessâ payments;
⢠Extension of Medicaid primary care payments;
⢠Elimination of Medicare and Medicaid DSH payment reductions; and
⢠Establishment of Meaningful Use support payments for rural facilities struggling.
⢠Permanent extension of the rural ambulance and super-rural ambulance payment.
 Rural Medicare beneficiary equity. Eliminate higher out-of pocket charges for rural
patients (total charges vs. allowed Medicare charges.)
 Regulatory Relief
⢠Elimination of the CAH 96-Hour Condition of Payment (See Critical Access Hospital
Relief Act of 2014);
⢠Rebase of supervision requirements for outpatient therapy services at CAHs and rural
PPS See PARTS Act);
⢠Modification to 2-Midnight Rule and RAC audit and appeals process.
 Future of rural health care (Bridge to the Future)
I Innovation model for rural hospitals who continue to struggle.
47. Delivery System Reform (DSR)
January 2015 Announcement
oHHS Secretary Sylvia M. Burwell announced measurable goals and a timeline to
move the Medicare program towards paying providers based on the quality,
rather than the quantity of care.
Goals
1.Alternative Payment Models:
1. 30% of Medicare payments are tied to quality or value through alternative
payment models by the end of 2016
2. 50% by the end of 2018
2.Linking FFS Payments to Quality/Value:
â 85% of all Medicare fee-for-service payments are tied to quality or value
by 2016
â 90% by the end of 2018
50. Care Management: Target Populations
100% of Population
20-25% of Population
5-7% of Population
2-3% of Population Complex Individual Case Management
(40% of costs)
Complex Disease Management
Embedded/Primary Care
Source: Joseph F. Damore, Premier Health Alliance, March, 2015
52. 2016
All Medicare FFS (Categories 1-4)
FFS linked to quality (Categories 2-4)
Alternative payment models (Categories 3-4)
2018
50%
85%
30%
90%
53. ACOs Accelerating Nationwide
⢠Medicare Shared Savings Program (MSSP) is type of ACO
⢠ACO is an example of an Alternative Payment Program (APM)
⢠Almost 700 public and private ACOs
⢠Located in every state
⢠7.8M Medicare lives under a MSSP currently
⢠Medicare specific ACOs, steady growth:
⢠4/1/2012 27 ACOs Added
⢠7/1/2012 89 ACOs Added
⢠1/1/2013 106 ACOs Added
⢠1/1/2014 123 ACOs Added
⢠1/1/2015 89 ACOs Added
⢠ACO Investment Model (AIM) Program:
⢠Hundreds more Jan. 1, 2016
54. Should you stay or should you ACOâŚ
-Shared Savings? Perhaps not.
-Cost of federal ACO bureaucracy is an added negative.
-Is the market dominated by health plans with own initiatives?
-What is already driving transformation?
-Can you get âthereâ from here with existing network?
55. First Things First
Care Redesign
â˘PCMH
â˘Clinical Integration
â˘Care Management
â˘Post-acute Care
â˘EHR
â˘Data Analytics
Care redesign must not outpace
Changes in payment
New Payment Arrangements
â˘Care Transformation Costs
â˘Care Management Payments
â˘Shared Savings
â˘Episodes of Care Payments
â˘Global Payments
Population
Health
Transformation
Source: Joseph F. Damore, Premier Health Alliance, March, 2015
56. The SGR Repeal Details
⢠March 26 - House passed 212-33
⢠April 14 â Senate passed 92 â 8
⢠April 16 â President signed the bill
⢠SGR is now history!
57. SGR Repeal andâŚ
Rural Impacts
Two-Year Extension:
⢠Medicare Dependent Hospital (MDH) - $100 million
⢠Low-Volume Hospital (LVH) - $450 million
⢠Work geographic index floor under the Medicare physician
fee schedule (GPCI) - $500 million
⢠All current ambulance payment rates including rural and
super rural- $100 million
⢠Exceptions process for Medicare therapy caps -$1 billion
⢠Rural Home Health Add on Payments
⢠Community Health Centers (CHC), National Health Service
Corps Fund (NHSC), and Teaching Health Centers
58. SGR Repeal and the Rest of
The StoryâŚ..
⢠Replaces it with a physician payment
system based on âquality, value and
accountabilityâ
⢠Five year period of 0.5% annual FFS
updates in transition to ânew systemâ
59. Doc Fix Implications
Bottom line:
⢠Current plan leaves $141B between 2015 and 2025
unpaid for or in other words, added to the deficit
⢠Physicians pushed along to APMs and a value-
based system, impact on hospitals and volume?
⢠RHC cost-based reimbursement are exempt
⢠Physician alignment a key reality
60. -Mandatory quality reporting for CAHs and RHCs.
-Development of an NQF Measures Application
Partnership (MAP) for small-volume providers.
-Transition time and technical assistance money for
these providers to make the transition.
-Feature bonuses for good performance in CAH and
RHCs (say 103% of cost) versus a cut in
reimbursement for bad performance (97% of cost,
e.g.).
The Future
61. ⢠Primary Care
⢠Ambulatory Services
⢠Emergent Care (EMS/non-emergent transportation/ER)
⢠Rehabilitative Services
⢠Behavioral Health
⢠Transitional Care (observation/swing bed, etc.)
⢠Pharmacy (community?)
⢠Oral Health
⢠Prevention/Wellness
Either provided directly or by agreement within or outside local rural system
Access is defined by service type and need as determined by community assessment
Core elements may require subsidy of some sort to provide same if market isnât providing
Services beyond core elements funded on fee schedule (market-based) systems
Primary (core) Elements for
Rural Design
62. ⢠Primary Health Center (PHC):
⢠Traditional ambulatory/clinic services
⢠Emergency Care (tele-emergency allowed/required)
⢠Care Coordination and Disease Management
⢠Transitional care (e.g. , observation, extended stay)
capacity
⢠EMS/Non-emergent Medical Transportation may be
provided through PHC
New Provider Type?
63. Key Issues
⢠Protection from burdensome and excessive policies
o Physician Supervision
o 96-Hour Certification Rule in CAHâs
o Two-midnight Policy
o CAH vs PPS Outpatient Coinsurance: OIG Report
⢠Protect 340B Program
⢠ACO Regulations for CAH and rural providers
⢠Public HealthâEbola, Enterovirus D68, HIV/AIDS
⢠HPSA/MUA/MUP Data Collection Changes
⢠Health Care Payment Learning and Action Network
63
64. Key Issues
⢠NQF Rural Quality Task Force
⢠Veteranâs access to rural providers
www.va.gov/opa/choiceact or (866) 606-8198
⢠Meaningful Use Stage 2 and now 3
⢠Rural Health Clinic (RHC) Program
⢠Federally Qualified Health Center (FQHC)
⢠Population Health
⢠Tele-health Opportunities
⢠CMS Request Letters to CAHs on Validating
distance
65. ď§ NRHA doesnât have a PAC
ď§ Website: ruralhealthweb.org
ď§ Depends solely on grassroots advocacy
ď§ Members have access to:
ďźRural Health Blog
http://blog.ruralhealthweb.org
ď§ Join NRHA today at ruralhealthweb.org
Our Grassroots Effort
Notes:
Despite the fiscal and resource challenges Rural hospitals are on par with CMS Process of Care, CMS Outcomes, Patient Safety and HCAHPS Inpatient/Patient Experience, in comparison to Rural, while performing better when it comes to Price and Efficiency and ED Throughput.
Note that Rural hospitals have maintained their level of performance in the trended analysis of the data, while urban hospitals have surged due to the âcarrot and stickâ model of Value Based Purchasing.
NOTES: As of August 28
*PA, MI, AR and IA have approved Section 1115 waivers for Medicaid expansion; IN has a pending waiver for expansion; WI amended its Medicaid state plan and existing Section 1115 waiver to cover adults up to 100% FPL in Medicaid, but did not adopt the expansion.
Each state can decide whether to expand Medicaid and there is no deadline. Many states have decided whether or not to expand Medicaid starting January 2014. Because each State can decide if and when to expand Medicaid, there will be significant variations across states and over time.
In a PCMH Environment, care teams will provide care management, practicing at the top of the licenses. In this model, complex individual management (2-3%) of population will require physician level services. Complex disease (usually chronic) will be provided to the next 5-7% of population and usually provided by a non-physician practitioner (NPP) under direction of a physician. Disease management (non-complex) will be provided the next 20-25% of population and this can be done by a combination of dieticians, Community Health Workers, RNs, LPNs, Rehab specialists, Exercise coaches, etc. Then, 100% of population provided wellness and prevention services (walking trails, health screenings, educational classes, smoking prevention, weight control, exercise programs, etc.).
Sec. 201. Extension of work Geographic Practice Cost Index (GPCI) floor. Boosts payments for the work component of physician fees in areas where labor cost is lower than the national average. The provision extends the existing 1.0 floor on the âphysician workâ cost index until January 1, 2018.
Sec. 202. Extension of therapy cap exceptions process. The Medicare program currently limits (âcapsâ) the amount of annual per-patient therapy expenditures. Congress created an exceptions process in 2006 that allows patients to exceed the cap based on medical necessity. This provision extends the therapy cap exceptions process until January 1, 2018 and reforms the process of medical manual review to help support the integrity of the Medicare program.
Sec. 203. Extension of ambulance add-ons. Extends the add-on payment for ground ambulance services, including in super-rural areas until January 1, 2018.
Sec. 204. Extension of increased inpatient hospital payment adjustment for certain low-volume hospitals. This provision extends Medicare Low-Volume hospital payments. The Centers for Medicare and Medicaid Services (CMS) has traditionally provided an additional payment to hospitals for the higher costs associated with operating a hospital with a low volume of discharges. This provision extends special add-on payments until October 1, 2017.
Sec. 205. Extension of the Medicare-dependent hospital (MDH) program. MDHs are rural hospitals with no more than 100 beds that serve a high percentage of Medicare beneficiaries. MDHs are paid based on a blend of current prospective payment system rates and costs. This provision extends special payments to MDHs until October 1, 2017.
Sec. 210. Medicare Home Health Rural Add-On. This policy extends a three percent add-on to payments made for home health services provided to patients in rural areas through January 1, 2018.
Sec. 221. Extension of funding for Community Health Centers (CHC) and National Health Service Corps Fund (NHSC) and Teaching Health Centers. The fund for the CHC Program will expire in September 2015. These dedicated mandatory funds supplement annual spending for the CHC program. In 2013, the most recent data available, 1,302 federally funded health centers located in all 50 states, the District of Columbia, and six U.S. territories, distributed evenly between urban and rural areas, served 22.7 million patients across 9,518 sites. Meanwhile, the vast majority of the 90 million visits to health centers were for primary medical care. This provision will provide two additional years of this funding through fiscal year 2017. The funding for the NHSC will end in 2015. The NHSC helps bring health care professionals to the areas where they are needed the most by providing scholarships and loan repayment in exchange for a Prepared by the Staff of the House Energy and Commerce and Ways and Means Committees, March 24, 2015 commitment of service in an underserved community. This provision will fund the NHSC for an additional two years through fiscal year 2017.