This document discusses the challenges facing rural healthcare in the United States. It notes that rural residents generally have worse health outcomes and less access to care compared to urban residents, due to issues like physician and specialist shortages. Many rural hospitals are financially vulnerable and at risk of closure. The document outlines advocacy efforts by the National Rural Health Association to raise awareness of the crisis of rural hospital closures and develop legislative solutions to stabilize rural healthcare.
The Health Systems Administration program at Georgetown has its students complete case projects for a fictional community, Middleboro. Throughout the program we created several deliverables: Community Profile, Community Health Assessment, Strategic Plan, Marketing Plan, and Business Plan.
Because everyone matters.
IBM Health and Social Programs Summit, October 2014
Craig Rhinehart’s Blog
Insights from NASHP Conference in Atlanta
Trick or Treating for State Healthcare Innovation Treats
http://craigrhinehart.com
Yvonne Hughes – 2014 nominee for Modern Healthcare's Community Leadership AwardModern Healthcare
Yvonne Hughes – 2014 nominee for Modern Healthcare's Community Leadership Award.
The success of the healthcare industry depends on leaders who define themselves by leading efforts to change lives and contribute to their communities through their work. But many go above and beyond commitments central to their roles, reaching out to support causes that may be wholly unrelated to healthcare, but which build and sustain strong communities and the quality of life within them. Modern Healthcare's Community Leadership Awards was established to recognize these leaders while bringing attention to the worthy causes they support. Modern Healthcare's Community Leadership Awards was established to recognize these leaders while bringing attention to the worthy causes they support.
http://www.modernhealthcare.com/section/community-leadership
The Health Systems Administration program at Georgetown has its students complete case projects for a fictional community, Middleboro. Throughout the program we created several deliverables: Community Profile, Community Health Assessment, Strategic Plan, Marketing Plan, and Business Plan.
Because everyone matters.
IBM Health and Social Programs Summit, October 2014
Craig Rhinehart’s Blog
Insights from NASHP Conference in Atlanta
Trick or Treating for State Healthcare Innovation Treats
http://craigrhinehart.com
Yvonne Hughes – 2014 nominee for Modern Healthcare's Community Leadership AwardModern Healthcare
Yvonne Hughes – 2014 nominee for Modern Healthcare's Community Leadership Award.
The success of the healthcare industry depends on leaders who define themselves by leading efforts to change lives and contribute to their communities through their work. But many go above and beyond commitments central to their roles, reaching out to support causes that may be wholly unrelated to healthcare, but which build and sustain strong communities and the quality of life within them. Modern Healthcare's Community Leadership Awards was established to recognize these leaders while bringing attention to the worthy causes they support. Modern Healthcare's Community Leadership Awards was established to recognize these leaders while bringing attention to the worthy causes they support.
http://www.modernhealthcare.com/section/community-leadership
Closing rural hospitals are reducing access to care in multiple states
Between January 2010 and January 2020, 114 rural hospitals closed. More than 30 of these were critical access facilities. Data from the University of North Carolina Cecil G. Sheps Center for Research provides further insights showing that from 2005 to 2020 a total of 170 rural hospitals shut down. There seems to be no indication this trend is subsiding and a sizable portion of it has occurred during a time of record economic expansion. There is no telling how many more would have closed their doors had a weakened economy continued.
Read the complete story here and contact John Baresky for further details...
Empowering Healthcare Leaders: The Business Case for Language Access_10.3.14Douglas Green
Empowering Healthcare Leaders: The Business Case for Language Access provides a framework for calculating total potential encounters with limited English patients, the economic benefit and cost of not providing language access and a frame work to align the economic benefits with organizational goals under the Affordable Care Act.
The Solomon Islands HiT determines that the country’s health system has significant weaknesses but also considerable strengths. Despite the range and difficulty of issues facing policy-makers in the Solomon Islands, there have been significant achievements in health, including considerable progress in advancing population health status. The performance of the health system is positive, achieving high coverage, high satisfaction levels, and steady progress on health outcomes. Nonetheless, the country faces important health challenges that could undermine development gains made to date
Prof. Martin Gaynorin esitys VATT-päivässä 1.11.2016
Gaynor on professori Carnegie Mellon yliopistossa, tutkija Britannian johtavassa, julkisen sektorin reformeihin keskittyvässä tutkimuslaitoksessa (Bristolin yliopiston Centre for Market and Public Organisation) ja jäsenenä NHS:n kilpailuasioita käsittelevässä asiantuntijapaneelissa.
Gaynor on tehnyt vaikutusvaltaisia tutkimuksia ja kirjoittanut laajasti terveydenhuoltomarkkinoiden toiminnasta, kilpailusta, kilpailua rajoittavista tekijöistä, tuottajien saamista korvauksista sekä Yhdysvalloissa että Briteissä.
JONAVolume 41, Number 3, pp 129-137Copyright B 2011 Wolter.docxchristiandean12115
JONA
Volume 41, Number 3, pp 129-137
Copyright B 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N
Rural Hospital Nursing
Results of a National Survey of Nurse Executives
Robin P. Newhouse, PhD, RN, NEA-BC
Laura Morlock, PhD
Peter Pronovost, MD, PhD
Sara Breckenridge Sproat, PhD, RN
Objective: The objective of the study was to describe
nursing characteristics in small and larger rural
hospitals and determine whether differences exist in
market, hospital, and nursing characteristics.
Background: A better description of nursing in rural
settings is needed to understand the work context.
Methods: A national sample of rural hospital nurse
executives (n = 280) completed the Nurse Environ-
ment Survey and Essentials of Magnetism instrument.
Results: Larger rural hospitals are more likely than
small hospitals to have a clinical ladder (32.4% vs
19.4%), more baccalaureate-prepared RNs (20.8%
vs 17.1%), greater perceived economic (mean, 9.5 vs
8.5) and external influences (mean, 41.1 vs 39.8),
lower shared vision among hospital staff (mean, 18.4
vs 19.4), and higher levels of quality and safety
engagement (mean, 16.9 vs 16.1). Most nurses em-
ployed in rural hospitals are educated at the associate
degree (77.4%) level.
Conclusions: Contextual differences exist between
small and larger rural hospitals. To promote the
best patient outcomes, attention to contextual
differences is needed to tailor nursing interventions
to fit the resources, environment, and patient needs
in a given healthcare setting.
America’s rural populations encounter barriers to
quality healthcare.1 These quality barriers corre-
spond with an alarming increase in healthcare costs,
placing a direct and specific economic burden on
rural areas.2 Rural populations are expected to
experience heightened healthcare needs (aging pop-
ulation and increase in minorities), greater income
disparities (lower income and education than urban
settings), provider price hikes, and increased de-
mand for expensive technology (to which rural
residents do not always have access).2
Forty percent (1,998 of 5,010) of US community
hospitals registered with the American Hospital Asso-
ciation (AHA) are rural (nonmetropolitan).3 These hos-
pitals provided care for 12.8% (5.1 million) of all US
hospitalizations in 2007.4 The definition of Brural[ is var-
iable, with estimates for the rural population ranging
between 10% and 28% of the US total population.5,6
Rural was defined in this study based on the sam-
pling frame from a prior study using the Office of Man-
agement and Budget (OMB) pre-2003 classification
system for metropolitan/ nonmetropolitan areas.7,8
This system is based on metropolitan statistical areas
(MSAs) generated by the US Census Bureau, which
uses a county-level classification. Rural hospitals are
defined as those located in counties that do not
qualify as MSAs. Although there are many alternative
definitio.
Using the case study below, develop a written report of your market .pdfmanjan6
Using the case study below, develop a written report of your market analysis. Include a visual
diagram of your overall market analysis use of strategic thinking maps (see diagram in the
Module) as a tool to assist with the different facets of the strategic planning process.
The map is to be used as a supplement for your written market analysis. The market analysis
produced will be used in the final submission of your Capstone Project.
Your well-written market analysis should meet the following requirements:
Be 3-4 pages in length, not including the cover, abstract (optional), or reference pages.
Utilize headings to organize the content.
Include the strategic thinking map in addition to/or as a part of the 3-4 pages of content.
Include a minimum of four references with associated in-text citations.
The circumstances in Pocahontas County resonate in many rural communities across the country:
• A depressed local economy
• Substantial barriers to health access
• Difficulty in attracting health professionals.
Portrait of Pocahontas County
Pocahontas County is located in the southeast region of West Virginia. The county has a total of
942 square miles and is the site of the head waters for eight rivers: Cherry River, Cranberry
River, Elk River, Ganley River, Greenbriar River, Tygart Valley River, Williams River, and
Shaver Fork of the Cheat River. Pocahontas County consists of the following towns: Arborale,
Bartow, Buckeye, Cass, Dunmore, Durbin, Greenbank, Hillsboro, Marlington, and Slatyfork.
As of the 2010 Census there are 9,131 people residing in Pocahontas County. The racial makeup
is 98% Caucasian, .78% African American, .43% Hispanic, .14% Asian, and .07% Native
American. The median income for a household within the county is $26,401.
Access to Health Services
Pocahontas County has a shortage of healthcare providers. There is one hospital, Pocahontas
Memorial Hospital, and one nursing home, Pocahontas Center. The ratio for dentists is 8,851 to
1. The ratio for primary care physicians is 8508 to 1 (County Health Roadmaps & Rankings,
n.d.). The county’s physician-to-population ratio is significantly higher than the Unites States
overall ratio.
Pocahontas Memorial Hospital is a 25-bed, level-4 trauma center. A rural health clinic is located
within the hospital. The health clinic offers laboratory services, immunizations, disease
management, and monthly specialty clinics (cardiology, podiatry, and nephrology).
For more information about Pocahontas Memorial Hospital, visit the following website:
http://www.pmhwv.org/
Solution
Health care Limitations
Executive summary
The health care industry which is also known as the health economy or the medical industry is a
broad industry which specializes in the delivery of services regarding treatment of diseases,
conducting diagnostic services and therapies to identify various diseases so at to understand the
kind of treatment to be subjected to such diseases (World Health Organization. (2002). the
industr.
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
4. More likely to report fair to poor health
Rural counties 19.5%
Urban counties 15.6%
More obesity
Rural counties 27.4% VS urban counties 23.9%
Less likely to engage in moderate to vigorous exercise: rural
44% VS urban 45.4%
More chronic disease (heart, diabetes, cancer)
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
Strong sense of community responsibility,
propensity toward collaboration (unique ways to
develop and provide services needed.)
Creation of regional networks to provide greater
access to state-of-the-art health care.
- IOM 2005
7. Rural is Different
Rural areas score higher than urban on
appropriate provision of preventative services
related to breast exams/family history of
cancer, influenza immunization...
– Pol et al., 2001
8. Rural is Different
Rural hospitals have lower risk-adjusted rates
of potential safety-related events.
– Jolliffe 2003
9. Rural is Different
Rural hospitals have significantly lower
adverse event rates than urban counterparts.
– Whitener and McGranahan, 2003
10. Rural is Different
Rural hospitals have significantly lower rates
of postop hip fracture, hemorrhage, and
hematoma.
– Cromartie, 2002
11. Rural is Different
Rural critical access hospitals performed as
well as or better than urban hospitals in four
of the five pneumonia-related indicators.
– International Journal for Quality Healthcare,
2007
12. Rural is Different
Hospitals in rural areas have significantly
higher ratings on HCAHPS measures than
those located in urban areas.
– 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 – 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 indicates…
• 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. “Only 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. . “In that hour that she lived, she would
have received 35 minutes of emergency room care, and she very
well could have survived” Belhaven Mayor Adam O’Neil.
(The nearest hospital is now 75 miles away.)
It’s about the patients…
“[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. That’s a
lot higher than in counties
with hospitals close by.”
David Lucas, Georgia
State Senator.
28. It’s about access to care…
• 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
• “Access to care remains the number one concern in rural health care.”
-- Rural Healthy People
• [The closings] “are a growing problem of ‘medical deserts’…it is much
like the movement of a glacier: nearly invisible day-to-day, but over
time, you can see big changes.”
- 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 – challenges in Health Exchanges; Challenges in Medicaid expansion
• Continued cuts in Medicare
• Continued threats of cuts in Medicare
33. Sequestration – mandated 2% cuts to
Medicare providers extended
AGAIN.
•Result:
* Rural Job losses;
* Rural revenue lost
* Rural patient services cut
* Possible rural hospital closures
34. Medicare Cuts Enacted
• Sequestration cuts – 2% for nine years
• Bad debt reimbursement cuts
• Documentation & coding cuts
• Readmission cuts
• Multiple therapy procedure cuts
• ESRD reimbursement cuts
• Super rural laboratory extender – expired
• Outpatient hold harmless payments (TOPS) – expired
• 508 reclassifications – 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, NRHA’s 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 ¾ 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 goals—
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 here…
“Another Rural Hospital Closes”
-Georgia Health News Feb. 13, 2014
“Rural Hospitals are on Life Support”
-Insurance News Net April 1, 2014
“More Rural Hospitals Face Closure”
-Fierce Health News April 3, 2014
“Rural Hospital Closure Creates Challenges”
-Deerfield Valley News April 10, 2014
44. “Rural America is Losing its Hospitals”
-Newser July 12, 2014
“Rural Hospital Closures Strand Many in Need”
-News and Observer July 28, 2014
“Rural Hospitals Pressured to Close as Healthcare
System Changes”
-Reuters Sept. 3, 2014
“More Critical-Access Hospital Closings Likely”
-Modern Healthcare Sept. 30, 2014
45. Health Affairs Report:
• Conclusion: Minimum-Distance Requirements
Could Harm High-Performing Critical-Access
Hospitals And Rural Communities
• President’s Budget continues to include eliminating
CAH designation if < 10 miles
• This idea has NOT gained any traction on the hill
• “We 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.”
46. Save Rural Hospitals Act
Rural hospital stabilization (Stop the bleeding)
• Elimination of Medicare Sequestration for rural hospitals;
• Reversal of all “bad debt” 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 “Hold Harmless” 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:
– 85% of all Medicare fee-for-service payments are tied to quality or value
by 2016
– 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 ACO…
-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 “there” from here with existing network?
55. First Things First
Care Redesign
•PCMH
•Clinical Integration
•Care Management
•Post-acute Care
•EHR
•Data Analytics
Care redesign must not outpace
Changes in payment
New Payment Arrangements
•Care Transformation Costs
•Care Management Payments
•Shared Savings
•Episodes of Care Payments
•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 – Senate passed 92 – 8
• April 16 – President signed the bill
• SGR is now history!
57. SGR Repeal and…
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 Story…..
• Replaces it with a physician payment
system based on “quality, value and
accountability”
• Five year period of 0.5% annual FFS
updates in transition to “new system”
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 isn’t 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 CAH’s
o Two-midnight Policy
o CAH vs PPS Outpatient Coinsurance: OIG Report
• Protect 340B Program
• ACO Regulations for CAH and rural providers
• Public Health—Ebola, 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
• Veteran’s 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. NRHA doesn’t have a PAC
Website: ruralhealthweb.org
Depends solely on grassroots advocacy
Members have access to:
Rural Health Blog
http://blog.ruralhealthweb.org
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 “carrot and stick” 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 “physician work” cost index until January 1, 2018.
Sec. 202. Extension of therapy cap exceptions process. The Medicare program currently limits (“caps”) 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.