Post on 11-Jan-2016
Larry BaronnerPennsylvania Office of
Rural Health
Health Care inRural Pennsylvania:
An Overview
What is Rural?
Most define “rural” by default
In general: areas outside of populations of 50,000 or more
OMB Definition: Metropolitan/ Micropolitan/Non-metropolitan
Census Definition: Urbanized Area/ Urbanized Cluster
Federal Office of Rural Health Policy Definition: Rural-Urban Commuting Areas
Center for Rural Pennsylvania: Rural/Urban
Who Is Rural?
Nationally – 20 percent of the population lives in areas that are designated as rural
Pennsylvania – 23 percent of the population lives in rural areas
Rural Pennsylvaniaat A Glance
One of the most rural states in the nation
2.8 million rural residents 42 of 67 counties designated as
rural (CRP)
Rural-Urban Commuting Areas (RUCAs)
For Pennsylvania
LegendDark Yellow Code 4 (Large Town)Medium Orange Code 5 (High Commuting to Large Town)Light Orange Code 6 (Low Commuting to Large Town)Dark Yellow Code 7 (Small Town)Medium Yellow Code 8 (High Commuting to Small Town)Light Yellow Code 9 (Low Commuting to Large Town)Green Code 10 (Rural Areas)
Source: Community Information Resource Center, Rural Policy Research Institute
Health Status in Rural Pennsylvania
Fewer residents exercise regularly, 1/3 are overweight, and 60 percent are at risk for sedentary lifestyles
High risk occupations: farming, mining, and forestry/fisheries
Chronic diseases: diabetes, hypertension, obesity; behavioral health issues; dental health concerns
Source: Behavior Risk Factor Surveillance Survey
Generally,Rural Residents…
…enter care later than do their urban counterparts;
…enter care with more serious and persistent issues;
…require more extensive and expensive care;
…have more transportation challenges; …have less options to pay for services
and medications (public insurance; employer-sponsored health care); and
…have less choice among providers.
Accessing Healthcare Services in
Rural Pennsylvania
The Primary Issue forRural Health Care Is…
ACCESS…
… to healthcare services … to payment mechanisms … and to transportation
Provider Distribution
Nationally – Only 9 percent of physicians practice in rural areas
Pennsylvania – 2/3 of primary care physicians practice in the four most populated counties
Access to specialists, dentists, etc.
Health care is one of the top employers in any county
Health care employs almost 12 percent of the rural workforce
Annual revenues of $73 million in average rural county
Each health care dollar “rolls over” 1.5 times in the local economy
Concern of keeping these dollars local
Source: Pennsylvania Rural Health Association
• Certified by CMS to receive cost-based reimbursement from Medicare
• Intention to improve financial performance• Reduce hospital closures
• Certified under different set of Conditions of Participation
• More flexible than acute care hospitals• Located in a rural area
• Over 35 miles from another hospital• 15 miles in mountainous terrain or secondary
roads• Necessary Provider designation (January 1 ,
2006 sunset)
What is a Critical Access Hospital
Critical Access Hospitals InPennsylvania, July 2014
Source: Pennsylvania Office of Rural Health
National Map of CAHs
What are the requirements for CAHs
• Maintain an annual average length of stay of 96 hours for acute patients– Swing bed services – no length of stay limit
• Maximum of 25 acute care inpatient beds (can also be used for swing bed services)
• Must provide 24-hour emergency services with medical staff on-site or on-call (30 min)
• Must have agreements with an acute care hospital related to patient referral and transfer, communication, emergency and non-emergency patient transportation
• Must have arrangements with respect to quality assurance (i.e. QIO)
Promoting Healthy Communities Through Hospital-based Population Health StrategiesUSING THE COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS
Hospitals – No longer responsible for just their patients!
Recent policy and regulatory changes are demanding a new accountability driven by;
• Internal Revenue Service’s 2007 revisions to Form 990, Schedule H establishing a mandatory community benefit reporting framework for 501©3 hospitals and
• The 2010 Affordable Care Act’s requirement that tax exempt hospitals conduct triennial Community Health Needs Assessments (CHNAs) with input from public health experts and other community stakeholders.
Public Health Accreditation Boards (PHAB) seeking accreditation are to participate in or conduct a collaborative process resulting in a comprehensive community health assessment.
Focused on Population Health status Public health issues facing the community
CHNA Challenges for Hospitals Lack of resources Lack of capacity “Population Health” new concept for hospitalsOverlapping interestsTrust issuesPrioritization of community health improvement effortsBringing together diverse organizations that have differing
needs, resources, cultures and missions can be challenging
Purpose of the CHNA Process (for hospitals)Identification of; unmet acute care needsPopulation health issuesLocal service gapsPriority health concerns for service planning and developmentDevelopment of ACA-mandated implementation plansPreparation of proposals for submission to charitable, foundation, and governmental funding opportunities
Benefits of Collaborative CHNAs
Bring together the following; Hospitals and hospital systems; Public Health Departments School systems Charitable organizations Social service agencies Faith-based groups Governmental organizations Employers
Economies of scale in collecting and analyzing necessary primary and secondary data
Build trust and rapport among the participants leading to collaborative strategies
Additional Partners and Their Role Pennsylvania Department of Health Bureau of Health Planning (PA DOH -
BHP) Pennsylvania Office of Rural Health (PORH) and the Flex Program Hospital and Healthsystem Association of Pennsylvania (HAP)
These partners can; Serve as conveners Provide educational services Provide technical assistance Provide or secure third-party funding to support the process
PORH Strategy to Assist Pennsylvania Rural HospitalsTHE HEALTHY COMMUNITIES INSTITUTE
HCI Counties
Why do clients use the HCI Systems?
• Planning/Decision Support Tool
• Standards Tool: Federal IRS 990, Health Care Reform, MAPP, Healthy People 2020, CHIP, SHIP
• Communications Tool
• Evaluation Tool
• Quality Improvement Tool
• Partnership-building/Alignment Tool: inter- and intraorganizationally
Increase appropriate utilization
Reduce readmission rates
Contain or reduce costs of care Improve access to care
Reduce mortality rate
Improve continuum of care
• 100 – 200 indicators • Constantly updates
• Data Visualization
Local Community Data
• Database >2000 Promising Practices
• Programs & Policies • Evidence-based
Implementation Strategies
• Form working groups
• Set local goals
• Manage objectives
Collaboration Centers
• HP 2020 trackers • Local Priority trackers • Comparative and
longitudinal evaluation
Evaluation &Tracking
Continuous Health Improvement: Effectively Moving from Data to Action
HCI System: 4 Pillars
Fulton County Medical Center
214 Peach Orchard Road, McConnellsburg, PA 17233 www.fcmcpa.org (717) 485-3155
Overview History of FCMC CHNA’s FCMC website
◦ WHERE TO access CHNA through the COMMUNITY RESOURCES tab◦ WHERE TO access COMMUNITY DASHBOARD.◦ Example of an INDICATOR - Children who are Obese: Grades K-6 ◦ Indicators, promising practices and funding
Why Healthy Communities Institute Community Planning Whose job is it? Forum – How do we tackle this?
2013-2015 Health Needs Assessment
- 6 Priorities1. Alcohol Tobacco and Other Drug Use (ATOD)
2. Diet, Obesity & Inactivity
3. Heart Disease
4. Diabetes
5. Children, Youth, and Families
6. Quality of Life for People over 65
214 Peach Orchard Road, McConnellsburg, PA 17233 www.fcmcpa.org (717) 485-3155
FCMC Website Priority areas highlighted
Dashboard specific to CHNA
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The Challenge: Crossing the Shaky Bridge
2012 201520142013 2016
Fee for Service
Payment System
Population Based
Payment System
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES
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• In the past 24 months, the healthcare field has experienced considerable changes with an increased number of rural-urban affiliations, physicians transitioning to hospital employment models, flattening volumes, CEO turnover, etc.
• Federal healthcare reform passed in March 2010 with sweeping changes to healthcare systems, payment models, and insurance benefits/programs
• Many of the more substantive changes will be implemented over the next two years
• State Medicaid programs are moving toward managed care models or reduced fee for service payments to balance State budgets
• Commercial insurers are steering patients to lower cost options
• Thus, providers face new financial uncertainty and challenges and will be required to adapt to the changing market
The Healthcare Environment Has Changed!
INTRODUCTION
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Fee-For-Service Financial ModelAssumptions
• Utilization• Inpatient and Outpatient• Impact of ACA• Impact of Blue Cross steerage initiatives
• Revenue• Third party price increases• Cost based Medicare revenue• DSH payments (Zeroed out in 2014)• Bad debt % of patient service revenue (75% reduction in 2014)• Impact of ACA• Meaningful use incentive payments• Other operating revenue• Non-operating gains and
• Expenses• Salaries, wages and benefits• Productivity• Supplies and other
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES
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• Subset of most recent challenges
• Payment systems transitioning from volume based to value based• Increased emphasis as quality as payment and market differentiator• Reduced payments that are “Real this time”
•New environmental challenges are the TRIPLE AIM!!!•Market Competition on economic driver of healthcare: PATIENT VALUE
We Have Moved into a New Environment!
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES
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Changing Payment System Incentives
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES
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Micro-economic Environment – Physicians Perspective Current State Phase 1 Phase 2 Phase 3 Future State
PCPs • Loss leaders • Employed to
maintain primary care base in their communities
• Independent PCPs • Relatively low
compensation • Emphasis on high
volume episodic care
• System aligned (employed and independent)
• Increasing compensation
• Revenue centers • System employed
and integrated • Relatively high
compensation • Emphasis on care
management and chronic disease management
• Operating at top of license, leveraging non-physician practitioners and team members
Specialists • Profit centers • Emphasis on high
volume of high dollar procedures
• Caught between volume emphasis and system cost emphasis
• Declining compensation
• Regional consolidation with lower volumes
• Increasing employment by systems
• Cost centers • Increase value
through care management models that drive down costs
• Quality must be demonstrated
• Make (employ) or buy (purchase externally) decision based on cost
Physician Perspectives
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES
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Implementation Framework – What Is It?
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES
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• Partner with Medical Staff to improve quality • Restructure physician compensation agreements to build quality measures
into incentive based contracts• Modify Medical Staff bylaws tying incentives around quality and outcomes into
them• Ensure most appropriate methods are used to capture HCAHPS survey data
• Consider transitioning from paper survey to phone call survey to ensure that method has increased statistical validity
• Electronic Health Record (EHR) to be used as backbone of quality improvement initiative
• Meaningful Use – Should not be the end rather the means to improving performance
• Increase Board members understanding of quality as a market differentiator• Move from reporting to Board to engaging them (i.e. placing board member
on Hospital Based Quality Council)• Quality = Performance Excellence
Initiative I – Operating Efficiencies, Patient Safety and Quality
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES
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• Understand that revenue streams of the future will be tied to primary care physicians, which often comprise a majority of the rural and small hospital healthcare delivery network
• Thus small and rural hospitals, through alignment with PCPs, will have extraordinary value relative to costs
• Physician Relationships• Hospital align with employed and independent providers to enable
interdependence with medical staff and support clinical integration efforts• Contract (e.g., employ, management agreements)• Functional (share medical records, joint development of evidence based
protocols)• Governance (Board, executive leadership, planning committees, etc.)
Initiative II – Primary Care Alignment
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES
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• Develop system integration strategy
• Evaluate wide range of affiliation options ranging from network relationships, to interdependence models, to full asset ownership models• Interdependence models through alignment on contractual,
functional, and governance levels, may be option for rural hospitals that want to remain “independent”
• Explore / Seek to establish interdependent relationships among small and rural hospitals understanding their unique value relative to future revenue streams
• Identify the number of providers needed in the service area based on population and the impact of an integrated regional healthcare system
• Conduct focused analysis of procedures leaving the market
• Understand real value to hospitals• Under F-F-S• Under PBPS (Cost of out of network claims)
Initiative III – Rationalize Service Network
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES
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Initiative IV – Population Based Payment System
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES
• A narrow rural/urban provider network focused on patient value
• Aggregates multiple rural/CAH populations for critical mass
• Restricted to payers willing to commit to population health and payment
• On CCO’s terms
• NOT for existing fee-for-service or cost contracts
• Legal entity with corporate powers
• Governance structure for setting strategy, policy, accountability
• Actively secures and manages risk/reward-based payer contracts
• Supports PCP-focused quality & care coordination across the network
• Retains local hospital independence, but with contractual accountability
• Houses care management infrastructure
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Where Are ACOs Forming?
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES
Source: healthaffairs.org
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ACOs in Washington
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES
Source: Leavitt Partners Center for Accountable Care Intelligence
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ACOs in Pennsylvania: Examples
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES
Source: ipagroup.org
Pennsylvania Office of Rural Health202 Beecher-Dock House
University Park, PA 16802Telephone: (814) 863-8214
Fax: (814) 865-4688porh@psu.eduwww.porh.psu
Larry Baronner, Critical AccessHospital Coordinator (ldb10@psu.edu)
Lisa Davis, Director (lad3@psu.edu)