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Brock Slabach, MPH, FACHE Senior Vice President for Member Services National Rural Health Association.

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Presentation on theme: "Brock Slabach, MPH, FACHE Senior Vice President for Member Services National Rural Health Association."— Presentation transcript:

1 Brock Slabach, MPH, FACHE Senior Vice President for Member Services National Rural Health Association

2 Improving the health of the 62 million who call rural America home. NRHA is non-profit and non-partisan.

3 National Rural Health Association Membership 2013

4 Membership and Foundation Join NRHA Today! Give to our newly formed Foundation

5 Our Grassroots Effort  NRHA doesn’t have a PAC  Website:  Depends solely on grassroots advocacy  Members have access to: Periodic Washington Updates (webinars): Rural Health Blog  Join NRHA today at

6 62 million rural Americans rely on rural health providers. 20 percent of the population lives in rural America, yet they are scattered over 90% of the landmass. Extreme distances, challenging geography and weather complicate health care delivery. “Rural Americans are older, poorer and sicker than their urban counterparts… Rural areas have higher rates of poverty, chronic disease, and uninsured and underinsured, and millions of rural Americans have limited access to a primary care provider.” (HHS, 2011) Disparities are compounded if you are a senior or minority in rural America. Status of Rural

7 Rural disparities/challenges Rural Health Clinics – Social Security Act Community Health Centers, created in the War on Poverty. Rural disparities still grave. Serve more challenging populations: language, cultural issues. Delayed care - - sicker populations.

8 Nearly a half century later, extreme problems persist… Owsley County is a county located in the Eastern Coalfield region of Kentucky. As of 2010, the population was 4,755. According to the 2010 Census reports, Owsley County is the "poorest county in the United States.” Robert F. Kennedy famed poverty tour highlighted the malnutrition of eastern Kentucky (field hearings on hunger). His tour was not unique: his brother John had planned to come in December of 1963, Johnson came in 1964 and, in later years, Nixon, Ted Kennedy, Bill Clinton, Paul Wellstone, and John Edwards all conducted "poverty tours" that included eastern Kentucky.

9 Death by Zip Code University of Washington Study, July 2013 Largest report on status of America’s health in 15 yrs. Health equates to wealth The study found that people who live in wealthy areas like San Francisco, Colorado, or the suburbs of Washington, D.C. are likely to be as healthy as their counterparts in Switzerland or Japan, but those who live in Appalachia or the rural South are likely to be as unhealthy as people in Algeria or Bangladesh. For example, women in Marin County, California, where the median household income is $89,605, have the highest life expectancy -- 85 years -- while women in Perry County, Kentucky, with median income $32,538, have the lowest life expectancy – just under 73 years. Men living in wealthy Fairfax County, Virginia, median income $108,439, have a life expectancy of almost 82 years, while men in nearby McDowell County, West Virginia, where the median household income is $39,550, had the lowest life expectancy in the country – 63.9 years.




13 Why is there an assault on rural health care? Loss of champions; New members who don’t know why certain rural payments exist; Strong fiscal conservative movement; CMS negative attitude toward CAHs; Confusing rural payment system - - many see payments as “bonuses”

14 Rural champions exit Congress Many other rural champions are also leaving or have left – Sen. Harkin (D-IA), Sen. Rockefeller (D-WV), Sen. Inouye (D- HI), Sen. Conrad (D-ND), Sen. Bingaman (D-NM), Sen. Lugar (R-IN), Sen. Snowe (R-ME). Senator Max Baucus (D-MT) – Staunch rural health advocate, will not seek re-election in 2014 CAH program Rural primary care programs Rural demonstration projects NOTE: Sen. Ron Wyden (D-OR) next in line for Finance Chair.

15 Why did Congress create varying Medicare payments to rural providers? RHCs: 1977 – “…to address an inadequate supply of physicians serving Medicare beneficiaries in rural areas.”


17 Critical Access Hospitals are not immune… SEQUESTRATION - 2% CUT TO ALL RURAL HOSPITALS CAH REIMBURSEMENT CUTS – (President’s budget) ELIMINATION OF CAH STATUS FOR NEARLY 50 HOSPITALS (President’s budget) PROPOSAL TO ELIMINATE ALL CAHs (CBO budget proposal) PROPOSED CUTS IN FLEX AND OUTREACH GRANTS PROVIDER TAX CUTS 35% CUT UNCOMPENSATED CARE 41% of CAHs operate at a financial loss. Medicare cuts will mean reductions in services, job loss, or worse, hospital closures - - jeopardizing rural seniors’ access to care.

18 HHS Office of Inspector General Report threat to majority of Critical Access Hospitals in the country. –Unlike previous proposals that called for the elimination of CAH status of a small fraction of CAHs, this proposal would decimate rural health. –Unprecedented slashing of the rural health delivery system. –Greatest attack to date. Why Report Can be so Damaging in this Congress. –Unlike previous attacks which provided general reductions of many programs, this is laser targeted specifically on CAHs –Could not hit Congress at a worse time. OIG Report/Attack on Critical Access Hospitals

19 Headway made with Press and Congress “NRHA, AHA Slam OIG Report Urging Cuts To Critical Access Hospitals” Inside Health Policy “Deep cuts to Medicare funding ‘would effectively kill rural healthcare’.” Modern Healthcare


21 Rural Medicare Extenders Expire March 31, 2014 In the Senate Finance Permanent repeal of SGR (expires Mar 31) MDH and LVH permanent (expires Mar 31) General supervision for outpatient Work floor for GPSI Telehealth 96 hour rule offered, retracted

22 Important Backdrop Omnibus spending bills (appropriations) passed for discretionary spending accounts last week; rural health language inserted. Expiration of nation’s borrowing authority (debt ceiling) occurs on or around Feb. 7, 2014. Keep rural health programs from becoming funding sources for other priorities.

23 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

24 Federal Update ACA Issues


26 Slowdown In Health Cost Growth HospitalsNational Health Expenditures Source: CMS OACT National Health Statistics Group; Historical Tables. 3.9% 4.3% Annual Change in Spending Growth

27 Source: Centers for Medicare and Medicaid Services, Offices of Enterprise Management

28 MEDICAID Disproportionately important to rural America (rural patients and rural economies). 17.4 % of a state’s budget. One-half of all newly insured under ACA will be covered by expanded Medicaid. (Estimated 5 million in rural would be covered.) Supreme Court decision: Allowed states to “opt-out” or seeking waivers Many rural states are opting out – possibly leaving rural uninsured

29 Mental Health Essential Health Benefits Requirements Within the new health care law, mental health services are now considered “essential health benefits” for the purposes of plans being included within the newly created state exchanges. Furthermore, if an insurance plan is allowed to be a part of the new state exchanges, then the health plan must include mental health parity as applied in the Public Health Service Act. Additionally, Medicaid must also include mental health parity as well as include payments for mental health services. This means that mental health services must be included in the benefits offered within plans that are part of the state exchanges and also Medicaid and that mental health services must have the same cap on pay-outs as medical and surgical benefits (mental health parity).


31 Rural is Different Quality Measures: Hospital Strength Index™  Rural hospital performance on CMS Process of Care measures is on par with urban hospitals,  Rural hospital performance on CMS Outcomes measures is better than urban hospitals,  Rural hospital performance on HCAHPS inpatient patient experience survey measures is better than urban hospitals,  Rural hospital performance on price and cost efficiency measures is better than urban hospitals. © Copyright 2012 iVantage Health Analytics, Inc.

32 Rural is Different Emergency Department  The mean Total Wait Time in a rural Emergency Department is approximately half as long as the wait in an urban Emergency Department (29 vs. 56 minutes),  The mean Wait Time to see a Physician in a rural Emergency Department is nearly 2.5 times less than the wait in an urban Emergency Department (98 vs. 247 minutes),  More than 50% of all Emergency Department visits to Critical Access Hospitals were categorized as low acuity cases. © Copyright 2012 iVantage Health Analytics, Inc.

33 ACO Shared Savings (Medicare Beneficiaries)  Approximately $2.2 billion in annual cost differential (savings) occurred in 2010 because the average cost per rural beneficiary was 3.7% lower than the average cost per urban beneficiary,  Approximately $7.2 billion in annual savings to Medicare alone if the average cost per urban beneficiary were equal to the average cost per rural beneficiary,  Approximately $9.4 billion per year is the existing and potential differential between Medicare beneficiary payments for rural vs. urban including the opportunity for savings if all urban populations could be treated at the rural equivalent © Copyright 2012 iVantage Health Analytics, Inc. Rural Relevance Under Healthcare Reform Study

34 Key Takeaways Protect Provider Payments --CAH’s --Physicians --Offsets to pay for other programs Protection from burdensome and excessive policies --Physician Supervision--Telehealth --96 Hour Certification Rule in CAH’s --Two-midnight Policy --Recovery Audit Contractors --Therapy caps Support Expiring Medicare Extenders past March 31, 2014 --MDH and LVH --Permanent SGR Fix --GPCI Rural Floor

35 Brock Slabach, MPH, FACHE Sr. Vice-President for Member Services National Rural Health Association Thank you!

36 SUPPLEMENTARY MATERIAL Legislation to Support

37 Rural Hospital Access ActS. 842 and H.R. 1787 Senate Resolution on importance of rural health providers S.R. 26 Strengthening Rural Access to Emergency Services Act S. 328 Extension of FESC DemonstrationS. 239 Healthy Vets Act of 2013H.R. 635 Rural Hospitals are Essential ActH.R. 356 The DSH Reduction Relief ActS. 1555 and H.R. 1920

38 Legislation to Support The Medicare Audit Improvement ActS. 1012 and H.R. 1250 The Two-Midnight Rule Delay ActH.R. 6398 Protecting Access to Rural Therapy Services Act S. 1143 and H.R. 2801

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