1. National Rural Health Association November 2015

2.  Rural programs fighting for survival, today, originated from historic challenges ◦ Critical Access Hospital program ◦ Federally Qualified Health Centers ◦ Rural Health Clinics ◦ Swing Bed program  Medicare and Medicaid, originally projected by some to fail within first two years

3.  Rural hospital closures stemming from: ◦ Significant changes in reimbursement ◦ Expanded regulatory burden ◦ Low volume realities under value based purchasing  Provider shortages stemming from: ◦ Medical education limits ◦ Recruitment and retention limitations ◦ Distance to specialty/subspecialty support ◦ Growing breakdown in rural EMS system

4.  Gap widening between urban and rural beneficiaries ◦ Lack of Medicaid expansion is most highly rural states ◦ Reduced adoption of ACO’s and other value-based payment vehicles ◦ Proliferation of narrow networks ◦ Reduced level of employer-based insurance ◦ Increase in cost of private insurance premiums

5.  Rural providers historically hampered by law of small numbers in a world driven by volumes ◦ CAH program born of DRG implementation and subsequent impact ◦ Older and poorer communities translate to less desirable payer mix than urban counterparts ◦ Cost per patient driven by higher fixed costs spread across lower volumes

6.  Rural Providers are better positioned to thrive in new models of care than urban counterparts ◦ Primary care vs. specialty focus ◦ Telemedicine and community-based care experience ◦ Continuum of care often connected ‘under one roof’ ◦ Social determinants of health better understood ◦ Care coordination based upon personal connection with patient panel

7.  Trickle down strategy not bringing significant rural providers into Alternative Payment Models  Initial risk-bearing models required an aggregation of patients across communities  Growing understanding of the need to address underlying realities of cost-based reimbursement ◦ Calculating savings against a constant baseline ◦ Law of diminishing returns

8.  Medicare Shared Savings Program successes  Disease Specific Shared Savings models  Episodic Bundled Payment structures  Intensive Care Coordination options ‘stolen’ from oncology model  Financial lessons from FESC and other rural demonstration projects  Care coordination, home monitoring and other research-based tools

9.  State-based initiatives to define new option for struggling CAH’s  NRHA Future of Rural Health Task Force  AHA Urban/Rural Task Force  Save Rural Hospitals legislation includes ‘glidepath’ demonstration option  Building upon the success of historic demonstration projects ◦ Montana ◦ EACH/RPCH

10.  Power of NRHA Policy Congress white papers  Task Force recommendations and new model development  Partnership with other associations  Conference peer-to-peer learning  Journal evidence-based practices  Targeted education on key issues i.e. HIT and Population Health  GRASSROOTS ADVOCACY!

11.  Office of Rural Health Policy continues to strengthen and expand  HRSA participation in issues ranging from Health Professional Shortage Area designation to Office of National Coordinator interest in expanding rural tele-health  White House Council seat at the table on rural issues  Centers for Medicare & Medicaid Innovation  Senate/House caucus & committee testimony

12.  Peer support and encouragement to reduce burn-out, turnover  Avoiding ‘avoidance’  Identifying delivery system gaps and new models to address them  Embracing ambiguity as a license to test better options  Remember rural health challenges existed more than 50 years ago and we found many opportunities for success – we will again