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Health Care in Rural Pennsylvania: Pennsylvania Office of

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1 Health Care in Rural Pennsylvania: Pennsylvania Office of
An Overview Larry Baronner Pennsylvania Office of Rural Health

2 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 OMB Definition Metropolitan: urban areas of 50,000 persons or more, plus adjacent territory Micropolitan: at least one urban cluster of 10,000-50,000 persons plus adjacent territory Non-metropolitan: all other areas by default Census Definition Urbanized Areas and Urbanized Clusters RUCAs 10 levels based on geography and commuting patterns. 1 is most urban; 10 is most rural Pennsylvania Definition Urban/Rural: based on counties, municipalities, and school districts with a population density of 274 persons or less

3 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

4 Rural Pennsylvania at A Glance
One of the most rural states in the nation 2.8 million rural residents 42 of 67 counties designated as rural (CRP) Others are Texas, North Carolina, Georgia, Ohio, and Kentucky Migrant farmworkers = 8,000

5 Rural-Urban Commuting Areas (RUCAs)
For Pennsylvania Legend Dark 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

6 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

7 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.

8 Accessing Healthcare Services in Rural Pennsylvania

9 The Primary Issue for Rural Health Care Is…
ACCESS… … to healthcare services … to payment mechanisms … and to transportation Nationally – Only 9 percent of physicians practice in rural areas Pennsylvania – 2/3 of primary care physicians practice in the three most populated counties Primary care for Physical, dental, and behavioral health care services Specialty care Insurance: According to the Blue Cross/Blue Shield Association in 2000 publication “The Uninsured in America” In Pennsylvania, 71% have employer-sponsored health insurance 7% are have non-group insurance 8% are on Medical Assistance 2% on other public insurance 12% are uninsured Mental health: according to the PA Department of Health, 2000 Suicide rate /100,000 For Pennsylvania as a whole: 10.9% For rural PA: 12% For non-rural PA: 10.6% 34% of PA is designated as a mental health shortage area Dental care: Percentage of persons who have had a dental visit within last year: Highest rates are within cities and in areas adjacent to a city; locations by a city of 10,000 or less have the lowest rates of dental visits 37% of PA designated as dental shortage area Education post-secondary training community colleges Employment small employers <5 employees no employee-sponsored health insurance seasonal work

10 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.

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13 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

14 What is a Critical Access Hospital
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)

15 Critical Access Hospitals In Pennsylvania, July 2014
Source: Pennsylvania Office of Rural Health

16 National Map of CAHs It's important to remember that the CAH designation was created to ensure access to high quality inpatient, outpatient and  ER services to seniors in isolated area. Part of that is also attributable to the Flex program, which supports the CAHs. And we can point to at least 1,300 reasons why it is a public policy success.  And while we've had lots of individual success stories, we still don't have the sort of national proof that quantifies this. We know that CAHs are more financially stable and that they're offering more services but at the end of the day we also ought to be able to say that we're improving the health of the population the designation and program were created to serve and that is the Medicare beneficiaries served by CAHs. So that's what this project is all about: Showing a national impact on the health of seniors served by CAHs. Because if we can't say that, it's hard to justify why we need the designation or the program.

17 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)

18 Using the Community Health Needs Assessment Process
Promoting Healthy Communities Through Hospital-based Population Health Strategies Using the Community Health Needs Assessment Process

19 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

20 CHNA Challenges for Hospitals
Lack of resources Lack of capacity “Population Health” new concept for hospitals Overlapping interests Trust issues Prioritization of community health improvement efforts Bringing together diverse organizations that have differing needs, resources, cultures and missions can be challenging

21 Purpose of the CHNA Process (for hospitals)
Identification of; unmet acute care needs Population health issues Local service gaps Priority health concerns for service planning and development Development of ACA-mandated implementation plans Preparation of proposals for submission to charitable, foundation, and governmental funding opportunities

22 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

23 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

24 PORH Strategy to Assist Pennsylvania Rural Hospitals
The Healthy Communities Institute

25 HCI Counties

26 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 Why do clients use the HCI Systems?

27 Increase appropriate utilization
Reduce readmission rates

28 Contain or reduce costs of care
Improve access to care

29 Reduce mortality rate Improve continuum of care

30 Continuous Health Improvement:
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

31 Fulton County Medical Center
214 Peach Orchard Road, McConnellsburg, PA   (717)

32 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?

33 2013-2015 Health Needs Assessment - 6 Priorities
Alcohol Tobacco and Other Drug Use (ATOD) Diet, Obesity & Inactivity Heart Disease Diabetes Children, Youth, and Families Quality of Life for People over 65 214 Peach Orchard Road, McConnellsburg, PA   (717)

34 FCMC Website Priority areas highlighted Dashboard specific to CHNA

35 Fee for Service Payment System Population Based Payment System
The Challenge: Crossing the Shaky Bridge Fee for Service Payment System Population Based Payment System 2012 2013 2014 2015 2016 MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES

36 The Healthcare Environment Has Changed!
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  INTRODUCTION

37 Fee-For-Service Financial Model
Assumptions 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) 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

38 We Have Moved into a New Environment!
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 MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES

39 Changing Payment System Incentives
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES

40 Physician Perspectives
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES

41 Implementation Framework – What Is It?
MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES

42 Initiative I – Operating Efficiencies, Patient Safety and Quality
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 MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES

43 Initiative II – Primary Care Alignment
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.) MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES

44 Initiative III – Rationalize Service Network
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) MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES

45 Initiative IV – Population Based Payment System
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 MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES

46 Where Are ACOs Forming? Source: healthaffairs.org MARKET OVERVIEW
TRANSITION FRAMEWORK STRATEGIES

47 Source: Leavitt Partners Center for Accountable Care Intelligence
ACOs in Washington There are 20 ACOs in the state of Pennsylvania Pennsylvania ranks 11th out of the 50 states for total number of ACOs ACOs in PA cover between 250,000 and 500,000 lives Source: Leavitt Partners Center for Accountable Care Intelligence MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES

48 ACOs in Pennsylvania: Examples
Source: ipagroup.org MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES

49 porh@psu.edu www.porh.psu Larry Baronner, Critical Access
Pennsylvania Office of Rural Health 202 Beecher-Dock House University Park, PA Telephone: (814) Fax: (814) Larry Baronner, Critical Access Hospital Coordinator Lisa Davis, Director


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