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.

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