Improving the health of the 62 million who call rural America home.

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1 Michigan Rural Health Conference May 3, 2018 Brock Slabach, MPH, FACHE Sr. Vice-President National Rural Health Association Leawood, KS Improving the health of the 62 million who call rural America home. NRHA is non-profit and non-partisan. 1

Annual Conference May 8 11, 2018 New Orleans, LA Rural Hospital Innovation Summit May 8 11,

2 National Rural Health Association Membership Destination NRHA Plan now to attend these upcoming events. Annual Conference May 8 11, 2018 New Orleans, LA Rural Hospital Innovation Summit May 8 11, 2018 New Orleans, LA RHC/CAH Conference September 25 28, 2018 Kansas City, MO Policy Institute February 5 7, 2019 Washington, DC Visit RuralHealthWeb.org for details and discounts. 4 2

3 New Mexico, USA Oct ,

4 Michigan Top 20 Rural Hospitals in USA 2018 Top 20 Rural Community Hospitals Chippewa County War Memorial Hospital, Sault Sainte Marie, MI ( ) MidMichigan Medical Center Alpena, Alpena, MI ( ) 2018 Top 20 Critical Access Hospital Aspirus Ironwood Hospital & Clinics, Ironwood, MI ( ) 4

9% of GDP, higher than at any point since WWII, between 2021 to 2028 More bad news: the total national debt will reach $33T or

5 The State of Rural America Workforce Shortages Vulnerable Populations Chronic Poverty Storm Clouds Brewing 2020: Federal deficit will exceed $1 trillion Due to recently passed tax legislation, rate of deficit will be 4.9% of GDP, higher than at any point since WWII, between 2021 to 2028 More bad news: the total national debt will reach $33T or 96% of GDP over the next decade Be watchful of discussion on methods to reduce this burden, like watching the storm clouds on the horizon, we need to be prepared! 5

health shortage areas; and 3,500 areas are short of mental health

Rural Populations Suffer many Health Disparities Rural hospitals

6 6,000 areas in the U.S. are primary care health shortage areas; 4,300 areas are dental health shortage areas; and 3,500 areas are short of mental health shortage areas. Rural Populations Suffer many Health Disparities Rural hospitals care for older, poorer, and sicker populations than non rural providers: These rural populations also have less access to primary, dental, and mental healthcare: 6

Rural Health Disparities Vary by State Rural communities in the South are faced with the highest rates of premature death and diabetes in the nation.

A Rural Divide in American Death Center for Disease Control January, 2017 Study: The death rate gap between urban and rural America is getting wider Rates of

Mortality is tied to income and geography. Minorities, especially Native Americans die consistently prematurely nation wide, but more pronounced in rural.

7 Rural Health Disparities Vary by State Rural communities in the South are faced with the highest rates of premature death and diabetes in the nation. Opioid abuse is most prevalent across the Mid Atlantic and West, while rural populations in the Northeast see the highest suicide rates. Rural Mortality Rates. A Rural Divide in American Death Center for Disease Control January, 2017 Study: The death rate gap between urban and rural America is getting wider Rates of the five leading causes of death heart disease, cancer, unintentional injuries, chronic respiratory disease, and stroke are higher among rural Americans. Mortality is tied to income and geography. Minorities, especially Native Americans die consistently prematurely nation wide, but more pronounced in rural. Startling increase in mortality of white, rural women. Causes: Risky lifestyle (smoking, alcohol abuse, opioid abuse, obesity) Environmental cancer clusters Suicides January

8 Mapping the Opioid Crisis Deaths per 100,000 residents 8

9 The rate of opioid-related overdose deaths in nonmetro counties is 45% higher than in metro counties. Opioids Overall substance abuse rates are higher in rural communities Factors contributing to substance abuse in rural America include: Low educational attainment Poverty Unemployment High-risk behaviors Isolation 9

10 We know there are solutions Protect Medicaid as a funding source to provide treatment. Expand access to substance abuse treatment services including medication assisted treatment and traditional substance abuse treatment. Develop evidence-based prevention programs tailored to the needs of rural communities. Increase the implementation of harm reduction strategies. Promote use of evidence-based prescribing guidelines and strengthen prescription drug-monitoring programs. Expand use of substance abuse treatment as an alternative to incarceration. The opioid crisis places stress on sparse rural health resources 83 rural hospitals have closed since 2010 Vulnerable and Closed Rural Hospitals 674 are vulnerable to closure 77% of rural counties are Primary Care Health Professional Shortage Areas 9% of rural counties don t have a single physician 10

11 Chronic Poverty Poverty in Rural America PBS News, March

12 Rural Resilience 12

13 Legislative Update Budget and Appropriations FY2018 A Brief History CR through Dec. 8 (passed Sept. 8) House passed Omnibus (Sept 14) no Senate action CR through Dec 22 (passed Dec 7) CR through January 19 (passed Dec 21) Government shutdown Jan mostly weekend CR through February 8 (passed January 21) CR through March 23 (passed February 9) Included a two year budget deal topline numbers but details remained 13

President s Budget DOA Bad news for rural (Bright side: Obama proposed CAH cuts not included) Dramatic cuts plus policy changes for bad debt and 340B Omnibus (remainder of FY18) $49,609,000 will be

14 President s Budget DOA Bad news for rural (Bright side: Obama proposed CAH cuts not included) Dramatic cuts plus policy changes for bad debt and 340B Omnibus (remainder of FY18) $49,609,000 will be available for the Medicare Rural Hospital Flexibility Grants Program, as requested by NRHA $15,942,000 of the above 49,609,000 are provided for the Small Rural Hospital Improvement Grant Program for quality improvement and adoption of health information technology $1,000,000 of the above funds will be focused on telehealth services, including pilots and demonstrations on the use of electronic health records to coordinate rural veterans care between rural providers and the Department of Veterans Affairs. $10 million for the State Offices of Rural Health (SORH), an NRHA goal in our appropriations requests. An additional $15 million is provided for Rural Residency Development Program through September 30, $100 million is provided through September 30, 2022, for the Rural Communities Opioids Response Program. 14

15 Now what Time to work on FY19 which begins October 1, 2018 Budget already complete as part of two year budget deal reached as part of CR in January Appropriations process Some of Rural Provisions Advancing to Finance Rural Training Tracks Rural Health Clinic raising caps Wage Index Rural EMS Regulatory Relief 15

16 Senate Grassroots Action Imperative Orrin Hatch (Utah) Chairman Chuck Grassley (Iowa) Mike Crapo (Idaho) Pat Roberts (Kansas) Michael Enzi(Wyoming) John Cornyn (Texas) John Thune (South Dakota) Richard Burr (North Carolina) Johnny Isakson(Georgia) Rob Portman (Ohio) Patrick Toomey(Pennsylvania) Dean Heller (Nevada) Tim Scott (South Carolina) Ron Wyden (Oregon) Ranking Member Debbie Stabenow(Michigan) Maria Cantwell(Washington) Bill Nelson (Florida) Robert Menendez (New Jersey) Thomas Carper(Delaware) Benjamin Cardin(Maryland) Sherrod Brown (Ohio) Michael Bennet(Colorado) Robert Casey(Pennsylvania) Mark Warner (Virginia) Claire McCaskill(Missouri) Bill Cassidy (Louisiana) Current Politics Mean Slow Movement Republican control of both House and Senate Speaker of the House Paul Ryan is retiring pending power struggle may spark arguments Fiscal constraints mean no one wants to spend Each party is sensitive to the midterms Each party wants to help rural but neither party wants to help the other party 16

17 Midterms House: 17 open seats vacated by Ds vs. 37 open seats vacated by Rs (to gain the majority D s need to pick up 24 seats) Favorable Map for Senate Republicans 33 elections (23 Ds, 2 Is that caucus with D, 8 Rs) 3 R retirements (TN, UT, AZ) 2 Special Elections MN (D Franken resignation) and MS (R Cochran resignation) Impact on ability to move legislation THE FARM BILL 17

2018 Farm Bill Current Farm Bill expires end of FY18 Pass a new bill every 5 years Normally a bipartisan process this time around was a little bit different Markup in the House Agriculture Committee

18 2018 Farm Bill Current Farm Bill expires end of FY18 Pass a new bill every 5 years Normally a bipartisan process this time around was a little bit different Markup in the House Agriculture Committee this week was hours of political posturing and arguing We did hear a lot of support for rural development and the rural economy There are a number of programs critical to rural health in the Farm Bill Rural Programs in the Farm Bill Title VI, Rural Infrastructure and Economic Development, is the section of the bill that includes USDA funding for important rural health programs The first Subtitle is Improving Health Outcomes in Rural Communities, and under that Section 6001, Prioritizing Projects to Meet Rural Health Crises in Rural America includes four programs for rural health: Temporary Prioritization of Rural Health Assistance Distance Learning and Telemedicine (DLT) Grants Community Facilities Direct Loans and Grants Rural Health and Safety Education Programs 18

19 Rural Programs in the Farm Bill In the 2018 Bill, the USDA Secretary can authorize additional funds and redirect funds in the case of a rural health emergency What does that mean? It s all about opioids. Our comment on that? Rural America is already experiencing a rural hospital closure crisis, and faces a severe lack of resources. We are already facing a rural health emergency. We need more. NRHA Farm Bill Requests The Farm and Ranch Stress Assistance Network (FRSAN) Helps support agricultural workers and their families in rural communities by providing easily obtainable resources for mental health services Needs to be properly funded Rural Health Liaison Would act as a direct point of contact at the USDA for questions related to health care in rural communities and for the streamlining of rural health programs 19

20 NRHA Farm Bill Requests Include the provisions of the Addiction Recovery for Rural Communities (ARRC) Act Distance Learning and Telemedicine Grants The 2018 Farm Bill includes provisions for at least 10% of Distance Learning and Telemedicine Grants to be set aside for an emergency for something like the opioid crisis ARRC would set aside at least 20% of Distance Learning and Telemedicine Program grant funding for substance abuse treatment Community and Facilities Direct Loan and Grant Would prioritize applications concentrated on substance use disorder prevention, treatment and recovery services USDA Rural Health and Safety Education Would prioritize grant funding for applicants seeking to improve education and outreach substance use disorder issues NRHA Farm Bill Requests Creation of an emergency hospital fund under Title VI, Section 6001 (A) Temporary Prioritization of Rural Health Assistance When a rural community is faced with the closure of the hospital the community often looks for resources to keep that essential point of access to care Members of Congress begin to examine potential resources to help keep the hospital open USDA has experience with working with keeping struggling hospitals from closing through their rural development program, which is at times faced with borrows struggling to pay back their loans This same expertise, coupled with available funding and loans, can be used to help struggling hospitals to keep their doors open to continue to serve their communities. 20

Maternity Care is Disappearing in Rural America In 1985, 24% of rural counties lacked OB services.

More than 200 rural maternity wards closed between 2004 and 2014.

challenging, higher rates of childbirthrelated hemorrhages and higher rates of maternal and infant

21 Maternity Care is Disappearing in Rural America In 1985, 24% of rural counties lacked OB services. Today, 54% of rural counties are without hospital based obstetrics. More than 200 rural maternity wards closed between 2004 and Rural Obstetric Factors Rural areas have higher rates of chronic conditions that make pregnancy more challenging, higher rates of childbirthrelated hemorrhages and higher rates of maternal and infant death Half of rural women in rural communities live more than the recommended 30 minutes from a hospital offering maternity services. Workforce shortages and medical liability costs. 21

of white women to have never had hospital-based obstetric services and more than 4 times

22 Rural Minority Mothers and Babies Rural counties with higher percentages of African American women were more than 10 times as likely as rural counties with higher percentages of white women to have never had hospital-based obstetric services and more than 4 times as likely to have lost obstetric services between The Administration Regulatory Update 22

NRHA Meeting with Seema Verma, CMS Administrator Jodi Schmidt, Past President of NRHA and Brock Slabach discussed regulatory burden and

6, 2017 Rural Regulatory Wins Sole Community Hospital Exemption for Medicare payments of 340B drugs Changes to Quality Payment program

enforcement of direct supervision requirement for outpatient therapy services Sociodemographic risk is Hospital Readmission Reduction

23 NRHA Meeting with Seema Verma, CMS Administrator Jodi Schmidt, Past President of NRHA and Brock Slabach discussed regulatory burden and new models, Including CAH VBP Program Ms. Verma visted NRHAs Leawood, KS Office on Nov. 6, 2017 Rural Regulatory Wins Sole Community Hospital Exemption for Medicare payments of 340B drugs Changes to Quality Payment program (QPP) Low volume exemption expanded Change in enforcement of 96 hour (Condition of Payment) rule for CAHs Two year moratorium on enforcement of direct supervision requirement for outpatient therapy services Sociodemographic risk is Hospital Readmission Reduction Program Change to the calculation of the additional payment available to SCHs and MDHs when they experience a 5% or greater decrease in inpatient volume New Chronic care management codes for RHCs and FQHCs 23

340B Concerns Continue The Hill Energy and Commerce o Report o Legislation Senate o Hatch letter: move 340B from HRSA to CMS o Hearings in HELP and Finance Committees Department of Health and

24 340B Concerns Continue The Hill Energy and Commerce o Report o Legislation Senate o Hatch letter: move 340B from HRSA to CMS o Hearings in HELP and Finance Committees Department of Health and Human Services New HHS Secretary Alex Azar Former HHS Official under President George W. Bush Eli Lilly Executive Wants to speed move to value Drug pricing reform Upcoming regulations IPPS OPPS PFS 24

25 IPPS Rule Release 90 day comment period NRHA full analysis soon Payment/AcuteInpatientPPS/FY2019-IPPS-Proposed-Rule-Home- Page.html Rural Hospital Lab Services Vulnerable Rural Hospitals Face Tough Deciions On Profitable But Questionable Billing Schemes CBS News Reports and KCUR/KBIA in Missouri ran a story outlining issues regarding reference lab billing programs. 25

26 Resources TCPI: Practice Transformation Networks (PTN) Designed for all clinicians/clinic type RHC/FQHC eligible Listing of PTN Contractors National Rural Accountable Care Consortium (NRACC) national in scope PTN and focuses on rural practices (RHCs) Support for Small Practices: Small Underserved and Rural Support (SURS) RHC and FQHCs are not eligible to participate, PFS clinics only HPSA will qualify for service 15 Clinicians or less Additional resources: QPP.CMS.GOV Quality Improvement Organizations (QIO) Practice Transformation Networks That Are Recruiting PTN Name Recruitment Region Target Clients Contact Name/ NRACC Nationwide All Practice Types Kate Angellotti Northern New England Maine, New Hampshire, Vermont All Practice Types Eleesa Marnagh The Care Transitions Network New York Behavioral Health, Primary Care Samantha Holcombe VCSQI SAN 2.0 Nationwide All Practice Types Deborah (Nadzam) Melnyk, PhD Proprietary & Confidential, Not for Distribution 52 26

Practice Transformation Networks That Are Recruiting PTN Name Southwest Pediatric Recruitment Region Southern CA (Orange and San Diego Counties) Target Clients Pediatric WDOH Washington Children 0-20

27 Practice Transformation Networks That Are Recruiting PTN Name Southwest Pediatric Recruitment Region Southern CA (Orange and San Diego Counties) Target Clients Pediatric WDOH Washington Children 0-20 Primary Care, Specialty Care AZHEC (Health Current) Health Quality Innovators Arizona Maryland, Washington D.C., Virginia, West Virginia Pediatrics, Integrated Health Homes, FQHCs, Specialists Primary Care Contact Name/ Michael German Melissa Thoemke Stacey Rochman Candace Mangum Proprietary & Confidential, Not for Distribution 53 Infrastructure: the bipartisan job creator rural America needs Amy Klobuchar, Jan 30,

It s time to Rebuild Rural America Health care is infrastructure in Rural America Small infrastructure investments = Big rural health gains Health care is an economic driver 20% of rural economy

28 It s time to Rebuild Rural America Health care is infrastructure in Rural America Small infrastructure investments = Big rural health gains Health care is an economic driver 20% of rural economy President Trump s $1.5 Trillion Infrastructure Plan Only $200 billion over 10 years - Paid for by cuts elsewhere in POTUS budget proposal $100 billion direct grants to local governments to trigger investment $50 billion block grants for rural America $20 billion for large projects to "lift the American spirit $30 billion for miscellaneous existing infrastructure $1.3 trillion from localities, private investors and others "The White House says it will finally address a dysfunctional system in which Washington calls too many of the shots, federal red tape gets in the way and some communities fail to put enough 'skin in the game' all while dire needs go unmet." 28

29 Prospects for Infrastructure Bill Pessimism from Congress Money: D s don t think it s enough federal money No one knows the funding source Midterms possible lame duck strategy Rural Innovation History Montana Medical Assistance Facilities (MT-MAF) Essential Access Community Hospital (EACH)/Rural Primary Care Hospital (PeaCH) Declining hospital utilization has created excess hospital capacity in rural areas, has depressed occupancy rates, and threatens the financial viability of rural hospitals. J Rural Health, Fall, 1991 Both HCFA Demos precursor to Critical Access Hospital (CAH) in BBA 1997, essential to this sweeping legislation Frontier Extended Stay Clinic (FESC), Frontier Community Health Integration Project (FCHIP), Rural Community Hospital Demonstration Program (REACH) 29

MedPAC on MIPS: Burdensome and Inequitable Reporting Burden: $1B reporting burden in 2017 alone Much of the reported info is not meaningful Each clinician scored on different measures representing

30 MedPAC on MIPS: Burdensome and Inequitable Reporting Burden: $1B reporting burden in 2017 alone Much of the reported info is not meaningful Each clinician scored on different measures representing different level of effort Results in non comparable scores across clinicians, nonetheless used to allocate payments CMS has exempted more clinicians in 2018 than are required to participate! MedPAC Proposal: Voluntary Value Program (VVP) Common Denominator All are volume-based, fee for service models With variant payment provisions, for example: Fee schedules (DRG, PFS, etc.) Cost-based Reimbursement (CBR) Hybrids of the two Variations on a flawed theme 30

31 VBP Doesn t work for Rural Incremental, piece-meal change with marginal benefit Misalignment between Delivery System Reform (DSR) and payment arrangement incentives Risk adjustment is inadequate to properly protect the vulnerable Multiple payers with differing incentives toward transformation (if they exist at all): Medicare: Bundling, MACRA, VBP, HRRP, HCAHPS, etc. Medicaid: Managed Care (cost), PCPs, DSRIPs, etc. Commercial Insurance: ACOs, Utilization Review, ED retroactive denials, narrow networks, etc. Uninsured/Underinsured Medicare single largest payer in rural hospitals CAHs exempt from quality reporting requirements Fee for Service (FFS) payment system Volume dependent (even thought CBR) Little incentive to change delivery system features Pennsylvania Global Budget Model Only rural innovation project currently Starting now for five years Game changer as APMs go Daydream: what if, someday? scenario Harmonize disparate payment systems and their attendant incentives (sometimes conflicting incentives) Enables clinical system to fully transform to emphasize prevention and chronic disease management Jump over ITERATIONS of change to a sustainable, long-term model Solved the paradox of changing your payment arrangements to keep pace with delivery system reforms 31

32 First Things First Delivery System Reforms (DSR) PCMH Transitions of Care Chronic Care Management Post-acute Care EHR Network Formation Care redesign should not outpace Changes in payment Population Health Transformation New Payment Arrangements MACRA Care Transformation Costs Care Management Payments Shared Savings Episodes of Care Payments Global Payments Source: Joseph F. Damore, Premier Health Alliance, March, 2015 Celebrate the greatness of rural health care! Rural independence; rural work ethic; rural ingenuity; rural providers doing more with less. Fortitude even through the most challenging of times. Higher quality Higher patient satisfaction Cost-effective Fewer Resources 32

33 So what do we do? The Politically Powerful are Listening: If we ve learned nothing from the last election, it s that we can t listen to rural America enough. Senate Minority Leader Chuck Schumer Questions? THANK YOU Brock Slabach Senior Vice President National Rural Health Association bslabach@nrharural.org 33

Rebalancing Health Care in the Heartland The Rural Imperative of Population Health Des Moines, IA

Rebalancing Health Care in the Heartland The Rural Imperative of Population Health Des Moines, IA Brock Slabach, MPH, FACHE Sr. Vice-President National Rural Health Association Leawood, KS December 1,