State of Rural Healthcare In US

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2 State of Rural Healthcare In US According to the American Hospital Association (AHA): There are 5564 registered hospital in US 4862 are considered community hospitals 1829 are rural hospitals

3 Aging Population in Rural Geographies According to the US Census Bureau, adults in rural areas are older than those living in nonrural areas, with a median age of 51, compared to age 45 in non-rural areas Hospitalization rates and lengths of stay increase with age among adults, peaking for those over 65 This creates increased demand for healthcare in rural areas As a result, the majority of rural providers serve a greater proportion of patients over the age of 65 than two-thirds of all U.S. acute care hospitals

4 State of Rural Healthcare In US According to a report from ivantage Health Analytics, a firm that compiles a hospital strength index based on data about financial stability, patients and quality indicators: 80 rural hospitals have closed since 2010 Across the US 673 rural hospitals are vulnerable to closure Although nearly all rural hospitals are feeling the squeeze, facilities in states that have not expanded Medicaid are under more financial pressure CLOSED % of hospitals vulnerable to closure are in states that have not expanded Medicaid.

5 State of Rural Healthcare In US Rural America includes approximately 57 million people, about 18% of the population and 84% of the geographic area of the USA There are 1,855 rural hospitals that support nearly 2 million jobs Every dollar spent by a rural hospital produces another $2.29 of economic activity A typical critical access hospital employs 141 community members Rural hospitals handle more than 21.5 million emergency visits

6 State of Rural Healthcare In US According to the ivantage Study: Across the U.S., 673 rural hospitals are vulnerable to closure Of the 673 hospitals, 355 are in markets with great health disparities If the 673 vulnerable hospitals were to close, 99,000 healthcare jobs in rural communities across the nation would be lost Closure of the at-risk hospitals would result in an estimated $277 billion loss to the gross domestic product

7 State of Rural Healthcare In US Diabetes Rural hospitals serve communities with greater rates of diabetes Diabetes is the seventh-leading cause of death in the nation The American Diabetes Association estimates the total cost of diabetes has risen 41 percent from $174 billion in 2007 to $245 billion in 2012 Particularly prevalent in rural America, rural hospitals are on the frontline in providing diabetic screening and care for populations which may not have access to primary or specialty care

8 State of Rural Healthcare In US Opioid Epidemic According to the CDC, the death rate from opioid-related overdoses is 45 percent higher in nonmetropolitan counties Distances in rural geographies mean longer wait times for critical interventions and antidotes like Naloxone Rural communities are isolated from treatment facilities and addiction counseling Nationwide, only 11 percent of patients seeking addiction treatment receive care

9 Maryland Hospitals Maryland hospitals are protected with the all payer waiver with CMS GRMC was first hospital in US with global budget revenue reimbursement GBR created by the Maryland Health Services Cost Review Commission (HSCRC) to give hospitals a financial incentive to change the way they manage their resources With the ultimate goal of slowing down cost increases while preserving the quality of care Maryland already regulated charges in all the state s acute care hospitals, but GBR takes it a step farther

10 Maryland Hospitals focus: Value, not Volume HSCRC sets rates annually based on patient mix and services Revenue becomes predictable Revenue is adjusted population, service levels or shifting services to other settings Focus is shifted from volume to improving care and managing health at the community level Hospitals are financially motivated to control lengths of stay, reduce unnecessary testing, prevent inappropriate admissions, and generally operate in a more efficient manner Hospitals are incentivized to reduce readmissions, a motivator for careful patient education and postdischarge follow-up

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12 Hospital Reimbursement Maryland vs. Rest of Nation Nation $2.50 Charge to Cost Ratio (Illus.) $2.00 $ % 250% 200% 150% 100% 50% 0% 1.2 to 1 Maryland 2.5 to 1 Nation $1.00 $0.50 $0.00 $2.50 $2.00 Medicare/Mcaid Comm. SelfPay Avg. Cost Payments Maryland Cost Mark-up $1.50 $1.00 $0.50 $0.00 Medicare/Mcaid Comm. SelfPay Avg. 12 Cost Payments

13 Hospital Reimbursement Maryland vs. Rest of Nation The Statewide UCC % is built into all hospitals rates; the UCC Pool acts as a settlement methodology to account for hospitals that experience more or less UCC than the State Low UCC Funding Hospital pays into UCC Pool Statewid e UCC Included in all hospital rates High UCC Funding Hospital receives payments from UCC Pool The Statewide UCC pool fund 13

14 HSCRC s Mandate Ensure Equity / Fairness / Stability Maximize Access to Care Contain Hospital Costs Reduce the Total Cost of Care per Medicare Beneficiary Provide Accountability 14

15 CMS Demonstration Model Effective January 1, Year Pilot Project Annual all-payer, per capita, total hospital cost growth limited to 3.58% Maryland s Medicare per beneficiary total hospital cost growth rate must be below the national Medicare per beneficiary average, resulting in $330m of Medicare savings over five years Maryland s Medicare per beneficiary total cost growth rate cannot exceed the national average by more than 1 percentage point, and must be break even with the national average by year 4. Maryland will reduce its 30-day Medicare readmission rate to the national average in five years Annual Potentially Preventable Complication (PPC) reduction of 6.89%, for a cumulative 5 year reduction of 30% 15

16 Global Budget Revenue (GBR) Inpatient and outpatient revenue is constrained by the GBR System GBR provides hospitals with a global revenue base that is 100% fixed Approved revenue amount in a given year is fixed cap No adjustment for changes in volume or service mix No adjustment for changes in Case Mix Index (CMI) Overall incentive to reduce service utilization and encourage improvements in population health If hospitals are successful in reducing utilization, AND, associated variable costs, profitability should increase Changes to hospital s rate order are made annually 16

17 Rate Order Revenue Center: Hospitals have different revenue centers depending on the services they provide Service Unit: The service unit is the same for all hospitals (i.e. every hospital charges for Operating Room services by the minute) Unit Rates: Unit rates (prices) vary by hospital These rates must be charged to all payers - no contract negotiations Service Unit Revenue Center Unit Rates Med./Surg. Acute Patient Days $1, Obstetric Acute Patient Days $ Med./Surg. I.C.U. Patient Days $2, New Born Nursery Patient Days $ Admissions Admission $ Emergency Services MD RVU'S $ Clinic Services RVU'S $ Operating Room Minutes $ Laboratory MD RVU'S $ Radiology-Diagnostic HSCRC RVU'S $ Physical Therapy MD RVU'S $ Observation RVU'S $

18 Rate Center Corridors +10 % +5 % Rate Center - 5 % - 10 % Total GBR charged at the end of each 6 month increment Must be with 0.5% of the Total Budget 18

19 Updates to Rate Orders Hospitals generally receive an updated rate order once per year - effective July 1 Unit rates are updated for: Inflation (Update Factor) Change in Markup (Payer Mix and UCC) Population Infrastructure Investments Price Variances and Penalties NSP I and NSP II Assessments and Fees Quality Measures (MHAC, QBR) Other Adjustments (RRR, Market Share) 19

20 Maryland s System Spurs Innovation: GRMC s Well Patient Program GRMC developed an innovative approach to Care Coordination called the Well-patient Program Patients are identified as high utilizers of hospital care via data analytics (CRISP) integrated to hospital IT system (Care Alerts) Patients Enrolled into Well-patient Program: Assigned Nurse Navigator Social Worker Psychiatrist or psychologist PCP s partner to manage chronic conditions

21 Maryland s System Spurs Innovation: GRMC s Well Patient Program Hospital Services Supporting Wellness: Cardiopulmonary Rehabilitation Obesity Management and Education Smoking Cessation Classes Chronic Kidney Disease (CKD) Clinic CHF Clinic Health Education and literacy programs Community Health Workers Home Health Telemedicine

22 Maryland s system allowed GRMC to be the first hospital in the US to implement a Global Budget RESULTS: According to CRISP data, GRMC has an extremely low cost per Medicare beneficiary Below state average Below national average

23 Percentage Garrett Regional Medical Center Potentially Avoidable Utilization Revenue PAU Rate for CY15 and CY16 Compared to the State PAU Rate GRMC PAU Rate CY 15 CY 16 Jan-April CY 16 Jan-Jun I M P R O V E M E N T

24 GRMC Surgical Site Infection Rate (Drives Readmission Rates and indicator for quality and safety) One of the drivers of GRMC s low readmission rate is surgical site infection rate Percent 0.26% 0.22% 0.16% GRMC Self Directed Goal was for SSI to be < 0.6% Garrett Nation I M P R O V E M E N T Very Low in 2014, still made improvement in 2015 CDC January 2015 SSI event Module- reports NHSN data for (16,147 SSI s following 849,659 operative procedure) showed an overall SSI rate of 1.9%

25 Garrett Regional Medical Center HSCRC reported Risk Adjusted 30 Day Inpatient All Payer Readmission Rate Comparative for All Maryland Hospitals for Jan-April % 14% 12% 10% 8% 6% 4% 2% 0% 5.9% 7.3% 9.1% 9.3% 9.5% 9.5% 9.5% 9.7% 9.7% 9.9% 10.0% 10.1% 10.1% 10.1% 10.3% 10.4% 10.5% 10.5% 10.6% 10.7% 10.7% 10.8% 10.8% 10.8% 11.0% 11.1% 11.3% 11.4% 11.4% 11.6% 11.8% 11.8% 11.9% 11.9% 11.9% 12.1% 12.1% 12.3% 12.5% 12.6% 12.7% 12.9% 13.9% 13.9% 14.3% 14.6% 14.8% GRMC 5.9% Statewide Average 11.4% GARRETT COUNTY MEMORIAL UM-REHABILITATION & ATLANTIC GENERAL HOSPITAL UM-CHARLES REGIONAL CALVERT MEMORIAL HOSPITAL FREDERICK MEMORIAL PENINSULA REGIONAL PRINCE GEORGES HOSPITAL UM-SHORE REGIONAL HEALTH SHADY GROVE ADVENTIST WASHINGTON ADVENTIST GREATER BALTIMORE MEDSTAR MONTGOMERY FORT WASHINGTON MEDICAL ANNE ARUNDEL MEDICAL MEDSTAR ST. MARY'S UM-ST. JOSEPH MEDICAL HOWARD COUNTY GENERAL WESTERN MARYLAND MEDSTAR SOUTHERN UM-SHORE REGIONAL HEALTH SUBURBAN HOSPITAL MERITUS MEDICAL CENTER UNION HOSPITAL OF CECIL LEVINDALE CARROLL HOSPITAL CENTER DOCTORS COMMUNITY UM-UPPER CHESAPEAKE LAUREL REGIONAL HOSPITAL MEDSTAR HARBOR HOSPITAL MEDSTAR FRANKLIN SQUARE HOLY CROSS HOSPITAL MEDSTAR UNION MEMORIAL UM-HARFORD MEMORIAL MEDSTAR GOOD SAMARITAN SINAI HOSPITAL MERCY MEDICAL CENTER ST. AGNES HOSPITAL NORTHWEST HOSPITAL CENTER UM-BALTIMORE WASHINGTON UNIVERSITY OF MARYLAND JOHNS HOPKINS HOSPITAL UM-SHORE REGIONAL HEALTH BON SECOURS HOSPITAL JOHNS HOPKINS BAYVIEW MCCREADY MEMORIAL UMMC MIDTOWN CAMPUS P O S I T I V E

26 Survival Rate in Percent Garrett Regional Medical Center Risk Adjusted Survival Rate Trend Mortality Rate Rapid Improvement Final Jan- Sep Final Sep- Dec 2014 GRMC State Final Jan- Jun 2015 Time Frame Final Jan- Dec I M P R O V E M E N T Prelim Jan- Jun 2016 Source: CRISP Data Report

27 Garrett Regional Medical Center Maryland Hospital Acquired Conditions (MHAC) Scores rd best performance in Maryland! Improvement GRMC Maryland Hospital Acquired Conditions 0.3 Jan- June Prelim CY14 Jan- June CY14 n= 43 Jan- Sept CY14 n= 56 Jan- Dec CY14 n=71 Jan-Mar CY15 Final n= 5 Jan-June CY15 Final n= 11 Jan- SeptJan- Dec CY15 Final CY15 Final n= 25 n=25 Jan-Feb CY16 n=4

28 According to Senator Ben Cardin GRMC is the role model for rural healthcare in the US today According to GRMC CEO: It s Because of the Maryland System

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