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

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1 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, 2016

2 Improving the health of the 62 million who call rural America home. NRHA is non-profit and non-partisan.

3 National Rural Health Association Membership

4 Membership and Rural Health Foundation New website released this week Foundation link

5 Destination NRHA Plan now to attend these upcoming events. Policy Institute February 6-9, 2017 Washington, DC Annual Conference May 9-12, 2017 San Diego, CA Rural Hospital Innovation Summit May 9-12, 2017 San Diego, CA Quality/Clinical Conference July 11-14, 2017 Nashville, TN RHC/CAH Conference September 26-29, 2017 Kansas City, MO Visit RuralHealthWeb.org for details and discounts. 5

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7 Rural Vote Fuels Trump; Clinton Loses Urban Grip Wall Street Journal, Nov. 9

8 The Rural Vote Had Tremendous Impact

9 Republican Controlled Government Republican President Republican House Republican Senate First time since 1928 we had a Republican Senate, House and President at the same time Incomplete Supreme Court Trump nominees should be able to be appointed by Republican Senate - - but don t have 60 votes.

10 What will happen to ACA under President Trump Rep. Tom Price of Georgia selected as HHS Secretary Seema Verma selected as CMS Administrator Rep. Price author of repeal and replace legislation of the ACA House Republicans: A Better Way Permit insurers to sell health insurance across state lines Repeal or roll back the ACA and implement at least some of the proposals outlined in the GOP party platform and the House Republican leadership white paper on healthcare. However: Divisions among House GOP and Senate Democrats will work to filibuster. Payment transformation will continue in earnest--volume to value?

11 Trump and Medicare Taking shape with Price and Verma picks Medicare premium-support model: privatizing Medicare Medicare Advantage on steroids (read A Better Way ) Rural payment protections? Government negotiating drug prices? Elimination of IPAB? CMMI? Verma a proponent of state innovation models

12 Congressional leadership Key to negotiating deals will be Chuck Schumer D- NY

13 Rural Hospital Closures and Risk of Closures 79 X Percent Vulnerable 35%

14 Save Rural Hospitals Act Sponsors: Graves (MO) and Loebsack (IA) Rural hospital stabilization (Stop the bleeding) Elimination of Medicare Sequestration for rural hospitals; Reversal of all bad debt reimbursement cuts (Middle Class Tax Relief and Job Creation Act of 2012); Permanent extension of current Low-Volume and Medicare Dependent Hospital payment levels; Reinstatement of Sole Community Hospital Hold Harmless payments; Extension of Medicaid primary care payments; Elimination of Medicare and Medicaid DSH payment reductions; and Establishment of Meaningful Use support payments for rural facilities struggling. Permanent extension of the rural ambulance and super-rural ambulance payment. Rural Medicare beneficiary equity. Eliminate higher out-of pocket charges for rural patients (total charges vs. allowed Medicare charges.) Regulatory Relief Elimination of the CAH 96-Hour Condition of Payment (See Critical Access Hospital Relief Act of 2014); Rebase of supervision requirements for outpatient therapy services at CAHs and rural PPS See PARTS Act); Modification to 2-Midnight Rule and RAC audit and appeals process. Future of rural health care (Bridge to the Future) Innovation model for rural hospitals who continue to struggle.

15 Future Model: Community Outpatient Model 24/7 emergency Services Flexibility to Meet the Needs of Your Community through Outpatient Care: Meet Needs of Your Community through a Community Needs Assessment: Rural Health Clinic FFQHC look-a-like Swing beds No preclusions to home health, skilled nursing, infusions services observation care. TELEHEALTH SERVICES AS REASONABLE COSTS. For purposes of this subsection, with respect to qualified outpatient services, costs reasonably associated with having a backup physician available via a telecommunications system shall be considered reasonable costs.. The amount of payment for qualified outpatient services is equal to 105 percent of the reasonable costs of providing such services. $50 million in wrap-around population health grants.

16 Rural hospitals and the rural economy rise and fall together Three years after a rural hospital community closes, it costs about $1000 in per capita income. On average, 14% of total employment in rural areas is attributed to the health sector. Natl. Center for Rural Health Works. (RHW) The average CAH creates 107 jobs and generates $4.8 million in payroll annually. (RHW) Mark Holmes, professor, University of North Carolina Health care often represent up to 20 percent of a rural community's employment and income. (RHW) Medical deserts form in rural communities where hospitals close.

17 Rural Disparities There is tremendous variation in the burden of illness, injury, disability, and mortality referred to as health disparities between populations. Relative to their non-rural counterparts, rural providers serve populations challenged by: Greater socioeconomic disadvantages Poorer outcomes Less access to primary, dental, and mental healthcare *Population Health metrics are percentile ranked for all acute care rural and non-rural providers by hospital service area. **Lower percentile scores indicate higher density (i.e. providers serving a greater proportion of individuals over 65 receive lower scores). Source: ivantage Health Analytics, September, 2016

18 Source: AHRQ Key: n = number of measures. Better = Population received better quality of care than reference group Same = Population & reference group received about the same quality of care Worse = Population received worse quality of care than reference group Rural Quality Disparities

19 Rural Innovation Volume to Results: A major leap to Population Health

20 Paradigm Shift Popularized by Thomas Kuhn in his book: The Structure of Scientific Revolution: A paradigm shift is tantamount to what religion often calls a major conversion. It is equally rare in both science and religion. Any genuine transformation of worldview asks for such a major switch from the track we re familiar with that often those who hold the old paradigm must actually die off before a new paradigm can gain traction and wide acceptance. A paradigm shift becomes necessary when the plausibility structure of the previous paradigm becomes so full of holes and patchwork fixes that a complete overhaul, which once looked utterly threatening, no appears as a lifeline.

21 Chronic Disease Growth Projections

22 Chronic Disease Growth Projections Source: State of Healthcare 2010

23 Prevalence of Medicare Patients with 6 or more Chronic Conditions

24 County Health Rankings Model 24

25 Rural Population Health: Common Elements of Success Prevention: Annual Wellness Visits Chronic Care Management Advanced Care Planning Behavioral Counseling Depression Screening (PHQ-9) Mental Health Support Coding: Complete and accurate documentation of all chronic conditions is key to correct payment under value-based models. Quality: Process Pre-visit Planning Patient Satisfaction

26 Rural Health Clinics (RHC) and Community Health Centers (FQHC) HCPCS Codes on RHC Claims April 1, 2016 Revenue Opportunities: Annual Wellness Visits Chronic Care Management Annual Depression Screening (Patient Health Questionnaire PHQ-9) Transforming Clinical Practice Initiative (TCPI) Voluntary participation in QPP starting January 1, 2017

27 Accountable Care: MSSP Common Elements of Success: Network formation and collaboration around common goals Community Health Needs Assessments (community-based) Nearly all have hired Care Coordinators Nearly all are engaged in the following: --Annual Wellness Visits (AWV) --Chronic Care Management (CCM) --Transitional Care Management (TCM) Nearly all are operating 24/7 Nurse Care Hotlines Using analytic tools for analysis of population health

28 Global Budgeting CMMI published White Paper on Global Budgeting and rural providers Maryland All-Payer Model Fixed global budgets based on historical cost trends Pennsylvania initiated Global Budgeting demonstration Approximately 8 rural hospitals participating Hope to start January 1, 2018 Karen Murphy, Secretary of Health in PA a former CMMI leader Rural providers and SORH so far enthusiastic Featured at 2017 Rural Hospital Innovation Summit, San Diego Concerns: Variations in cost due to seasons and epidemics Services covered under budget and for what populations/payers?

29 First Things First Care Redesign PCMH Clinical Integration Care Management Post-acute Care EHR Data Analytics Care redesign should not outpace Changes in payment Population Health Transformation New Payment Arrangements Care Transformation Costs Care Management Payments Shared Savings Episodes of Care Payments Global Payments

30 Questions? T H A N K Y O U Brock Slabach Senior Vice President National Rural Health Association bslabach@nrharural.org

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