SURVEY OF VIRGINIA S RURAL HEALTH CLINICS Clinic Data and Needs Assessment Report Fall 2015 Survey conducted by Virginia Rural Health Association in partnership with mjs Consulting, Inc. Funding from Health Resources and Services Administration
Background In May of 2015, Virginia Rural Health Association (VRHA) received a grant from Health Resources and Services Administration (HRSA) to determine the feasibility of starting a Rural Health Clinic (RHC) coalition or association in Virginia. VRHA partnered with mjs Consulting, Inc. to design and analyze a Clinic Data and Needs Assessment Survey of all of Virginia s RHCs. Method Site visits with the current Rural Health Clinics in Virginia were conducted in the summer and fall of 2015 and this survey was administered verbally by VRHA staff Beth O Connor. Twenty-four Rural Health Clinics participated in this survey which included two parts a Clinic Data component with information on individual clinics and a section asking about what would make a RHC coalition or association successful in Virginia. These results were shared at Regional Meetings with all the RHCs in the Fall of 2015. This final report of all the results will be shared with the RHCs at the Capstone Meeting in the Spring of 2016 to develop a strategic plan for the RHC association or coalition. Clinic Data Results Contained in this section are the results of the Clinic Data component of the survey. Clinic Characteristics Of the 20 clinics who responded to the question, the majority of RHCs in Virginia were started in the mid-1990s. The largest single growth year was 1995. Sixty percent of RHCs are for profit organizations and the remaining 40% nonprofits. None of the current RHCs have a mobile clinic affiliated with their standing clinic. Outreach efforts do include home visits (n=6), nursing home visits (n=6), and hospital/hospice visits (n=3). 8 7 6 5 4 3 2 1 0 Date Received RHC Designation, n=20 1987 1994 1995 1996 1997 2000 2008 2010 2014 RHC Data Collection and Needs Assessment Report 1 Compiled by mjs Consulting, Inc.
prescription medications at a reduced price. This could be another growth opportunity for clinics interested in this program. 80 70 The majority of RHCs have not joined an Accountable Care Organization (ACO) and do not have plans to join one. Only 20% have indicated they have joined one. Few RHCs know of their ranking as a Health Professional Shortage Area (HPSA). Five clinics did know their ranking with one as an 8, one as a 9, and three were 12. This could be an area where additional education could be provided as this ranking can help with recruitment and retention of providers. The majority of RHCs do not participate in the 340B pharmacy program. This program provides an opportunity to purchase Payer Percentages by Clinic Funding 60 50 RHCs have a blend of third party reimbursement sources. The percentages vary from 40 30 clinic. Most clinics received the 20 bulk of their reimbursement 10 from Medicaid and Medicare. RHCs do receive an enhanced 0 reimbursement from these two payer sources. Every clinic does see some uninsured, but Uninsured/Private Pay Medicaid Medicare Private Insurance it does not, on average, make up the bulk of their patients. Additionally, most clinics see patients with private insurance but there is greater variance on the percentage of patients with this coverage. 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 Number of Patient Visits in Last FY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Most RHCs receive the bulk of their funding from third party reimbursements. A few clinics do have other sources of funding outside of these reimbursements which include VIS program for pediatric vaccines, insurance company incentives, bank loans, meaningful use reimbursements, and RHC funds. One RHC receives money from three local jurisdictions, grants, fund raising events, public donations, and patient revenues. RHC Data Collection and Needs Assessment Report 2 Compiled by mjs Consulting, Inc.
Patients, Patient Visits, and Services Provided Many clinics were unable to list their unduplicated patient numbers. Of those who could, the responses were 1,500, 4,737, and 20,000. The number of patient visits provided varied drastically. One clinic provided as many 70,000 visits while another 2,300. The average number of patients seen by the RHCs is 17,800. Services provided by the RHCs are contained in a table below. Of those who responded, they all provided general medical visits and most provided lab services. The other services varied across clinic. Types of Services Provided by RHCs Primary care/family/internal Lab testing (13) Temporary splints (10) medicine (17) Physicals (8) Minor procedures (8) Lesion removals (8) Pediatrics (6) Immunizations (6) Minor surgery (4) IVs (5) Workers compensation (4) Injections (4) Women s health (3) Preventative (3) Same day appointments and walk-ins (3) EKG (3) X-ray (3) Allergy shots (3) Diabetes Education (2) Bone density (2) Specialty (2) Dental (2) Point of care testing (2) Injections Mental Health Stress tests Prenatal HIV/AIDS Nursing home care Emergency stabilization Pre-operative clearances Vasectomies Trigger points Occupational medicine CDLs Pain management Information Technology In terms of information technology, 80% of the responding RHCs (n=19) use an electronic medical record (EMR). The systems used are listed below: eclinical (n=4) Allscripts (n=3) Amazing Charts (n=2) Greenway (n=2) e-md Solution Series (n=2) Athena HCS Advanced MD Epic Ninety percent of the 20 responding clinics have access to Broadband internet. Staff Staff within the RHCs vary. All have at least one paid physician and a paid advance practice practitioner. Other types of providers are less frequent within the clinics. The table below lists the type of staff person and, where applicable, the average number of staff within each type. Other providers found in RHCs but not listed in the table are Medical Assistants (10 clinics staff them), Radiology technicians (4 clinics staff them), Lab staff (2 clinics staff them), Janitorial staff, and an LPN/psych coordinator. RHC Data Collection and Needs Assessment Report 3 Compiled by mjs Consulting, Inc.
Staff Type Number MD/DO (n=24) Average amount 2.5 (13 highest amount, 0.25 lowest amount) Nurse Practitioners/Physician Assistants (n=24) Average amount 2.2 (8 highest amount, 1 lowest amount) Nurses (n=22) Average amount 4.9 (highest amount 15, lowest amount 0) Pharmacists (n=4) 3 rent space 1 hospital Social Workers (n=2) 1 FT 1 PT Case Managers 0 Health Coaches (n=1) 2 Dieticians (n=3) Dentists (n=1) 2 clinics with 1 FT 1 clinic with 1 PT 3 PT, 14 volunteers Dental Assistants (n=1) 2 Dental Hygienists (n=1) Office/Administrative Staff (n=23) 2 PT Average amount 7.8 (highest amount 50, lowest amount 0.5) RHCs also utilize unique staffing options. One clinic is using residents to supplement staff. Another clinic takes advantage of the J-1 visa program which allows them to bring practitioners from other countries to practice within the clinic. Another clinic, in order to assist with recruitment and retention of providers, is paying staff s student loan debt. Recruiting staff members can be a challenge for RHCs and positions can be open for extended period of time without being filled. The average time open for a position within the clinic is 3.6 months. Some clinics stated positions being unfilled for as long as two years and as short as 2 weeks. For those clinics with open positions for an extended period of time, the average longest time to wait before being able to fill a position is 9.5 months. Four clinics stated that they had little to no turnover in positions. Quality Data Of the responding clinics, 85% stated they collect some form of quality data. When asked what type of quality data they collect, 5 utilize reports from their electronic medical record, 5 use the Physician Quality Reporting System (PQRS), 4 collect data on specific clinical indicators such as lipid profiles and A1C levels, and 3 use meaningful use reports. The remaining use corporate quality surveys, annual quality surveys, financial quality improvement goal data, and requirements of their Accountable Care Organization. RHC Data Collection and Needs Assessment Report 4 Compiled by mjs Consulting, Inc.
Needs Assessment Results The Needs Assessment component of the survey really concentrated on needs of the clinics and ways that a RHC coalition or association might meet those needs. Suggestions for success for a coalition or association were also assessed and offered. Clinic Challenges When asked what was most challenging for individual clinics, the highest rated items were ICD10 and the changes that would come with that, working with managed care companies, understanding state regulations, understanding federal regulations, quality measures, capital improvement, and recruiting and retaining providers. The clinics were asked to identify what out of all of the possible categories listed to the left was specifically challenging. The following were their responses: Managed care companies/insurance companies challenging/not processing correctly/not paying correctly/ prior authorization issues (n=7) ICD-10 (n=4) Recruitment of staff (n=4) Regulation language (n=3) EMR Meaningful use Quality measures Cost of purchasing health insurance for employees Workflow Raising money to do rising uninsured patient numbers Below are other areas of RHC operations, governance or administrative that are particularly challenging. Better information/advocacy on RHC issues (n=9) -RHC billing rates need increasing (n=3) -Benefit of remaining an RHC when ACOs take over -Not paying RHC rates -Meaningful use payouts excluded for RHC -Contracting software not RHC friendly -Out of the RHC loop local meetings would help -Where do RHC patient complaints go? RHC Data Collection and Needs Assessment Report 5 Compiled by mjs Consulting, Inc.
-Could use a contact person for TA and ask questions Billing/coding issues (n=2) Challenge of having patients from multiple states and Medicaid cost reporting Having to pay both DOs as Medical Director because of credentialing issues The State Survey: need a manual for policies & procedures, need someone to do a mock survey Benefits of Rural Health Clinic Coalition or Association The clinics were asked what member benefits they d like to see as part of an RHC coalition or association. The areas most requested were education, sharing of best practices, timely information on important issues, clinical training and education, and information on state and federal regulations. Below are the responses to what benefits could the clinic see for a RHC association or coalition: Networking (including clinical staff) (n=9) Services (n=7) - Cost reporting (n=2) -Assistance with recruitment (n=2) -Fundraising -Developing an ACO of RHCs -Group insurance agreements Technical assistance (someone to call) (n=6) -Regulations -Billings dos and don ts Education (n=5) -Cost report clarifications -Training Sharing information within and without coalition (n=3) -Information from National RHC meetings -Distribution of fact sheets -Regulation updates -Reimbursement information Benchmarks and standardization (n=3) Assistance managing cash flow issues Advocacy The majority of the clinics support the idea of forming coalition or association of Rural Health Clinics. RHC Data Collection and Needs Assessment Report 6 Compiled by mjs Consulting, Inc.
The clinics had a number of thoughts of what it would take for a coalition or association to be successful. Buy-in from all the RHCs to participate and share (n=6) Communication open and face to face (n=5) Provide quality services (n=2) Webinars, virtual conferencing (n=2) Strong leader who can coordinate efforts Limited bureaucracy Problem focused annual meetings Collect data to share Specific information to RHCs to meet immediate needs Best practice depository Site visits frequent exchange of information group clinics according to population type Interest in seeing the formation of a Rural Health Clinic association or coalition (n=18) Yes Unknown Contributions to Coalition or Association Knowing that individual clinics have a wealth of information and best practices to share with other clinics, they were asked what they do well that they d like to share with other clinics. Below are the responses: Billing (n=4) Cross-training for staff (n=2) Team work and cohesiveness (n=2) Retain staff We know a chart consultant Experience in cost reporting Insurance company credentialing education on RHC operations Willing to share anything Find balance between staying financially viable and still treat indigent patients and take all the Medicare & Medicaid patients that have a need. Many docs in the area won't take older patients. State inspection prep, chart reviews ability to adjust and pivot quickly Stratus interpreter service advantage of having one person serving as point for following regulations Virginia vaccine program Final Comments and Thoughts The clinics were asked what keeps them up at night and what was their biggest frustration. Worrying about patients (n=3) Government regulations (n=3) Provider issues (not enough, waiting list, credentialing) (n=3) Managing competing demands (n=2) Revenue, cash flow (n=2) insurance companies (n=2) Disaster recovery (n=2) Billing differences from FQHCs to RHCs Meaningful use Employee issues EHR RHC Data Collection and Needs Assessment Report 7 Compiled by mjs Consulting, Inc.