Transcript PPT file - Pennsylvania Academy of Family Physicians

Health Care in
Rural Pennsylvania:
An Overview
Larry Baronner
Pennsylvania Office of
Rural Health
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
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
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)
Rural-Urban Commuting Areas (RUCAs)
For Pennsylvania
Source: Community Information
Resource Center, Rural Policy
Research Institute
Dark Yellow
Medium Orange
Light Orange
Dark Yellow
Medium Yellow
Light Yellow
Green
Legend
Code 4 (Large Town)
Code 5 (High Commuting to Large Town)
Code 6 (Low Commuting to Large Town)
Code 7 (Small Town)
Code 8 (High Commuting to Small Town)
Code 9 (Low Commuting to Large Town)
Code 10 (Rural Areas)
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
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.
Accessing
Healthcare
Services in Rural
Pennsylvania
The Primary Issue for
Rural Health Care Is…
ACCESS…
 … to healthcare services
 … to payment mechanisms
 … and to transportation
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.
 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
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)
Critical Access Hospitals In
Pennsylvania, July 2014
Source: Pennsylvania Office of Rural Health
National Map of CAHs
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 onsite or on-call (30 min)
• Must have agreements with an acute care hospital related to
patient referral and transfer, communication, emergency and nonemergency patient transportation
• Must have arrangements with respect to quality assurance (i.e.
QIO)
Promoting Healthy
Communities Through
Hospital-based Population
Health Strategies
USING THE COMMUNITY HEALTH NEEDS
ASSESSMENT PROCESS
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
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
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
Benefits of Collaborative
CHNAs
Bring together the following;
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

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


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
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
PORH Strategy to Assist
Pennsylvania Rural
Hospitals
THE HEALTHY COMMUNITIES
INSTITUTE
HCI Counties
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
Increase appropriate
utilization
Reduce readmission
rates
Contain or reduce costs of care
Improve access to care
Reduce mortality rate
Improve continuum of
care
Continuous Health Improvement:
Effectively Moving from Data to Action
Local Community
Data
Evaluation
&Tracking
• 100– 200 indicators
• Constantly updates
• Data Visualization
Implementation
Strategies
HCI System: 4 Pillars
• HP 2020 trackers
• Local Priority trackers
• Comparative and
longitudinal evaluation
• Database >2000
Collaboration
Centers
• Form working groups
• Set local goals
• Manage objectives
Promising Practices
Programs
& Policies
•
• Evidence-based
Fulton County Medical Center
214 Peach Orchard Road, McConnellsburg, PA 17233  www.fcmcpa.org  (717)
485-3155
Overview
History of FCMC CHNA’s
FCMC website
◦
◦
◦
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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?
2013-2015 Health Needs
Assessment - 6 Priorities
1.
Alcohol Tobacco and Other Drug Use (ATOD)
2.
Diet, Obesity & Inactivity
3.
Heart Disease
4.
Diabetes
5.
Children, Youth, and Families
6.
Quality of Life for People over 65
214 Peach Orchard Road, McConnellsburg, PA 17233  www.fcmcpa.org  (717)
485-3155
FCMC Website
Priority areas
highlighted
Dashboard specific to
CHNA
The Challenge: Crossing the Shaky Bridge
Fee for
Service
Payment
System
2012
MARKET OVERVIEW
Population
Based
Payment
System
2013
TRANSITION
2014
FRAMEWORK
2015
2016
STRATEGIES
35
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
36
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)
• Impact of ACA
• 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
37
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
38
Changing Payment System Incentives
Macro-economic Environment – Payment System
Perspective
Government
Private
MARKET OVERVIEW
Current State
• Cost based
reimbursement
for CAHs
• Fee-For-Service
(FFS) to PPS acute
care hospitals
• FFS
• Insurance
provided to
patients through
employers
• Primary employer
relationships with
insurers
•
•
•
•
•
•
Phase 1
ACO pilot projects
FFS increasingly
tied to patient
value
Cost based
reimbursement
for CAHs with
impacts from
sequestration and
RAC audits
FFS with steerage
based on network
penalties and
patient incentives
FFS with quality
scores
High deductible
health plans
negatively
impacting patient
volume
TRANSITION
Phase 2
• Population based
payments (PBP)
for ACOs
• ACOs with budget
based payment
predominates
• Interim payment
models similar to
Phase 1
Phase 3
• Transition from
ACOs to Medicare
Advantage plans
(budget to full
capitation)
Future State
• PBP with quality
performance
criteria
• Medicare
Advantage plans
with providers at
full risk
• Pilot projects for
risk sharing with
providers
• Insurance
exchanges
become an option
for individuals and
small groups to
obtain insurance
• Providers and
insurers
functionally
merging through
acquisition or
development of
provider based
health plans
• PBP with quality
performance
criteria
• Provider based
health plans
FRAMEWORK
STRATEGIES
39
Physician Perspectives
Micro-economic Environment – Physicians
Perspective
PCPs
•
•
•
•
•
Specialists
MARKET OVERVIEW
Current State
Loss leaders
Employed to
maintain primary
care base in their
communities
Independent PCPs
Relatively low
compensation
Emphasis on high
volume episodic
care
• Profit centers
• Emphasis on high
volume of high
dollar procedures
TRANSITION
Phase 1
Phase 2
• System aligned
(employed and
independent)
• Increasing
compensation
Phase 3
•
•
•
•
•
• Caught between
volume emphasis
and system cost
emphasis
• Declining
compensation
• Regional
consolidation with
lower volumes
• Increasing
employment by
systems
FRAMEWORK
•
•
•
•
Future State
Revenue centers
System employed
and integrated
Relatively high
compensation
Emphasis on care
management and
chronic disease
management
Operating at top
of license,
leveraging nonphysician
practitioners and
team members
Cost centers
Increase value
through care
management
models that drive
down costs
Quality must be
demonstrated
Make (employ) or
buy (purchase
externally)
decision based on
cost
STRATEGIES
40
Implementation Framework – What Is It?
MARKET OVERVIEW
TRANSITION
FRAMEWORK
STRATEGIES
41
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
42
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
43
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
44
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
45
Where Are ACOs Forming?
Source: healthaffairs.org
MARKET OVERVIEW
TRANSITION
FRAMEWORK
STRATEGIES
46
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
47
ACOs in Pennsylvania: Examples
Source: ipagroup.org
MARKET OVERVIEW
TRANSITION
FRAMEWORK
STRATEGIES
48
Pennsylvania Office of Rural Health
202 Beecher-Dock House
University Park, PA 16802
Telephone: (814) 863-8214
Fax: (814) 865-4688
[email protected]
www.porh.psu
Larry Baronner, Critical Access
Hospital Coordinator ([email protected])
Lisa Davis, Director ([email protected])