Transcript Healthcare Reform - Kentucky Rural Health Association

Rural Health Federal Update
Kentucky Rural Health
Association
Brock Slabach, MPH, FACHE
Senior Vice President for Member Services
National Rural Health Association
Improving the health of the
62 million who call rural
America home.
NRHA is non-profit
and non-partisan.
National Rural Health Association Membership
2012
2012-13 Meetings
 RHC/CAH Conference
Kansas City, MO, September 25-28, 2012
 M&M Conference
Asheville, NC, December 5-7, 2012
 Rural Health Policy Institute
Washington, DC, February 3-5, 2013
 Annual Conference
Louisville, KY, May 7-10, 2013
Looking Forward
• SGR Fix Required, 30% lower FFS to
docs
• Sequester scheduled for January 1, 2%
reduction
• Bush era tax cuts end Dec. 31
• Payroll tax cuts end Dec. 31
A Little History
• CBO Options for Deficit Reduction
• Republican Proposal for rural, $14B cut
• House Ways & Means Dems: CBO
option
• President’s Budget
• MedPAC
• Pay Fors on Budget Deal Feb. 2012
– Medicare bad debt
States with Most MDH Facilities
Tennessee: 24
Texas: 19
Illinois: 13
Mississippi: 13
Pennsylvania: 13
Kentucky: 11
New York: 11
North Carolina: 11
Louisiana: 10
Alabama: 8
Missouri: 8
Virginia: 8
Oklahoma: 8
MDH
Medicare Dependent Hospitals
Fact Sheet - find out why MDHs are important to your community
and rural America
Letter to Editor - send a letter to your local newspaper
Letter to Members of Congress - send a letter to your members of
Congress
Letter to HHS Secretary Kathleen Sebelius from NRHA
Study by North Carolina Rural Health Research and Policy
Analysis Center on the economic benefits of rural MDH
facilities.
List of All Medicare Dependent Hospitals in the United States.
Map of all Medicare Dependent Hospitals State by State.
Low-Volume Adjustment
• Fact Sheet - find out why Low-Volume hospitals are
important
• Letter to Editor - send a letter to your local
newspaper
• Letter to Members of Congress - send a letter to
your members of Congress about your Low-Volume
Hospital.
Why did Congress create
varying Medicare payments
to rural providers?
From 1980 to 1991 at least 360 rural
hospitals were closed. -An average of
30 per year.
The Inpatient Prospective Payment
System (PPS) led to the decline in the
numbers of rural hospitals.
Rural Hospital Closures: 1980-90
Our Advocacy Message
• VALUE
Rural is Different
Quality Measures: Hospital Strength Index™
 Rural hospital performance on CMS Process of Care measures is
on par with urban hospitals,
 Rural hospital performance on CMS Outcomes measures is better
than urban hospitals,
 Rural hospital performance on HCAHPS inpatient patient
experience survey measures is better than urban hospitals,
 Rural hospital performance on price and cost efficiency measures
is better than urban hospitals.
© Copyright 2012 iVantage Health Analytics, Inc.
www.iVantageHealth.com
Rural is Different
Emergency Department
 The mean Total Wait Time in a rural Emergency Department is
approximately half as long as the wait in an urban Emergency
Department (29 vs. 56 minutes),
 The mean Wait Time to see a Physician in a rural Emergency
Department is nearly 2.5 times less than the wait in an urban
Emergency Department (98 vs. 247 minutes),
 More than 50% of all Emergency Department visits to Critical
Access Hospitals were categorized as low acuity cases.
© Copyright 2012 iVantage Health Analytics, Inc.
www.iVantageHealth.com
Rural Relevance Under Healthcare Reform Study
ACO Shared Savings (Medicare Beneficiaries)
 Approximately $2.2 billion in annual cost differential (savings)
occurred in 2010 because the average cost per rural beneficiary
was 3.7% lower than the average cost per urban beneficiary,
 Approximately $7.2 billion in annual savings to Medicare alone if
the average cost per urban beneficiary were equal to the average
cost per rural beneficiary,
 Approximately $9.4 billion per year is the existing and potential
differential between Medicare beneficiary payments for rural vs.
urban including the opportunity for savings if all urban
populations could be treated at the rural equivalent
© Copyright 2012 iVantage Health Analytics, Inc.
www.iVantageHealth.com
Rural vs. Urban Medicare Payments
Average Medicare Beneficiary Payments for IP, OP and Physician Services by CMS Region (2010)
© Copyright 2012 iVantage Health Analytics, Inc.
www.iVantageHealth.com
How do we fight…
• Investing in rural health care is needed
for both the
– rural patient (and maintaining
access to care); and
– rural community
• Demonstrate cost-effectiveness of
providing care in rural America.
Other Issues
• Physician Supervision
• ICD10 Conversion Delay, Oct. 1, 2014
• OIG Investigation of CAH’s
SCOTUS/ACA/rural
impact
• 3 days of arguments
• Issues:
– Anti-Injunction Act
– Mandate – Commerce Clause
– Medicaid – Spending Clause
– Severability
The Ruling
• The individual mandate is a valid
exercise of Congress’s Taxing
Power.
• The mandate is not a valid exercise
of the Commerce Clause.
• Other provisions, including ALL rural
provisions will be implemented as
outlined in the bill.
The Ruling - Medicaid
• The federal government cannot rescind ALL
Medicaid funding if states don’t comply with
new requirements.
• The federal government can refuse NEW funds
if states don’t meet NEW Medicaid Rules.
The Ruling
• Important: The money, payment
modifications, and workforce
modifications that have already gone
into effect will NOT be rescinded.
What it Means
• Political battle is reheating:
• Battles to remodel?
• Battle to repeal? House voted for 33rd time to repeal part or all
of ACA.
• Legal Battle continues (Medicaid)
• “The framers created a federal government of limited powers
and assigned to this court the duty of enforcing those limits.
The court does so today. But the court does not express
any opinion on the wisdom of the Affordable Care Act.
Under the constitution, that judgment is reserved to the
people."
NRHA and Health
Reform
• For reform to be effective in rural America, the
access to care crisis in rural America must be
eliminated.
• To resolve the access crisis, reform must eliminate:
– The workforce shortage crisis
– Long-standing payment inequities
– Aging Rural Infrastructure
– Health Disparities
ACA – Where the money goes…
Kaiser Family Foundation new tool
•
http://healthreform.kff.org/federal-funds-tracker.aspx#options
– Health Centers: Funding for Federally Qualified Health Centers to support
infrastructure improvements and to expand access at new and existing sites.
– Health Care Facilities and Clinics: Funding to support the infrastructure needs of
health care facilities and to expand the availability of primary care clinics, including
school-based health centers and nurse-managed health clinics.
– Maternal and Pregnancy: Funding for new maternal health and early childhood
programs, as well as abstinence education.
– Medicare and Medicaid Special Projects: Funding for outreach and to support
innovations in the two programs..
– Prevention and Public Health: Funding to improve public health infrastructure,
combat public health concerns, and increase access to and the use of preventive
services.
– Workforce and Training: Funding awarded to support the expansion of the health
care workforce through training and placement programs.
The Politics of Rural
• Battle for White House
• Battle for Congress
Possible big changes to
WH and Congress…again.
THANK YOU
Brock Slabach, MPH, FACHE
Senior Vice President for Member Services
National Rural Health Association
[email protected]
“Medicare Extenders”
 Various provisions have expired or are set to expire
at the end of FY or CY 2012
 SGR Fix. Part of budget deal through end of year.
 Hospital wage index improvement
 Extended reclassifications under section 508 of the Medicare
Modernization Act (modifies payment to “super rural” facilities).
Congress extended this provision through June, 2012. Phased out
over time.
 Extension of outpatient hold harmless provision
 Extended outpatient hold harmless provision and allows Sole
Community Hospitals with more than 100 beds to also be eligible
for this adjustment. Budget deal extended through Dec. 31, 2012,
limited to less than 100 beds. Requires GAO/MedPAC Report.
Importance of Hold Harmless
Provision
• Of the 138 hospitals with SCH status that received OPPS
Hold Harmless or TOPS payments in CY 2009, 137 had a
negative outpatient service margin on Medicare payments.
• If these hospitals were to lose hold harmless payments,
their losses would be far more profound: 34 hospitals would
have negative margins exceeding 50%; 103 hospitals
would have negative margins exceeding 25%.
• Congress provides protections for SCHs because if these
hospitals were to fail, residents of the communities they
serve would be without hospital services.
Other Extenders
A second group of “extenders” are set to
expire at various points in 2012:
 Medicare Dependant Hospital
 ACA reauthorized the Medicare Dependant Hospital Program. To be
classified as an MDH, a rural hospital under 100 beds must have at least
60 percent of its days or discharges covered by Medicare Part A. MDH
classification payments were extended in the Affordable Care Act. MDH is
scheduled to expire for discharges occurring on or after October 1, 2012.
 Extension of improved payments for low-volume
hospitals
 Applied a percentage add-on for each Medicare discharge from a hospital
15 road miles from another hospital that has less than 1,600 discharges
during the fiscal year. The Affordable Care Act § 3125 made this policy
effective through fiscal year (FY) 2012.
Medicare Dependent
Hospital
• Established in 1990 to support small rural hospitals
who treat significant Medicare patients. To qualify as
a MDH, a hospital must be
– located in a rural area,
– have no more than 100 beds, and
– demonstrate that Medicare patients constitute at least 60
percent of its inpatient days or discharges.
• The Congressional Budget Office scored the one
year extension in the ACA as costing less than
• Cost: $100 million over 10 years.
• 200 MDH hospitals.
Medicare Extenders
 Extension of exceptions process for Medicare
therapy caps
 Extended the process allowing exceptions to limitations on medically
necessary therapy. Extended until Dec. 31. 2012.
 Extension of payment for the technical component
of certain physician pathology services.
 Extended provision that allows independent laboratories to bill Medicare
directly for certain clinical laboratory services. In budget deal and expires
June 30, 2012 then phased out.
 Extension of the work geographic index floor under
the Medicare physician fee schedule.
 Extended a floor on geographic adjustments to the work portion of the fee
schedule, with the effect of increasing practitioner fees in rural areas. In
budget deal and expires Dec. 31, 2012.
Medicare Extenders
 Extension of ambulance add-ons
 Extended bonus payments made by Medicare for ground and air
ambulance services in rural and other areas. Included in budget
deal, expires Dec. 31, 2012 and requires GAO/MedPAC analysis.
 Extension of physician fee schedule
mental health add-on
 Increased payment rate for psychiatric services delivered by
physicians, clinical psychologists and clinical social workers by 5
percent. NOT EXTENDED.
 Extension of Medicare reasonable costs payments for
certain clinical diagnostic laboratory tests furnished to
hospital patients in certain rural areas
 Reinstated the policy included in the Medicare Modernization Act of 2003 (P.L.
108-173) that provides reasonable cost reimbursement for laboratory services
provided by certain small rural hospitals. Medicare and Medicaid Extenders Act
of 2010 extended this policy through July 1, 2012.
 Extension of Community Health Integration Models
 The Affordable Care Act temporarily removed the cap on the number of eligible
counties in a State that can apply for the program. Valid through FY 2012.
 Extension of Payment for Qualifying Hospitals in Low
Spending Counties
 1109 of the Health Care and Education Reconciliation Act of 2010 provides for
additional funding of $400 million in FY2011 and FY2012 for hospitals located in
counties that rank in the lowest quartile for Medicare Parts A and B per capita
spending. This funding will expire at the end of FY 2012.
Offsets
• Bad Debt Reduction: Reduce bad debt reimbursement
for ALL facilities to 65%. CAH and RHC (and all other
facilities currently receiving 100%) will draw down over 3
years
• “Rebase” DSH payments: Rebase Medicaid DSH
payments to States starting in 2021
• “Rebase” Clinical Laboratory Payments starting in 2013
• Reduce funding for Public Health and Prevention Fund
• Technical correction for FMAP Disaster funding
ACA in effect now
• Insurance reforms
– High risk pools; $5 billion funded
– Pre-existing conditions
– Caps on coverage eliminated
• Preventive care benefits
• Covering children up to age 26
• Closing of “donut hole” for seniors.
Workforce Improvements
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Significant Expansion of NHSC
Significant funding of Title VII and Title VIII
Rural Physician Training Grants
Graduate Medical Education Improvements
Increased Residency Slots in Rural Areas
Grants to Improve Primary Care Training
Health Care Workforce Commission
2008 Presidential Electoral Map
County by county
Counties “re-sized” to reflect population
The rural purple
POLITICS
Job Approval Ratings
Approve
Disapprove
Spread
President Obama
48.4
46.6
+1.8
Congress
12.4
80.8
-68.4
U.S. House: “Blue Dog
Democrats face extinction in
next election”
Of the 24 remaining Blue Dogs:
• five are not seeking reelection;
• More than a half-dozen others are facing
treacherous contests in which their reelection hopes
are in jeopardy.
The Battle for the U.S. Senate
DEM REP IND
51
47
2
Polls: Firm D
Likely D
Lean D
Toss-Up
Firm R
Likely R
Lean R
2014 Election:
33 Seats up for election.
•20 Democratic seats
•13 Republican seats)
Retiring: 6 Democrats,
3 Republicans, 1 Independent
8
4
3
10 (MT, NV, ND, NM, MO, WI, VA, MA, ME, HI)
5
3
0