The Future of Rural Health Care
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1 The Future of Rural Health Care Presentation to the Joint Fall Meeting of the Iowa Rural Health Association & Iowa Association of Rural Health Clinics September 20, 2012 Johnston, Iowa Keith J. Mueller, Ph.D. Director, RUPRI Center for Rural Health Policy Analysis Head, Department of Health Management and Policy College of Public Health University of Iowa
2 Themes of this presentation Changes in delivery and finance of care Policy implications of those changes Developing a high performance rural system Closing thoughts for rural advocates and associations
3 $ $ must be squeezed out of current health care expenditures: 20+% of GDP by 2020 is not acceptable Both price and quantity of services must be reduced Changes will happen in the delivery system, fundamental not cosmetic For health systems, PRESSURE TO GROW AND SUSTAIN PATIENT VOLUME
4 Prevention and population health Community well being Bundled payment Value based purchasing Managed care organizations Accountable care organizations
5 Expansion of Medicaid enrollment with some federal help in paying providers, but limited Expansion of enrollment in the individual and small group markets CAN T EXPECT CURRENT / HISTORIC APPROACHES TO DELIVERING AND FINANCING CARE TO RESPOND TO THIS SHIFT
6 Inpatient payment to PPS hospitals effective October 1, 2012 Will be developed for outpatient payment Demonstration project for CAH payment Value based modifiers for physician payment
7 Decrease in uncompensated care Increase in covered lives (commercial health plans) and therefore negotiated prices Increase in Medicaid coverage and shift of that client base toward different payment schemes Non patient revenues subject to turns in the economy
8 Not your father s medical home Potential future of primary c are Emphasis on integrated services, management of chronic conditions, team based, patient centered care
9 Including Medicare Shared Savings Program (MSSP) But don t wait for that to sink or swim Including Pioneer Demonstration from Centers for Medicare and Medicaid Innovation (CMMI) And much more..
10 Accountable Care Organizations Pioneer and Shared Savings ACOs, Western Census Region Metropolitan county Non-metropolitan county ACO coverage area
11 ACO DISTRIBUTION BY STATE Source: David Muhlestein, Andrew Croshaw, Tom Merrill, Cristian Pena. Growth and Dispersion of Accountable Care Organizations: June 2012 Update. Leavitt Partners. Accessed August 20, 2012 from LeavittPartners.com
12 Time of change: health care systems, new private insurance products, new payment methods Creates threats and opportunities Public programs are part of the trends Aligning policy specifics with the broad goals for a better system in the future
13 FFS to VBP PC Physicians to Other Primary Care and PCMH personnel Face to face encounters to telehealth Independent entities to systems Encounter based medicine to person based health Revenue centers to cost centers and vice versa
14 Verify they are real Place in perspective and priority Intervene as necessary Example of Medicare Dependent Hospitals
15 Merging funding and policy streams: community transitions meet CMS innovations Support innovations that meet minimum access standards
16 Medicaid is currently a crucial safety net program for rural persons: In 2010, 17.9% of rural persons were enrolled in Medicaid compared to only 15.5% of urban persons. 13.2% of rural persons over age 65, but only 12.1% of urban persons in this age group are on Medicaid. 9.8% of rural elderly received Medicaid benefits compared to 9.0% of urban elderly
17 Medicaid is currently a crucial safety net program for rural persons: In 2010, 17.9% of rural persons were enrolled in Medicaid compared to only 15.5% of urban persons. 13.2% of rural persons over age 65, but only 12.1% of urban persons in this age group are on Medicaid. 9.8% of rural elderly received Medicaid benefits compared to 9.0% of urban elderly
18 In part because of the higher rates of coverage of rural persons, Medicaid is a particularly important source of payment for rural providers: Almost one third of rural physicians derive 25% or more of their patient revenues from Medicaid, as compared to 19.9% in urban areas. Physicians in rural areas are more likely to serve Medicaid beneficiaries than are their urban counterparts.
19 Medicaid financed 40% of the $177.6 billion spent nationally on long term care in Medicaid is the primary source of funding for publicly provided mental health services, accounting for 46% of spending in 2007.
20 Access standards for any contracts FMAP and state participation: expectations and balance Weighing rural consequences
21 Short term and long term costs to Medicaid program and state budget Estimated (by Urban Institute) 130,000 persons newly eligible in Iowa Balance of state cost through 2020 and federal government matching payment Burden of uncompensated care without balancing Disproportionate Share payment Cost to public treasuries and public insurance from uncompensated Economic impact of Medicaid expansion
22 Preservation in the face of threats (20+ years of rural policy activities) Pay for performance and rural considerations Health systems and payment changes: ACOs
23 Health professions training programs Loan repayment and other incentive programs Public health programs Infrastructure support
24 The RUPRI Health Panel envisions rural health care that is affordable and accessible for rural residents through a sustainable health system that delivers high quality, high value services. A high performance rural health care system informed by the needs of each unique rural community will lead to greater community health and well being.
25 Better Care: Improve the overall quality, by making health care more patient centered, reliable, accessible, and safe. Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and, environmental determinants of health in addition to delivering higher quality care. Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government. Source: Pursuing High Performance in Rural Health Care. RUPRI Rural Futures Lab Foundation Paper No. 4.
26 Affordable: costs equitably shared Accessible: primary care readily accessible Community focused: priority on wellness, personal responsibility, and public health High quality: quality improvement a central focus Patient centered: partnership between patient and health team
27 Preserve rural health system design flexibility: local access to public health, emergency medical, and primary care services Expand and transform primary care: PCMH as organizing framework, use of all primary care professionals in most efficient manner possible
28 Use health information to manage and coordinate care: records, registries Deliver value in measurable way that can be basis for payment Collaborate to integrate services Strive for healthy communities
29 In health care work force: community paramedics, community health workers, optimal use of all professionals, which requires rethinking delivery and payment models implications for regulatory policy including conditions of participation In use of technology: providing clinical services through local providers linked by telehealth to providers in other places E emergency care, E pharmacy, E consult In use of technology: providing services directly to patients where they live
30 Where people choose to live Through local providers linked to integrated systems of care Who, together with their patients, manage health conditions Not the same design everywhere, but the high quality, patient centered everywhere
31 Organizations should pursue first do now harm but also alternative visions for the future Health care systems active in reshaping delivery, with Triple Aim in mind Dialogue has to lead to action
32 For Further Information The RUPRI Center for Rural Health Policy Analysis The RUPRI Health Panel
33 Dr. Keith J. Mueller Department of Health Management and Policy College of Public Health 105 River Street, N232A, CPHB Iowa City, IA keith
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