Best Wishes for the New Year

The National Rural Health Resource Center wishes you a happy and healthy season and all the very best in 2013!

We look forward to working with you in the new year!

Terry Hill, Executive Director

One method of acquiring and transferring knowledge used by The National Rural Health Resource Center (The Center) over the past decade has been holding national summit meetings on specific rural hospital topics. This method does not replace formal research, but instead is designed to supplement more scientific research and is usually translated into short white papers for national distribution and discussion.

This past June, The Center, with support from HRSA’s Office of Rural Health Policy, brought a small group of critical access hospital (CAH) financial experts and thought leaders together to address issues related to CAH financial performance. The meeting was prompted by the declining financial circumstances of many CAHs, as well as the new challenges presented by the Affordable Care Act.

Participants included accountants from the major accounting firms serving CAHs, rural CFOs and CEOs, researchers, state Flex program staff and federal officials. The participants did extensive pre-work and then engaged in a structured dialog designed to address the Summit goals. A white paper including the major Summit outcomes was developed and will soon be distributed nationally.

Summit participants agreed that most CAHs are not maximizing their reimbursement, due partially to the complexity of the rules and regulations and due partly to limited use of needed expertise.  CAHs often turn to consulting experts for help, but when negative bottom lines become common, many hospitals seem reluctant to pay for all that is needed. There are also questions as to which CAH financial measures are most important, and which financial consultations are most productive.

The Summit participants identified the following 10 measures as most important to maintaining the financial health of CAHs:

1.    Days in net accounts receivable

2.    Days in gross accounts receivable

3.    Days cash on hand

4.    Total margin

5.    Operating margin

6.    Debt service coverage ratio

7.    Salaries to net patient revenue

8.    Payer mix percentage

9.    Average age of plant

10. Long term debt to capitalization

The participants then identified the financial interventions that would have the most positive impact on the average CAH’s bottom line. These included:

·         Cost report review and strategy;

·         Strategic financial and operational assessments;

·         Revenue cycle management; and,

·         Physician practice management assessments.

The participants recommended ongoing financial education for hospital boards, mid-level managers and senior leaders. On site education was deemed to be optimal, however, there was considerable value seen in good webinar presentations that could be recorded, stored and used on-site with various shifts. Lean training was also recommended as a method of improving business processes as well as a good way of saving money.

The Summit participants concluded the meeting by noting that the American health care system is transitioning from a “Pay for Volume” system to a “Pay for Value” system. In the years ahead, CAHs will be challenged to maximize and document their value, as well as calculate where they fit into the new value-based reform models. In that regard, they will be somewhat like an intrepid explorer, going down treacherous river rapids, with one foot in one canoe (the old system), and the other foot in an accompanying canoe (the new system). At some point, they must cross over to put both feet into the new canoe, but the timing will be critical. Too early or too late a transition and they risk going under.

Honoring Veterans at End of Life

Kami Norland, Community Specialist

How can we best serve the unique end-of-life care needs of our veterans? Through my involvement with the Palliative Care Rural Initiative project in Veterans Integrated Service Network (VISN) 23 over the past year, I learned that one out of every four dying Americans is a veteran, yet 96 percent of veterans are cared for outside of the Veterans Affairs (VA) health care network, according to the National Hospice and Palliative Care Organization. This means that the majority of veterans are cared for by hospice and health care professionals in their hometown.

As health care providers, we work diligently to assess each patient as an individual and deliver high-quality, customized care. No time is more crucial to provide this level of customized service than hospice, where treatment is designed to relieve symptoms and provide comfort and support to individuals with life-limiting illnesses.

It has been pointed out time and again that when people reach the last chapter of their life journey, there is a natural tendency to reminisce, resolve issues, and reference previous experiences of emotional intensity—which, for veterans, includes their history in the military.

Both research and evidence-based practice have demonstrated that a person’s military history can exacerbate physical, psychological, social, and spiritual symptoms toward the end of life. The Department of Veterans Affairs notes, for example, that Vietnam veterans may still suffer from “trench foot,” a fungal infection of the feet from walking in wet conditions; that symptoms of posttraumatic stress disorder may surface; that social isolation and distrust of authority may develop (or redevelop) in veterans who have felt a lack of support in the adjustment from military to civilian life; and that spiritual questions may arise as individuals encounter death outside of the battlefield.

The VA also cites the following contributing factors that may influence a veteran’s behavior and responses to end-of-life issues:

·         Entry status: enlisted or drafted-  drafted veterans may experience higher levels of distrust of authority than veterans who enlisted.

·         Branch of service and rank- Each branch of service has its own distinct culture. Veterans do not always share their rank with friends and loved ones yet sometimes reactions to life events are better understood when this status is revealed. Regardless of rank, each veteran carries a responsibility for fellow soldiers although they cannot ensure their well-being and safe return.

·         Combat or noncombat experience- veterans who were directly exposed to the effects of combat may experience elevated levels of anxiety and posttraumatic stress disorder but noncombat veterans can experience these symptoms as well.

·         Type of war or time served- each war or conflict carried its own significant burdens which may be re-experienced by veterans at the end of their lives.

·         Prisoner of war experience- we cannot begin to imagine what our POW veterans have experienced physically, mentally, and emotionally.  At the end of life, these experiences may be the ones that color their memories.

For health care providers, being aware of an individual’s military history and the elements to which the veteran was exposed can assist in proper diagnosis and intervention. Establishing a process to inquire about an individual’s military history has proven successful for numerous health care providers. The VA, in collaboration with the National Hospice and Palliative Care Organization, has developed a simple Military History Checklist that reviews the above factors for each patient to enable providers to best serve Veterans’ unique health care needs. The Military History Checklist is available online at www.wehonorveterans.org and through numerous electronic health record platforms.

In addition, it is important to invite veterans approaching the end of life to tell their stories, to celebrate their accomplishments, and to express appreciation for their service to our county. Thank you veterans, for your service to our country. 

Contact Kami Norland for more information about how the National Rural Health Resource Center is involved in honoring veterans end-of-life care needs.

Health Care Provider Retention

Angie LaFlamme, Program Coordinator II

In September I attended the 17^th Annual National Rural Recruitment and Retention Network (3RNet) Conference in beautiful Tacoma, WA. This conference is always great for reconnecting with colleagues and friends to catch up, share stories and best practices as well as discuss and learn about all things recruitment and retention. The conference agenda was packed full of extremely knowledgeable speakers on a variety of topics including recruitment and retention, National Health Service Corps news, immigration updates and rural education to name a few.

One of the agenda items that really intrigued me was a presentation called Retrofitting Retention Resources by Sharon Vail, Executive Director of the Rimrock Health Alliance. She shared an effective tool for the retention of physicians in rural communities where each factor within the matrix was assigned a color, as well as a numeric value and was broken into 5 divisions: Geographic, Scope of Practice, Medical Support, Hospital/Clinic/Community Support and Future Opportunities. The assessments are not tied to performance reviews, but used to help physicians be as successful as possible. The Rimrock Health Alliance believes that knowing your strengths and challenges as a health care facility is extremely important and that the importance of a good retention plan will leave nothing to chance.

At The Center we recognize the importance of a good retention plan and believe it is vital in retaining providers and protecting that investment both from a business and community perspective. The estimated costs of replacing one primary care physician can result in a minimum of $20,000 to $30,000 in recruitment costs and a loss of $300,000 to $400,000 in annual gross billings plus additional expenses related to ancillary employment within the community.

Health care provider turnover is disruptive to health care delivery, continuity of care and patient loyalty within the community. Other negative effects such as low morale and decreased efficiency only add to the reasons to why it is so critical to have an effective provider retention plan aimed at decreasing turnover and preserving a stable health care provider workforce. Keep in mind that retention plans will only be successful if an organization and surrounding community are committed to it.

The Midwest Retention Toolkit is an excellent tool to help guide you in creating your own retention plan. It was created by The Center and the National Rural Recruitment and 3RNet under contracts with the Indiana State Department of Health; Minnesota Department of Health, Office of Rural Health and Primary Care; and Wisconsin Department of Health Services, Primary Care Office; and the Wisconsin Primary Health Care Association through funding from the National Health Service Corps.

This toolkit includes worksheets, sample surveys, agendas, and plans that may be utilized with all of these types of providers although many of the samples are based on physician retention. The tools ensure they are properly orientated to the practice, integrated into the community along with their family and recognized for their service and impact on local health care. The toolkit also features a national resource section with websites and contact information.

To access the Midwest Retention Toolkit and begin building your retention plan, log onto https://www.3rnet.org/resources.

 “Physician retention is more than keeping physicians from leaving the organization. It is about retaining the hearts and minds, commitment and loyalty of our physicians.” Kaiser-Permanente

EHRs and the Long Road to Quality Excellence

Terry Hill, Executive Director

(This content was originally published for the Texas Organization of Rural & Community Hospitals)

My mom often told me, “The road to hell is paved with good intentions.” Her words come to mind now, as I consider rural hospitals’ long, bumpy road to meaningful use of electronic health records (EHRs).  In the past several years, our National Rural Health Resource Center has worked with dozens of rural hospitals across the United States. Almost all have struggled to meet the challenging deadlines, with insufficient resources and inadequate understanding of how it’s all going to work. Rural hospitals started out in EHR adoption significantly behind their urban counterparts, and they continue to trail in the race to meaningful use and the associated financial incentives.

Many of the obstacles and breakdowns are beyond the control of individual hospitals. National legislation locked in some of the deadlines, incentives and processes, and federal agencies such as the Office of the National Coordinator (ONC) have good intentions, but limited understanding of rural hospital circumstances. We should all be used to this by now. Health policy makers have historically overlooked rural in most of their major plans and policies.

Instead of lamenting the unfairness of the circumstances, let’s look instead at what rural hospitals can control with EHR implementation. At the top of the list is the crafting an inspiring vision as to why all of this disruption is necessary. And, this must be developed and communicated by top leadership, and cannot be delegated to others. Ultimately, EHR implementation has to be about quality and patient safety, not technology. At its best, an EHR system can hardwire quality. Paper medical records have proven to be dangerous and inefficient, and are archaic holdovers from the twentieth century.  Almost all other industries have moved on to electronic records because they are more accurate and provide vastly superior information for decision making. Health care is not an exception; numerous studies have shown the benefits of EHRs, and their role in improving quality and safety is no longer in question.

After leadership develops the compelling EHR vision, it is necessary to plan the road from where the hospital is now, to where it wants to be. This strategic plan for EHR implementation must include improving clinical quality processes, providing education, and communicating to staff why this difficult change is eventually going to be worth the time and effort.  In short, IT HAS TO BE ABOUT QUALITY!  In most hospitals we’ve worked with, this key message is not adequately communicated. The road to meaningful use, to financial incentives or to some techie’s vision of nirvana, does not inspire the staff, nor does it enlist the physicians.

Determining the inspiring destination, charting the course and getting the right people on the bus does not mean that the road will be easy, but it will mean that arrival at the final destination will be worth the long trip, and you may enjoy yourself more along the way.  In this approach to EHR adoption, technology will be appropriately used as a tool and not as a destination. Improved patient care will be the big payoff, and staff and leadership will look back proudly at having survived the turmoil and making their local health care system safer and more efficient. With this approach my mom’s road to hell will turn out to be the road not taken.

A Gaping Hole in Achieving MU Beyond 2014

Joe Wivoda, Chief Information Officer

The new Stage 2 requirements for meaningful use have a significant focus on patient engagement and information exchange. There are also more requirements for physicians and others to use their electronic health records (EHRs) more completely (e.g. increased use of computerized provider order entry), but the requirements for information exchange and patient engagement represent a significant challenge, and exciting opportunity, for hospitals and clinics, both rural and urban. The requirement to have 5% of unique clinic patients (5% of hospital discharges) actively view their health information will take concerted communication and marketing efforts, but the electronic exchange of summaries of care at transitions will be the most difficult.

The reason this requirement will be the most difficult is because many of the players, such as long term care and home care, have no financial incentive to implement EHR technology that can accommodate electronic exchange. The rule states that 10% of transitions to a new care setting must have a care summary transmitted electronically. Consider a rural hospital as an example: Rural populations are often older than urban, and many care transitions are to home care or long term care (LTC). The numbers are difficult to find, but according to Examining Post Acute Care Relationships in an Integrated Hospital System (Feb. 2009, available from http://aspe.hhs.gov/health/reports/09/pacihs/report.shtml), 35.2% of Medicare patients were discharged to either long term care or home care. Considering that the majority of discharges are to the patient's home, long term care and home care represent the majority of discharges to other facilities.

Many long term care facilities have EHRs that are used for documenting care, but like hospitals and clinics, they vary in their capabilities and level of adoption. Most LTC EHRs are designed around payment requirements; documenting primarily what is required to get reimbursed by Medicare and Medicaid. Since meaningful use does not apply to LTC or home care, their EHRs are not focused on information exchange. Thus, we are faced with the requirement of exchanging information with facilities that have no financial incentive to implement expensive upgrades to their EHRs to accommodate the hospital's requirements so the hospital can get more money. That is a tough sell.

We know that this is the right thing to do for patient safety and efficiency. Hospitals should be looking at their referral patterns and talking with long term care facilities about the benefits of exchanging information electronically. Networks are perfectly positioned to facilitate these conversations. Know that it will take time to implement the technology required, both at the hospital and the LTC facility, so start planning now. Without partnering with LTC it will be nearly impossible to meet the information exchange requirement in Stage 2.

Hospice Redirects Newton’s First Law of Motion

Kami Norland, Community Specialist

It is easy to get wrapped up in the day-to-day doldrums of life even if you are leading a “mission-driven” life of working for a non-profit health care organization. One can easily become consumed with tasks and deadlines and forget about how each of these daily, “up-stream” tasks contributes towards making a positive impact on the world; after all, it’s only natural to follow Newton’s first law of motion which states: Every object in a state of uniform motion tends to remain in that state of motion unless an external force is applied to it.

Recently I was preoccupied with Newton’s first law until an external force jarred my uniform motion into a new awareness. This external force was a lesson I learned through The Center’s contract with the Department of Veterans Administration (VA) where we partnered with five community hospice organizations to focus on improving care coordination for rural Veterans requiring end-of-life care. I observed how these hospice providers work diligently to assess each patient as an individual and deliver high quality, customized care where treatment is designed to relieve symptoms and provide comfort and support to individuals with life-limiting illnesses. In my opinion, the concept of hospice care is valuable because it leads the American health care system in providing holistic care where individuals are treated as complex, multi-dimensional creatures that require support and dependence in all aspects of living, not just physical, but mental, social and spiritual as well.

As I listened to these hospice providers share their stories of facing mortality daily, I felt their compassion and their wisdom for what it means to truly embrace life and the value of relationship building. They spoke of their patients with genuine care as they described how they stop their Newton’s law of motion to simply listen and accommodate to their patients’ needs. They acknowledged that there is so much they can do for people at the end-of-life: pain relief, support for emotional, social and spiritual care and that hope does not have to be lost when looking at options such as hospice and end-of-life care. Each of the community hospices also described how they embrace the philosophy to live life to the fullest—even until death.

Despite this philosophy sounding so cliché; I find solace in this perspective because it enables me to establish a well thought out plan of how I want to perish, where, with whom and under what circumstances I am presented with reaching this stage of life. I know myself best and know how I want to be cared for. Noting how there are discrepancies in how my family members perceive mortality, I want to be able to eliminate potential disagreements, distress and financial strain on my loved ones when it is my time to go; so even though I am relatively young, safe, and healthy, I want to document an advanced care plan so I can be assured that my desires for living life to the fullest even until death will be met by my care team.

“Advanced care planning, if done at the right time, and done well, helps prevent unnecessary suffering at end-of-life” explained one hospice provider. As a society, I think we need to recognize that at the two poles of life—when we’re born and when we die—we have to be fully dependent on others. We don’t consider the absolute dependence and vulnerability, even incontinence, of infants and toddlers as anything abnormal or undignified because we’re physically dependent on others, so why do we as a culture view this differently towards our exit in life? At both poles of life, caring for another is what we do; it’s part of our very humanity and hospice providers can offer this type of humanity more effectively if this service is offered locally and a plan has been discussed.

Receiving hospice services is rare for several reasons. Foremost, it’s because we live in a culture of advanced medicine where physicians are trained to provide every intervention possible to treat or cure - and most often, up until death. There appears to be a common perception that if the physician, the patient, and the family can’t do “everything possible to treat”, then they have failed—the illness or injury won. The result of this action is that the patient will sometimes endure ongoing, painful and expensive treatments because it is admittedly extremely difficult to “let go”. Then in the end, the patient and the family has little or no time to process or prepare for this important transition in life and the family is left with exorbitant medical bills and a sense of loss and defeat. Hospice services may also not be formally offered in hospitals because it is not historically considered a profitable service. However, on the contrary, hospice services can provide financial benefit to a hospital as it eliminates the number of emergency room visits and costly medical treatments. Research indicates that the last six months of an individual’s life are the most expensive if traditional medical treatments focused on curing, rather than providing comfort are administered.

I can imagine that most of you are now thinking “what a morbid thought” and may feel uncomfortable approaching this taboo subject of death. I get it, I come from a stoic Norwegian family and even broaching a blog about this topic is reminiscent of the awkward conversations driven by parents about teenage sex, and akin to that conversation, I, like my parents felt then, feel now that this is a life lesson that if we prepare ourselves for this stage in our lives, we could prevent unneeded suffering, reduce the burden on our families, all the while having our needs met. So, I encourage you to create that external force in your uniform motion and consider an advance care planning conversation for yourself, for your loved ones; for this is not a conversation about death, rather a conversation about living and how you choose to live your life up until death.

To aid in this discussion and for more information, reference the video and discussion guide at http://www.considertheconversation.org.

Final Meaningful Use Stage 2 Rule Commentary--"Now Is the Time"

Joe Wivoda, Chief Information Officer

The final rule for Stage 2 of Meaningful Use came out August 23rd--earlier than expected and with few actual surprises. CMS took the public comments seriously and modified the proposed rule in many areas based on those comments. The final rule is released with commentary and is a full 672 pages long, and this overview is based on a quick review. More information will be available as we dig into the rule further.

Don't forget, this rule does not go into effect until 2014 at the earliest. If you attest to Meaningful Use Stage 1 you get two years to reach Stage 2, unless you attested in 2011, in which you get three years.

There is no reason to panic, you have time to understand the new rule, but there are some themes that are important to be aware of now.

Utilize Your EHR

The menu requirements for Stage 1 have, for the most part, been incorporated into core requirements in Stage 2. Many of the core requirements have higher thresholds under Stage 2. This means that you will need to utilize your EHR more. For example, in Stage 1 the CPOE requirement was that 30% of patients have at least one medication order. One could argue that if you met that requirement exactly, and no more, you would be operating in a less safe manner, since you now have multiple processes for the same tasks. The new rule for CPOE is that 60% of medication, 30% of lab, and 30% of radiology ORDERS need to be in CPOE.

Now is the time to understand the new core requirements and begin planning and redesigning workflows to meet them.

Information Exchange

Electronically transmitting information for transitions of care for 10% of care transitions is a new requirement for Stage 2. The work that is being done on HIEs today will create the infrastructure for these transmissions, but more work will need to be done. Since so many hospital discharges are to long term care (LTC) facilities, hospitals will need to work with them to participate in the HIE. LTC does not receive any incentives for Meaningful Use, and many LTC EHRs are not prepared to exchange information today (though some are).

Now is the time to consider your referral patterns and engage those providers to begin planning for information exchange.

Patient Engagement

Under Stage 1 providers only needed to provide electronic information to patients when they asked for it, and then providers were only required to provide it 50% of the time. Stage 2 will require hospitals and eligible professionals to not only provide the information, but it also requires that 5% of patients access their information through a portal. There is also a requirement that 5% of patients are communicated with using secure messaging. There are exclusions for areas that have limited Internet connectivity, but almost all providers will need to meet these requirements.

Now is the time to talk with your vendor about their portal offerings, or if they can interface with a Personal Health Record (PHR), and begin planning how you will engage patients to actively view their information online.

Clinical Quality Measures

The requirements for Clinical Quality Measure reporting in Stage 1 were fairly easy, although the measures did not necessarily apply well to rural facilities. The new rule provides many more options for reporting and electronic submission will be required. More information will be available about the quality measures that you can choose from.

Now is the time to speak with your vendor to make sure that the reports you think are most appropriate are incorporated into the Stage 2-certified version of your EHR.

Some Changes to Stage 1

There are some changes to Stage 1 requirements that go into effect in 2013 and 2014. Many are additional exclusions. For example, if you can demonstrate that collecting some vitals are not part of the scope of your practice (e.g. Chiropractor), then you do not need to meet the objective of collecting vitals. The requirement of exchanging clinical information will be removed in 2013, but since the Stage 2 exchange requirements are so important, you cannot put off work on the exchange requirements.

Now is the time, if you have questions about those exclusions, to understand the changes to Stage 1.

Conclusion

The new Stage 2 rules for Meaningful Use have only been out for a few hours, and for the most part do not go into effect until 2014 at the earliest. This provides time to fully understand the rules and begin discussions with your vendors, referral partners, patients, HIE, and other stakeholders to properly prepare to meet the rules. The purpose of these new rules is to encourage health care providers to utilize electronic systems to be more safe and efficient, and to improve quality. Information exchange between providers of care and providing relevant clinical information directly to patients electronically are important ways to achieve these goals.

More Information

CMS final rule * CMS final rule (42 CFR Parts 412, 413, and 495) * Fact sheet on CMS's final rule

ONC standards and certification criteria final rule * ONC final rule (45 CFR Part 170) * Fact sheet on ONC's standards and certification criteria final rule - forthcoming

More information on the Stage 2 rule * HHS news release * CMS EHR Incentive Programs website

A Lot to Learn from the Last Frontier

Joe Wivoda, Chief Information Officer

Rural health care faces many challenges, such as workforce attraction and retention, geographic constraints, and the high cost of HIT.  These problems are magnified in Alaska.  With a population of less than 750,000 (47th in the US) and an average density of 1.2 people per square mile, it becomes clear why The Last Frontier presents so many challenges to health care (and I didn't even mention the winter weather).  As part of our Technical Assistance to Rural Health HIT Network Development grantees I was privileged to spend a few days in Alaska getting more acquainted with them and how they overcome some of the challenges to providing healthcare in this beautiful state.

With so much land area and low population density it is difficult to provide traditional access to health care.  Some clinics are hundreds of miles from a hospital, and with Alaska's unpredictable weather flying can be difficult.  The Alaska Native Tribal Health Consortium (ANTHC) has created a vast telemedicine network to support rural clinics.  During my visit with Richard Hall at ANTHC, I learned that they have been doing amazing work to bring primary care services to remote areas using HIT, while coordinating the efforts of several organizations to make it happen.

One of the organizations that ANTHC partners with is the Tanana Chiefs Conference.  I was able to spend the day with Jim Williams at Tanana Chiefs and visited the clinic in Nenana.  At the clinic I talked with a Community Health Aid/Practitioner (CHAP) that provides care to several patients each day.  The CHAP program was designed to overcome workforce shortages that exist in small villages across Alaska and consists of 16 weeks of training plus preceptorship and practicum.  I was impressed with the amount of telemedicine and telepharmacy that was in use at the clinic!

Alaska has a number of critical access hospitals that are located far from tertiary facilities.  The Alaska State Hospital and Nursing Home Association (ASHNHA) has formed a network of some of these smaller hospitals to "support the use of HIT as a tool to improve the quality and cost efficiency".  Like many other rural hospitals, these facilities struggle with finding HIT talent, and most of them have one IT person on staff with limited access to outside resources.  I spent a day with Jeannie Monk and spoke with the member CFOs about Meaningful Use and the financial incentives.  These hospitals are working closely with each other to find ways to share expertise and best practices, even though they are hundreds of miles apart in many cases.

Alaska is a vast, beautiful place.  The geography and size, along with a small population and cold winters, create significant challenges to providing health care to the native and non-native communities.  All three of the networks that I visited in June are doing amazing work to overcome these challenges.  There is much we can all learn from them.

Health Reform, the Supreme Court and Networks—Finding Comfort in the Chaos

Sally Trnka, Senior Program Coordinator

(This content was originally published in Cooperative Connections Newsletter)

Raise your hand if you are exhausted from the never ending news coverage, heated campaign promises, and scores of misinformation being broadcast pertaining to health care reform.  (It’s okay…go ahead!)  The complexities and confusion surrounding the recent Supreme Court decision aren’t lost on anyone and the confusion is compounded by election-year rhetoric and posturing that dismantles communication and banishes progress.  Since we’re not running for office, we’ll give it to you direct—and with a sprinkling of enthusiasm for the role of rural health networks in the changing healthcare landscape.  

The 5-4 Supreme Court ruling upholding the Affordable Care Act determined that the individual mandate, the most controversial part of the ACA, was a valid exercise in Congress’s power to tax (although it is not a valid exercise of the Commerce Clause, which was the clause that many opponents were expecting would deem the mandate unconstitutional).  In addition to upholding the policies and provisions that are scheduled to take effect in the coming years, the ruling solidified that the money, payment modifications and workforce modifications that have already gone into effect will not be rescinded. 

Okay, so that much you know, but what does all of this mean for rural?  There are a variety of rural-specific provisions within the ACA that will move forward as scheduled because of the ruling.  A compressive list of the rural-relevant provisions can be found on the website of the National Rural Health Association (NRHA).  Because it’s a long list, we’ll walk through a few of them, and why they are critical to the success of rural health care facilities. 

Approximately 25% of the country’s population resides in rural areas however, there are more rural Americans who are uninsured and underinsured than their urban counterparts.[1] The ACA contains provisions for the guaranteed issue and coverage renewability, along with the prohibition of exclusions based on pre-existing conditions.  This will help to ensure that more citizens are covered.  Increased coverage, however, does not equal access and workforce shortages will continue to be felt acutely in rural communities.  Currently, less than 10% of physicians serve the country’s rural population and with increased insurance coverage, the strain felt by providers will be even greater.  Included in the ACA are investments in the National Health Service Corps which will assist medical students with scholarships and loan repayment programs should they decide to practice in rural communities.  The ACA also designates critical access hospitals, for the first time, eligible sites for Corps assisted physicians.  The ACA also calls for increased funding for Area Health Education Center’s (AHEC) to improve the pipeline of potential future health care leaders, although the House of Representatives recently voted AHEC out of the running for funding for next year.  (Hopefully the Senate will reinstate funding.)  The improvement in the rural healthcare workforce will be vital to support the higher rates of chronic disease exhibited in rural communities[2].  With an increased focus on primary care and prevention, the ACA incentivizes patients to seek care before their condition becomes chronic or requires treatment from a specialist. 

Networks will play a crucial role in all of the health reform models as rural providers and hospitals become valuable players in both accountable care organization (ACO) and Medical Home demonstration projects.  The development and participation in ACO and the Medical Home concept all require collaboration, staff and resource sharing, collective innovation, and willingness to challenge the status quo.  Increasingly, rural hospitals will have to prepare themselves for a challenging future, based on value, quality transparency, and physician-hospital partnerships while maintaining a successful business model in the current system.  It’s is somewhat like navigating two canoes downstream with a leg in each canoe…it could end up being very painful!

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[1] Lenardson, J., Ziller, E., Coburn, A. & Anderson, N. Profile of Rural Health Insurance Coverage: A Chartbook. Rural Health Research and Policy Centers. June 2009. 

[2] Glasgow, N., Johnson, N., Morton, L. Critical Issues in Rural Health. Wiley-Blackwell. May 2004. 

A special thank you to the National Rural Health Association for their breakdown of the rural-relevant provisions in the ACA.