Tim Size, Executive Director

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Rural Health Advocacy 24 hours a day 7 days a
week
Tim Size, Executive Director Rural Wisconsin
Health Cooperative Sauk City, Wisconsin
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Outline of Presentation

• Myths About Rural Are Alive Well
• Almost Worst Rural Health Policy Awards for
  2005
• Cross Section Public-Private Rural Health Issues
• Medicare Advantage
• Physician Supply
• Healthcare Costs
• Population Health
• Becoming More Effective Active Advocates

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MYTHS ABOUT RURAL
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Myths that Mislead Public Private Policy

• Rural is west ( TX, NC, PA, OH, MI, NY top rural
  pop )
• Rural Americans are naturally more healthy
• Rural economy is mostly about agriculture
• Rural health care costs less than urban care
• Rural health care is inordinately expensive
• Rural health care is lower quality urban is
  better
• Rural hospitals are just band-aide stations
• Rural hospitals clinics are poorly
  managed/governed
• Rural residents dont want to get care locally

U.S. 2000 Census, Non-Metro Population By State
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2005 Almost Worst Rural Health Policy Awards

• ? First Draft of June MedPAC Report
• ? 1st Launch of Hospital Compare Web Site
• ? Proposed CMS Rural Hospital Building Ban
• ? Federal Appropriations Bill for FFY 2006

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Medicare Payment Advisory Commission

• CAH payment designation ended two decades of
  failed attempts to retro-fit to rural the PPS
  Medicare payment methodology designed for large
  urban hospitals
• MedPAC is an advisory commission to Congress
• The initial draft of the June MedPAC report was
  seen as inaccurate, hostile review of the CAH
  program
• Draft framed CAH designation as Federal charity
  with recipients having to prove they were
  deserving poor
• The pushback from Commissioners, with technical
  help from the field, was substantial and effective

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Hospital Compare Labled CAH as 2nd Class
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NRHA Responded with Reporting Guidelines

• Need to actively prepare for future when payers
  and consumers pay attention to public reporting
• Rural hospitals should fully engage in the
  quality improvement and public reporting movement
  
• CAHs and PPS are both acute care hospitals
• CAH or PPS difference not relevant to quality
  report
• Compare service outcomes, not institution size
• Consumers should be able, at a minimum, to
  readily compare all hospitals in their hospital
  referral region

NRHA Policy Brief Approved 5/20/06
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Proposed Building Ban
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Appropriations Fight in 2005 for 2006

• President proposed to eliminate 8 programs worth
  232 million and dramatically cut 3 others.
• House of Representatives followed many of those
  recommendations the Senate did not.
• The first Conference Report eliminated 6 programs
  worth 134 million and dramatically cut several
  others. But it was defeated 209 to 224 in the
  House!
• The final bill restored funding for research and
  policy and AHECS, and added money for outreach
  and community health centers. Some programs
  still cut.

Jennifer Friedman, VP Government Affairs and
Policy National Rural Health Association
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Presidents Again Slashes Rural Health
Does not include 29 million cut from eliminating
AHECs total cuts are over 160 million.
Jennifer Friedman, VP Government Affairs and
Policy National Rural Health Association
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Cross Section Rural Health Issues
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Challenges of a Privatized Medicare
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Strong Access Standards Are Key

• Beneficiary rights to local access, even if out
  of network, is key for beneficiaries and for
  local providers to have any clout in plan
  negotiations
• Plans must ensure that services are
  geographically accessible and consistent with
  local community patterns of care.
• Need to open up current black-box which limits
  beneficiary awareness and evaluation of CMS
  enforcement of consistency of access standards
  across plans, markets and time

CMS Medicare Managed Care Manual, Chpt. 4, page
57
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Protecting CAH/RHC Reimbursement

• HR 880 (Ron Kind) pay for CAH RHC at a rate
  that is gt 101 percent traditional Medicare
• SB 2819 (Coleman/Durbin) is comparable to HR 880
  adds option of 103 percent of the applicable
  interim payment rate
• Right to local access still key payment rates
  are meaningless if patients can be steered
  elsewhere
• AHA NRHA Supporting

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Other Needed Medicare Advantage Improvements

1. Major increase beneficiary decision-making
   assistance
2. Immediate on-line verification beneficiary
   coverage
3. Restore States Rights to question plan behavior
4. Regional CMS Office role as source of definitive
   info
5. Regional CMS Office handle provider complaints
6. Plan applications on-line within 30 days of
   approval
7. Full/timely transparency re enrollment and
   quality data
8. Encourage collaboration amongst rural providers
   to level playing field re contract
   development/review

DHHS National Advisory Committee on Rural Health
Human Services, Medicare Advantage
Sub-Committee, 6/13/06
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PHYSICIAN SUPPLY
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Wisconsin Academy of Rural Medicine

• Builds on pioneering work of Howard Rabinowitz at
  Jefferson Medical College in Philadelphia.
• Result of 25 years asking land grant UW be true
  to roots
• Goal rural focused medical school within the
  Madison based University of Wisconsin medical
  school
• Recruit students with rural background and career
  goals
• Locate education and training programs in rural
  areas of WI during 3rd and 4th years of Med
  School
• Use rural appropriate curriculum

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HEALTHCARE COSTS
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Health Care Costs - Review of Reality

• In 2005, employer-based health insurance premiums
  rose by 9, the fifth consecutive year over 9
• HMOS, PPOs and POS plans all showed this increase
• Annual premium charges an employer for a health
  plan covering a family of four averaged 10,800
  in 2005
• Gross earnings, full-time, minimum-wage 10,712
• Since 2000, premiums have increased 73, vs 14
  cumulative inflation 15 cumulative wage
  increase
• The average employee contribution has increased
  more than 143 since 2000

National Coalition on Health Care
http//www.nchc.org/
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What To Do About Unsustainable Cost Trends?

• Most agree that health care costs must be
  controlled but disagree on the best ways to
  address rapidly escalating health spending and
  health insurance premiums
• Price controls and imposing strict budgets on
  health care spending?
• Free market competition solves the problem?
• With healthier lifestyles, less medical care
  required?
• Cost of inaction will severely affect employer's
  bottom lines, business location and consumer's
  pocketbooks
• How do different approaches effect rural health
  care?

National Coalition on Health Care
http//www.nchc.org/
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POPULATION HEALTH
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Health Outcomes Driven By Multiple Determinants

• Access to Health Care (est 10)
• Health Behaviors (est 40) e.g. smoking, physical
  inactivity, overweight, sexually transmitted
  disease, motor vehicle crashes
• Socioeconomic factors (est 40) e.g. education,
  poverty, divorce rates
• Physical environment (est 10)

2005 Wisconsin County Health Rankings, University
of Wisconsin Population Health Institute
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Critical Link Population Economic Health

• Businesses will move to where healthcare
  coverage is less expensive, or they will cut back
  and even terminate coverage for their employees.
  Either way, it's the residents of your towns and
  cities that lose out, Thomas Donohue?President
  CEO, U.S. Chamber of Commerce
• If we can change lifestyles, it will have more
  impact on cutting costs than anything else we can
  do, Larry Rambo, chief executive officer of
  Humanas Wisconsin and Michigan health insurance
  markets.

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Initial Local Hospital Community Steps

• Devote a periodic Board meeting to review
  available population health indicators
• Add Board members with specific interest in
  population health measurement and improvement
• Create a population health subcommittee of the
  hospital board to explore opportunities for
  hospital partnerships with other community
  organizations
• With local employers, develop interventions to
  improve employee health expand experience to the
  larger community

Population Health Improvement Rural Hospital
Balanced Scorecards by Size T, Kindig D,
MacKinney C., Journal of Rural Health 3/06
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Strong Rural Communities Initiative

• Sponsored by states Rural Health Development
  Council embedded in Wisconsin Department of
  Commerce
• Acquired 700K from 3 sources with 4th looking
  good
• The goal improve health of rural communities and
  reduce healthcare cost inflation by accelerating
  use of collaboration among medical, public health
  and business organizations that enhance
  preventive health services
• Six local community projects chosen from 22
  proposals
• Variety approaches to modifying poor fitness,
  nutrition habits through wellness programs at
  work/community

RWHC Eye On Health Newsletter, 7/06
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ADVOCACY SKILLS
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Besides Funding, What Drives Advocacy?

• Need to Correct Bias - MedPAC Report
• Opportunity to Reframe - Hospital Compare
• Short-term Fix Needed/Possible - Building Ban
• Broad Coalition Possible - R.H. Appropriations
• Address Core Need - Physician Supply
• Anticipate Problems - Medicare Advantage
• Cant Be Avoided - Healthcare Costs
• Long-term Significance - Population Health

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Your Advocacy Behaviors Matter

• Be Brief
• Be Accurate - NEVER false or misleading info
• Personalize Your Message - cite examples
• Be Prepared - know your issue
• Be Aware Every Issue Has Two Sides - there are
  voters on other side
• Be Courteous/Dont Threaten
• Be Patient - long process be in for long haul

Wisconsin Hospital Associations Grass Roots
Handbook
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NRHAs Three Prong Advocacy Strategy

• Make your best case Develop concise, credible,
  persuasive, fiscally responsible, but emotive
  arguments.
• Make friends and form alliances Find
  Congressional champions, develop agency contacts,
  form alliances with a diverse set of groups.
• Make it happen Use some or all of your advocacy
  tools government relations, grassroots and
  media advocacy based on your level of
  engagement.

Jennifer Friedman, VP Government Affairs and
Policy National Rural Health Association
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Rural Health Needs Your Advocacy 24/7

• Rural advocates have an ongoing challenge, an
  attitude in parts of Washington, and around the
  country (including CMS) that is frequently ill
  informed, about rural health and the reality of
  improving rural health and health care
• Rural advocates must not become complacent, all
  of us must become more skilled and more active.

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