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Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN, MPH, Policy Director, Clinical Issues June 24, 2014
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Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Dec 18, 2015

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Page 1: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Understanding the Evolving Rural MarketplaceCost, Quality, Access, and Population Health

Andrew Busz, FAHM, Policy Director, FinanceIan Corbridge, RN, MPH, Policy Director, Clinical Issues

June 24, 2014

Page 2: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

How is Rural Different?

Geography Population/Demographics Payor Mix Volume of services- Impact on cost per unit due

to higher proportion of overhead costs Capitation and risk sharing difficult due to low

enrollment numbers.

Page 3: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

The Jigsaw Puzzle of Provider Types in Rural Areas.

• Combines different approaches to ensure access to care in rural areas.

• The mix of provider types and degree of collaboration is unique to each community.

Page 4: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Critical Access Hospitals

Restricted in some ways, granted greater flexibility in others compared to larger hospitals

Cost-based payment for Medicare and Medicaid

Page 5: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Federally Qualified Health Centers

Specific board structure, including consumers Serves underserved clientele in urban and rural

areas Provides wrap-around services Required to take all comers on a sliding-scale

basis Paid an encounter rate by Medicare and

Medicaid FFS, rather than fee schedule

Page 6: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Rural Health Clinics

Required to employ or contract with mid-level providers (PA or ARNP)

Paid an Encounter Rate by Medicare and Medicaid FFS, rather than fee schedule

Encounter rate for hospital-based RHCs reflects hospital cost component

Page 7: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Free Clinics

Primary clientele is uninsured population Primary financial support through donations or

hospital sponsorship Clinical care provided by area providers on a

volunteer basis Many now closing due to ACA coverage

expansions

Page 8: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Independent Physicians and Clinics

Paid regular fee schedule by Medicare, Medicaid, and Commercial Insurance

Increasingly rare in rural areas due to payor mix

Page 9: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Public Health and Social Service Agencies

Publically funded Focus on population health and preventative

services

Provides services generally not covered by insurance

Page 10: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Regional Support Networks and Community Mental Health

Funded directly by the state

Regionally organized

Generally coordinated with, rather than integrated with medical services

Page 11: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Population Health and Quality in Rural Areas – the Current Environment

Page 12: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

A Health Snapshot

County Health Rankings, accessed on 6/1/14 http://www.countyhealthrankings.org/resources

Page 13: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

What Influences Health

County Health Rankings, accessed on 6/1/14 http://www.countyhealthrankings.org/resources

Page 14: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Funding Population Health

• Poor incentives

• Eroding funding for public health

• Grants, are they a solution or a double edged sword

Personal Health Care84%

Public Health

3%

Other14%

National Health Expenditures 2010

CDC, accessed on 6/1/14 http://www.cdc.gov/nchs/data/hus/hus13.pdf#112

Page 15: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Community Health Needs Assessment – A Brief Look

Priority 1

Priority 2

0 5 10 15 20 25 30

Health Promotion Behavioral HealthObesity Tobacco UseChronic Disease Social Determinants of Health/Health DisparitiesAccess to Care

Page 16: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Population Health Quality

• USPSTF prevention screening recommendations are free under the ACA… however

• Poor prevention screening across the state

• Rural residents are less likely to receive preventive services

The Commonwealth Fund and NORC, accessed on 6/1/14 http://www.commonwealthfund.org and http://NORC.org

Page 17: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Population Health Quality (cont’d)Mammography Screening

County Health Rankings, accessed on 6/1/14 http://www.countyhealthrankings.org/resources

Page 18: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Rural Quality Measurement• Largely sheltered from national level measurement

• Us-side vs. Down-side

• Challenge of the “small N”

• Few rural specific measures• NQF website – 7 measures tagged with a “rural”

designation• Total NQF measures = 637

• Are rural specific measures needed?

Page 19: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

The Managed Care Environment

Page 20: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Managed Care Plans Defined population and benefits

Historically focused on per unit costs

Short term return horizon

Risk avoidance

Historically not responsible for global issues such as uninsured costs, teaching costs, or overall population health

Page 21: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Current Managed Care Workarounds for Rural Providers

Medicare Advantage: based on FFS cost-based or encounter rates

Medicaid: enhancement/reconciliation to shield plans from higher per unit costs

Commercial: percent of charge rather than prospective arrangements

Page 22: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Threats to Critical Access Hospitals

Cost-based payment/ geographic restrictions

Provider supervision changes

Length of stay restrictions/ 96 hour rule

Inadequate network adequacy standards

Page 23: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Threats to FQHCs and RHCs“The FQHC/RHC’s unique payment methodology does not always promote efficiency and value and increasingly impedes some state’s evolving delivery system and payment transformations.”

2/24/2014 letter from National Association of Medicaid Directors to HHS

Page 24: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Making the Transition

Page 25: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Accountable Care Organizations

Requires large population/geography

Requires sophisticated data, contracting, and EHR capabilities

Ability to provide full range of services

Barriers:

Lack of data to manage care

Restrictions on clinical integration

Page 26: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

State Health Care Innovation Project (SHCIP) and Transformation

All-payor Database –Claims data Availability and sharing of EHR data Role of Accountable Communities of Health

(ACH) Proper allocation of funding that targets root

determinants of health while maintain viability of medical infrastructure and access to care

Page 27: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

ACO

What Direction Will Things Take?

Plan

Provider

Payor

ACH

Page 28: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Population Health and Quality in the Emerging World

Page 29: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Supporting Population Health

• Health care will have greater accountability for the health of a community

• Do we have the right:• Partners,• Resources, and • Payment structure… To deliver population health?

Page 30: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Improving Population Health – Federal Efforts

• ACA• Public Health Fund

• Free prevention screening (SUPSTF A & B)

• CMS Innovation Center – State Innovation Models (SIM) program grants

• Greater focus on population health measures

Page 31: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Improving Population Health (cont’d) –State and Local Efforts

• State Innovation Bill (2572)• Communities of health• Extension program• All payer claims database• Common performance measures

• Behavioral Health Integration Bill (6312)

• State SIM grant application – core focus areas: tobacco use, obesity and diabetes…

Page 32: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

Opportunities to Enhance Rural Population Health Improvement Efforts

• Local collaboratives with broad representation

• Increased focus on screening and prevention

• Measurement• Rural specific measures• Focus on ambulatory care and screening measures

• Use of HIT and new data systems to track and improve quality

Page 33: Understanding the Evolving Rural Marketplace Cost, Quality, Access, and Population Health Andrew Busz, FAHM, Policy Director, Finance Ian Corbridge, RN,

WSHA – Leading Population Health for our Members

• WSHA will:

• Explore state wide population health goal• Help support partnerships and collaboration• Toolkit to support community engagement

• Support the dissemination and spread of new ideas/best practices across stakeholders

• Work toward aligning incentives to support population health