A warm welcome and hearty thanks for reading this message!!  I would like to develop a relationship with you and that means it has to based upon "Trust".  To that end I will work tirelessly to develop new and creative financing, equipment, service and parts strategies and solutions that will far exceed your expectations. 

What you take on as debt, equity or finance/lease can greatly impact your P&L, balance sheet and cash flows and need to be thoughtfully assessed to determine the best path for any project or acquisition.

As a summary of who LFC Capital is:

We are essentially an equipment leasing company.  But so much more.  We are a diverse group of Private Investors that offer Creative, Flexible and Competitive solutions to address the many challenges in IT and Asset (Equipment, etc.) based acquisition, management and disposition strategies.  LFC will also work with other Investors, Private Equity, Venture Capital, Community Banks, Investment Banks, and Hedge Funds to make virtually any transaction and or credit rating possible to finance.  All in an effort to tailor a solution to improve their Clinical Quality, Operational Efficiencies and Financial Performance!

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While the temporary, one-year SGR bill included a number of rural victories, including the extension of critical rural Medicare extenders, the package left many rural health care providers wanting more.  Among other items, the bill did not address the problematic 96-hour condition of payment rule for Critical Access Hospitals (CAHs) or changes to the physician supervision guidelines that are causing significant challenges for CAHs and small PPS hospitals. 

But NRHA has not given up.  NRHA supported legislation in both the House and the Senate would address both of these issues, and we need you to help us push them forward.  The Critical Access Hospital Relief Act (S. 2037/H.R. 3991) is a bipartisan effort to permanently address the 96-hour condition of payment issue by eliminating the problematic statutory language that CMS is basing its decision on.  The Protecting Access to Rural Therapy Services (PARTS) Act (S. 1143/H.R. 2801) would mandate that CMS revert all physician supervision levels to "general" for CAHs and small, rural PPS facilities. 

Your engagement on these issues, and your advocacy with members of Congress, will be critical to moving these legislative items forward.  NRHA Government Affairs is happy to help any interested parties get in contact with your Representatives and Senators, write op-ed pieces, or organize letter campaigns.  Again, your efforts will be critical to advancing these important issues.  Act now!
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On March 10, 2014, a team from Illinois and Washington made a presentation to the Hospital Outpatient Payment (HOP) Panel that would move a series of codes from direct physician supervision to the general supervision category. CMS has rendered a PRELIMINARY decision pursuant to regulation that agreed with some recommendations, reversed others and altered one. The list of recommend changes and the CMS preliminary decision on each is listed below:

36430   Blood Transfusion Services—change from direct supervision to extended duration

36593   Declot Vascular Devices—change to general supervision 

96401   Chemo anti-neo sq/IM—keep direct supervision

96402   Chemo horma anti/neo sq/IM—keep direct supervision

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Would you agree?  Hiring and maintaining a staff dedicated to cost accounting in healthcare is a perpetual process.  It is a specialty niche that requires dedication and repetition to learn and understand due to the high learning curve.   In our experience, it is hard to find qualified individuals that actually want to do cost accounting on a full time basis.  Once hired, they typically have higher aspirations and move on to other positions when available.  This, of course, affects the continuity of the process. 

Considering the cost of salaries and benefits, non-productive time due to the high learning curve and the reoccurring hiring and training costs due to turnover, internal staffing can be expensive.  Would outsourcing this process be a good option?

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The Journal of Rural Health issue 30:2 is now available online.

Topics covered in this issue include:
Asthma outcomes; rural veterans’ travel reimbursement, high dual use, health and health care access among women, and enhanced community outreach in Alabama; the role of personality in students who choose rural primary care clerkships; determinants of adolescent suicide idealization; clinical decision support systems and rural quality disparities; increasing cervical cancer screening; barriers to cancer symptom management in American Indians; rural Medicaid smokers’ trust in physicians; and volume to value―success strategies for rural providers.

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On March 10, 2014, a team from Illinois and Washington made a presentation to the Hospital Outpatient Payment (HOP) Panel that would move a series of codes from direct physician supervision to the general supervision category. Pat Schou, Executive Director of the Illinois Critical Access Hospital Network (ICAHN), Daniel Congreve, M.D. of Kewanee Hospital, Kewanee, IL and Robert Sinclair, M.D., Lincoln Hospital District #3, Davenport, WA made the trip to Maryland to present the following codes to the HOP Panel for consideration:

36430   Blood Transfusion Services

36593   Declot Vascular Devices

96401   Chemo anti-neo sq/IM

96402   Chemo horma anti/neo sq/IM

96409   Chemo IV push single drug

96411   Chemo IV push add/drug

96413   Chemo IV infusion/hr

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At a hearing in the House Ways and Means Committee this morning, several Members of Congress questioned Department of Health and Human Services Secretary Kathleen Sebelius on the President's Budget Proposal for federal fiscal year 2015. Members from both parties expressed concern about parts of the President's Budget that would adversely affect rural hospitals.  Specifically, proposals related to cuts to Critical Access Hospitals were voiced. While Secretary Sebelius did not directly address the specific cuts proposed, she did voice concern for rural health care and rural patients throughout the nation and promise to work with Committee Members to find rural solutions. Secretary Sebelius also spoke to the expansion of the National Health Service Corps and the Administration's hope that this expansion will help rural patients access more health care providers.

NRHA thanks the bipartisan leaders on the Ways and Means Committee for their continued support of rural health care. More information on the hearing is available here. Please contact NRHA Government Affairs Staff at (202) 639-0550 with any questions.
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March madness is upon us. I’m not referring to the NCAA Basketball tournament, the bizarre weather that transitions from winter to spring or the Ides of March that Shakespeare warned us about. But, we’re counting down to the end of March and the expiration of the Sustainable Growth Rate (SGR) moratorium, low-volume hospital (LVH) add-ons and the Medicare Dependent Hospital (MDH) program. Get ready for the ride because March promises to be a maddening one for rural providers.

NRHA is working hard to ensure that Congress passes a permanent repeal of the SGR and the permanent extension of both the LVH and MDH programs…all without any “pay-fors” that harm rural providers. A schedule of possible pay-fors (repeated from the Obama Budget) have been circulated among Congressional leaders that are very disturbing, which includes eliminating CAH’s within 10 miles from another facility, reduce CAH reimbursements to 100% of costs and reduce Medicare coverage of bad debts.  NRHA has been assured by Congressional leaders that none of the possible pay-fors have been agreed to.

That being said, March madness is here. As we countdown the days until March 31, pressure on Congress to get something passed will mount. Your participation in our

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LEAWOOD, KS, February 24, 2014 – In a letter to HHS Secretary Kathleen Sebelius, the National Rural Health Association (NRHA) and forty-seven other of the nation’s largest healthcare provider organizations issued a joint call for additional time and flexibility in the Meaningful Use program to ensure its continued success.

While underscoring the Meaningful Use program’s invaluable role in advancing technology adoption among hospitals and physicians, the letter states that strict adherence to current program requirements endangers overall success of the EHR program, disrupts providers’ healthcare operations and potentially jeopardizes patient safety.

Hospitals only have until July to adopt, implement, test and train staff to meet either Stage 1 or Stage 2 Meaningful Use requirements in 2014. Eligible professionals have until October to begin collecting data to attest to meeting program requirements.

“Failure to do so will not only result in a loss of incentive payments, but also the imposition of significant penalties,” the letter states, adding that, “it is clear the pace and scope of change have outstripped the ability of vendors to support providers.”

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At NRHA’s Policy Institute (PI) last week in Washington, DC, Scott Goodspeed, iVantage Principal gave a report on the impact of sequestration on rural hospitals nationwide. It appears that one of the possible offsets to pay for a one-year extension of the nation’s debt limit, which is set to expire soon, is to continue sequestration of government funds, including Medicare, until 2024.

Continued sequestration is a dangerous prescription for rural health especially as the federal government considers other ideas to cut the budget deficit. Remember the idea to remove certification of CAH’s that are less than 10 miles from another hospital? Here is a story from west Texas on “Losing Hospitals” that documents what would happen if this bad idea ever became a reality.

Finally, researcher Jan Probst from the South Carolina Rural Health Research Center in Columbia, SC wrote a fantastic

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Each year NRHA honors outstanding individuals and organizations in the field of rural health who have dedicated their time and talents to improving the health and well being of others. Previous recipients have stretched the boundaries of possibility by forging innovative programs and services, making rural life healthier and more compassionate.

Nominations are now open.

Consider nominating your favorite rural health professionals so that they may be honored nationally for their contributions to rural health. The entry deadline is Feb. 11. Selections will be made solely on the basis of a 300-500 word narrative, which is part of the nomination form. If more than three nominations are submitted for a candidate or organization, only the first three will be considered. To ensure an equitable process no letters of recommendation will be accepted. The 2014 Awards Luncheon will be at the Paris Hotel in Las Vegas on April 24 at NRHA's 37th Annual Rural Health Conference.

NRHA will only accept online submissions. Please

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The Journal of Rural Health issue 30:1 is now available online.  Topics covered in this issue included - Rural-urban differences in veteran care: ischemic stroke, adhering to preventive service guidelines and preventing infection; colorectal cancer screening and care in Appalachia; intimate partner violence and depressive symptoms in rural couples; health care avoidance; weight status and lifestyle behaviors in youth; overweight and obesity in a Chinese population by urbanization; telemedicine for weight management; and rural clinician views on remote monitoring technologies.

We currently provide full-text articles online to all NRHA members. To access these articles online, log in to NRHA Connect and click on the "Journal" tab. 

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At the close of a year it’s often helpful to look back and take stock of the year that just ended and plan the start of a brand new year. NRHA had many victories on key pieces of legislation, for which we’re very thankful. So, as we look forward to 2014, here is a recap of the issues that may impact you next year:

  • SGR Fix. The Murray-Ryan bipartisan budget deal contains a temporary moratorium on the implementation of the sustainable growth rate (SGR) formula to the physician fee schedule through March 31, 2014. This means your physicians paid on the Medicare physician fee schedule will not receive a reduction on January 1, 2014. The bad news is we’ll be back in 2014 re-hashing this whole debate with another deadline.
  • Sequestration. The 2% reduction in Medicare payments to providers will continue in 2014, even though defense and education received a reduction in their sequestration cuts.
  • ACA. The affordable Care Act (ACA) will be implemented fully in 2014 as the Marketplace exchange insurance policies become effective on January 1, in addition to Medicaid expansion in close to 25 states. Rural providers will need to ensure their inclusion in the networks of insurance companies being sold on the Marketplace exchanges.
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At approximately 2:55 this afternoon, the Senate Finance Committee approved the "Chairman's Mark" of the SGR Repeal and Medicare Beneficiary Access Improvement Act of 2013. NRHA was successful in making sure that a number of rural provisions were included as amendments and adopted by the Committee. NRHA considers the adoption of these amendments a significant victory.

The bill would permanently repeal the Sustainable Growth Rate (SGR) and permanently extend a number of rural Medicare extenders. NRHA has long fought for a number of Medicare extenders, essential to rural providers, to be extended at current levels in perpetuity.  Additionally, NRHA has sought for regulatory burden reduction that would alleviate the burdens placed on various rural providers. A number of amendments offered at today's mark-up accomplished these purposes.

Among the important actions taken at the hearing, Amendments 117 and 121 were adopted in the Chairman’s Mark at the beginning of the hearing and, therefore, did not require a vote.

Amendment 117 (Thune/Bennet/Enzi/Roberts 1): This amendment would return supervision requirements for outpatient therapy services furnished at Critical Access Hospitals back to “general supervision.” This was the supervision level observed at nearly every CAH prior to 2009.

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The Chairman of the Senate Finance Committee released the bill “SGR Repeal and Medicare Beneficiary Access Improvement Act of 2013" to be considered Thursday morning. The bill repeals the Sustainable Growth Rate system and includes:
Floor on Geographic Adjustment for Physician Fee Schedule
Medicare Payment for Therapy Service
Medicare Ambulance Services
Medicare Dependent Hospitals
Low-Volume Hospitals
NRHA is pleased that the Senate Finance Committee included the above in the Mark, and is especially pleased that many of these important payments were made permanent.  However, reductions in payments are included and NRHA is working to do an analysis of the impact of these proposals..
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According to testimony in today's Senate HELP Committee hearing, as of last week, just three people have successfully enrolled through the federal health insurance exchange in the state of Alaska. Despite that and other stories of technical ineptness from across the country, CMS Administrator Tavenner told the committee that the Administration's target enrollment for the months of October and November is 800,000.

Does the ACA implementation "train wreck" (as predicted by Senate Finance Chairman Max Baucus (D-MT)) indicate a complete derailment or merely a scheduling delay? What are the concerns for rural patients and providers?

The next 30 days are critical. As both Republicans and Democrats pile on their complaints to the Administration, the computer glitches, access concerns and over-the-phone enrollment problems just keep building. If the system is not functioning fully in the very near future, it is almost inevitable that penalties of the individual mandate requirement will be postponed. A delay of the penalties innately causes a funding crisis for all of health care reform. A significant enough funding crisis could cause the legislation to implode under its own weight.
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The Autumn 2013 issue of the Journal of Rural Health is now available online. A quarterly journal published by NRHA, JRH serves as a medium for communication among health scientists and professionals in practice, educational, research, and policy settings. It is a peer-reviewed international journal devoted to advancing professional practice, research, theory development and public policy related to rural health.

We currently provide full-text articles online to all NRHA members. To access these articles online, log in to NRHA Connect and click on the "Journal" tab. 

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Nero is infamously known as the emperor who "fiddled while Rome burned." Particularly interesting since its thought he started the fire in Rome himself. It seems that there are groups of politicians in Washington who are set on a similar course with rural health care. Due to a lack of legislation on the extension of the Medicare dependent hospital program (MDH) and low-volume hospital adjustment (LVH) Washington is fiddling while rural is burning.

In 1982 Congress passed TEFRA which radically changed hospital reimbursement from a cost-based system to the prospective payment system (PPS). This Johns Hopkins and Harvard devised scheme was never tested in a small-volume environment prior to its sweeping change. As a result, close to 400 hospitals, mostly all small and rural, closed by 1995. During this period of time Congress was scratching its head and wondered why. Something must be done.

So, in 1990 Congress developed the MDH program and in 2005 they implemented the LVH program in order to stabilize the deleterious effects of the PPS system on small-volume facilities. In 1997, due to continued stress on our smallest of rural hospitals, Congress passed the Balanced Budget Act (BBA) which created the critical access hospital (CAH) program.

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Due to the many changes in healthcare, our friends at Together Rx Access conducted a thorough review of their cardholders’ needs and the ability of the Program to meet these needs going forward. Based on that review, Together Rx Access has determined that individuals and families who need help obtaining their prescription medicines may be better served by the health coverage options available through the Health Insurance Marketplace, expanded Medicaid programs in select states, or by individual company prescription assistance programs. As a result, the Together Rx Access Program will close at the end of the year.

Uninsured individuals can enroll in the prescription savings program until December 31, 2013. To help cardholders transition to other programs, they can continue to use their Together Rx Access Card at participating pharmacies until February 28, 2014. After this day, savings will no longer be available with the Together Rx Access Card.

Together Rx Access understands that community members may need to find other ways to access their medicines. At, uninsured individuals and their families can find a list of several resources that may help them save on their prescription medicines, and also help them access healthcare services in general.

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Here’s your chance to share your best practices at the national, state and local level by submitting them for the National Rural Task Force’s (NRTF) 2013 compendium.

The National Rural Task Force is a group of members of the National Rural Health Association (NRHA) and the National Association of Community Health Centers established in 2007 to “discuss rural issues, communication strategies and build partnerships to promote the long-term growth and sustainability of rural community and migrant health centers” through a cooperative agreement with HRSA’s Office of Rural Health Policy.

While NRHA will continue to accept submissions surrounding best practices and models for workforce development, technology, training and quality improvement, it is planned that the 2013 compendium will be centered around preparing for and implementing the Affordable Care Act in 2014. NRHA is specifically issuing a call for submissions of best practices/models surrounding education, outreach, enrollment and provision of services during previous large insurance program implementations. This could include state expanded Medicaid, Children’s Health Insurance Programs, and/or prescription coverage expansion.

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