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Congratulations to Paul Klehn, CIO of Liberty Hospital in Liberty, Missouri! 

Paul was recently elected President of the Heart of Amercica HIMSS. 

Both NRHA and Allscripts are honored to be long term partners of Paul’s and his organization. 

Sincerely,

Allscripts Corporation

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Yesterday, the National Rural Health Association participated in the Texas Medical Association’s 9th annual Border Health Caucus Conference on Capitol Hill.

 

This year’s theme was “Disease Knows no Borders” and included presentations by the Veterans Administration, members of Congress and physicians working along the United States-Mexico border. The conference was geared toward legislative staff, researchers and other border health stakeholders.

 

As part of a panel alongside Rep. Ruben Hinojosa, D-Texas, and Juan Escobar, MD, president of the El Paso County Medical Society, I was able to discuss current issues impacting the rural health care workforce and efforts being made to help improve access and quality of care for those living along the border.

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Keep your lap bar down and safety belt strapped...we are in for a white-knuckler ride...
   

In a crazy, but dramatic style, two U.S. appeals courts issued contradictory rulings on health exchange subsidies within hours of each other.  The first dealt a huge blow to the president’s health law by striking subsidies down for millions of Americans covered through HealthCare.gov, the Federal Exchange.  In effect, crippling the law.  The second court ruling, a couple of hours later, sided in an opposite manner.  

No subsidies were cut off immediately as the legal fight will continue.

At issue is whether individuals can get subsidies to help make insurance affordable in both federal and state exchanges. The first ruling determined that the IRS acted beyond its authority in providing the tax credit, and that instead it should only be done under the authority of a state.  This holding would eliminate all subsidies provided in the 34 Federal Exchanges, making the insurance mandate not affordable for millions.  

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Providers of rural health care are challenged as never before. These pressures are coming from many different sources; causing leaders to juggle many balls while doing their best to keep from dropping one. The Rural Policy Research Institute (RUPRI) has identified six key areas that leaders need to juggle at the same time. They are:

  • Optimize operations within the current fee for service environment
  • Innovate
  • Efficient operations
  • Reduce variation
  • Population health, for example, implement Patient Centered Medical Homes (PCMH)
  • Engage the medical staff

While juggling innovation, the possibilities are endless. However the barriers to implementation can be high. To our surprise, CMS has assisted rural providers by promulgating regulations that can spur innovation in your rural community in two key areas: tele-emergency and tele-health.

CMS advised state survey agencies that the CAH Conditions of Participation (CoP) can allow for an emergency department (ED) to use physician services through tele-health connections. CAHs can analyze the possibility of scheduling physicians’ on-call services using this method. This could reduce ED physician costs while yielding high patient satisfaction.

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As many hospitals and health
 care providers have experienced firsthand, a natural disaster can mean financial strain, organizational confusion and increased risk for patients. 

Last week, Paul Black, interim CEO of Winston Medical Center, reported that his community is still recovering from a tornado that recently destroyed the rural Mississippi hospital.

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Hello.  I am trying to find the standard of care for patients who require Rapid Sequence Intubation at Critical Access Hospitals where there is only one provider in the Emergency Department.  Specifically, are nurses allowed to Administer (i.e. "Push") medications such as Etomidate, Propofol or succinylcholine on a Physician's order, or must the Physician push the medication?  Can a mid-level provider be the one to order and/or administer these meds?  Can anyone share a current Policy on this?

Many thanks.

Alfredo Torres, MD, FACP
River Hospital
Alexandria Bay, NY, 13607

Atorresmd@msn.com


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On cue, the data is starting to roll in regarding the impact of Medicaid expansion enabled by the Affordable Care Act (ACA). We’ve heard the political arguments, for and against, leading up to the implementation of this particular feature of the ACA, some with apocalyptic overtones. Now that we’re getting actual data on this policy matter, politicians can run, but they can’t hide.

The Colorado Hospital Association (CHA) and its Center for Health Information and Data Analytics released a report earlier this month that was important. It found that significant changes emerged in the states that expanded Medicaid in the 1st quarter of 2014 compared with those that didn’t. There was a 3.5% increase in Medicaid revenue, on average, in expansion states and at the same time the percentage of self-pay patients decreased by 1.6%. The average charity care per hospital decreased from $2.8 million to $1.9 million, or an approximate 33% decrease.  In non-expansion states, the percentage of hospital Medicaid revenues did not change; self-pay patients increased slightly, and average charity care per hospital increased by 10%. I suspect that the evidence will continue to grow that demonstrates the positive impact of Medicaid on the financial health of our rural hospitals.

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Plan now to attend the Rural Quality and Clinical Conference July 16-18 in Atlanta, Georgia.

NRHA’s Rural Quality and Clinical Conference is an interactive event for quality improvement executives and coordinators, performance improvement coordinators, infection control practitioners, rural clinicians, medical directors, information technology experts, quality improvement organizations and nurses practicing on the front lines of rural health care. The conference offers two tracks: the r

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The House Ways and Means Subcommittee on Health held a hearing this morning on hospital payments including a discussion on the two-midnight rule, RAC audits, the 96-hour condition of payment rule, and the supervision requirements for outpatient therapy services. While the hearing was not specifically called to address the 96-hour rule or physician supervision, many members of the panel expressed concern to CMS about these payment policies and the complications that various hospitals are experiencing.  Some Representatives included specific stories from rural hospitals in their districts that have contacted them about these challenges.

NRHA is thankful to the Subcommittee for its focus on these issues and to the individual Representatives that raised these important issues.  NRHA commends the various rural hospitals who have reached out to their elected officials and shared their compelling stories with them.  We encourage all rural hospitals to invite their Congressional Delegation to visit their facilities and share their concerns with these elected officials.  If you have any questions on how to contact your elected representatives, please contact
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The Journal of the American Medical Association Surgery (JAMA) misunderstood rural health again. JAMA seems to have resumed its inquiry into critical access hospitals (CAHs) in an article released today, titled “Transfer Rates and Use of Post-Acute After Surgery at CAH vs Non-CAHs,” This article won’t surprise those who have already come to expect sweeping conclusions based on minimal evidence.

Bottom line, it is time for non-rural health researchers to stop exaggerating their claims on CAHs.

The article examines the differences in transfer rates between CAHs and non-CAHs for six surgical procedures commonly performed in each (hip and knee replacements, hip fracture repair, colorectal cancer resection, cholecystectomy and transurethral resection). The data revealed that after adjustment for patient and hospital factors, three of the surgical procedures (hip replacement, colorectal cancer resection and cholecystectomy) had a higher likelihood of transfer by a CAH versus a non-CAH. Simply put, the authors describe these procedures as being "commonly performed in CAHs," but they only identified 22,543 cases in all CAHs in their sample, even using five years of data and six procedures. These 22,543 cases in CAHs only account for 2 percent of all cases for these procedures, while non-CAHs account for 98 percent of total cases.

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The Rural Health Fellows program is a yearlong, intensive training program that develops leaders who can articulate a clear and compelling vision for rural America.

Each year, NRHA selects 10 to 15 highly motivated individuals who have proven their dedication to improving the health of rural Americans through their educational or professional experience.

These Rural Health Fellows undergo an intensive yearlong skillbuilding program, including three advanced leadership training seminars, attendance at several of NRHA's educational conferences, monthly conference calls on rural health leadership, policy and strategic planning and a guided group project that will involve Fellows in the process of rural health policy analysis on a national level.

Fellows will gain valuable insights and build critical skills in three primary domains:

1. Personal, team and organizational leadership;
2. Health policy analysis and advocacy;
3. National Rural Health Association governance and structure.

These ambitious learning and skill development objectives will be accomplished through a combination of experiential and action learning, exposure to premier faculty and seasoned practitioners and reinforcement through executive coaching and structured team assignments.
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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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