Yes, you read that correctly. Health Affairs reported in its May 2015 edition that “Hospital Closures Had No Measurable Impact on Local Hospitalization Rates or Mortality Rates, 2003-11.” The article declares that “these findings may offer reassurance to policy makers and clinical leaders who are concerned about the potential acceleration of hospital closures as a result of health care reform.”

            The fact that the authors of this article concluded with this statement does not make it so. With the help of our research colleagues at the Universities of Minnesota and North Carolina, NRHA offers the following observations in response:

1. This was predominately a study of urban hospital closures: Only 44 of the 195 hospitals that closed (22 percent) were rural. 

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NRHA Member Ed Gamache from Michigan forwarded me an article entitled "Association of hospital volume with readmission rates: a retrospective cross-sectional study" from the British Medical Journal (BMJ). Here is the article's conclusion:

Standardized readmission rates are lowest in the lowest volume hospitals—opposite from the typical association of greater hospital volume with better outcomes. This association was independent of hospital characteristics and was only partially attenuated by examining mortality and readmission together. Our findings suggest that readmissions are associated with different aspects of care than mortality or complications.

This is consistent with NRHA data on rural relevance provided through iVantage Health Analytics. We document that not only is quality equal to or better between rural and urban providers, but rural communities do so less expensively.

This BMJ article is another offering that supports our claims that rural communities provide better care at lower costs. It's all about the value!
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Right now, both the House and Senate are working on bills dealing with trade adjustment assistance (TAA). Essentially, these proposals pay for job training and other assistance for those who are displaced by trade.


While, the National Rural Health Association generally doesn’t focus on trade issues, the House bill H.R. 1892 has snared health care into this bill as a pay-for. The bill, which is backed by House Ways and Means Chairman Paul Ryan, extends Medicare sequestration for one year and also cuts payments for dialysis treatments to pay for its trade adjustment assistance measures.


According to CBO, the bill would be a $700 million dollar cut to Medicare, by imposing a 0.25 percent cut in Medicare in fiscal year 2024.


Currently, the Senate version does not include these or any pay-fors. The Senate Finance Committee is scheduled to take up its own version of the legislation Wednesday.


Contact your members of Congress today and tell them not to pay for a trade bill by endangering access to care for seniors and the disabled. Rural providers and hospitals cannot continue to absorb the cuts without hurting rural America’s access to necessary health care.

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Among the amendments passed to the Senate Budget Resolution (S. Con. Res. 11) early Friday, was the National Rural Health Association-supported amendment no. 356 to allow the VA to provide veterans access to non-VA health care services when the nearest VA medical facility within the 40 miles from a veteran’s home is unable to offer appropriate care for the veterans.

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  1. Significant Equity Gaps in Rural vs Urban.   Access to healthcare is a basic human right. Rural patients are sicker, more likely to suffer from chronic disease, not only have reduced access to primary care but also specialty care. Eliminating cost-based reimbursement for swing bed services in critical access hospitals (CAHs) would place countless rural facilities at risk of closing, this would not only severely limit access of rural residents to post-acute services but place these residents at risk of losing access to care across the care continuum. The 1997 Budget Act was one of the most important legislative efforts to narrow the tremendous gap in equity that has existed and continues to exist in rural communities as it relates to access and scope of services available.   Efforts to  return to the prospective payment system for swing bed usage in CAHs undermines the intent of the original legislation and does not acknowledge the present gaps and disparities that continue to exist in U.S. and rural healthcare.

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Today, the House passed HR 2, the Medicare Access and CHIP Reauthorization Act, with a strong bipartisan vote of 392 to 37. The President has indicated he will sign this bill into law when it reaches his desk.

Though strong support for the bill is building in the Senate, they have yet to schedule a vote. And they will begin a two-week recess this week, not returning until the after the March 31 deadline has passed on these programs that are critical to rural patients and providers.

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Today, the House of Representatives unveiled a bill to permanently fix the Sustainable Growth Rate.  Included in the legislation is a two-year extension of each of the current "Rural Medicare extenders" as well as a two-year renewal of the federal Children's Health Insurance Program (CHIP).  Two imperative rural PPS hospital provisions, the Medicare Dependent 
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The Office of Inspector General (OIG) for the U.S. Department of Health and Human Services (HHS) once again can’t see the forest for the trees in its recent report on the cost of swing bed services. OIG's attention to a mass of detail prevents it from seeing the bigger picture, a picture that tells an important story regarding rural health:

  1. Rural health is a continuum of services that are dependent on each other to protect our nation’s rural patients. This mosaic of care in rural America saves Medicare 2.7% on a Medicare spend per beneficiary vs. care provided in urban areas.

    This number is significant, amounting to almost $7 billion annually that could be saved if urban communities spent at the same rate as rural. Even in Washington terms, that’s real money.

  2. Swing bed services in critical access hospitals (CAHs), as envisioned by Congress in 1997, ensure safety net
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The National Quality Forum (NQF) that is (not the 1966 Zero Mostel classic as in the title of this blog). On February 5-6, 2015 NQF dove into rural quality issues for the first time by hosting the “Performance Measurement for Rural Low-Volume Providers:  Rural Health Committee In-Person Meeting” at the NQF headquarters in Washington, DC. The NQF is a membership organization (NRHA is a member) that gives its “seal of approval” to quality measures developed in the health care industry. In addition, CMS contracts with NQF to help CMS select measures that are used in Medicare quality measurement programs, such as the Hospital Inpatient Quality Reporting (IQR) and Value-based Purchasing (VBP).

By urging of the Federal Office of Rural Health Policy (FORHP), CMS issued a contract with NQF to prepare a report on the following:

  • A consensus set of measurement challenges for low-volume providers
  • Make recommendations regarding measures appropriate for use in CMS pay-for-performance programs for rural hospitals and clinics
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I believe it is important to note the benefit directly attributable to the early adoption of the "End of Life" conversation that could save your health care facility/system hundreds of thousands, perhaps millions per year.   The quantification for this proclamation is how many deaths occurred within your facilities last year, how many times were they admitted/readmitted prior to death, what impact on HCAHPS were analyzed, what net loss was attributable to these findings?  Which can ultimately lead an organization to a plausible solution: what can be done to bring these associated costs under control?

Read my blog post in LinkedIn and that of the article contained within.  It's worth the journey... 

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The Federal Office of Rural Health Policy announced that for the 2016 Marketplace insurance plan year, the Centers for Medicare & Medicaid Services have released a draft of Essential Community Providers (ECPs) and many Rural Health Clinics (RHCs) are included on the list for the first time.

From the announcement:

ECPs are providers who care for predominantly low-income, medically underserved individuals.  Under the Affordable Care Act, insurers (called Qualified Health Plan issuers) must include a minimum number of ECPs within their provider networks for plans sold on the insurance Marketplaces.  Insurers can use the list to select ECPs to include in their provider networks.  The draft list of ECPs and a description of the list are available here.

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Tuesday was another fascinating exercise in democracy and while there is much to analyze, the significant takeaway is this: Rural America continues to turn a brighter shade of red as the rural/urban electorate seemingly grows further and further apart. The expanding rural/urban divide could even be seen in not-so-rural states like Maryland who shockingly elected only their second Republican Governor in nearly 50 years. This is entirely because the voter turn-out was low in Baltimore but high in eastern and southern Maryland, the rural portions of the state. 

Yesterday’s election has two other significant underlying stories:

  1. The Hispanic vote, didn’t show-up in high numbers, but nevertheless was overwhelmingly for Democratic candidates – 63%. This means that very little inroads were made for Republicans despite the strong efforts by Reince Priebus, chairman of the Republican National Committee, to gain diversity in candidates. Without significant changes in this vast voting bloc, Republicans should be worried about losing their gains in 2016.

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As rural health care workers we are all aware of the unpredictability of what malady may enter our doors.

Through training, practice, ongoing study, reading and information from our professional organizations, we are all constantly learning and staying up to date on the latest therapies and illnesses.

To date I am not aware of Ebola’s presence at a rural site. One truism of rural medicine is that any known diagnoses, as well as evolving problems can enter our facilities at any time. We subconsciously monitor changes in our charges be they environmental, infectious, traumatic, etc.

With that same spirit and urgency, I am sure we are all monitoring and looking at how we would handle Ebola in our facilities. Obviously, the CDC website has been receiving a lot of hits from us.

NRHA has no official statements yet on Ebola.

This summer, NRHA launched a rural preparedness page on our website and has added information specific to Ebola as we receive it.  
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The National Rural Health Association participated in the “Champions of Change” event hosted by the White House on Monday, October 20th, which highlighted the Affordable Care Act (ACA) and various organizations that are working to assist with enrollment efforts.


Representatives from faith-based organizations, local libraries and other community grassroots organizations were in attendance to discuss efforts to help enroll individuals to receive health care coverage under ACA.


Health and Human Services Secretary Sylvia M. Burwell

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Four members are vying to be NRHA's president-elect and multiple others are nominated for Board of Trustees and Rural Health Congress positions.

The president-elect will serve in that role in 2015 and as president in 2016.

Please review each candidate's nomination submission in advance of the voting period beginning Oct. 28.

Tommy Barnhart

In my 40-plus-year health care career I have seen tremendous change but none as dramatic or all-encompassing as we are now experiencing or about to undergo.

In my consulting experience, I have been extensively involved with rural providers of all types and will leverage that experience in my NRHA presidency.

NRHA is the strongest voice for rural health and needs strong leadership during these changing times. NRHA must continue to advocate for sustainable payment systems while new systems are developed, tested and implemented while advocating for sustainable rural workforce and delivery programs.
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Senators Heidi Heitkamp (D-N.D.) and John Thune (R-S.D.) are currently gathering signatures for a letter to be sent to CMS asking for a more robust review of rural impacts of any new regulation. The letter, set to be sent on Thursday, asks that CMS rural impact statements are made more clearly and for better review of rural input of regulations. 

NRHA strongly encourages all NRHA members to call their Senators and ask them to join on this letter.  A copy of this letter may be forwarded by NRHA members to their Senators for review. Senators wishing to join on this letter should contact Senator Heitkamp or Senator Thune BEFORE this Thursday (October 2).  

Any questions about how to contact your Senator or about the letter may be directed to NRHA Government Affairs staff. Because of the Rural Health Clinic and Critical Access Hospital Conferences this week, please send questions via email to Maggie Elehwany, David Lee
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The Oct. 1 deadline is approaching to begin reporting meaningful use of electronic health records (EHR) for fiscal year 2015, NRHA and 16 other national associations sent a message to Patricia Burwell, HHS Secretary to implement more realistic Meaningful Use timelines.

The linked letter states, “only 143 hospitals and 3,152 Eligible Professionals have documented an ability to meet Stage 2 requirements using 2014 Edition Certified Electronic Health Record Technology.” 

If HHS chooses not to meet these requirements, hospitals and Eligible Professionals could face the loss of incentive payments and even worse, significant penalties, disproportionately harming rural providers.
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Have healthcare executives and managers considered the unintended (or intended) consequences associated with the implementation of PPACA?

  1. Radiology/Assets:  Aging Infrastructure impacts HCAHPS, Patient Safety and revenue streams.
  2. IT:  The $$$ depletion from the Balance Sheet for IT rollouts that fail to meet MU 2 attestation standards - "Buyer Beware!" - one size does not fit all.
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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. 


Allscripts Corporation

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