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The Federal Landscape for Critical Access Hospitals

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The Federal Landscape for Critical Access Hospitals

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    4. Economic factors hit health care sector particularly hard Job losses; increases in the uninsured; folks putting off elective procedures and end up with higher acuity; tougher cases Support services being cut at the state level (home care aids, transportation, etc.) Always difficult to recruit providers in rural areas; even tougher now And while most agree that the increased focus on quality is a good thing, the rapid ramp up of reporting requirements both at the Federal and State level is a challenge And, doing all this at a time when facilities are aging, capital can be hard to get and there is a need to invest in HIT Typical reaction in tough economic times is to retrench; that’s easy to do in some industries but not always possible in HC; folks still get sick; still need services; and you can’t turn them away MEDICARE PART A TRUST FUND PROJECTED TO BE INSOLVENT IN 2019 PART B COST/PREMIUMS CONSUMING AN INCREASING PORTION OF SOCIAL SECURITY PAYMENTS HEALTH OUTCOMES VARY WIDELY FROM PLACE TO PLACE AND ARE INFERIOR TO MANY OTHER DEVEOPED COUNTRIES Economic factors hit health care sector particularly hard Job losses; increases in the uninsured; folks putting off elective procedures and end up with higher acuity; tougher cases Support services being cut at the state level (home care aids, transportation, etc.) Always difficult to recruit providers in rural areas; even tougher now And while most agree that the increased focus on quality is a good thing, the rapid ramp up of reporting requirements both at the Federal and State level is a challenge And, doing all this at a time when facilities are aging, capital can be hard to get and there is a need to invest in HIT Typical reaction in tough economic times is to retrench; that’s easy to do in some industries but not always possible in HC; folks still get sick; still need services; and you can’t turn them away MEDICARE PART A TRUST FUND PROJECTED TO BE INSOLVENT IN 2019 PART B COST/PREMIUMS CONSUMING AN INCREASING PORTION OF SOCIAL SECURITY PAYMENTS HEALTH OUTCOMES VARY WIDELY FROM PLACE TO PLACE AND ARE INFERIOR TO MANY OTHER DEVEOPED COUNTRIES

    5. Hear consistently that CAHs are facing workforce shortages - docs, nurses, allied health etc. HRSA has a number of programs that are important to rural, including the NHSC, the HHS J1 and Conrad 30 programs as well as nursing scholarships and loans. AHECs also play a key role. Problem is demand greatly outstrips supply of funding For example, under the Nursing Scholarship Program we awarded 172 scholarships out of 4,894 applications (only about 3.5 percent of the total applications) during 2007. Similar numbers in the nursling loan repayment and far more applicants for NHSC loan repayment than we could fund Also the challenge with Medicare GME and the whole underlying training and acredidation system is that it favors urban-based training Some legitimate reasons for this (some training has to take place in an AHC But may be other places where we could do more ambulatory and community training How to strike a balance; MedPAC discussing this, others Hear consistently that CAHs are facing workforce shortages - docs, nurses, allied health etc. HRSA has a number of programs that are important to rural, including the NHSC, the HHS J1 and Conrad 30 programs as well as nursing scholarships and loans. AHECs also play a key role. Problem is demand greatly outstrips supply of funding For example, under the Nursing Scholarship Program we awarded 172 scholarships out of 4,894 applications (only about 3.5 percent of the total applications) during 2007. Similar numbers in the nursling loan repayment and far more applicants for NHSC loan repayment than we could fund Also the challenge with Medicare GME and the whole underlying training and acredidation system is that it favors urban-based training Some legitimate reasons for this (some training has to take place in an AHC But may be other places where we could do more ambulatory and community training How to strike a balance; MedPAC discussing this, others

    6. All know about the long decline in family medicine match rate Numbers in the pipeline for other PC disciplines such as internal medicine also not high enough to fill this expected gap AAMC calling for an increase in med school enrollment Clearly needed but … which disciplines??? Also important to note that WF issues and in particular physician training is shared responsibility .. Feds have a role States also have a role; WWAMI good example of where it works well; other States across country not so wellAll know about the long decline in family medicine match rate Numbers in the pipeline for other PC disciplines such as internal medicine also not high enough to fill this expected gap AAMC calling for an increase in med school enrollment Clearly needed but … which disciplines??? Also important to note that WF issues and in particular physician training is shared responsibility .. Feds have a role States also have a role; WWAMI good example of where it works well; other States across country not so well

    7. There is $5 billion for health professions training, including $65 million for the NHSC Dept of Labor gets $3.95 billion, including $500 M States for WIA projects and $750 m for competitive grants for worker training in high growth and emerging industries and HC is definitely that if you look at Labor’s own WF projections for the next 10 years And, as a way to bring more attention to these important issues, HRSA will hold a National R and U US WF Summit in August in WDC focusing on primary care … … Joint effort of ORHP, BPHC, BHPr, NHSC There is $5 billion for health professions training, including $65 million for the NHSC Dept of Labor gets $3.95 billion, including $500 M States for WIA projects and $750 m for competitive grants for worker training in high growth and emerging industries and HC is definitely that if you look at Labor’s own WF projections for the next 10 years And, as a way to bring more attention to these important issues, HRSA will hold a National R and U US WF Summit in August in WDC focusing on primary care … … Joint effort of ORHP, BPHC, BHPr, NHSC

    8. For the last few years, there have been significant changes in the Medicare program. It has begun making the transition from a passive payer of health services to a more active purchaser of these services. Most folks would agree this is the right way to go … And it has led to the beginning steps toward pay for performance and is laying the groundwork for value-based purchasing. It’s hard to argue with the notion that Medicare payments should be tied to making sure high quality of care is given The challenge, however, comes in the details. And as with most major public policy changes like this the big question is are we designing a system that will work as well for rural as it will for urban and that question is vitally important for CAHs The jury is still out on that. For the last few years, there have been significant changes in the Medicare program. It has begun making the transition from a passive payer of health services to a more active purchaser of these services. Most folks would agree this is the right way to go … And it has led to the beginning steps toward pay for performance and is laying the groundwork for value-based purchasing. It’s hard to argue with the notion that Medicare payments should be tied to making sure high quality of care is given The challenge, however, comes in the details. And as with most major public policy changes like this the big question is are we designing a system that will work as well for rural as it will for urban and that question is vitally important for CAHs The jury is still out on that.

    9. Diagnosis related group Right now, hospitals get a full payment update if they report on a limited but growing set of quality measures pneumonia, congestive heart failure and AMI, patient satisfaction The complaints you hear are that while these measures are broadly relevant for hospitals as a whole, they are only partially relevant for rural hospitals As this chart shows, the kinds of things we’re measuring are a small part of what small rural hospitals do And when you have small numbers, measuring quality can be tricky and no one has come up with an answer for that yet … Diagnosis related group Right now, hospitals get a full payment update if they report on a limited but growing set of quality measures pneumonia, congestive heart failure and AMI, patient satisfaction The complaints you hear are that while these measures are broadly relevant for hospitals as a whole, they are only partially relevant for rural hospitals As this chart shows, the kinds of things we’re measuring are a small part of what small rural hospitals do And when you have small numbers, measuring quality can be tricky and no one has come up with an answer for that yet …

    10. About 18 months ago, CMS produced a report to Congress on how it might create a value-based purchasing program, meaning how they might create a system for adjusting payments to hospitals based on how they score on a range of quality measures. It was a thoughtful report and was based on feedback they got from two large public meetings. It pointed out the challenges making this move might pose for small rural hospitals It included a good discussion of the challenge of small numbers But, it also didn’t offer any solutions to those problems. But this is an issue that is here to stay. Congress has begun offering bills to move Medicare in this direction. And philosophically, it makes sense. We ought to be able to find a way to reward good high quality hospital services. About 18 months ago, CMS produced a report to Congress on how it might create a value-based purchasing program, meaning how they might create a system for adjusting payments to hospitals based on how they score on a range of quality measures. It was a thoughtful report and was based on feedback they got from two large public meetings. It pointed out the challenges making this move might pose for small rural hospitals It included a good discussion of the challenge of small numbers But, it also didn’t offer any solutions to those problems. But this is an issue that is here to stay. Congress has begun offering bills to move Medicare in this direction. And philosophically, it makes sense. We ought to be able to find a way to reward good high quality hospital services.

    11. But, the challenge is how to get there in a way that works for all hospitals, whether you are a 600-bed teaching hospital or a 10-bed CAH. I’m not sure how to get there but there are folks who are putting some thought to this. The Rural Policy Research Institute has produced a response to CMS’ VBP Report to Congress and it’s a good, thoughtful examination of the issues. It notes that we have to get to a place with more relevant measures for rural hospitals And it discusses the low numbers issues. But, the challenge is how to get there in a way that works for all hospitals, whether you are a 600-bed teaching hospital or a 10-bed CAH. I’m not sure how to get there but there are folks who are putting some thought to this. The Rural Policy Research Institute has produced a response to CMS’ VBP Report to Congress and it’s a good, thoughtful examination of the issues. It notes that we have to get to a place with more relevant measures for rural hospitals And it discusses the low numbers issues.

    12. The Rural Policy Research Institute folks have also produced a report looking at the specific issues related to CAHs. The CMS Report on VBP is silent on CAHs. It focuses only on PPS hospitals. But, it seems inconceivable that we would leave 1,300 CAHs out of a system that the rest of Medicare will eventually be in but … At same time, this points out that we do need to be careful about how CAHs are pulled in. A bill from Sens. Grassley and Baucus would create a demonstration VBP program for CAHs while requiring it for all PPS facilities. That approach might make sense; provide some time to do it right. The Rural Policy Research Institute folks have also produced a report looking at the specific issues related to CAHs. The CMS Report on VBP is silent on CAHs. It focuses only on PPS hospitals. But, it seems inconceivable that we would leave 1,300 CAHs out of a system that the rest of Medicare will eventually be in but … At same time, this points out that we do need to be careful about how CAHs are pulled in. A bill from Sens. Grassley and Baucus would create a demonstration VBP program for CAHs while requiring it for all PPS facilities. That approach might make sense; provide some time to do it right.

    13. The VBP is just one of a number of quality issues facing CAHs. CMS has dramatically changed the roles of the QIOs for the current scope of work. Under the previous scope, there was a requirement to work with CAHs and we saw a lot of benefit to that. We’ll have to wait and see what the impact of the change is. On a more positive note, we’re seeing introduction of a broader set of measures including a transfer measure and other OP measures, which are more relevant to rural. We’re also hearing that some RH and CAHs are getting a bit overwhelmed by the public and private reporting requirements. The VBP is just one of a number of quality issues facing CAHs. CMS has dramatically changed the roles of the QIOs for the current scope of work. Under the previous scope, there was a requirement to work with CAHs and we saw a lot of benefit to that. We’ll have to wait and see what the impact of the change is. On a more positive note, we’re seeing introduction of a broader set of measures including a transfer measure and other OP measures, which are more relevant to rural. We’re also hearing that some RH and CAHs are getting a bit overwhelmed by the public and private reporting requirements.

    14. Our hope is that the Flex program can be a help in a range of quality and performance improvement activities for CAHs. Got re-authorized in 2008 .. New charge: QI PI and Benchmarking Completes a shift away from conversion SHIP: Also a resource; technically $8k per seeing some States be creative with funds Buying software for all hospitals to ease with the Hospital Compare reporting; Others doing joint training Like to see more of that … Problem for 2009: Authorization Our hope is that the Flex program can be a help in a range of quality and performance improvement activities for CAHs. Got re-authorized in 2008 .. New charge: QI PI and Benchmarking Completes a shift away from conversion SHIP: Also a resource; technically $8k per seeing some States be creative with funds Buying software for all hospitals to ease with the Hospital Compare reporting; Others doing joint training Like to see more of that … Problem for 2009: Authorization

    15. CAH designation is no longer “the new thing” Program is well established; been around for more than 10 years View CAH and Flex as “public policy success” stabilized RHs; improved access W/ success come challenges W/ close to 1,300 CAHs, a major part of the Medicare program As such, invites scutiny and attention; just like any other large part of the Medicare program New studies; finding some good things; also some concerns; CAH designation is no longer “the new thing” Program is well established; been around for more than 10 years View CAH and Flex as “public policy success” stabilized RHs; improved access W/ success come challenges W/ close to 1,300 CAHs, a major part of the Medicare program As such, invites scutiny and attention; just like any other large part of the Medicare program New studies; finding some good things; also some concerns;

    16. Creates an interesting new era for CAHs Take a look at this study on Hospital remoteness and 30-day risk standardized mortality rates The upshot is that they thought they’d find differences as they moved out to small rural hospitals But, they didn’t. Small rural hospitals, including CAHs, did just fine. It included transfers in which patient went upstream and counted that outcome and attributed back to RH Important caveat; some might say misleading Others might say shows good continuity of care Know Hosp Compare would not count those; so #s might be different w/ standard Point is; lots of ways to look at this; context key Creates an interesting new era for CAHs Take a look at this study on Hospital remoteness and 30-day risk standardized mortality rates The upshot is that they thought they’d find differences as they moved out to small rural hospitals But, they didn’t. Small rural hospitals, including CAHs, did just fine. It included transfers in which patient went upstream and counted that outcome and attributed back to RH Important caveat; some might say misleading Others might say shows good continuity of care Know Hosp Compare would not count those; so #s might be different w/ standard Point is; lots of ways to look at this; context key

    17. Got other studies now out; two sponsored by the Agency for Health Research and Quality An Iowa study showed that quality improved after conversion to CAH … good news; and not surprising Another study looked at a standard measure of efficiency … found that PPS more “efficient” … Defining “efficiency” challenging Have Flex monotoring team studies that show on HC measures, CAHs do as well or better on Pneumonia; not as well on AMI or CHF (again, not surprising) Got other studies now out; two sponsored by the Agency for Health Research and Quality An Iowa study showed that quality improved after conversion to CAH … good news; and not surprising Another study looked at a standard measure of efficiency … found that PPS more “efficient” … Defining “efficiency” challenging Have Flex monotoring team studies that show on HC measures, CAHs do as well or better on Pneumonia; not as well on AMI or CHF (again, not surprising)

    18. Also know that the HHS Office of the Inspector General has been looking at and will continue to look at CAH costs We’re working with them; offered to help; and we’re interested in their findings; Some health economists have a long-standing concern that efforts to control costs less under C-B reimbursement than under a PPS Others dispute; say always pressure to control costs for your other payers and to keep costs and charges in line with competitors Also know that the HHS Office of the Inspector General has been looking at and will continue to look at CAH costs We’re working with them; offered to help; and we’re interested in their findings; Some health economists have a long-standing concern that efforts to control costs less under C-B reimbursement than under a PPS Others dispute; say always pressure to control costs for your other payers and to keep costs and charges in line with competitors

    19. Mention all of this … to try to provide some context These kinds of questions & studies part of life in an established p-gram; Important to know what’s going on Overall believe we have a good story to tell CAH status has been a lifeline; At same time; important to identify problems and be proactive in addressing any concerns; Better to do that than have a “solution” hoisted upon you Mention all of this … to try to provide some context These kinds of questions & studies part of life in an established p-gram; Important to know what’s going on Overall believe we have a good story to tell CAH status has been a lifeline; At same time; important to identify problems and be proactive in addressing any concerns; Better to do that than have a “solution” hoisted upon you

    20. Important to stay in touch with key issues in larger hospital environment; MedPAC, others looking at things like re-admissions and how to avoid; bundled payments to promote better continuity of care Those likely to happen in PPS; What might it mean for CAH, how would you do it? Better to be thinking now Similarly; lots of discussion on medical home; some see it as a way to improve quality; others to control costs; some see it as both What might that mean in a CAH context? Important to stay in touch with key issues in larger hospital environment; MedPAC, others looking at things like re-admissions and how to avoid; bundled payments to promote better continuity of care Those likely to happen in PPS; What might it mean for CAH, how would you do it? Better to be thinking now Similarly; lots of discussion on medical home; some see it as a way to improve quality; others to control costs; some see it as both What might that mean in a CAH context?

    22. CMS will be making $35 billion in Health Information Technology incentive payments between 2011 – 2015 And, after 2015, Medicare will begin reducing payments for providers that do not use HIT/HER Still sorting through this language to better understand how it will actually work Defining what “meaningful” HITadoption is also going to be a key issue Meaningful Use comments due by June 26. CMS will be making $35 billion in Health Information Technology incentive payments between 2011 – 2015 And, after 2015, Medicare will begin reducing payments for providers that do not use HIT/HER Still sorting through this language to better understand how it will actually work Defining what “meaningful” HITadoption is also going to be a key issue Meaningful Use comments due by June 26.

    23. Also payments for RHCs and FQHCs … through Medicaid They’ll get payments if they meet a threshold of Medicaid, SCHIP and uncompensated care that exceeds 30 percent of their visits There are other HIT funds in ARRA Want to set up HIT Regional Extension Ctrs to provide TA and education Specifically mentions CAHs and reaching out to rural and individual or small group practices Also payments for RHCs and FQHCs … through Medicaid They’ll get payments if they meet a threshold of Medicaid, SCHIP and uncompensated care that exceeds 30 percent of their visits There are other HIT funds in ARRA Want to set up HIT Regional Extension Ctrs to provide TA and education Specifically mentions CAHs and reaching out to rural and individual or small group practices

    24. Other Resources HIT Extension Program- Regional Technical Assistance Centers HIT workforce training Regional health information exchange Construction, renovation and equipment, and acquisition of HIT Medicare Incentives for PPS Hospitals $2M Base +Discharge Payment x Medicare Share No penalty until 2014 Incentives discontinue after 2015 Medicare Incentives for CAHs Eligible for 4 years of enhanced Medicare Payment with immediate full depreciation of certified EHR Costs Total EHR Costs x (Medicare Share + 20%) Only eligible through 2014, if adoption occurs after 2014 no additional incentives occur Maximum Eligible Professionals are eligible for either Medicare or Medicaid Incentives – NOT BOTH Acute Care Hospitals, including CAHs are eligible for both Eligible Professional cannot be Hospital based and must have a patient load of 30% Medicaid Payments cover up to 85% of net allowable costs to adopt and operate EHR Technology Allowable costs for the first year are to be the average costs expended for the implementation or upgrade of an EHR system to not exceed $25 K and cannot occur after 2016 Subsequent years are to be calculated at 85% 0f 10K to not exceed 2016 If provider is ped, then patient volume must be 20% Medicaid and the incentives will be taken at 2/3 the rate If eligible provider practices at a FQHC or RHC then patient volume must be 30% “needy” Individuals Medicaid, sliding fee, uncompensated care, or receiving assistance under Title XXI Eligible Hospitals All Children’s Hospitals, Acute Care Hospitals (including CAHs) with at least 10% Medicaid Patient Volume (EHR Cost + Medicaid Share) x 50% for one year period or (EHR Cost + Medicaid Share) x 90% for 2 year period 4 year transition schedule to be utilized to attain Aggregated Payment Medicare Incentives for PPS Hospitals $2M Base +Discharge Payment x Medicare Share No penalty until 2014 Incentives discontinue after 2015 Medicare Incentives for CAHs Eligible for 4 years of enhanced Medicare Payment with immediate full depreciation of certified EHR Costs Total EHR Costs x (Medicare Share + 20%) Only eligible through 2014, if adoption occurs after 2014 no additional incentives occur Maximum Eligible Professionals are eligible for either Medicare or Medicaid Incentives – NOT BOTH Acute Care Hospitals, including CAHs are eligible for both Eligible Professional cannot be Hospital based and must have a patient load of 30% Medicaid Payments cover up to 85% of net allowable costs to adopt and operate EHR Technology Allowable costs for the first year are to be the average costs expended for the implementation or upgrade of an EHR system to not exceed $25 K and cannot occur after 2016 Subsequent years are to be calculated at 85% 0f 10K to not exceed 2016 If provider is ped, then patient volume must be 20% Medicaid and the incentives will be taken at 2/3 the rate If eligible provider practices at a FQHC or RHC then patient volume must be 30% “needy” Individuals Medicaid, sliding fee, uncompensated care, or receiving assistance under Title XXI Eligible Hospitals All Children’s Hospitals, Acute Care Hospitals (including CAHs) with at least 10% Medicaid Patient Volume (EHR Cost + Medicaid Share) x 50% for one year period or (EHR Cost + Medicaid Share) x 90% for 2 year period 4 year transition schedule to be utilized to attain Aggregated Payment

    25. $500 million to strengthen the health care workforce $300m to National Health Service Corps $200m Title VII- Primary Care, Dentistry, AHECs Topic: Strengthening the Health Workforce Program Purpose: Support programs such as the National Health Services Corps which place providers in underserved communities. Further, it will fund existing workforce programs (Title VII and VIII) which are critical for the education and training of the next generation of doctors, nurses and other providers. Amount of AARA Funding: The act provides $500 million to support these programs $300 million goes towards the National Health Services Corps to assist communities in health professional shortage areas (HPSAs) in the recruitment and retention of clinicians through scholarships and loan repayment contract in return for primary health care services (mental, medical, dental etc) in underserved communities of greatest need. May include both national and state loan repayment programs, SEARCH, etc. The NHSC scholarship application opened early March The NHSC loan repayment program opened in March and is to be open for 18 months. There will be 3-month application cycles over the AARA funding. $200 million for all the disciplines trained through the primary care medicine and dentistry program, public health prevention program, scholarship and loan repayment programs (Nurse training) RPF opened March 19th Submission Date: April 17th Funding Obligation: June 1st, 2009 Impact on Grantees: Inform grantees when funding opportunities are available since there are more available funds Listen to the workforce issues grantees mention (non-compete apps) because there will be more placements available Topic: Strengthening the Health Workforce Program Purpose: Support programs such as the National Health Services Corps which place providers in underserved communities. Further, it will fund existing workforce programs (Title VII and VIII) which are critical for the education and training of the next generation of doctors, nurses and other providers. Amount of AARA Funding: The act provides $500 million to support these programs $300 million goes towards the National Health Services Corps to assist communities in health professional shortage areas (HPSAs) in the recruitment and retention of clinicians through scholarships and loan repayment contract in return for primary health care services (mental, medical, dental etc) in underserved communities of greatest need. May include both national and state loan repayment programs, SEARCH, etc. The NHSC scholarship application opened early March The NHSC loan repayment program opened in March and is to be open for 18 months. There will be 3-month application cycles over the AARA funding. $200 million for all the disciplines trained through the primary care medicine and dentistry program, public health prevention program, scholarship and loan repayment programs (Nurse training) RPF opened March 19th Submission Date: April 17th Funding Obligation: June 1st, 2009 Impact on Grantees: Inform grantees when funding opportunities are available since there are more available funds Listen to the workforce issues grantees mention (non-compete apps) because there will be more placements available

    26. ARRA: Community Health Centers $2 billion to support CHC services, repairs and renovations, and investments in HIT $155m New Access Points- awarded to 126 CHC for FY09 and FY10 $337m Increased Demand for Services (IDS)- awarded to 1,128 CHC for FY09 and FY10 http://bphc.hrsa.gov/recovery Topic: Health Center Program (Federal Qualified Health Centers) Program Purpose: Health centers provide comprehensive culturally competent, primary health care services to over 16 million medically underserved and uninsured patients. Health centers are community-based and patient-directed organizations that improve the health of their patients and communities by addressing financial, geographic, cultural, linguistic and other barriers to care. Amount of AARA Funding: The act provides $2 billion to support services, investments in HIT, and renovations and repairs. New Access Point grants were awarded to a total of 126 community-based organizations that submitted highly-rated but unfunded applications to become New Access Points in FY 2008.  The new health centers will receive $155 million in FY 2009 and 2010. (April 1, 2009) Those grants mean another 750,000 people in 39 states and two territories will have access to quality health care. Increased Demand for Services (IDS) grants were awarded to 1,128 health center grantees that applied to receive a share a of $337 million, awarded by formula in 2009 and 2010, to help health centers care for an additional 2 million people hit hard by the economic downturn. Half of the new health center patients, it is expected, will have no health insurance. (June 1, 2009) Health Center Modernization, Renovation and Repair grants will provide assistance for construction, renovation and equipment and for HIT. There will be grants for minor capital, major capital and to support HIT systems and networks. The scheduled award date is July 1, but there have not been any RFPs for these opportunities. "We have acted quickly to put Recovery Act dollars to good use in communities across America," said President Obama. "The construction and expansion of health centers will create thousands of new jobs, help provide health care to an estimated 750,000 Americans across the country who wouldn’t have access to care without these centers, and take another step toward an affordable, accessible health care system." Impact on Grantees: FQHCs are partners in the community (many are part of the consortiums for rural health Outreach and Network grants). With the additional funds, CHCs will be able to support the increased demand for health services by uninsured patients. More information: http://bphc.hrsa.gov/recovery/ (includes the organizations funded through the New Access Points and IDS grants) Topic: Health Center Program (Federal Qualified Health Centers) Program Purpose: Health centers provide comprehensive culturally competent, primary health care services to over 16 million medically underserved and uninsured patients. Health centers are community-based and patient-directed organizations that improve the health of their patients and communities by addressing financial, geographic, cultural, linguistic and other barriers to care. Amount of AARA Funding: The act provides $2 billion to support services, investments in HIT, and renovations and repairs. New Access Point grants were awarded to a total of 126 community-based organizations that submitted highly-rated but unfunded applications to become New Access Points in FY 2008.  The new health centers will receive $155 million in FY 2009 and 2010. (April 1, 2009) Those grants mean another 750,000 people in 39 states and two territories will have access to quality health care. Increased Demand for Services (IDS) grants were awarded to 1,128 health center grantees that applied to receive a share a of $337 million, awarded by formula in 2009 and 2010, to help health centers care for an additional 2 million people hit hard by the economic downturn. Half of the new health center patients, it is expected, will have no health insurance. (June 1, 2009) Health Center Modernization, Renovation and Repair grants will provide assistance for construction, renovation and equipment and for HIT. There will be grants for minor capital, major capital and to support HIT systems and networks. The scheduled award date is July 1, but there have not been any RFPs for these opportunities. "We have acted quickly to put Recovery Act dollars to good use in communities across America," said President Obama. "The construction and expansion of health centers will create thousands of new jobs, help provide health care to an estimated 750,000 Americans across the country who wouldn’t have access to care without these centers, and take another step toward an affordable, accessible health care system." Impact on Grantees: FQHCs are partners in the community (many are part of the consortiums for rural health Outreach and Network grants). With the additional funds, CHCs will be able to support the increased demand for health services by uninsured patients. More information: http://bphc.hrsa.gov/recovery/ (includes the organizations funded through the New Access Points and IDS grants)

    27. USDA also got extra funding, beyond their normal appropriation, to fund capital projects They’ll have $67 million in loans and $63 million in grants Know that USDA has made a concerted effort over the past few years to reach out to CAHs Prime opportunity to do more … Reach out to them via the State USDA offices USDA also got extra funding, beyond their normal appropriation, to fund capital projects They’ll have $67 million in loans and $63 million in grants Know that USDA has made a concerted effort over the past few years to reach out to CAHs Prime opportunity to do more … Reach out to them via the State USDA offices

    28. There is billions in funding to expand broadband deployment with an emphasis on rural communities. USDA offers grants and loans for broadband. Commerce is also offering grants. This is, obviously, important to rural health as it is directly tied to the ability to take advantage of health information technology. New research from USDA shows that while broadband is broadly available in many rural areas, there are significant cost issues. So, this deployment could help make it universally available and also hopefully lower the costs … There is billions in funding to expand broadband deployment with an emphasis on rural communities. USDA offers grants and loans for broadband. Commerce is also offering grants. This is, obviously, important to rural health as it is directly tied to the ability to take advantage of health information technology. New research from USDA shows that while broadband is broadly available in many rural areas, there are significant cost issues. So, this deployment could help make it universally available and also hopefully lower the costs …

    29. What Does This Means for Rural? Long-Standing Access Problems Uninsured; Insurance Market Challenges Heavier Chronic Disease Burden Opportunity to Improve Outcomes and Value Workforce Already Focused on Primary Care but in dire need of more providers What Does This Means for Rural? Long-Standing Access Problems Uninsured; Insurance Market Challenges Heavier Chronic Disease Burden Opportunity to Improve Outcomes and Value Workforce Already Focused on Primary Care but in dire need of more providers

    30. Rural as a Leading Edge of Health Care Reform New Report from the White House Office of Health Reform Rural Listening Session at White House May 4, 2009 A lot of discussion about health care reform Administration has made the argument that even in the worsening economy you can’t afford not to address this issue, that it affects so many parts of the economy from business competitiveness to personal finance, etc. And the Key Committees on the Hill have been discussing it, Sen. Baucus has released a blueprint for reform. The White House recently held a forum on health care There seems to be wide agreement that something needs to be done, but then again that is the easy part. The challenge is in the details and there are widely differing approaches from the left and the right. But, there are some key themes that are emerging. Access: uninsured, under insured, problems in the individual and group marketplace … hits rural as heavily dependent on the individual market and public programs Re-Emphasizing Primary Care: We’ve known this in rural for years; studies show regular access to PC improves outcomes but we don’t have enough out there. Improving Outcomes: Spend a lot and still get poor outcomes; Strengthening Medicare and Medicaid: Important to ruralA lot of discussion about health care reform Administration has made the argument that even in the worsening economy you can’t afford not to address this issue, that it affects so many parts of the economy from business competitiveness to personal finance, etc. And the Key Committees on the Hill have been discussing it, Sen. Baucus has released a blueprint for reform. The White House recently held a forum on health care There seems to be wide agreement that something needs to be done, but then again that is the easy part. The challenge is in the details and there are widely differing approaches from the left and the right. But, there are some key themes that are emerging. Access: uninsured, under insured, problems in the individual and group marketplace … hits rural as heavily dependent on the individual market and public programs Re-Emphasizing Primary Care: We’ve known this in rural for years; studies show regular access to PC improves outcomes but we don’t have enough out there. Improving Outcomes: Spend a lot and still get poor outcomes; Strengthening Medicare and Medicaid: Important to rural

    31. Health Care Reform: Senate Finance Committee Transforming the Health Care Delivery System: Proposals to Improve Patient Care and Reduce Health Care Costs Expanding Health Care Coverage: Proposals to Provide Affordable Cover to All Americans Financing Comprehensive Health Care Reform: Proposed Health Systems Savings and Revenue Options Timeline Timeline

    32. Health Care Reform: Senate Finance Committee Themes for transforming Health Care Delivery Value-based purchasing for hospitals & CAHs Transitional care payments CMS Chronic Care Management Innovation Bundling of Payments & Readmissions GME Primary Care Redistribution

    33. Health Care Reform Resources RUPRI Health Panel- Rural Perspectives & Commentary http://www.rupri.org/panelandnetworkviewer.php?id=9 Department of Health and Human Services http://www.healthreform.gov Senate Finance Committee http://finance.senate.gov/healthreform2009/home.html

    36. We are awarding more than 100 outreach grants this spring We’ll have a competition this summer for our QI program focusing on chronic disease and using a patient registry with specific chronic disease management training … guidance out in June and applications due in October … expect to make 75-90 awards … Also have the NW planning grants … community planning funding … Recovery Act also has $650 million in funding for prevention and wellness, focusing on chronic diseases … not yet clear how that money will go out but we will know soon. Tremendous opportunity for rural given high rates of chronic diseaseWe are awarding more than 100 outreach grants this spring We’ll have a competition this summer for our QI program focusing on chronic disease and using a patient registry with specific chronic disease management training … guidance out in June and applications due in October … expect to make 75-90 awards … Also have the NW planning grants … community planning funding … Recovery Act also has $650 million in funding for prevention and wellness, focusing on chronic diseases … not yet clear how that money will go out but we will know soon. Tremendous opportunity for rural given high rates of chronic disease

    37. Last year, our agency began a new initiative focused on providing training to health care teams on Rx and patient safety. All of us put funds into it and we got a fairly good response as a number of the teams are rural folks, but mostly FQHCs but also a few CAHs. The training relies on the IHI “Model for Improvement” The deal is the training is free but you need to put up the funds to get to the training. If you tried to pay for this training on your own, it would cost in the six figures. Many of the folks are HRSA grantees but we have made a deal that allows CAHs and RHCs to apply for the program even if they are not HRSA grantees. We’d like to see a bigger representation of of CAH and RHC folks this year Last year, our agency began a new initiative focused on providing training to health care teams on Rx and patient safety. All of us put funds into it and we got a fairly good response as a number of the teams are rural folks, but mostly FQHCs but also a few CAHs. The training relies on the IHI “Model for Improvement” The deal is the training is free but you need to put up the funds to get to the training. If you tried to pay for this training on your own, it would cost in the six figures. Many of the folks are HRSA grantees but we have made a deal that allows CAHs and RHCs to apply for the program even if they are not HRSA grantees. We’d like to see a bigger representation of of CAH and RHC folks this year

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