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Developing Hospital-Physician Linkages through the Rural Health Clinic Program An Integration Strategy for CAHs Agenda A Brief History of the Rural Health Clinic Program Program Requirements Independent vs. Provider-Based Reimbursement Basics Strategic Issues Case Examples Conclusions

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developing hospital physician linkages through the rural health clinic program

Developing Hospital-Physician Linkages through the Rural Health Clinic Program

An Integration Strategy for CAHs

agenda
Agenda
  • A Brief History of the Rural Health Clinic Program
  • Program Requirements
  • Independent vs. Provider-Based
  • Reimbursement Basics
  • Strategic Issues
  • Case Examples
  • Conclusions

Rural Health Consultants, Inc.

a brief history of the rural health clinic program
A Brief History of the Rural Health Clinic Program
  • Established in 1977 through P.L. 95-210
  • Purpose:
    • To increase the availability and accessibility of primary care services in underserved rural communities through enhanced reimbursement and creation of practice opportunities for mid-level practitioners

Rural Health Consultants, Inc.

a brief history of the rural health clinic program4
A Brief History of the Rural Health Clinic Program
  • Explosive program growth in early 1990s
    • More than 1,000 RHCs certified in the 18 months from Oct 1993-March 1995
    • From 1990-1995, the number of RHCs increased by more than 650%
  • Currently about 3,300 RHCs located in 47 States

Rural Health Consultants, Inc.

what is a rural health clinic
What is a Rural Health Clinic?
  • A clinic/office that is engaged principally in the provision of outpatient primary medical care
  • Meets location, service, and other requirements

Rural Health Consultants, Inc.

rhc program requirements location
RHC Program Requirements: Location
  • Census Bureau defined non-urbanized area
  • Designated within the past 3 years as:*
    • Federally designated Health Professional Shortage Area (HPSA), or
    • Federally designated Medically Underserved Area (MUA), or
    • Governor designated shortage area

Rural Health Consultants, Inc.

rhc program requirements staffing
RHC Program Requirements: Staffing
  • Physician
    • Provides medical direction
    • Supervises clinical staff
    • Participates in development of P & P
    • Reviews patient records
    • Provides patient care
  • Mid-level practitioner
    • PA, NP, or CNM onsite and available to see patients at least 50% of the time the clinic is open for patient care

Rural Health Consultants, Inc.

rhc program requirements physical plant
RHC Program Requirements: Physical Plant
  • May be permanent or mobile
  • May be a stand-alone building or a designated space within another facility
  • Designation is site specific

Rural Health Consultants, Inc.

rhc program requirements core services
RHC Program Requirements: Core Services
  • Diagnostic and therapeutic services commonly furnished in a physician’s office
  • Six basic lab tests:
    • Chemical examination of urine
    • Hemoglobin or hematocrit
    • Blood sugar
    • Examination of stool for occult blood
    • Pregnancy test
    • Primary culturing for transmittal

Rural Health Consultants, Inc.

rhc program requirements written policies procedures
RHC Program Requirements: Written Policies & Procedures
  • Developed by physician, mid-level, and clinician who is not a member of the clinic staff
  • Describes services provided directly by clinic staff or through arrangement
  • Provides guidelines for medical management of health problems
  • Provides for keeping of patient medical records and privacy of these records
  • Reviewed annually

Rural Health Consultants, Inc.

rhc program requirements quality assurance
RHC Program Requirements:Quality Assurance
  • Must maintain Quality Assessment and Performance Improvement (QAPI) Program*
    • Evaluate clinical effectiveness, access to care, and patient satisfaction
    • Measure, analyze, and track processes of care and clinic operations

Rural Health Consultants, Inc.

types of rhcs
Types of RHCs
  • Independent or Free-Standing (I-RHC)
  • Provider-Based (PB-RHC)

Rural Health Consultants, Inc.

independent rhc
Independent RHC
  • An independent clinic/practice that is owned and operated by a physician, NP, PA, CNM, for-profit entity, or not-for-profit entity, consistent with state corporate practice of medicine laws

Rural Health Consultants, Inc.

provider based rhc
Provider-Based RHC
  • An “integral and subordinate” unit of a Medicare certified hospital, CAH, SNF, or home health agency
    • PB-RHC conforms to hospital policies and procedures
    • Chain of command between nursing and office staff at PB-RHC and appropriate personnel at hospital
    • Certification inspections and process conform to hospital procedures, etc.

Rural Health Consultants, Inc.

provider based rhc15
Provider-Based RHC
  • Meets “provider-based” requirements
    • May be on-campus or at a remote location
      • Within 35 miles (except when main provider is a rural hospital with less than 50 beds)
    • Operates under ownership, administrative, and financial control of the main provider
    • Clinical services and financial operations are integrated with main provider, etc.

Rural Health Consultants, Inc.

pb rhc medicare payment hospital 50 beds
PB-RHC: Medicare Payment Hospital > 50 Beds
  • Cost per visit rate (does not include x-ray and lab)
  • Cap on payment per visit, annually adjusted
    • 2004 cap = $68.65
  • Productivity standards (apply to employed providers)
    • 1 FTE Physician = 4,200 visits per year
    • 1 FTE Mid-Level = 2,100 visits per year

Rural Health Consultants, Inc.

pb rhc medicare payment cah hospital 50 beds
PB-RHC: Medicare Payment CAH/Hospital < 50 Beds
  • Cost per visit rate (does not include x-ray and lab)
  • No cap
  • Productivity standards (apply to employed providers)

Rural Health Consultants, Inc.

provider based rhc medicaid payment
Provider-Based RHC:Medicaid Payment
  • Prospective per visit rate, based on:
    • For existing RHCs:
      • Average of 1999 and 2000 rates
    • For new RHCs:
      • Average rates of similar clinics, or
      • Actual first year costs
  • Rate established in first year, then annually adjusted
  • Check with State for operational details

Rural Health Consultants, Inc.

pb rhc strategic questions
PB-RHC Strategic Questions
  • Is the mission of the hospital to assure access to primary care?
  • Are additional networking opportunities part of the strategic plan?
  • Is a current shortage area designation in place?
  • Are mid-level practitioners available?

Rural Health Consultants, Inc.

pb rhc strategic questions20
PB-RHC Strategic Questions
  • Does the hospital have the expertise to manage a primary care practice?
  • Is physician-hospital integration desirable?
  • Are medical staff interested/supportive?
  • Should physicians be employed or contracted?

Rural Health Consultants, Inc.

financial impact of addition of pb rhc to cah
Financial Impact of Addition of PB-RHC to CAH

Rural Health Consultants, Inc.

conclusions benefits
Conclusions: Benefits
  • Bringing a PB-RHC into a CAH creates opportunities for:
    • Assuring that primary care is available locally
    • Vertical integration with physicians
    • Enhanced Medicare and Medicaid payment
    • Diversion of primary care from CAH Emergency Department
    • Enhanced recruitment/retention through hospital-physician network with aligned incentives

Rural Health Consultants, Inc.

conclusions cautions
Conclusions: Cautions
  • Doesn’t always result in financial benefits
    • Feasibility assessment is essential!
  • Productivity matters
    • Create incentives for clinicians
  • Organizational changes can be complex and disruptive

Rural Health Consultants, Inc.