R URAL H EALTH C HALLENGES AND THE R EMEDIAL P ROSPECTS OF T ECHNOLOGY A ZALEA H EALTH L EADERS S UMMIT 2016
R URAL URAL IS IS D D IFFERENT IFFERENT – N – N OT OT W W ORSE ORSE • Rural areas score higher than urban areas on appropriate provision of preventive services related to breast exams, family history of cancer, flu immunization... • Hospitals in rural area have significantly higher ratings on HCAHPS measures than those located in urban areas • Rural hospitals match urban hospitals on performance at a lower price Stats courtesy of Alan Morgan, CEO of National Rural Health Association • Sample rural GA hospital versus statewide averages (HCAHPS): • Pain control: 86% satisfied vs. 71% state average • Physician communication: 95% satisfied vs. 83% state average • 82% gave hospital a score of 9 or 10 vs. 71% state average
W HA HAT ’ S A A ILING ILING R R URAL URAL H H EAL THCARE ? EALTHCARE Half of Americans live in the red counties, half live in the orange counties… dadaviz.com via @conradhackett
W HA HAT ’ S A A ILING ILING R R URAL URAL H H EAL THCARE ? EALTHCARE • More likely to report fair to poor health • Rural counties 19.5% • Urban counties 15.6% • Higher obesity rates: Rural counties 27.4% vs. urban counties 23.9% Stats courtesy of National Rural Health Association • More chronic disease: • Sample rural hospital vs. GA state averages: • 26% higher cardiovascular disease mortality • 16% higher cancer mortality • 1/5 of Americans live in rural areas, but 1/10 of physicians practice there ( The Atlantic , Aug. 28, 2014)
W HA HAT ’ S A A ILING ILING R R URAL URAL H H EAL THCARE ? EALTHCARE Recent legislation including the Affor Recent legislation including the Af fordable Car dable Care Act e Act has placed many bur has placed many burdens on hospitals dens on hospitals • Medicare / Medicaid reimbursements cuts • E.g. sequestration • Current and looming disproportionate share cuts • Quality-oriented penalties (e.g. readmissions) • CBO projects 10.4% decline 10.4% decline in Medicare reimbursement by 2020 • Even among newly insured, higher deductibles have led to increased uncompensated care • One half of all non-elderly, non-poor households do not have enough liquid assets to meet deductibles over $2,500 Source: Kaiser Family Foundation • Increased compliance costs I F U.S. COSTS OF COMPLYING WITH HEALTHCARE REGULATIONS ($1.863 TRILLION ) WERE A COUNTRY , IT WOULD BE THE WORLD ’ S 10 TH LARGEST ECONOMY ! ¡
W HA HAT ’ S A A ILING ILING R R URAL URAL H H EAL THCARE ? ? EALTHCARE MEDICAID EXPANSION WAS INTENDED TO OFFSET ACA’S CUTS : : MORE PAYING PATIENTS, LESS UNCOMPENSATED CARE. BUT.... • U.S. Supreme Court made expansion optional • 23 states, including Georgia, have declined • Georgia’s Medicaid program remains closed off to all childless adults, and parents making more than 40% of federal poverty level ($8,000 annually = too wealthy for Medicaid)
C ONSEQUENCES ONSEQUENCES OF OF C C LOSURE LOSURE ACCESS TO CARE • Increased travel time to nearest hospital – costly during emergencies • Travel limitations for poor and elderly populations • Pungo Hospital, Bellhaven, NC • Closed in 2014; 20,000 people now in counties without ER • Six days after closing, 48-year-old woman died of heart attack waiting for helicopter • “If someone has a stroke, and we can’t get a CT on them to administer treatment, or if they have trauma and they can’t get fluid replacements, they’re going to die.” - Belhaven physician Mark Beamer Sources: Kaiser Health News, Charlotte Observer
C ONSEQUENCES ONSEQUENCES OF OF C C LOSURE LOSURE ACCESS TO CARE • North Georgia Medical Center, Ellijay, GA • Closed in 2016 • “[Physician’s offices] have been treated like an emergency room… We have people walking in with open knees requiring stitching, and people are coming in weak and fragile and passing out in the waiting room.” Source: Times Courier
C ONSEQUENCES ONSEQUENCES OF OF C C LOSURE LOSURE ACCESS TO CARE
C ONSEQUENCES ONSEQUENCES OF OF C C LOSURE LOSURE ECONOMIC IMPACT • Three years after a rural hospital community closes, it costs about $1000 in per capita income • On average, 14% of total employment in rural areas is attributed to the health sector. • One rural physician generates an average of 23 jobs in the local economy Sources: National Rural Health Association; Rural Health Works; Mark Holmes, UNC Professor
C ONSEQUENCES ONSEQUENCES OF OF C C LOSURE LOSURE ECONOMIC IMPACT • Hancock Memorial Hospital, Sparta, GA • Closed in 2001 • “When [trying] to recruit a new industrial employer, one of the first things they ask is, ‘Do you have a hospital?’” – Hancock County Commission Chair Sistie Hudson • Source: “When Rural Hospitals Close, Towns Struggle to Stay Open” – Marketplace, 2014
TECHNOLOGY AS A REMEDY? Inpatient- Inpatient- Tech- ech- Center Centered ed Driven Driven Car Care Car Care Outpatient Outpatient -Center -Centered ed Car Care Past à Present à Future
W HY HY T ELEHEAL TH ’ S T T IME IME IS IS H H ERE ERE ELEHEALTH • E-visits increased by 400% between 2012 and 2014 1 – still rising • Rural communities dwindling -- telemedicine can extend access to specialty services to underserved areas • Rise of direct-to-consumer health puts increased pressure on institutional providers to maintain market share • Technological advancements make telemedicine more affordable than ever • Shift to value-based care places greater emphasis on routine, convenient, preventive care 1 Deloitte, http://www2.deloitte.com/content/dam/Deloitte/global/Documents/Technology-Media-Telecommunications/gx- tmt-2014predictionevisits.pdf
W HY HY T ELEHEAL TH ’ S T T IME IME IS IS H H ERE ERE ELEHEALTH What ¡Op8ons ¡Consumers ¡Would ¡Select ¡for ¡Middle-‑of-‑the-‑ Night ¡Care ¡ Video ¡Visits ¡ 21% ¡ 24 ¡Hour ¡Nurse ¡Line ¡ 44% ¡ Online ¡Symptom ¡Checker ¡ 17% ¡ Ambulance ¡ Other ¡ 9% ¡ [PERCENTAGE] ¡ [PERCENTAGE] ¡ ER ¡ Source: ¡Kaufman ¡Hall ¡& ¡Associates ¡
T ELEHEAL TH AND AND P P OPULA TION H H EAL TH ELEHEALTH OPULATION EALTH Atlanta Journal-Constitution Forbes Becker’s Hospital Review Modern Healthcare Regarding per-patient-per-month reimbursement under CPC+ model, “ practices might offer telemedicine visits or simply provide longer office visits for patients with complex needs.”
T ECHNOLOGY ECHNOLOGY AS AS A R R EMEDY EMEDY • Traditional Hub-and-Spoke “Access” Model HUB Continuous care Specialty services reducing ER visits and w/out MD travel readmissions Increased services Shared reimbursement at rural spoke – for live two-way care keeping patients in keeping patients in their communities their communities Transfers of cases not clinically appropriate Life-saving for spoke emergency care without lengthy PR and marketing patient travel advantages Coordinated care for superior quality SPOKE
T ECHNOLOGY ECHNOLOGY AS AS A R R EMEDY EMEDY • School- or Employer-Based Population Health Model HEALTH SYSTEM Greater access to Encourages patients to care – relieves receive routine care travel burdens and where otherwise work absences for avoided (e.g. due to employees and high deductibles) parents Reduces unnecessary ER Keeps student and visits and readmissions employee populations Developing relationships healthier with families – PR and marketing advantages Allows on-site staff to provide more varied, meaningful care
T ECHNOLOGY ECHNOLOGY AS AS A R R EMEDY EMEDY • Consumerism/mHealth Model Development of direct-to-patient • health apps Offer as premium service to self-pay • patients Contract with commercial payers to • include e-visits in plans Some health providers are white-labeling • mobile health services to better reach their patient populations (e.g. Piedmont Hospital)
T ECHNOLOGY ECHNOLOGY AS AS A R R EMEDY EMEDY • Home-Health Model Remote patient monitoring and follow-up • Reduced readmissions Optimal efficiency and quality Telemedicine-equipped ambulances • Reduced unnecessary ER visits Lives saved in remote areas • Physician-Led Models Mercy Virtual Care Center in Chesterfield, MO, launched in fall of 2015, featuring Standalone specialty practices • more than 300 providers serving 38 Concierge Medicine hospitals in areas such as stroke care and • ICU monitoring. Since launching, Mercy Back-up to urgent care centers, rural clinics • claims to have sent home 1,000 ICU patients who otherwise would have been Back-up to hospital emergency rooms, ICUs • expected to die, and saved $40 million. (e.g. telepsychiatry) Photo and story via U.S. News and World Report
R EIMBURSEMENT EIMBURSEMENT – P – P RIV TE P P AY AY RIVATE G EORGIA EORGIA T T ELEMEDICINE ELEMEDICINE A A CT CT OF OF 2005 (“P 2005 (“P ARITY ARITY L L AW AW ”) ”) O.C.G.A. § 33-24-56.4 O.C.G.A. § 33-24-56.4 ...every health benefit policy that is issued, amended, or renewed shall include payment for services that are covered under such health benefit policy and are appropriately provided through telemedicine...and generally accepted health care practices and standards prevailing in the applicable professional community at the time the services were provided.
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