THE CHANGING FACE OF RURAL HEALTH CARE New Opportunities Amidst Transition Eric Harkness Director of the Office of Health Policy 1 November 14, 2018
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Hospital Closings since January 2010 Affecting Tennessee Since 2010, Tennessee has had the 2 nd highest rural hospital closure rate in the nation and the highest rate of closures per capita. 3
The Upshot: Access to Health Care is a Challenge for Many in Tennessee… 8
…And the way we deliver health care — especially in rural areas — is changing, too. 9
Today: Rural Health Care FQHC General Surgeon Health Department Pharmacy Specialists: Ortho and Cardiac Hospital: • ED Primary • Lab Care • Diagnostic • ICU Nursing • OB Home 10
Tomorrow: Rural Health Care FQHC/ Primary Care Health Department Pharmacy Telemedicine to Emergency Anywhere Department: • Lab • Diagnostic • ICU 11
An Inside Look at a Stand-Alone ED ICU/Observation Primary & Prenatal Care Diagnostics Telemedicine to Anywhere Lab Rapid Transport 12
Telemedicine to Anywhere: A [Large] Part of the Wave of Change 13
What is Telemedicine, Legally Speaking? Tennessee Code Annotated Definition (Title 56. Insurance § 56-7- 1002): (6) “Telehealth”: (A) Means the use of real-time, interactive audio, video telecommunications or electronic technology, or store-and-forward Two-Way telemedicine services by a healthcare services provider to deliver Communication healthcare services to a patient within the scope of practice of the healthcare services provider when: Provider is at (i) Such provider is at a qualified site* other than the site where the patient is his/her clinic or located; and Patient is at a (ii) The patient is at a qualified site or at a school clinic staffed by a school with healthcare services provider and equipped to engage in the telecommunications described in this section; and nurses (B) Does not include: Phone calls, (i) An audio-only conversation; emails, and faxes (ii) An electronic mail message; or don’t count (iii) A facsimile transmission *(4) “Qualified site” means the office of a healthcare services provider, a hospital licensed under title 68, a facility recognized as a rural health clinic under federal Medicare regulations, a federally qualified health center, any facility licensed under title 33, or any other location deemed acceptable by the health insurance 14 entity;
What is Telemedicine, Legally Speaking? Selected Code (Title 56. Insurance § 56-7-1002): (b) Healthcare services provided through a telehealth encounter shall comply with state licensure requirements promulgated by the appropriate Regulatory licensure boards. Telehealth providers shall be held to Parity the same standard of care as healthcare services providers providing the same healthcare service through in-person encounters. (c) A telehealth provider who seeks to contract with or “Delivery who has contracted with a health insurance entity to Style” participate in the health insurance entity's network shall be subject to the same requirements and Parity contractual terms as a healthcare services provider in the health insurance entity's network. 15
What is Telemedicine, Legally Speaking? Selected Code (Title 56. Insurance § 56-7-1002): (e) A health insurance entity shall provide coverage for healthcare services provided during a telehealth encounter in a Payment manner that is consistent with what the health insurance policy or Parity contract provides for in-person encounters for the same service. (f) Nothing in this section shall require a health insurance entity to pay total reimbursement for a telehealth encounter, including the More use of telehealth equipment, in an amount that exceeds the amount that would be paid for the same service provided by a Payment healthcare services provider in an in-person encounter. Parity (g) Any provisions not stipulated by this section shall be governed by the terms and conditions of the health insurance Payor contract. Discretion 16
Regulatory Board Status of Telemedicine Rules Rules Established: • Medical Examiners Drafts or conversations started: • Dentistry • Psychology • Social Work and Licensed Professional Counselor • Nursing (very, very early conversations) 17
Not quite the Wild West, but… 18
…There is tremendous opportunity to take advantage of wide open spaces and new ways of doing things. 19
When it comes to capitalizing our opportunities in Health Care, Are we asking the right questions? 20
Can the health care sector solve for health? Can Health Care deliver the HEALTH we want? 21
2017: The U.S. Ranks Last Among Peers 22
Overall Health System Performance 23
Equity of Health Systems 24
Population Health Outcomes 25
The U.S. Healthcare System Doesn’t Achieve Expected Value 26
Health Care System Performance Compared to Spending Higher UK AUS health system performance NETH NOR NZ SWIZ GER Eleven-country average SWE CAN FRA US Lower health system performance Lower health care spending Higher health care spending Note: Health care spending as a percent of GDP. Source: Spending data are from OECD for the year 2014, and exclude spending on capital formation of health care providers. E. C. Schneider, D. O. Sarnak, D. Squires, A. Shah, and M. M. Doty, Mirror, Mirror: How the U.S. Health Care System Compares Internationally at a Time of Radical Change, The Commonwealth Fund, July 2017.
High Inequity in U.S. Healthcare Spending (NIHCM 2012) 28 National Institute for Health Care Management
Chronic Diseases are Driving Most of U.S. Healthcare Spending Total expenditures in $ billions by disease category, 2012 Ill-defined conditions $247 Circulatory $241 Musculoskeletal $186 Respiratory $157 Endocrine $138 Nervous system $133 Cancers and tumors $124 Injury and poisoning $118 Genitourinary $113 Digestive $107 Other $93 Mental illness $80 Infectious diseases $67 Dermatological $44 Pregnancy and childbirth $39 $- $50 $100 $150 $200 $250 $300 Source : Bureau of Economic Analysis Health Care Satellite Account (Blended Account). Accessed January 25, 2016. Note : Expenditures on nursing home and dental care are not included in health services spending by disease. Ill-defined 29 conditions includes check-ups, follow-up appointments, preventive care, and treatment of minor conditions such as colds, flus, and allergies.
The Health Challenge of our Times 30
The Big 4 Excessive Physical Caloric Inactivity Intake Tobacco & Substance Nicotine Use Addiction Disorders 31
Our Brain’s Reward Center Nicotine Sex THC Glucose Yeah! Physical Endorphins Activity (Endogenous Opiates) 32
Does this messenger know something about dopamine and our response to rewards? https://www.youtube.com/watch?v=DRhlECBKvvo 33
Determinants of Health Environment 5% Health Health care is only a Care fraction of what 10% determines our Health Social Behaviors health. Factors 40% 15% Genetics and Development 30% Sources: McGinnis JM & Foege WH. Actual causes of death in the United States. JAMA 1993: 270(18):2207-12 (Nov 10) 34 McGinnis JM, Williams-Russo P, & Knickman JR. The case for more active policy attention to health promotion. Health Affairs 2002; 21(2):78-93 (Mar).
Our Present Health Reality Prevention Cure Treatment 35
Our Present Need Prevention Cure Treatment Treatment Cure Prevention 36
A little late to change the oil? 37
We Must Move Upstream… …To create places and spaces where health is strengthened and fostered. 38
So, What Creates Health? A Few Examples: Adequate Physical Social Inclusion Sleep Activity Richness of Reimburse Early Brain Our Health Care for Development Environment Health Meaningful work — Moderation in Our Human Everything Biology including as a student Spaces & Nutritious, Intentional Places that Balanced Diet Pregnancy Foster Health 39
When it comes to the outcomes of our health care system, where’s the disconnect to health? 40
Except, Filled Beds = $$$$ & Empty Beds = Health = No $
As we take advantage of new technology and new ways of delivering health care, how do we rebuild our health system to deliver health, not just care? 42
WHAT ARE WE DOING IN TN? 43
Tennessee’s State Health Plan Are we creating or improving Are we learning Are we moving opportunities for from or teaching upstream? optimal health for others? all?
www.tn.gov/vitalsigns 45
Real Change Stars at the Local Level In 2019, 16 counties will conduct a pilot County Health Assessment that will inform their county in 3 key ways 46
County Health Assessment Pilot Counties – Beginning Jan. 2019 Bradley, Chester, DeKalb, Fentress, Gibson, Giles, Hamblen, Hancock, Henry, Marshall, Meigs, Monroe, Stewart, Trousdale, Union, Washington 47
Eliana Pearl Born July, 2014 6 lbs. 12 oz. 20 inches 49
What role can YOU play in protecting, promoting, and improving HEALTH ? 52
THANK YOU 53
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