Current through Register Vol. 42, No. 5, February 29, 2024
Alabama has a Rural Health Plan developed with the assistance
of the Alabama Department of Public Health's Office of Primary Care and Rural
Health, the Alabama Hospital Association, and rural hospitals. The current
State Rural Health Plan, published in 2008, was updated in both 2011 and
20161. This plan is incorporated into this State
Health Plan by reference hereto.
(1)
The Problem. Rural healthcare providers disproportionately serve
individuals who are older, sicker, poorer and underinsured/uninsured as
compared to people living in other parts of Alabama. Alabama's uninsured rate
(19-64 years) is 15.8%2. Policy makers anticipated a
rate less than 10% after passage of the Affordable Care Act, but the take up in
the Alabama Marketplace/Exchange is only 3%. Rural Alabamians (as well as
Americans on the whole) often lack adequate primary care access and have higher
rates of diabetes, heart disease, cancer, obesity, tobacco/opioid use, mental
health issues and stroke3. The health issues
plaguing rural Alabamians stress a fragile rural delivery system dealing with
lower volumes, rising costs, increased regulations, lower negotiating power and
a shortage of healthcare workers. As rural Alabama changes and evolves, so too
must rural healthcare delivery in the state. The issues facing Alabama's rural
care providers are multi-faceted:
(a)
Reimbursement and Operational Factors. As a rule, providers in rural areas
experience a higher mix of Medicare/Medicaid patients than do the facilities in
urban areas; but rural hospitals receive a lower amount of reimbursement per
patient from Medicare. Rural providers must have robust volume to thrive. But
the healthcare system is shifting away from an inpatient-dominant and
volume-driven system and consequently the state's rural delivery system is
becoming increasingly brittle. To counter the loss in volume, many rural
providers expand their service offerings which is often not ideal because
quality is correlated to volume in certain
specialties4.
As healthcare shifts from volume-based reimbursement to a
system based predominately on value, rural providers will continue to struggle
if payors do not make a distinction between the unique operating context of a
rural hospital and that of suburban and urban providers. Even when a
distinction is made, oftentimes it is deleterious to the provider. For example,
the Centers for Medicare and Medicaid Services (CMS) implementation of the
Prospective Payment System (PPS) assumes hospitals in rural areas will not
experience the same labor costs for health personnel services as do urban
hospitals. Therefore, the component parts of the prospective payment formula
provide for a lower wage allowance for rural hospitals. Another factor that
tends to limit reimbursement for rural hospitals is that the PPS system assigns
weights related to patient attributes to each diagnosis-related group (DRG).
The higher the weight per DRG, the more reimbursement a hospital will receive
if that hospital provides services to patients with higher weighted/reimbursed
DRGs. Therefore, urban facilities may receive more reimbursement, although the
weight assignment per DRG has not been proven as an accurate indicator of the
consumption of resources. The bottom-line effect of Medicare reimbursement on
rural hospitals is the payment rates are generally less for hospitals in rural
areas, leading to a less than adequate payment system. According to the Alabama
Hospital Association, in recent years approximately eighty-eight percent (88%)
of rural hospitals in the state experienced a net operating loss.
(b) Demographic Factors. A low
population density, worsened by the emigration of the younger population in
search of employment in larger communities, results in a high proportion of the
elderly and underinsured/uninsured remaining in rural communities. Alabama's
overall population density in 2019 averaged 94.4 people per square mile,
ranging from a low of 12.5 persons per square mile in Wilcox County to a high
of 586.2 persons per square mile in Jefferson County. In this case a
measurement of density may not be an accurate indicator as only 18 counties
have a density factor equal to or above the average and 49 counties below the
average. Rural facilities thus have a smaller market from which to draw
patients and fewer patients who pay adequately as compared to the costs of
providing the care. According to the Centers for Medicare and Medicaid
Services, in 2014 health care spending per capita for the 65 and older
population was over five times higher than health care spending for children,
and almost three times higher than for working-age
adults5. The population 65 and older comprises 16.9%
of the state population and 19.2% for the 49 rural counties, further
emphasizing the need to develop and implement a rural health
plan6. In addition, rural Alabama has a high
percentage of Veterans and a low percentage of commercially insured residents.
(c) Utilization Factors. Overall
use of inpatient services in rural areas continues to decline, while those same
services are increasingly used by the elderly who are covered by decreasing
Medicare reimbursement. Given that many of the rural hospitals are sole
community providers, the leading industry in the community, and one of the
major employers in the area, the decreasing use has caused concerns both
economically and politically. Leaders are rightly concerned that the demise of
the rural hospital leaves a discontinuity of health care services for citizens
in their areas.
(d) Insufficient
Health Professional Supply. Data from the Alabama Department of Public Health
indicates that every county in the state has at least some areas considered to
be medically underserved, with fifty-eight (58) counties shown as completely
medically underserved. While Alabama has made strides in licensure portability
in recent years, there are still barriers to address, including portability
within telehealth. Because of the problems attracting specialized professionals
and obtaining new technologies, few rural hospitals can provide special
services that might increase their revenue. The migration of young people to
urban communities, lack of adequate reimbursement, and limited patient
resources are other problems hindering the recruitment of professional
personnel and fueling the state's health professional shortages. Government
reports show that Alabama, like many other parts of the South, is experiencing
a physician shortage.
Children living in rural areas have less access to routine
primary care and, if they have a chronic condition or medically complex
diagnosis, must drive long distances to urban centers for care. Many rural
emergency rooms are not equipped for pediatric care, and those cases are often
transferred to regional hospitals. In addition, much of the rural emergency
care is through a volunteer EMS system, which could be enhanced.
Utilization of nurse practitioners, physician assistants, and
nurse midwives meets a real need in addressing the access problem faced by many
rural Alabamians. Health planners, providers, policy makers, and communities
must approach the recruitment and retention of non-physician health
professionals realistically. It is unrealistic to assume that every rural
community will be able to recruit and retain a physician. In order to provide
access to health care for the citizens of many of the state's most rural areas,
the utilization of non-physician health professionals must be seriously
encouraged. Also, payment for services provided by these non-physician health
professionals must be made by third party payors and self-insured programs in
order for their numbers to increase.
(e) No one strategy will solve the state's
problems with rural health care. Rural healthcare delivery must evolve and the
state must focus on appropriate and adequate access but untether from the idea
of access equals an inpatient hospital.
(2)
Recommendations. Using the
Bipartisan Policy Center's 2018 Report, "Reinventing Rural Health" as a
framework, the following are recommendations from the Committee:
(a) Communities should tailor available
services to the needs of the community, which for many rural areas are driven
by changing demographics. To build tailored delivery services, policies need to
be flexible and not just have a "one-size-fits-all" approach.
1. Support Opportunities for Transformation.
The healthcare industry nationally continues to move toward the outpatient
setting and towards a value-based approach. Rural hospitals feel the impact of
this transformation even more acutely and face unique challenges given both
their location and low patient volumes. Many of Alabama's rural hospitals rely
on enhanced reimbursement programs (e.g. Critical Access Hospital, Medicare
Dependent Hospital, Low Volume Hospital adjustment, etc.) to be able to offer
key outpatient services, despite low patient volumes.
2. Overall health improvement and management
of disease cannot be done when local access to basic services is lost. Lack of
access, either to an inpatient hospital or to urgent/emergent care, leads to
increased time and cost of transportation to healthcare services (particularly
among seniors, who experience an average of fourteen (14) additional minutes in
an ambulance7); reduced per capita income (-4%) and
increased unemployment (1.6%) due to the loss of jobs for hospital staff and
outward migration of community members8.
3. For communities that cannot sustain their
current healthcare delivery structure, the SHCC supports state regulatory and
statutory allowances for the establishment of new types of access sites that
support transformation while maintaining important access points to care. These
provider types would provide services critical to any rural community
including: primary care; urgent, emergency care and transportation (EMS);
observation, outpatient and ambulatory services including basic ancillary
services and minor procedures. Emergency services could be enhanced by having
several paramedics trained to work alongside and within the volunteer EMS
system. In addition, population health approaches, including chronic disease
management and care coordination, would be required. Optional services could be
provided if they are not locally available (e.g. patients who do not need acute
care could be treated and receive skilled nursing and/or rehabilitation
services, behavioral health, oral health or home health services).
4. The realities of the health care system
are that form follows payment and shifting to more transformative models will
require alternative and enhanced reimbursement models, recognizing the unique
challenges of low patient volumes coupled with an increasingly large population
of Medicare enrollees. All innovation models should ensure adequate
reimbursement to support such models.
5. These new provider types would require
strong relationships with an inpatient facility or partner organization, as
well as a plan to assure emergent and non-emergent transportation in the area
between the partner and the smaller entities as well as other service providers
in the area.
(b) Maintain
Certificate of Need (CON). The CON serves as an important guardrail against
reducing access and should not be repealed or limited in scope. Repealing or
limiting the scope of CON can reduce access to care for the most vulnerable by
destabilizing safety net hospitals. This occurs through a further degradation
of the payer mix among patients at safety net providers.
(c) Once the right system and services have
been identified for a community, funding mechanisms and payment models should
reflect the specific challenges that rural areas face - such as small
population size and high operating costs. Sparse populations mean a small
number of patients, so reimbursement metrics must consider low patient volumes.
Rural health care providers are eager to participate in value-based
alternative-payment models, but they need workable approaches and metrics.
Policymakers should consider the unique challenges faced in rural areas when
developing metrics and funding mechanisms.
1.
Exploration and support should continue to identify and increase access to
insurance and care for Alabama's uninsured.
2. Addressing Social Determinants of Health.
A lack of focus on Social Determinants of Health translates into poor health
status, which is borne out in Alabama's consistently low national ranking with
respect to issues like obesity, substance use disorder and infant mortality.
The SHCC supports the goals of the Alabama Coordinated Health Network (ACHN)
and Integrated Care Networks (ICN) and the programs outlined in the Quality
Improvement Programs (QIP) to address some of the higher impact health issues
affecting many rural residents.
(d) With appropriate services and funding,
rural communities can build sustainable and diverse workforces. Rural health
can no longer survive on the back of one physician serving an entire community
24/7. Building and supporting the healthcare workforce should be a high
priority, and the expectation of care quality should be comparable in rural as
in more urban areas of the country. Also, alternative providers practicing at
the top of their licenses, such as nurse practitioners and physician
assistants, can fill vital primary care roles in the community. Communities
should start young and think local for recruitment with pipeline programs that
encourage interest in the health care sector in local middle-and high-school
students. The State should adopt policies that increase the availability of and
participation in rural residency programs. Providers are starting to think
creatively by employing case managers, community-health workers and in-home
providers to help meet the needs of the community. Policies should support
these efforts.
1. Rural Development. The SHCC
encourages state policymakers' support and funding (where applicable) of
targeted rural initiatives that would assist rural providers.
2. Support Additional Graduate Medical
Education ("GME") Funding. Addressing the physician and nurse workforce
shortage is a priority for all rural providers. Rural hospitals face unique
recruitment challenges but increasing the opportunity for physicians to train
in rural hospitals allows medical residents to see the impact they can have and
the benefits of rural locations.
3.
Promote Rural Practice and Retention. The SHCC encourages state policymakers to
pass the Alabama Physician Initiative, which would provide scholarships for
certain medical students who are enrolled in and attending any college of
medicine in Alabama and who contract with the Alabama Medical Education
Consortium to practice for five (5) years after the completion of their
residency in rural areas of the state with the greatest need for physicians,
with funds allocated through the Alabama Department of Public Health. The SHCC
also supports funding and development of workforce development efforts between
academic centers (e.g. community colleges, vocational schools, career centers,
etc.) and healthcare providers to develop a pipeline of career-ready healthcare
professionals.
4. Rural Tax
Credits. The SHCC encourages renewal and/or passage of rural tax credits to
primary care physicians and advanced practice providers ("APP") who practice in
rural areas.
5. Physician
Recruitment. The SHCC encourages the secondary school systems to coordinate
medical student recruiting efforts with the medical schools.
6. APP Training. The SHCC encourages schools
of higher education to develop and expand APP training programs for utilization
of such personnel in rural hospital emergency departments and/or rural health
clinics. Encourage the continued support and recruitment of nurse practitioners
and nurse midwives and expand the number of nurse practitioner programs in the
state.
7. APP Utilization. Develop
and implement programs to promote the utilization of APPs by:
(i) Licensure and physician supervision
requirements should be modified where access to care is hindered.
(ii) Promoting reimbursement by all
payors.
(e)
Health professionals working in rural areas need the right tools for success.
Telemedicine is one tool that can be used to support both rural patients and
rural providers. Not only do these services improve access by connecting remote
patients with specialists located elsewhere, but they provide much-needed peer
support to rural health professionals who often work in professional isolation.
Telemedicine may prove to be critical in improving provider recruitment and
retention, though challenges remain with broadband availability and
reimbursement.
1. Expand Opportunities to
Utilize Telehealth. Rural hospitals face unique challenges to provide access to
care. Rural facilities are often located an hour or more away from the next
closest hospital or clinic. Both providers and patients must travel greater
distances to receive face-to-face care. Increasing the utilization of
telehealth provides the opportunity to address these barriers to care.
Telehealth services can include virtual visits originating at a patient's home
or at a medical facility, remote patient monitoring and specialist consults
between hospitals. The SHCC encourages policymakers to support innovation in
telehealth in the following ways:
(i) Support
reimbursement of telehealth services at the same rate as face to face
services.
(ii) Expand the
definitions to allow patients to receive services in their homes.
(iii) Continue to invest in high-speed
broadband access.
(iv) Create and
invest in communication and marketing materials on the benefits of telehealth
and focus distribution of those materials in the rural underserved communities
as part of the rural community plan.
(v) Financially support, fund and encourage
rural community hospitals to provide telehealth education and develop
telehealth portal locations for community access.
2. EMS Personnel. The SHCC encourages state
stakeholders to determine how EMS personnel and certified paramedics could be
utilized in rural areas beyond stabilization/transport and develop policies and
reimbursement mechanisms for such paramedical professional
utilization.
