ORH Newsletter Vol. MMVII Ed. VI
- It’s never too early!!! Mark your calendars now for the 25th Annual Rural Health Conference
- New Interpretive Guidelines on CAH Relocation: How They Could Impact Your Hospital
- Rural Rotations — Teaching the Next Generation of Physicians in Rural Oregon
- The Uninsured in Oregon: Who are they?
- FLEX Program Offers Monthly WebEx Seminars for CAHs
- A Roadmap to Health Insurance for All: Principles for Reform
- The Farm Bill — Is it Important?
- First Annual Student/Rural Hospital BBQ a Huge Success!
- For the Latest on Health IT, Visit the AHRQ National Resource Center Web Site
- Weeding Out the Weak
- And the Winners Are???
- Coming Events
September 24-27, 2008
The Riverhouse Hotel
Resort, Hotel & Conference Center
Bend, OR
CMS has announced revisions to the interpretive guidelines regarding the relocation of Critical Access Hospitals (CAHs). The new guidelines could have a major impact on CAHs in Oregon. The new guidelines require a "75% Test" criteria and require all "necessary provider" CAHs to continue meeting the criteria under which they received their status. This means if a CAH received their status from their state because they were located in a HPSA, the new location must also be located in a HPSA.
Making plans for the future means paying attention to the new guidelines. Approval is not assured prior to any changes. CMS will now offer preliminary determination based on the CAHs letters of attestation and projections. However, it is important to remember that final determination of the “75% Test” will only be granted once the hospital has relocated and the evidence of compliance is confirmed.
Of particular interest in Oregon will be the requirements for CAHs that are designated necessary providers. In order for a necessary provider to relocate, they must meet the following:
- remain rural;
- demonstrate they still meet all of the original requirements used by the state to establish designation;
- after relocation, meet the 75% test—services, staff and population;
- all necessary information submitted to CMS prior to relocation.
CMS will only make a decision after relocation has been completed. Should they determine that CAH does not meet the 75% requirements, CAH status will be terminated.
The previous CMS guidelines contained fixed criteria that had to be met by "necessary provider" CAHs. The new guidance provides examples of acceptable documentation but also allows a CAH alternative documentation and flexibility to demonstrate their compliance with the "75% Test." For example, if the CAH has had difficulty with staff retention or has a number of J1 visa workers, CMS, with proper documentation, is able to waive the requirement that 75% of the staff stays with the hospital after the move.
“It is important that CAHs are keeping these new guidelines in mind when they are planning future growth”, says Kassie Clarke.
To see the presentation on CMS Guidelines sponsored by the Office of Rural Health, go to:
http://www.ohsu.edu/ohsuedu/outreach/oregonruralhealth/events/flex-webex-learning-series.cfm
To look at the guidelines, please go to :
http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter07-35.pdf
To see a comparison of the old and new guidelines, provided by the NRHA, please go to:
OHSU Medical Students in Rural Oregon
Every year, 3rd and 4th year medical students from OHSU spread out across the state to work with physicians in rural Oregon. In fact, at the end of this academic year, OHSU and the Area Health Education Center will have sent over 1500 medical students into rural practice clerkships since the inception of the Rural and Community Health Clerkship (commonly referred to as the Rural Rotation Program) in 1992. “There is no better way for our students to learn about rural practice and get such great experience than being out there”, says Lisa Dodson, MD, AHEC Director. “These students are our future and we want them to see the opportunity that rural Oregon offers them.” The students learn first hand the joys and challenges of practicing in a rural setting.
The five-week Rural and Community Health Clerkship provides an opportunity for third-year medical students to experience primary care as practiced in rural and underserved areas in Oregon. Each of the students is supervised by a skilled and experienced primary care physician who is currently practicing in rural Oregon. According to Dr. Dodson, the success of the program depends on three things: dedicated rural providers willing to work with the students, rural communities excited to have the students and the students themselves.
The OHSU School of Medicine requires all medical students to participate in a clinical rotation in a primary care practice site in one of OHSU’s four Area Health Education Centers. (See current site locations at http://www.ohsu.edu/ahec/clerkship/list_precept.html ) The clinical practice unit (CPU), the base for the clerkships, is in a primary care medical practice with physicians who agree to supervise the education and training of students placed at the site. These CPUs are chosen to assure a high quality and representative experience for students while they participate in the practice’s health care activities. The preceptors are family medicine, general internal medicine or pediatrics physicians. These practices provide the greatest opportunity for students to experience, understand and appreciate the breadth, depth, challenges and satisfactions of working in a primary care setting. “When the program began, there were 12 students in 10 sites,” says Becki Anderson, Program Coordinator. “Today, we have students at 44 sites. That is something we should all be proud of.”
The Rural Rotation is more than just time to be off the Hill. The program sets high standards and a series of goals that are important to success for all those involved in the program, including patients. Those goals are:
- The student will develop an understanding of the unique nature of primary care in a rural or underserved community or population.
- The student will observe and participate in the examination, evaluation and management of patients representative of those seen in the practice, and will evaluate several clinical problems in depth.
- The student will refine self-directed and lifelong learning skills, particularly the ability to access and use biomedical information systems.
- During the clerkship the student will become familiar with local and regional consultative services.
- During the clerkship the student will become familiar with community resources and support services.
- The student will understand and appreciate the importance of population-based health care in a primary care setting.
- During the clerkship the student should experience the culture of the community and understand the lifestyle of a primary care health care provider in such a community.
Community-Oriented Primary Care (COPC) Project
The Rural and Community Health Clerkship gives students as well rounded experience as possible. The shape of our health care delivery system and the role of the physician within it continues to change. And an important part of this evolution has been an increased appreciation for a "population perspective".
Up to this point, student’s education has been aimed primarily at understanding medical problems as they affect the cell, organ and individual. The students have been taught to interview patients, take histories, make a diagnosis and treat. This one-to-one physician-patient model for delivering health care has been extremely successful in caring for a great many problems. However, the need to direct resources to improve the health care of defined populations is increasing. This provider-population model addresses not only the health problems of individuals seen in a practice, but also those of the broader community in which they live. The Rural and Community Health Clerkship is an ideal setting to begin learning about and applying some of the principles of community-oriented primary care and population-based clinical practice.
During their rotation, each student is required to complete a brief community project, prepare a written report and present the findings at the end of the rotation. For their project, students investigate a health issue affecting the particular population within the community in which they are working, or a clearly identified segment of that population i.e. children, migrants, women over 50, etc. This allows the students to better understand the community they live in and the patients they see in the clinical setting.
Examples of community projects include:
- Evaluation of immunization practices within a clinic or in the county at large. Identify community resources as well as barriers to full immunization. Make recommendations to assist the community or practice in improving rates.
- Assessing the adequacy of available social/medical services for a population segment such as senior citizens or disabled children.
- Examining patterns of emergency room use at the local hospital, e.g. who uses the ER and why? What diagnoses are seen there and why? Is the ER used for emergencies or for primary care services for some segment of the population?
- Assessment of patient education materials available to patients in a clinic or community. Consider issues such as reading level, language availability and ease of access.
Support from the Community
While the overall Clerkship program is run by the Area Health Education Center (AHEC) at OHSU, the support and coordination for the program is in the community. Each AHEC Region (see regional information at the website at http://www.ohsu.edu/ahec/ ) funds transportation and housing costs for each of the students and , along with local community members, make sure the students are integrated into the community. These local AHECs are the key to making this program a success in the community. You can find information about your local AHEC program by clicking on the links below. The ORH will have more on the local programs in the future editions.
There is not shortage of debate on the uninsured in Oregon. With M 50 proposing to cover 117,000 additional uninsured children, to the debate over the President’s veto of the federal SCHIP program, Oregonians are inundated with information on the uninsured. But just who is uninsured in Oregon?
The Office for Oregon Health Policy and Research recently released a study on the uninsured in Oregon. According to the report, one in every eight children under 18 and one in five working-age adults 18-64 were uninsured in 2006. Since 1996, uninsurance rates for children have been steadily rising. There are currently over 116,000 uninsured children in Oregon under the age of 19. On the basis of income only, more than half (estimated 60,000) of the currently uninsured children qualify for Oregon’s Medicaid program (the Oregon Health Plan) and the State Children’s Health Insurance Program (SCHIP), which offers coverage for incomes up to 185% of the federal poverty level, or $40,000 for a family of four in 2006. Working-age adults (18-64) are not only the most likely to lack health insurance, they are also the largest segment of the uninsured (See Chart 4). This group accounts for a majority of the uninsured in Oregon, with one in five going without insurance in 2006.
Lear more about who is uninsured in Oregon by going to the report at : http://www.ohpr.state.or.us/DAS/OHPPR/RSCH/docs/uninsuredprofile.pdf
The Oregon Flex Program has begun a monthly WebEx seminar program to address the needs of Oregon’s Critical Access Hospitals. “Scorecards, billing, quality and performance, and capital finance are just a few of the challenges facing CAHs,” says Kassie Clarke, FLEX Coordinator. “We are trying to give the hospitals the tools they need to meet the challenges.”
To see the upcoming schedule and learn how you can join, please click here:
http://www.ohsu.edu/ohsuedu/outreach/oregonruralhealth/events/flex-webex-learning-series.cfm
Authors: Sara R. Collins, Ph.D., Cathy Schoen, M.S., Karen Davis, Ph.D., Anne K. Gauthier, M.S., and Stephen C. Schoenbaum, M.D., M.P.H.
Presidential candidates, governors, and members of Congress are advancing proposals to expand health insurance coverage to all Americans. This report, prepared for The Commonwealth Fund Commission on a High Performance Health System, explores the different options and how each may not only increase coverage for the uninsured, but also improve quality and efficiency and gain control over spiraling health care costs. Proposals are grouped into three approaches: tax incentives and the individual insurance market; mixed private–public group insurance with shared responsibility for financing; and public insurance. The Commission believes the most pragmatic approach to coverage for all is mixed private–public group insurance that builds on the best features of our current system with shared responsibility for financing from individuals, employers, and government that minimizes dislocation for the millions of Americans who currently have good coverage.
Presidential candidates, governors, and members of Congress are advancing proposals to address the nation's most important health policy issue: the steady increase in the number of uninsured individuals. This is a welcome development, and augurs well for reversing the steady climb in the numbers of uninsured. Since 2000, the number of uninsured has increased by more than 20 percent, reaching 47 million in 2006. In addition, rising health care costs are squeezing many middle-income Americans with insurance, who report difficulties paying medical bills due to a lack of adequate coverage.
Extending health insurance coverage to all Americans is the most important step in improving access to quality health care. However, there is also an opportunity to achieve this goal in a way that helps the United States achieve a high performance health system that simultaneously yields better access, higher quality, and greater efficiency. This report, prepared for The Commonwealth Fund Commission on a High Performance Health System, investigates the ways in which our current health insurance system fails to promote high performance in the areas of access, equity, quality, efficiency, and cost control. It explains why universal coverage is essential to improving performance measures in each of these core areas. The report also describes the different ways in which policymakers may design universal coverage and how each option will have long-range implications for the system's ability to consistently achieve higher-quality and more efficiently delivered care, as well as its ability to gain control over health care cost growth.
The report presents principles for health insurance reform to help the public assess proposals based not only on their ability to achieve universal coverage, but also on their potential to move the nation's health care system toward high performance. It outlines the questions that all Americans should consider in evaluating the reform proposals suggested by federal and state policy leaders, and it contrasts proposals built around three distinct philosophies:
- Tax incentives for individual market insurance. Proposals that rely primarily on individuals' responsibility for obtaining coverage, with tax incentives to subsidize purchase of insurance in the individual insurance market.
- Mixed private–public group insurance with shared responsibility for financing. Proposals that build on our current mixed private–public system of health insurance with shared responsibility for financing coverage by government, employers, and households.
- Public insurance.Proposals that would cover nearly all Americans under public insurance programs, such as Medicare, with everyone covered through the same public system.
In the Commission's view, both the mixed private–public group insurance and the public insurance reform proposals have the greater potential to move the health care system toward high performance. Both approaches have the potential to provide everyone with comprehensive and affordable health insurance, achieve greater equity in access to care, realize efficiencies and cost savings in the provision of coverage and delivery of care, and redirect incentives to improve quality. From a pragmatic perspective, however, the mixed private–public approach would cause far less dislocation by allowing the more than 160 million people who now have employer-based health coverage to retain it, instead of asking them to enroll in a new program. This approach would build on the best features of our current system while addressing its most serious shortcomings: gaps in coverage and the absence of the incentives, organization, and infrastructure required for a high performance health system.
Why Does the Current Health Insurance System Fail to Promote High Performance?
Access to Care Is Unequal. The most important determinant of access to health care is adequate health insurance coverage. People with low and moderate incomes are most at risk of lacking coverage through an employer and most at risk of being uninsured. They also spend the largest share of their incomes on premiums and out-of-pocket health care costs.
Poor Access to Care Is Linked to Poor Quality. People who lack health insurance are much less likely to have a regular source of care, use fewer and less appropriate health services, are less likely to receive timely preventive and screening services, are less likely to receive appropriate care for management of their conditions, and have worse clinical outcomes. People without coverage have both poorer health status and shorter life expectancies.
Care Delivery Is Inefficient. Lacking adequate coverage impedes the delivery of efficient care once a person without coverage enters the health care system. Uninsured adults report the highest rates of test results or records not being available at the time of their appointment, as well as the highest rates of receiving duplicate tests. Physicians also report inefficiencies in securing pharmaceuticals and follow-up medical care for uninsured patients.
A Fragmented Health Insurance System Makes It Difficult to Control Costs. The U.S. spends a far greater share of its gross domestic product on health care and its citizens spend more out-of-pocket than other industrialized countries, which all have universal health insurance. The highly fragmented way in which we purchase health services in the U.S. allows prices to climb above those in other industrialized nations. In addition, a significant percentage of the cost of health insurance goes toward administrative activities. An estimated 10 percent to 40 percent of premiums is consumed by claims administration, underwriting, marketing, profits, and other administrative costs. Costs of insurance administration are the fastest-growing component of U.S. national health expenditures.
Financing of Care for Uninsured and Underinsured Families Is Inefficient. The total costs of uncompensated care in the United States were nearly $41 billion in 2004. This figure would be far higher if uninsured people received as much health care as insured people do. Uninsured adults and children receive just 55 percent of the medical care that those who are insured for the full year receive. Research suggests that private payers finance uncompensated care costs that are not covered by public funds through surcharges to private payers, ultimately resulting in higher private insurance premiums. Estimates of this "hidden tax" range from 8.5 percent of premiums nationally to up to 10.6 percent in California.
Positive Incentives in Benefit Design and Insurance Markets Are Lacking. Incentives in benefit design and in provider reimbursement are not consistently aligned to encourage the use of effective services, discourage the use of ineffective services, and reduce over-utilization, duplication, and waste. Adverse selection encourages insurance companies to expend considerable resources avoiding health risks in the small group and individual insurance markets.
Design Matters: Key Principles to Consider in Developing and Evaluation Health Reform Proposals
Extending health insurance coverage to people who currently lack it is a necessary, but not sufficient, condition for achieving high performance. The way in which a universal coverage system is designed will have a deep impact on its ability to make sustainable and systematic improvements in access to care, equity, quality of care, efficiency, and cost control. With these goals in mind, the following are some key principles policymakers and the public should consider in developing or evaluating health reform proposals:
Access to Care
- Provides equitable and comprehensive insurance for all.
- Insures the population in a way that leads to full and equitable participation.
- Provides a minimum, standard benefit floor for essential coverage with financial protection.
- Premiums, deductibles, and out-of-pocket costs are affordable relative to family income.
- Coverage is automatic and stable with seamless transitions to maintain enrollment.
- Provides a choice of health plans or care systems.
Quality, Efficiency, and Cost Control
- Health risks are pooled across broad groups and over lifespans; insurance practices designed to avoid poor health risks are eliminated.
- Fosters efficiency by reducing complexity for patients and providers, and reducing transaction and administrative costs as a share of premiums.
- Works to improve health care quality and efficiency through administrative reforms, provider profiling and network design, utilization management, pay-for-performance payment models, and structures that encourage adherence to clinical guidelines.
- Minimizes dislocation; people can maintain current coverage if desired.
- Simple to administer.
- Has the potential to lower overall health care cost growth.
Financing
- Financial commitment to achieve these principles.
- Financing should be adequate and fair, based on ability to pay, and is a shared responsibility of federal and state governments, employers, individual households, and other stakeholders.
Current Proposals for Health Insurance Reform
Current proposals to reform the health insurance system include: strategies that emphasize tax incentives for obtaining insurance through the individual market; proposals that build on existing private–public group insurance with a shared responsibility for financing coverage; and proposals to cover everyone through public forms of insurance, like Medicare.
Tax Incentives for Individual Market Insurance. Proposals by President George W. Bush, former New York City mayor Rudy Giuliani, Senator John McCain (R–Ariz.), and former Massachusetts governor Mitt Romney would create tax incentives for people to gain coverage through the individual insurance market.
Mixed Private-Public Group Insurance with Shared Responsibility for Financing. The state of Massachusetts, Governor Arnold Schwarzenegger of California, and five Democratic presidential candidates (Senators Hillary Clinton (D–N.Y.), Christopher Dodd (D–Conn.), and Barack Obama (D–Ill.), former North Carolina Senator John Edwards (D–N.C.) and New Mexico Governor Bill Richardson) have either proposed plans or passed laws — in the case of Massachusetts — for universal coverage that maintain and build on the current mixed private and public insurance system. Most include requirements for individuals to purchase coverage and for employers to offer or help pay for coverage, expansions in Medicaid and State Children's Health Insurance Program (SCHIP), and new group insurance options with financial support for premiums and out-of-pocket expenses for lower- and middle-income households.
Public Insurance. Representative Pete Stark (D–Calif.), Senator Edward Kennedy (D–Mass.), Representative John Dingell, (D–Mich.), Representative John Conyers (D–Mich.), and Representative (and presidential candidate) Dennis Kucinich (D–Ohio) have proposed universal coverage plans in which Medicare or a new government plan plays a central role.
Which Strategies Have the Greatest Promise to Move the System to High Performance?
Assessing the health insurance reform proposals against the key principles described earlier helps to illustrate each proposal's strengths and weaknesses (Figure ES-1).The proposals, which reflect different philosophical strategies and values, use a range of mechanisms to address health system issues of inadequate access to care, variable quality, and high cost. Design features of the three different approaches have significant implications for each of these issues, including the number of people covered, the cost to stakeholders and the overall health system, equity in access and financing, and improvements in efficiency and quality. Raising the right questions and weighing the evidence will help shape consensus.
Tax Incentives for Individual Market Insurance
Reform proposals that rely on tax incentives and voluntary purchase of coverage in the individual insurance market are, on their own, unlikely to achieve universal coverage (Figure ES-1). Buying coverage in the individual market will continue to be challenging if tax incentives are not coupled with an individual mandate, minimum benefit standards, regulations against risk selection, and premium and out-of-pocket spending limits as a share of income. Providing incentives for coverage in the individual market without an individual mandate or regulations against risk selection would not pool risks. Insurers would still write individual policies rather than policies for a broad group of people. With administrative costs in the individual market running from 25 percent to 40 percent of premium dollars compared with 10 percent in employer group markets and 2 percent in Medicare, covering more people through this market would only fuel growth in annual administration costs.
Supporters of these proposals argue that consumers spending their own money on health insurance and health care would be more cost-conscious, seek out lower cost providers, and avoid marginal or unnecessary care. These proposals would allow substantial choice of covered benefits and financial protection within the limits of people's budgets. However, they could limit options and increase costs for those with health risks, depending on existing consumer protections, which vary by state. People with preexisting conditions might face very high premiums, might be unable to get their health needs covered, or might not be offered a policy at all. If designed to avoid undermining employer-based coverage, the proposals would cause minimal dislocation with the ability to maintain current health insurance coverage.
These proposals would do little to alter incentives to improve health care quality and efficiency. From a financing perspective, the lack of risk pooling and higher administrative costs would inflate the size of tax credits necessary for making premiums affordable for lower-income people.
Mixed Private–Public Group Insurance with a Shared Responsibility for Financing
Most proposals that build on the current system would ensure universal coverage by requiring that all individuals purchase coverage and that employers either provide coverage to employees or contribute to premiums. Such mandates would be critical to ensure everyone is covered (Figure ES-1). Most proposals would also create new group insurance options, sometimes referred to as "exchanges" or "connectors" for people without access to employer coverage and for small businesses. These new health insurance exchanges would allow consumers a choice of private and public plans. Offering a public plan option like Medicare in these new health insurance exchanges would give individuals and businesses the ability to choose between private and public health plans. Most proposals specify a minimum standard benefit package for plans offered by employers and through the health insurance exchange.
Affordability of coverage would be assured through expansion of Medicaid and SCHIP for lower-income families and provision of premium assistance for lower- and middle-income people buying coverage in the new health insurance exchange. However, it is important that potential out-of-pocket costs also be taken into consideration when defining affordability under a mandate.
By building on multiple forms of existing group coverage and adding a new group insurance option, these proposals, on their own, would not make enrollment easier or more seamless. They would also retain much of the complexity of the current system. Automatically enrolling people through the tax system under an individual mandate would help ensure that people become and remain enrolled. The income tax system can also provide an administrative mechanism for income-related premium assistance and ceilings on out-of-pocket costs as a percentage of income.
These approaches would pool risk by building on the large risk pools of the employer market and public programs and create new health insurance exchanges with regulations against risk selection. The actual design of the new health insurance exchanges will be important, however, with respect to the restrictions against risk selection, the type of plans available for consumers, the extent of income-related subsidies and whether both out-of-pocket costs and premiums are taken into consideration when determining the amount a family pays.
By building on the current system, these proposals would cause minimal dislocation. People could keep their employer coverage as long as it met minimum benefit and affordability standards. By replacing small group or individual market coverage with coverage through health insurance exchanges or public programs, administrative savings could be achieved. If Medicare, Medicaid/SCHIP, and employer coverage were redesigned to reward health care providers for higher quality or more efficient care, even further savings are possible. Success will depend on effective national leadership, collaboration between the public and private sectors, and the creation of the information and infrastructure including information technology.
Financing would be a mix of federal and state general revenue taxation, employer and individual premium contributions, and modest cost-sharing. Subsidies for low-income families would offset all or part of their premium and out-of-pocket costs; broad risk pooling would help keep the size of subsidies low. The financial distribution of costs is likely to be closely proportional to earnings, and more progressively shared than financing under most approaches that provide tax incentives for coverage through the individual market. Some proposals would fund the federal portion of costs by repealing or not renewing tax cuts for higher-income households, thereby increasing the progressive nature of the overall financing.
Public Insurance
Public insurance programs offer the greatest potential for automatic and continuous enrollment and the ability to cover everyone (Figure ES-1). Enrollment could be facilitated through local Medicare or Social Security offices. Those failing to enroll could be signed up when they seek health care services or coverage could be verified as part of income tax filing. With everyone eventually enrolled at birth in an expanded Medicare, people would automatically be enrolled and stay enrolled across their lifespans. Most proposals would establish a minimum standard benefit package modeled on the typical plan offered to members of Congress or to employees of large firms. For those proposals requiring enrollees to pay cost-sharing or a portion of premiums, a ceiling on out-of-pocket costs and premiums as a percentage of income would be established to ensure affordability. Some proposals modeled, for example, on the Canadian health system would not include patient cost-sharing for basic services and would be financed by federal and state taxes.
Given Medicare's low administrative costs and broad risk pooling, substantial savings could accrue in an expanded Medicare approach through a reduction in administrative costs. Other sources of savings would likely arise from paying providers Medicare rates that are lower, on average, than private rates.
The proposals modeled on the current Medicare program would provide choice of plans, including the private plan options currently available to Medicare beneficiaries and the program's self-insured plan.
The public insurance approaches to health insurance reform would create dislocation, with people moving from their current coverage to coverage through Medicare or another public plan. However, people would still likely keep their same set of providers. Proposals that would allow employers to continue offering coverage would be less disruptive initially, although it is anticipated that most employers would ultimately prefer to pay a part of the Medicare premium rather than private coverage premiums, which would probably be higher.
These proposals would allow the nation to develop and utilize common quality metrics, gather data on the health care outcomes of the full population, and evaluate and improve the performance of providers based on a large pool of patients not fragmented by insurance type. They also would allow for the creation of uniform provider payment systems that reward high-quality care, standardization in health information technology, and the creation of universal processes to improve safety systematically across health care institutions.
Financing is likely to come largely from federal income and payroll taxes or new taxes, such as a value-added tax or consumption tax. This would be less administratively complex than providing premium subsidies based on income. The distribution of financing is most likely to be more progressively related to income than either individual insurance market or mixed private–public group insurance proposals.
Conclusion
Ultimately, we must move the health care system to high performance using goals and properly aligned incentives that orient all participants in the same direction: toward improved access, quality, equity, and efficiency. The most important feature of any health insurance reform proposal is whether it can succeed in providing health insurance and access to care to all. In addition, proposals should be examined for their ability to produce better access, higher quality, and greater efficiency. Whenever possible, we must seek synergy between coverage expansion and reform that will move the U.S. to a high performance health system.
Achieving universal coverage will require engaging everyone in a debate on values, our commitment to a healthy and productive life for all, and the merits of different strategies for achieving improved coverage and better performance from our health system. This guide is offered to both underscore the importance of such reforms and to help shape the debate and emerging consensus on future directions for the U.S.
Serious reform will require broad consensus and a significant financial investment by federal and state governments, employers, households, and other stakeholders. A shared responsibility among all stakeholders will be needed to achieve the goals of reform in a way that is effective and fair.
Citation
S. R. Collins, C. Schoen, K. Davis, A. K. Gauthier, and S. C. Schoenbaum, A Roadmap to Health Insurance for All: Principles for Reform, The Commonwealth Fund, October 2007
Article found in The Commonwealth Fund (www.commonwealthfund.org/publications)
One of the most important pieces of legislation coming from this Congress will be the reauthorization of the Farm Bill. But what exactly is the Farm Bill and why is it important to health care in rural Oregon?
The U.S. Farm Bill is actually a collection of laws, policies and legislation related to agriculture production, food distribution and hunger. The bill focuses on everything from basic farm programs within various “titles” or sections, such as: farm payments, agricultural trade, conservation, food assistance, agricultural promotion, credit, rural development and research and education. The Farm Bill does not cover all the policies that affect agriculture and rural areas, but it is the most comprehensive of bills affecting things rural.
Many people consider the first farm bill to be The Agricultural Adjustment Act of 1933 — designed to control the supply of agricultural products in the US and attempt to set price guarantees. There were changes to the bill throughout the 1930’s and when passed again in 1949, the law created various commodity programs that became known as “permanent law”. The mandatory, or entitlement, commodity programs established then are considered “permanent law.” Since that time a number of discretionary programs have also been added. These programs last for four to six years at which time Congress must rewrite, or reauthorize, the programs. If for some reason Congress is unable to complete a rewrite of the legislation, farm policy would revert back to the original entitlements passed in 1949. This possibility has pushed Congress to meet its deadlines.
Over the decades, the farm bill has changed to address the needs of agriculture. While price supports have remained a constant, various attempts at conservation and protection of small farms have also been addressed. With the globalization of trade and the growing role of US farmers in feeding the world, the US, and the Farm Bill, have had to address challenges to price supports. Farm support programs are now subject to the World Trade Organization and other international treaties. This fact has put great pressure on the US to change the way government supports are given to farmers.
The current reauthorization bill attempts to address larger rural issues, including and expanding on Rural Development, Research and Energy. Of particular interest to rural health care is Section VI- Rural Development. This section includes support for health care, EMS, expanded broadband connection, and critical infrastructure grants. Both the House and the Senate have passed their own version of the Farm Bill. Over the next several months, as the two chambers work on a single bill, you will hear more and more about the Farm Bill and its impact on rural communities. To see an overview of the legislation and to follow the Bill through the process, go the Senate and House Agriculture Committee websites:
The Office or Rural Health, AHEC and the OHSU Rural Interest Student Group held the First Annual Student/Hospital BBQ and it was a huge success! This was the first such event held in Oregon. “We have a gold mine of potential rural providers at OHSU and other institutions in Oregon. We need to start showing them what rural has to offer,” said Scott Ekblad, ORH Director.
“Each year, a new crop of students enters OHSU and many have an interest in rural practice,” says Dr. Lisa Dodson, AHEC Director. “We need to get them face to face with other rural providers and administrators to start talking now, while they are open to new possibilities.”
The BBQ, held at Champoeg Park on Saturday September 15, 2007, was an afternoon of food, fun and some serious conversations. Hospital administrators, clinicians and even some city officials, mingled with students to talk about rural health care, rural communities and rural life. PA, Nursing and Medical students were all excited to learn about the opportunities that rural Oregon offers. “We just can’t wait for next year,” says Kassie Clarke, Flex Coordinator. “It is great to watch so many future providers with a genuine interest in practicing rural.”
The AHRQ National Resource Center (NRC) for Health Information Technology Web site is the go-to source for the latest, highest-quality information and best practices in the health IT field. The site provides access to more than 7,000 resources on key issues, such as health information exchange (HIE), electronic health record (EHR) implementation, privacy, security, and interoperability standards. Plus, this site is the only source for real-time news and evidence from AHRQ-funded health IT research projects. The site also features the latest conference proceedings and materials from the AHRQ 2007 Annual Conference. If you are "in the trenches," trying to make health IT work, then you must go to http://healthit.ahrq.gov.
The NRC Web site now features an RSS feed to help you stay on top of the latest news and information on health IT. Visit http://healthit.ahrq.gov/rssfeeds to access the feed and incorporate it into your blog or Web browser. For more information on how to use the RSS feed, please contact us at NRC-HealthIT@ahrq.hss.gov.
AHRQ-funded projects are transforming everyday clinical care through health IT. Find out more about the critical lessons learned from these projects at the AHRQ National Resource Center Web site — a unique and dynamic resource that keeps getting better! Visit http://healthit.ahrq.gov.
AHRQ values your feedback and suggestions to improve and expand the AHRQ National Resource Center Web site. Please send any comments to: NRC-HealthIT@ahrq.hhs.gov
Molly Rowe, for HealthLeaders Magazine, Nov 14, 2007
It's a familiar story: Hospital X spends months planning to implement, say, a medication reconciliation process. The hospital develops a new form, conducts pilot testing, trains staff members until they're checking "reconciled" boxes in their sleep, and finally launches the process hospital-wide. A year and 20 process redesigns later, senior leaders are still trying to figure out why the process won't work.
New hospital initiatives have a 60 percent chance of failure, says healthcare management expert Quint Studer, founder and chief executive officer of the Studer Group. That's a pretty high figure considering the number of initiatives (like medication reconciliation) that are required each year to meet state and federal requirements or to participate in different patient safety organizations. Many of these floundering projects are critical to a hospital's success. So what goes wrong?
The success or failure of an initiative depends largely on the people, Studer says — specifically, a hospital's ability to deal with its underachievers. "In healthcare, not only can we not deal with low performers, we can't talk about them."
Job descriptions and annual reviews in healthcare tend to focus on competency, but most reviews don't capture excellence — a trait critical to a hospital meeting its quality, patient safety and financial goals. Take, for example, the physician who attracts patients to the facility but is consistently rude to staff or the senior manager who's been around for years but never meets his goals. Such employees can hold a hospital back.
Low performers
Palmetto Health Baptist Easley in Easley, SC, began taking a closer look at these types of employees three years ago. Prior to that, Baptist Easley, like many hospitals, conducted annual competency-based reviews. The reviews helped identify 63-staffed-bed Baptist Easley's best employees, but sometimes enabled the hospital to ignore the worst, says Chief Operating Officer Roddey Gettys. "Those low performers are the ones who suck the life out of the rest of the employees. They are the habitual complainers, whiners, moaners, groaners. Their work performance is affected by their attitude, and it tends to rub off," Gettys says.
Working with the Studer Group, senior managers categorized every Baptist Easley employee as a low, middle or high performer based on attitude, problem-solving, and eagerness to learn — as well as competency. Managers began spending more time on the high performers, rewarding them with gift cards and thank-you notes and continuously "re-recruiting," Gettys says. Low performers were given a 60-day no-nonsense warning: Change your performance or change your job.
The latter part of this warning was risky. Baptist Easley is within 15 minutes of two other large systems with which it competes for patients and employees. "We were concerned if we got rid of them, we might not be able to replace them," Gettys says.
To Gettys' surprise, morale went up, not down. High performers stepped in to cover shifts that couldn't immediately be covered by an outside agency, and employee satisfaction scores soared. "What we heard when we began walking low performers out of the hospital was high performers applauding, sending notes to say thank you," Gettys says.
Recruit excellence
Word of Baptist Easley's new work environment spread to the community. In June and July, 1,101 people applied for jobs at the hospital, which only employs 650 full-time people. Gettys estimates that 15 percent to 20 percent of those applications are for clinical positions.
Under the new performance review system, job applicants are reviewed differently to ensure that the people coming in are competent and high quality.
"Every applicant is required to read and sign a commitment form, saying 'I understand I'm expected to be an exceptional employee. I understand that I will be expected to perform at a very high level. I understand that my job depends on it.' We don't let applicants fill out an application until they sign that form," Gettys says.
Tough conversations
At Sacred Heart Hospital, Chief Operating Officer Faye Deich expects to lose employees — that's how she knows the review process is working. Located in Eau Claire, WI, the 200-staffed-bed hospital uses Studer's low-middle-high process to evaluate its 1,300 employees twice a year. All levels are ranked, from housekeeper to Deich herself.
Studer estimates that about 8 percent of hospital employees will fall into the low performer category. One-third will improve, one-third will self-select out of the organization, and one-third will need to be let go.
"There were people who I thought would never change who moved up and improved dramatically. I was really surprised, to be honest. And then we've had some people who could not change, and we've parted company," Deich says.
Not every leader is eager to address poor performance, especially when employees are basically competent. Jennifer Forgie, managing partner for OnPoint Consulting, a New York City leadership consulting firm, says managers don't always see managing people as a critical part of their role. This is especially true in healthcare, where managers are often promoted from clinical or technical areas and are faced with human resource or finance issues.
To improve their management skills, Sacred Heart managers are trained to have "tough conversations" using role playing and regular leadership development, Deich says. Leaders are taught to understand that these ongoing conversations are part of the job. "Leadership isn't a popularity contest, so if that's why you went into this, you may be misaligned because this is one of the things you have to do," Deich says.
Molly Rowe is leadership editor with HealthLeaders magazine. She can be reached at mrowe@healthleadersmedia.com.
The ORH recently completed a statewide survey of Rural Health Clinics in Oregon. All clinics that participated in the survey were entered into a drawing for $5000!! And the winners are —— Dunes Family Health Care and La Pine Community Clinic!
The winners will use the money to improve the local health system that benefits their community. Congratulations to the winners!!!!
- Oregon Health Forum Breakfast: Physician Payment Reform
Dec. 6, 2007 — 7:30 AM
Oregon Medical Association
11740 SW 68th Parkway
Portland
For more information, click here.
- Mid-Columbia Latino Providers Network Monthly Meeting
Meets the third Thursday of each month at noon. Meeting location alternates between Hood River and Wasco County, so please check with:
Angeles Ramirez
Families First
541/296-8118
angelesr02@hotmail.com
- Hot Topics: HPV Vaccine
January 24, 2008
Noon - 1PM
PSU Multicultural Center
For more information, click here.
- Rural Health Policy Institute
January 28-30, 2008
Washington DC
For more information, click here.
- What You Need to Know About Women’s Heart Disease
February 7, 2008
7 - 8PM
OHSU Center for Women’s Health Lobby
For more information, click here.
- 21st Annual Northwest Regional Rural Health Conference
March 20 & 21, 2008
Spokane, Washington
For more information, click here.
- NRHA Annual Conference
May 7-10, 2008
New Orleans, LA
Save the date!
- 25th Annual Oregon Rural Health Conference
September 24-27, 2008
The Riverhouse Hotel
Resort, Hotel & Conference Center
Bend, OR
Save the Date!
Would you like to add your rural health event to our calendar? You can let us know at any time by dropping us a line here.
