OHSU

July 2011 Newsletter

ORH News

Registration Now Available Online!

The 28th Annual Oregon Rural Health Conference

Bringing Health Home

September 21 – 23, 2011
Riverhouse Hotel and Convention Center
Bend,Oregon
Learn more about registration and conference information

Medical Students Bike Across Oregon to Raise Awareness of Rural Health Issues

Three second-year medical students are biking through Oregon to help raise awareness of the health care challenges facing rural Oregon. Matthew Sperry, Wes Fuhrum and Nathan Defrees have teamed with community physicians and leaders to discuss possible solutions to the primary care workforce shortage and the importance of health care on the economic development of rural communities.

The students left Oregon Health & Science University on Tuesday, July 5, biking first to the coast and working their way toward Reedsport. From there, they will continue on to Prineville and, finally, Enterprise on August 5. The Oregon Rural Health Association will be hosting a picnic for the students on their arrival at the Wallowa County Fairgrounds in Enterprise.

At stops throughout their trip, they will be giving presentations about the impact that health care has on rural communities. They will be stressing the physician shortage that is facing Oregon. “We have a provider shortage today, and it will only worsen as patients and doctors age. Projections show that Oregon will have 5,473 primary care physicians in 2020; but to meet Oregonians’ needs, we must have 6,841. This means we must recruit 1,355 additional physicians in the next 10 years,” says Kerry Gonzales, executive director of the OAFP.

“The Legislature has just ended, but we still have a lot of work to do if we are going to attract the necessary number of providers to rural Oregon,” says Scott Ekblad, Director of the Oregon Office of Rural Health. “Oregon does not have a state funded loan repayment program which is one of the key tools we can use to help recruit providers and we need to make sure people are prepared for the next legislative session in February.”

The students will have supporters along the way. Rural practitioners will be hosting the students along the way, including Robbie Law, M.D., Reedsport; Mike Hodulik, M.D., Florence; Bob Holland, M.D., John Day; John Schott, M.D., Baker City; and Liz Powers, M.D., Enterprise.

The trip is co-sponsored by the Oregon Academy of Family Physicians (OAFP), the Oregon Office of Rural Health at OHSU, the Oregon Rural Health Association and the Oregon Area Health Education Centers (AHEC). The coalition has been working to raise awareness of the primary care provider shortage in Oregon by working to pass a series of bills during this legislative session, including proposals for loan forgiveness and loan repayment; creating a medical residency network; and developing a visiting doctors program.

You can see their route and follow their trip on their blog via the ORH website.

Oregon Legislature Adjourn with Mixed Bag for Rural Health

The Oregon Legislature adjourned with some good and some bad for rural. Rural health got some good news with the continuation of the Medical Malpractice subsidy program and passage of a bill that could increase dental access. But it also took some hits when the legislature did not fund the Primary Care Services Loan Repayment program. Changes in Medicaid and the continued implementation of national and state health reform will have a major impact on health care in Oregon, whether rural or urban.

“The economic reality kept the legislature very focused this session,” says Scott Ekblad, Director of the Oregon Office of Rural Health. “We had hoped we could get funding for the Primary Care Services Loan Repayment program, a key recruitment tool, but it did not happen. The funding of the medical malpractice subsidy program was a great win.”

Here is a quick review:

Rural Malpractice Subsidy Program – SB 608

The Rural Malpractice Subsidy Program, “MedMal”, was scheduled to sunset at the end of 2011. The program is now continued with an appropriation of $6.1M. The program subsidizes liability premiums to qualifying rural physicians and nurse practitioners. While the Office of Rural Health will continue its role in the program, the program is now housed in the Oregon Health Authority. MedMal is one of the recruitment tools used by the ORH to attract providers to rural communities.

Primary Care Services Loan Repayment Program – HB 2400

The Oregon Legislature stopped funding The Primary Care Services Loan Repayment Program during the regular 2009 session. While no new funding was approved, the 2010 Legislature passed legislation to move the program from the Oregon Student Assistance Commission to the Office of Rural Health effective July 1, 2011. HB 2400 would have appropriated money to begin offering new loan assistance to qualified providers practicing in rural Oregon, a major recruitment incentive for new providers. The Legislature did not fund the program.

Loan Forgiveness– HB 2397

While the legislature did not fund the existing loan repayment program, they did create a new loan forgiveness program that is designed to targets students, who know they want to practice rural medicine, early in their medical education. Under this program, the state would make loans to students — training to be physicians, nurse practitioners or physician assistants — starting with the second year of their medical training. After completing their education, including their residency, the loan recipients would be committed to practicing primary care in rural Oregon. One year of the loan would be “forgiven” for each year of rural practice. In contrast, loan repayment is not awarded until a health care provider has completed their residency or training and is ready to practice.

Dental Therapist Bill – SB 738

SB 738 is the result of nearly four months of negotiations between the Oregon Dental Association, the Dental Hygienist Association and other interested parties and allows pilot projects to explore how dental therapists, akin to Physician Assistants, working under the general supervision of dentists, can provide high-quality preventive dental services to underserved populations in Oregon. At a time when Oregon is facing shortages of many health care providers, this type of innovative and collaborative thinking will help us meet the needs of Oregonians—especially those in rural and underserved areas. It comes at a time when new studies show a drastic lack of access to dental care.

PA Modernization Act Unanimously – SB 224

SB 224 de-links licensure from the practice agreement, allowing a PA to first get licensed, then find employment. In order to begin practice a licensed PA will need to complete a practice agreement with a licensed physician(s) and file the agreement with the board. In addition, the bill deletes archaic language that requires each PA’s scope of practice and supervision requirements to be determined by the medical board. The bill retains a restriction that a physician may only supervise four PAs.

Fee Increase to Fund EMT MTUs – SB 5529

The Mobile Training Units provide on-site, hands-on continuing medical education for all state EMS certification levels as well as provide in-service education for new skills or medications, provides annual recertification and instructional development to the Oregon State Police EMS instructor group. During the interim, budget cuts forced the EMS Office to cut one of the two MTUs and the proposed 2011-2013 budget would have cut the other. Rep Jim Thompson introduced HB 3850 to fund one MTU. However, the legislature voted to restore funding for the MTUs and the Trauma budget by doubling the medical marijuana card fees from $100 to $200.

Family Medicine Residency Network – HB 2401

HB 2401 originally asked for $1 million to help create a network for family medicine residency programs around the state to coordinate and work cooperatively. After indication from the House Health Committee that the bill would not be moved to Ways and Means, the funding was stripped from HB 2401 to make it a policy bill that encourages a cooperative family medicine residency network, facilitated by the Area Health Education Center at OHSU. The bill passed and became law on June 9, 2011.

Health Care Transformation - HB 3650

HB 3650, the most comprehensive health care bills of the session, will consolidate the managed care plans that currently administer the Oregon Health Plan into regional “coordinated care organizations” which supporters believe will be better able to manage chronic conditions and preventative care. These CCOs will be required to use primary care medical homes, a payment methodology other than fee for service and use electronic medical records.

Key contract language for hospitals was added stating “A health care entity may refuse to contract with a coordinated care organization (CCO) if the reimbursement … is below the reasonable cost to the entity for providing the service.” Cost-based reimbursement for Type A & B hospitals is protected until 2014. After that, an actuary will determine if changing the reimbursement method will pose a financial risk on a case-by-case basis.

The bill deals only with Medicaid but because of the role Medicaid plays in the larger health care system, it will impact the rest of the delivery system. It also directs the Oregon Health Authority to lay out plans on how public employee and school employee benefit plans could be included.

Gov. John Kitzhaber, said the bill will begin to “shift the focus and financial incentives of Oregon's healthcare system from after-the fact acute care to prevention, wellness and community-based management of chronic conditions.”

It is not all driven by health care quality however. The Oregon Health Plan faced an $860 million shortfall. HB 3650 is predicted to save the state an estimated $240 million in general fund by the end of the biennium.

The Oregon Health Authority is responsible for working out rules and implementation and bringing the plan back to the February legislative session for approval. Governor Kitzhaber has asked the Oregon Health Policy Board to over see several key components of the process. They are determining how to integrate care for dual eligible (Medicare and Medicaid), criteria for establishing a Coordinated Care Organization (CCO), methodology for setting a global budget and a developing a method for evaluating quality and efficiency.

Insurance Exchange – SB 99

Working to meet federal deadlines that require states to develop insurance exchanges or have the federal government impose them, Oregon will create an online Insurance Exchange to make it easier for individuals and small groups to comparison shop for health insurance based on cost and quality. The Exchange will also administer the federal subsidies to purchase insurance.

A nine-member board, appointed by the Governor and confirmed by the Senate, will oversee the Exchange. Rocky King was chosen as the interim Exchange Director until the board is created.

The Insurance Exchanges will include:

  • Dual Markets – allowing carriers to sell insurance both inside and outside the Exchange
  • A Role for Agents – with payment to be determined by the Exchange Board
  • Defined Contribution Plans – employers may designate the amount available and let employees choose from any qualified plan
  • Number of Plans – any plan that qualifies may be sold through the Exchange though the Exchange may limit the number of plans from each carrier
  • Board Membership – up to two of the nine board members may have health care affiliations

The Oregon Health Authority (OHA) will create a business plan for the Exchange that will come back to the legislature for approval in the February 2012 session. The Exchange must be set-up by January 2013 so that it can start enrollment and be active by January 2014. Oregon accepted a $48 million federal grant to develop the Exchange infrastructure.

Hospital Tax/OHP Provider Cuts – SB 5529

The Governor’s budget proposed reducing Oregon Health Plan (OHP) provider rates by 19% in the first year of the biennium. After negotiations with the hospital association, legislators agreed to use the hospital tax to lower the 19% reduction to 11.2% for all OHP providers including hospitals, physicians, dentists, Rx, and durable medical equipment. There was an additional increase in the hospital tax to buy down the hospital rate cuts to 1.2%.

The OHA budget presumes $240 million in General Fund savings from the health care transformation in the second year of the biennium. Adding in the federal matching funds, that means more than $700 million must be saved in the transformation process or cut from provider reimbursement.

If the transformation savings don’t materialize, hospitals are looking at rate cuts as high as 30% in the second year of the biennium. Rate cuts for other providers could be as high as 40%.

IT Agreements to Help Rural Providers, Hospitals and Clinics

O-HITEC, Oregon’s Health Information & Technology Extension Center, has reached agreements with the Oregon Rural Health Quality Networks (ORHQN), and the Oregon Medical Association (OMA) to help rural providers and sites reach the meaningful use deadlines set out under federal health care reform.

The American Recovery and Reinvestment Act of 2009 (Recovery Act) authorized the Centers for Medicare & Medicaid Services (CMS) to provide reimbursement incentives for eligible professionals and hospitals who are successful in becoming “meaningful users” of certified electronic health record (EHR) technology. The Medicare EHR incentive program will provide incentive payments to eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) that are meaningful users of certified EHR technology. The Medicaid EHR incentive program will provide incentive payments to eligible professionals and hospitals for efforts to adopt, implement, or upgrade certified EHR technology or for meaningful use in the first year of their participation in the program and for demonstrating meaningful use during each of five subsequent years.

As the Regional Extension Center for Oregon, O-HITEC is responsible for assisting Oregon’s rural hospitals and primary care providers in small practices install certified HER systems. In addition, they will assist in ensuring these providers and sites reach meaningful use requirements.

As a result of the federal grant, O-HITEC is able to provide over a dozen free and low-cost services that include meaningful use assessments, EHR vendor selection and installation assistance, on-site audits, education and training, and HIPAA privacy and security assistance.

ORHQN and OCHIN worked collaboratively to design a solution that would help both non-profits to assist network hospitals with tools and support services to improve patient care and reduce costs. ORHQN was able to apply their Small Rural Hospital Improvement Grant Program (SHIP) funds as a match for a federal grant program that originated in the ARRA Stimulus Package.

"Given our mission to continuously improve the quality of care available to rural communities throughout our State, we are pleased to partner with O-HITEC in providing such expertise and help for member hospitals to become meaningful users of Electronic Health Records," said William McMillan, President of ORHQN and CEO of Curry General Hospital. "Many are already on their way but almost all struggle with the capacity to bring this about on their own. This grant should provide a technical assistance boost for all our rural hospitals in achieving this status," said McMillan.

OMA physician members who pay their 2011 dues will have access to a new suite of services aimed at helping them achieve Meaningful Use of an EHR--at no additional cost. The program will provide support to the OMA to enhance member programming, while making it easier for physicians to participate in the incentive programs related to adopting and implementing a certified EHR.

All OMA members have access to benefits that include professional consulting support and services towards meeting the Meaningful Use requirements, discounted rates on certified EHR products and benchmarking and reporting tools required for meeting Meaningful Use requirements.

If you have questions on these agreements or you want to find out how O-HITEC can assist you, contact them at , or 503-943-2617.

Oregon Update

USDA Funds Klamath County 9-1-1 Call Center

On June 15, first responders from Klamath County celebrated the grand opening of the new Klamath 9-1-1 Call Center. The state-of-the art facility was funded with a $1.7 million loan through USDA Rural Development's Community Facilities Program. A grant of $19,920 was also provided by USDA for equipment. The new facility is the only public safety dispatch point for the entire county. It serves 68,000 residents and coordinates services from 27 public safety agencies.

Health Care Reform Glossary

There is no lack of confusion when it comes to understanding health care lingo. To help make it easier for consumers, policy makers and legislators, the NW Health Foundation has put together a great Health Care Reform Glossary.

Crook County CHIP

The Oregon Office of Rural Health has worked with more than 15 rural communities on Community Health Improvement Partnerships (CHIP). Check out the great work of the Crook County CHIP and how it is making their community a better and healthier place!

EMS

Oregon EMS Pediatric Equipment Grant
The Oregon EMS for Children (EMSC), a program of Oregon Emergency Medical Services and Trauma Systems Program, is now accepting applications for the Oregon EMS Pediatric Equipment Grant. It is imperative that licensed ambulance services and EMTs have the appropriate pediatric equipment and supplies to provide care for the critically ill and injured children. There are limited supplies of the following equipment available through the grant:

  • LSP Immobilization Board
  • Iron Duck Pedi-Air Align
  • BLS bag w/supplies
  • ALS bag w/supplies
  • Ferno Pedi-Mate Restraint System
  • EZ-IO kit and replacement needles

Awards will be based on information provided on the application including: geographic access, information provided on the patients cared for by the agency and current equipment availability. Participation in future surveys will also be a condition of the award.

To request equipment, complete the grant application online.

Columbia Memorial Hospital Named one of 2011 Most Wired!

Columbia Memorial Hospital has been recognized as one of the nations Most Wired – Small and Rural, according to the results of the 2011 Most Wired Survey released in the July issue of Hospitals & Health Networks magazine. The nation’s Most Wired hospitals are making progress towards greater health information technology (IT) adoption, according to Hospitals & Health Networks’ 2011 Most Wired Survey. As a field, hospitals are focused on expanding and adopting certain kinds of IT, such as computerized physician order entry (CPOE), to promote improved patient care and data collection.

Columbia Memorial CFO Guy Rivers said, “We are honored to be Oregon’s only 2011 Most-Wired Hospital, demonstrating widespread adoption of information technology throughout the organization. More than 15 years ago, CMH identified the value and benefits of being information technology leaders in healthcare and began implementing the building blocks of an advanced clinical and business information system. Each year, we have built on that commitment by choosing innovative technology that brings additional advancements into our healthcare setting. Our CEO Erik Thorsen has contributed greatly to this direction and today continues to ensure that our physicians, clinicians, and support staff have modern technology available and are trained in its use. We not only have a technical staff with the knowledge to make it all work together, there is a desire on everyone’s part to apply technology for better patient-centered care”.

Most Wired hospitals have made great strides forward in this area with the survey results revealing strong advances in CPOE. Among the key findings this year:

  • Sixty-seven percent of Most Wired hospitals ordered medications electronically in comparison to 46 percent of the total responders.
  • Fifty-eight percent of all organizations reported that they have implemented computerized standing orders based on treatment protocols that have been scientifically proven to be effective; in the Most Wired group, 86 percent have implemented such standing orders.
  • A greater reliance on digital records puts pressure on Chief Information Officers (CIOs) to ensure that data can be restored quickly in the event that systems go down. Eighty-two percent of the Most Wired hospitals and 57 percent of all surveyed hospitals can restore clinical data within 24 hours after a power loss.
  • Most Wired hospitals are leading in the use of encryption on movable devices to safeguard information. All Most Wired hospitals encrypt data for laptops and 76 percent encrypt smart phones in comparison to 85 percent of total responders that use encryption on laptops and 57 percent on smart phones.

“Most hospitals look beyond short-term drivers of meaningful use and view technology as part of a powerful toolkit to support their long-term goals for clinical quality improvement and preparation for reform,” said Patrick Blake, executive vice president and group president, McKesson Technology Solutions, a sponsor of the survey. “Using all aspects of an electronic health record, including CPOE, is becoming the expected standard of care in many communities. As a result, we continue to see growth in those areas.”

Strides are also being made in the integration of the electronic health records with digital clinical imaging, according to survey results. Progress in the areas of digital dictation, structured reporting, and voice recognition with picture archiving and communication systems is also being made. Under these systems, clinicians receive faster diagnostic results that can improve aspects of patient care.

The July H&HN cover story detailing results is available online.

Federal Update

Rural Health Clinic Updates

CMS failed to meet the statutory deadline of June 27th to issue RHC rule changes proposed by CMS in a June 27, 2008 Notice of Proposed Rulemaking (NPRM). 
By law, CMS must issue a final rule in response to a proposed rule, within 3 years of the publication of the proposed rule.  Failure to adhere to this timeline means that the rule must be withdrawn.

This means that the most controversial proposal - decertification of RHCs no longer located in rural areas or underserved areas - will not be implemented.  In addition, proposed changes to how the beneficiary co-pay and deductible is calculated when the Medicare patient is seen in an RHC will also not be implemented.

The National Association of Rural Health Clinics (NARHC) does not expect CMS to move quickly to reissue a new proposed rule.  NARHC will continue to work with CMS, Congressional leaders and Offices of Rural Health to ensure that the RHC program remains a viable option for improving and maintaining access to healthcare in rural underserved areas.

CMS rescinds lab signature rule. 
Late in 2010, CMS announced that all requisitions for laboratory services for Medicare beneficiaries would have to be signed by a physician, PA, NP or other qualified health professional as a condition for payment.  There was great concern amongst the provider community that this requirement would slow down the process for getting necessary lab work ordered and completed and represented an unwarranted administrative burden.

In response to stakeholder complaints, CMS announced early in 2011 that they were suspending the policy and now, CMS has announced that they are going to rescind the lab signature policy.  Although it will likely be September before the policy can be officially rescinded, CMS has said that they will continue to suspend enforcement of the requirement until the rescission process can be completed.

You too can participate in RHC TA calls.

Find a Family Planning Clinic

For more than 30 years, the U.S. Department of Health and Human Services (DHHS) has sponsored a network of clinics offering family planning and related preventive health services, regardless of ability to pay. This network currently includes more than 4,400 organizations that serve approximately 5 million people each year. These Title X-supported clinics and other entities play a critical role in ensuring access to confidential, voluntary family planning services and information to all who want and need them. Title X clinics deliver a broad range of family planning methods and services to low-income, uninsured, and underinsured individuals for free or at reduced cost.

These family planning services are provided under the auspices of Title X of the 1970 Public Health Service Act, "Population Research and Voluntary Family Planning Programs." Title X is the only Federal program devoted solely to the provision of family planning and related preventive health services. Within DHHS, Title X is administered by the Office of Family Planning within the Office of Population Affairs (OPA).

Title X-funded clinics offer counseling and education on a broad range of effective family planning methods, as well as access to contraceptive supplies. In addition, Title X-funded clinics provide a broad range of related preventive health services—such as routine physical exams; education on health promotion and disease prevention; breast and pelvic exams; cervical cancer screening; instruction in breast and testicular self-exam; STD and HIV prevention education, testing, and referrals; and pregnancy diagnosis and counseling. For many clients, Title X-funded clinics are their only continuing source of health care and health education.

There are many Federally funded clinics across the country that are available to provide women and men with reproductive health care. To find a clinic near you, please visit the Office of Population Affairs' website or call toll-free 866-640-7827.

New AHRQ Toolkit Helps Medical Practices Examine the Impact of Health IT on Workflow

A new toolkit funded by AHRQ and prepared by the University of Wisconsin-Madison’s Center for Quality and Productivity Improvement will assist small- and medium-sized practices in workflow analysis and redesign before, during, and after health IT implementation. Workflow Assessment for Health IT includes tools to analyze workflow, provides examples of workflow analysis and redesign, and describes the experiences of other organizations.

Adverse Events Equally Common in Outpatient Settings and Inpatient Settings

A new study confirms that the incidence of adverse events in the outpatient setting deserves the same scrutiny as those that occur in the inpatient setting. According to a retrospective analysis of more than10,000 malpractice claims paid and reported to the National Practitioner Data Bank in 2009, adverse events in the outpatient setting accounted for 43%, events in the inpatient setting accounted for 47%, and 9% involved events in both settings. The most common reason for a claim paid in the outpatient setting was diagnostic (45%); in the inpatient setting, the most common reason was surgical (34%). Major injury and death were the two most common outcomes in both settings. The study abstract was reported in the June 15 issue of the Journal of the American Medical Association.

The White House announces “Winning the Future: President Obama and the Native American Community.”

The White House has announced the launch of a new webpage as another tool to help Indian Country navigate the federal government.  The White House has been working to improve and strengthen the government-to-government relationship between the United States and tribal governments in order to improve the quality of life for all Native Americans.

This new webpage is designed to be a centralized forum to share information about ongoing efforts, while continuing to improve our government-to-government relationship. At a recent White House listening session, tribal leaders asked for a centralized list of offices within the federal government that were responsible for serving Indian Country and upholding the federal trust responsibility. The webpage contains a Resources Tab designed to be a toolkit for tribal leaders that brings together over 25 different agencies and departments into one, navigable location.

As the website is expanded and improved, periodic e-mail updates will keep Indian Country updated and informed of the issues that affect your communities on a day-to-day basis. You can sign up for e-mail updates on their webpage.

White House Rural Council to Strengthen Rural Communities

The White House has established the first White House Rural Council.  While rural communities face challenges, they also present economic potential.  To address these challenges, build on the Administration’s rural economic strategy, and improve the implementation of that strategy, the President signed an Executive Order establishing the White House Rural Council.

The White House Rural Council will coordinate programs across government to encourage public-private partnerships to promote further economic prosperity and quality of life in rural communities nationwide.  Chaired by Secretary of Agriculture Tom Vilsack, the Council will be responsible for providing recommendations for investment in rural areas and will coordinate Federal engagement with a variety of rural stakeholders, including agricultural organizations, small businesses, and state, local, and tribal governments.

In the coming months, the White House Rural Council will focus on job creation and economic development by increasing the flow of capital to rural areas, promoting innovation, expanding digital and physical networks, and celebrating opportunity through America’s natural resources. The Council will begin discussing key factors for growth, including:

  • Jobs: Improve job training and workforce development in rural America
  • Agriculture:Expand markets for agriculture, including regional food systems and exports
  • Access to Credit: Increase opportunity by expanding access to capital in rural communities and fostering local investment
  • Innovation: Promote the expansion of biofuels production capacity and community based renewable energy projects
  • Networks: Develop high-growth regional economies by capitalizing on inherent regional strengths
  • Health Care: Improve access to quality health care through expansion of health technology systems
  • Education: Increase post-secondary enrollment rates and completion for rural students
  • Broadband: Support the President’s plan to increase broadband opportunities in rural America
  • Infrastructure: Coordinate investment in critical infrastructure
  • Ecosystem markets: Expanding opportunities for conservation, outdoor opportunities  and economic growth on working lands and public lands