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NRHA: Mission Statement

Change the World February 6, 2007 West Virginia Policy Workshop Alan Morgan Chief Executive Officer. NRHA: Mission Statement.

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NRHA: Mission Statement

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  1. Change the WorldFebruary 6, 2007West Virginia Policy Workshop Alan MorganChief Executive Officer

  2. NRHA: Mission Statement The National Rural Health Association is a national membership organization whose mission is to improve the health of rural Americans and to provide leadership on rural issues through advocacy, communications, education and research.

  3. NRHA Membership 11,000

  4. Mission Achieved Through: • Advocacy • Communications • Education • Research

  5. “NRHA provides us with a great opportunity to come together and disagree.” Charlotte Hardt, NRHA President 2001

  6. Tools to Take Home • NRHA Local, State and Federal advocacy tool • Action alerts on status of rural grant funding • Coalitions, Collaborations, and Grassroots

  7. Advocacy and Policy Development • Action Alerts • Information Alerts • Congressional Testimony • Legislative Tracking

  8. Yes, I'm only a bill.And I'm sitting here on Capitol Hill.Well, it's a long, long Journey to the capital city.It's a long, long waitWhile I'm sitting in committee,But I know I'll be a law some dayAt least I hope and pray that I willBut today I am still just a bill.

  9. The Process - Referral to committee - Committee Action - Subcommittee Review - Mark up - Committee Action to Report a Bill - Written Report - Floor Action - Referral to other Chamber - Conference Committee - Final Action - Overriding a Veto (2/3rds)

  10. FY 2006 Conference Agreement • Telehealth increased • CHCs increased • Research & Policy level funding $8.8 • Outreach & Network level funding $39.2 • State Offices almost level $8.2 • FLEX level? $64 • AHECs level funding $28.9 • AED almost eliminated $1.5 • EMS eliminated • H CAP eliminated • Quentin Burdick eliminated • Geriatric Ed. Centers eliminated • H. Ed. Training Centers eliminated

  11. The Process - Referral to committee - Committee Action - Subcommittee Review - Mark up - Committee Action to Report a Bill - Written Report - Floor Action - Referral to other Chamber - Conference Committee - Final Action - Overriding a Veto (2/3rds)

  12. Policy Questions In 2007: • Proper implementation of Medicare • Advantage for CAHs? • Are rural beneficiaries receiving information • on Medicare drug benefit? • -What will “quality” mean? • -What about workforce?

  13. The 110th Congress The Balance of Power Has Shifted • House of Representatives: 110th Congress has 233 Democrats and 202 Republicans. The 109th Congress had 203 Democrats and 232 Republicans. • Senate: 110th Congress has 51 Democrats and 49 Republicans. (Senator Johnson, D-SD, unavailable for votes.) The 109th Congress had 45 Democrats and 55 Republicans. It will still be hard to gather a majority of votes, particularly in the Senate.

  14. Rural Health Leaders in the New Congress House Rural Health Coalition • Co-Chairs: Earl Pomeroy (D-ND) and Greg Walden (R-OR) • Had 174 Members; 146 reelected; 28 retired or lost election Senate Rural Health Caucus • Co-Chairs: Tom Harkin (D-IA) and Craig Thomas (R-WY) • Had 76 Senators; 7 retired or lost election.

  15. Recap of Last Year’s Budget Battle

  16. FY07 Spending Bills • Fiscal year 2007 started on October 1, 2006. Nine of the 11 spending bills are not finished. • Programs currently funded under a stop gap spending measure, a “continuing resolution,” through February 15. • Democratic leadership plans to continue funding under a joint resolution, based on 2006 levels with “some adjustments”.

  17. Recent History of Surpluses and Deficits Unified Surplus/Deficit in Billions of Dollars -296 Sources: Office of Management and Budget; Congressional Budget Office

  18. Five Years of Record Deficits Sources: Congressional Budget Office March Re-estimate of President’s FY07 Budget, 3/2006; FY07 Mid-Session Review 7/2006

  19. The President’s 2006 Budget Proposed to Cut Rural Health Care by $133 Million Does not include a cut of nearly $29 million from eliminating Area Health Education Centers, so total cut reaches nearly $162 million!

  20. “Reduction of $133 million in cuts to rural health programs run by HRSA. HHS is increasing overall rural health funding through other mechanisms, such as Community Health Centers, to make further improvements in rural health. For example, the Medicare Modernization Act makes available $25 billion to rural hospitals and health providers over the next 10 years. " President’s Budget Proposal FY 2007 Note: The official estimate from the Congressional Budget cites the rural provisions in MMA at $20 billion.

  21. NRHA Response 1. MMA addressed long-standing inequities in Medicare payments and sought to address provider shortages. MMA was never meant to replace HHS grant programs. MMA was about preserving access and helping providers keep their doors open, the HHS grant programs are meant to improve health care quality and develop innovative systems of care. 2. Even with MMA, many providers still struggle to stay “in the black”. 3. MMA provisions are expiring. 4. Under the Program Assessment Ratings Tool, the rural health safety net got a score of “adequate”. This is the same score awarded to Ryan White HIV//AIDS programs, for which the President requested a $95 million increase.

  22. Annual Budget Process • President sends his budget to Congress by the first Monday in February. • Congress supposed to pass a budget resolution by April 15. Budget sets target numbers for spending, tax revenues, etc. • Appropriations Committee drafts annual appropriations bills, providing funding for each line item. • New fiscal year begins October 1. If appropriations bills not passed in time, Congress usually passes “continuing resolutions” to keep the government running.

  23. It Will Be a Challenging Budget Environment • Under Pay-as-you-go (PAYGO) all new spending on entitlement programs (e.g., Medicare, Medicaid, SCHIP) must be offset by other spending cuts or tax increases. • Do NOT expect the floodgates to open on spending. • Democrats and the President set goals of balancing the budget by 2012.

  24. Timeline for Appropriations Process • House Committee action the week of June 13. • Senate Committee action the week of July 17. • Final Action – Who knows... Outlook for Appropriations?

  25. FY 2007 Appropriations (dollars in millions) *Includes $25 million for Delta Health Initiative. The House did not fund Delta for FY07; the Senate provided $35 million for Delta as its own line item.

  26. FY 2007 Appropriations (cont.)(dollars in millions)

  27. FY 2007 Appropriations (cont.)(dollars in millions)

  28. Congressional Update

  29. NRHA Legislative and Regulatory Agenda

  30. “It is not that difficult, really. If it improves rural health, we support it. If it doesn’t, we don’t.”Val Schott, 2001Former NRHA President

  31. Medicare Payment Advisory Commission (MedPAC) Federal law requires that MedPAC representation include “a balance between urban and rural representatives”. But only 1 out of 17 MedPAC Commissioners is Rural!

  32. Payment by Medicare Advantage Plans Under fee-for-service, CAHs are paid 101 percent of costs.  Unfortunately, this is not always happening under Medicare Advantage… • H.R. 880: Pay at 101% of cost for inpatient and outpatient services at CAH and services at rural health clinics, regardless of whether in or out-of-network. Reps. Kind (D-WI) and Osborne (R-NE) • S. 2819: Choice of interim rate (101% of cost) and cost reconciliation OR 103% of interim rate for inpatient, outpatient and swing bed services at CAHs and services at rural health clinics. Senators Coleman (R-MN), Durbin (D-IL) and Harkin (D-IA)

  33. Critical Access Hospitals • Safety Net Inpatient Drug Affordability Act (S. 1840/H.R. 3547) • CAHs could access 340B drug discount prices for inpatient and outpatient drugs • DSH hospitals could access 340B prices for inpatient drugs • Savings of $900 million annually for DSH hospitals, of which $100 million is rebated to Medicaid. Once CAH savings are added, the total annual savings for DSH hospitals, CAHs, Medicaid and Medicare will reach $1.2 billion. Source: Public Hospital Pharmacy Coalition

  34. Critical Access Hospitals (cont.) • Payment by Medicare Advantage Plans. • H.R. 880: intent is to pay at 101% of cost. • S. 2819: Choice of interim rate (101% of cost) and cost reconciliation OR 103% of interim rate. • Both include RHCs too. • Critical Access to Clinical Lab Services Act (S. 236/H.R. 1016): Cost-based reimbursement for reference lab services provided to patients not in the hospital. • CMS interpretive guidelines regarding relocation. Congressional letters sent to CMS expressing strong concern. House letter (60 Representatives) and Senate letter (36 Senators).

  35. Advocacy and Legislative Activity on CAH Relocation • NRHA and AHA criticized relocation policy in their comments on FY07 inpatient hospital regulation. • Hill briefings. • Letter from 60 Members of House of Representatives. Led by Representatives Walden (R-OR) and Pomeroy (D-ND) • Letter from 36 U.S. Senators. Led by Senators Roberts (R-KS) and Harkin (D-IA).

  36. Sole Community & Tweener Hospitals • Rural Community Hospital Assistance Act (S. 933/H.R. 2350): Expand cost-based reimbursement for inpatient and outpatient services to rural hospitals with 25 to 50 beds. • Sole Community Hospital Preservation Act (H.R. 2961): Makes permanent the hold-harmless provision for outpatient payments to sole community hospitals. • Eliminating the DSH Cap (S. 3624; S. 3606)

  37. FY07 IPPS Proposed Regulation • Biggest changes since creation of IPPS in 1983 • Diagnosis Related Groups (DRGs) based on cost starting in FY07 • Consolidated Severity-Adjusted DRGs effective in FY08, or sooner. • Overall update of 3.4 percent • NRHA submitted comments in favor of cost-based DRGs, with some technical fixes; Opposed to implementation of severity-adjusted DRGs.

  38. Effect of Both Changes In general, rural hospitals benefit from the restructuring of DRG weights, but once the severity-adjusted DRGs begin, they face a net loss. Source: Federal Register, April 25, 2006, Table L, p. FR24025.

  39. Rural Health Clinics • Increase the interim rate. • Allow contracting between RHCs and CHCs. • RHC regulations implementing Balanced Budget Act forthcoming this spring. • Process for decertification of clinics no longer in shortage areas. BBA requires shortage designation within preceding 3 years. • Process for decertification of clinics no longer in urbanized areas. • Process for seeking an exception if RHC loses its shortage or non-urbanized area designation. • Clarification of “commingling.” BBA prohibits sharing of staff, space, supplies with another Medicare entity. Multipurpose facility allowed, must exclude costs on RHC cost report. • Waiver of 50 percent staffing requirement for NP, PA or certified nurse midwife. • Mandate Quality Assessment and Performance Improvement Program. What are reasonable exceptions for RHCs that lose shortage or non-urbanized status?

  40. Health IT Legislation • House and Senate-passed legislation: Codify the Office of the National Coordinator for Health Information Technology, set up a structure for interoperability standards, other provisions. • H.R. 4157: Authorizes $15 million in each of 2007 and 2008 for hospital systems; $5 million for small, physician practices. • S. 1418: Authorizes $652 million over five years for grants. Also authorizes a revolving loan fund. • H-CARE: Authorizes grants specifically for rural providers. • Democrats more supportive of providing money for IT costs. What are rural IT needs? How are they different from urban, both in magnitude of need and type of need? What is the evidence that rural providers need more help? What is the right funding mechanism?

  41. Workforce Development • Conrad 30 reauthorized in ‘06 • Tax Credits for doctors in HPSAs, $1000 monthly for up to 5 years. (S. 824). • Tax credits for doctors in frontier areas (S. 2789). Source: The National Advisory Committee on Rural Health and Human Services, “Medicare Reform: A Rural Perspective,” May 2001.

  42. Emergency Services Rural Access to Emergency Services Act (S. 1180) • Allows CAHs to receive cost-based reimbursement for emergency services (eliminates 35 mile test) • Reimbursed if reasonably prudent person believes its an emergency • $5 million for demo projects to test ways to integrate ambulance into rural health system. • More appropriate designation of “rural” to cover rural squads that are near a metro area. • Expand quality projects to include ambulance squads • Access to Universal Service Fund Rural Health Care Program.

  43. Additional Emerging Issues • Graduate Medical Education • Rural Veterans (H.R. 5524)

  44. Health Care Quality • NRHA has launched a five-year initiative to improve the quality and safety of health care in rural America based on the Institute of Medicine’s recommendations. • NRHA/ORHP meeting June 23rd to inform potential key stakeholders about IOM’s first recommendation, which calls for comprehensive health system reform demos in five rural communities. Demos will use innovative approaches to the financing and delivery of health services, including P4P and IT. • Goal of meeting was to identify possibilities for implementation and funding of these demonstration projects. Rural Can Lead on Quality!

  45. Medicare Drug Benefit:Is There A Difference Between Urban and Rural? Overall Enrollment & Choice NO. Rural enrollment rates are close to urban enrollment rates (39% v. 43%) • 3.4 million rural beneficiaries signed up for drug benefit (39% of rural beneficiaries). Enrollment By Type of Plan YES. Rural has higher enrollment in stand-alone drug plans (21% v. 13%) YES. Rural has lower enrollment in MA drug plans (3% v. 16%) Benefits NO. Benefits in stand-alone drug plans are the same. YES. Benefits in rural MA drugs plans are less generous. • Higher average premium: $23.04 v. $19.63 • Higher average deductible: $75 v. $53 • Less coverage in the “donut hole”: 7.4% coverage in donut hole v. 18.8% Source: RUPRI, “Medicare Part D: Early Finding on Enrollment and Choices for Rural Beneficiaries,” April 2006.

  46. Medicaid is An Important Source of Health Coverage in Rural America Note: Disability measured as percentage reporting limitation in work activity due to health problems. Source: RUPRI, “Medicaid and Its Importance to Rural Health,” May 2006.

  47. Medicaid • NRHA is a member of the “Partnership for Medicaid,” a coalition of safety net providers with the goal of preserving and improving Medicaid. • The Partnership expects to testify before Secretary Leavitt’s Medicaid Commission and present ideas to strengthen and sustain Medicaid. • NRHA launched its Medicaid Issue Group.

  48. Nearly 46 Million Uninsured • Rural residents are more likely to be uninsured than urban resident (24% without insurance in rural areas not adjacent to an urban area as compared to 18% in urban areas.) Sources: U.S. Census Bureau; Kaiser Family Foundation analysis of 1998 data.

  49. NRHA Needs You… as Advocates!

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