Meeting the Challenges in California Rural Health Clinics

1. Meeting the Challenges in California Rural Health Clinics Presented to the California State Rural Health Association November 20, 2009

2. Objectives • Participants will learn about current political efforts on behalf of Rural Health Clinics. • Participants will learn about ARRA opportunities for Rural Health Clinics using Electronic Health Records. • Participants will learn about strategies for Rural Health Clinics to work with Federally Qualified Health Centers.

3. Current Political Efforts • Rural Health Clinic Patient Access and Improvement Act of 2009 • National Association of RHCs (NARHC) and its Executive Director Bill Finerfrock have been working for several years to get an RHC-specific bill introduced in Congress. • Senators Barrasso (R-WY) and Wyden (D-OR) sponsored S. 1355, which was introduced on June 25, 2009.

4. Current Political Efforts • Rural Health Clinic Patient Access and Improvement Act of 2009 (continued) • The purpose is to amend Title XVIII of the Social Security Act to improve access to health care for individuals residing in underserved rural areas and for other purposes. • Portions of the bill were proposed as an amendment to the Baucus health reform bill.

5. Current Political Efforts • Rural Health Clinic Patient Access and Improvement Act of 2009 (continued) • The bill was also introduced in the house as H.R. 3896 on October 21, 2009 by Congresswoman Emerson (R-MO). • It was referred to the House Ways and Means Committee.

6. Current Political Efforts • Sections of the legislation: • Rural Health Clinic Reimbursement. Provides $92 per Medicare visit with MEI increases • Rural Health Clinic Quality Reporting Initiative. Beginning in 2010 and ending in 2013, $2/visit for reporting data on quality measures

7. Current Political Efforts • Sections of the legislation (continued): • Rural Health Clinic and Community Health Center Collaborative Access. Allows a community health center to contract with a federally certified rural health clinic for the delivery of primary health care services to individuals who would otherwise be eligible for free or reduced cost care at the community health center. The RHC would be required to offer a sliding fee scale.

8. Current Political Efforts • Sections of the legislation (continued): • GAO Report on Diabetes Education and Medical Nutrition Therapy Services. By July 1, 2012, the Comptroller General of the United States will submit a report concerning the medical nutrition therapy counseling services provided by federally qualified health clinics which will examine diabetes education and medical nutrition therapy services provided in federally qualified health clinics and the feasibility of implementing diabetes education and medical nutrition therapy services in rural health clinics.

9. Current Political Efforts • Sections of the legislation (continued): • Rural Health Clinic Provider Retention Demonstration Project. The Secretary will establish a 3-year demonstration project beginning in 2011 which will award grants to 5 states to examine whether health care professionals can be recruited or retained to work in underserved rural areas by providing them with medical malpractice subsidies. Participating RHCs must provide access to health care services for all individuals, regardless of ability to pay and establish a sliding fee scale for low-income patients. Each participating state will provide grant funds to at least 1 provider-based RHC and at least 1 independent RHC.

10. Current Political Efforts • Sections of the legislation (continued): • Definition of Rural Health Clinic. The RHC statute would be amended to allow a rural health clinic that is in operation and is no longer located in an urbanized area to be considered as still satisfying the rural location requirement if it is determined that the clinic is located in an area defined by the State and certified by the Secretary as rural.

11. Current Political Efforts • Sections of the legislation (continued): • Medicare Advantage Plan Payments. Beginning on January 1, 2010, Medicare Advantage plans will provide a payment rate under the plan for RHC services furnished to enrollees of the plan that is not less than the applicable payment rate (which includes the payment of an interim rate and a subsequent cost reconciliation) or ,if the rural health clinic determines appropriate, 103% of the applicable interim payment rate.

12. Current Political Efforts • National Rural Health Association (NRHA), CSRHA’s national counterpart, also has a platform of RHC issues that include: • an increased per visit cap for RHCs • expansion of 340B program to RHCs • access for rural veterans • incentive payments to RHCs for quality reporting • increased collaboration between RHCs and community health centers • the creation of “teaching health centers,” which would allow RHCs to develop residency programs and become eligible for Medicare graduate medical education funds

13. The American Recovery and Reinvestment Act (ARRA) funding includes $17 billion in Medicare and Medicaid incentive payments for medical providers over a period of several years. Physicians who have not adopted certified electronic records systems by 2014 will see decreased reimbursement. ARRA Opportunities

14. The legislation provides Medicare and Medicaid incentives towards the use of certified EHR technology. The Medicare incentive is based on Part B participation. The Medicaid incentive is based on a provider's involvement in the Medicaid program or other care for “needy individuals”. ARRA Opportunities

15. EHR incentive payments are available through the Medicaid program to: Physicians Nurse Practitioners Certified Nurse Midwives Rural Health Clinics Federally Qualified Health Centers ARRA Opportunities

16. Who is a “Needy Individual”? Someone who is receiving assistance under Medicaid Someone who is receiving assistance from S-CHIP Someone who is furnished uncompensated care by the provider Someone for whom charges are reduced by the provider on a sliding scale basis based on an individual's ability to pay. ARRA Opportunities

17. For payments in the first year, the provider must demonstrate engagement in efforts to adopt, implement or upgrade certified EHR technology; for additional qualifying years the provider must demonstrate “meaningful use” of “certified” EHR technology. RHCs and FQHCs can receive an amount not in excess of 85% of net average allowable costs for certified EHR technology and support services. ARRA Opportunities

18. What is “Meaningful Use”? The eligible professional demonstrates that they are using certified EHR technology in a meaningful manner, including the use of electronic prescribing. The eligible professional demonstrates that such certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination. ARRA Opportunities

19. What is “Certified”? The term “certified EHR technology” means a qualified electronic health record that meets certain standards. This will mean certification by CCHIT (Commission for the Certification of Health Information Technology). ARRA Opportunities

20. RHC and FQHC Collaboration • What is an RHC? • RHCs were created in 1977 to stabilize health care delivery in rural underserved areas. • Three Basic Requirements: • Must be in a non-urbanized area (as defined by the Census Bureau); and, • Must be in a HPSA/MUA/Governor’s Designated shortage area; and, • Must utilize NP/PA/CNM 50% of clinic operational hours

21. RHC and FQHC Collaboration • What is an FQHC? • FQHCs were created in 1989-90 to provide care to the uninsured and low income individuals. • Can be urban or rural • Must serve population groups from MUA-MUP areas • Can be Community Health Centers, Homeless, Migrant, Indian Health Service; or • FQHC Look Alike – meets the requirements of FQHC (but does not receive Section 330 funding).

22. RHC and FQHC Collaboration • How RHCs and FQHCs are alike • Both types of clinics provide access to primary health services for low-income patients in medically underserved communities • Both are part of the “safety net” • Both must have a sufficient number of core staff to serve their patient population • Both must provide some basic lab testing (FQHCs have a broader requirement than RHCs) • Both must be able to show that they have agreements that allow patients to be admitted to hospital and to receive specialty care

23. RHC and FQHC Collaboration • How RHCs and FQHCs are alike (continued) • Definition of visits - RHC/FQHC visits are those medically necessary encounters with one of the following providers: • Physicians • Physician Assistants • Nurse Practitioners • Nurse Midwives • Clinical Social Workers • Clinical Psychologists • Visiting Nurses (in Home Health Shortage Areas)

24. RHC and FQHC Collaboration • How RHCs and FQHCs are alike (continued) • The Role of RHC/FQHC Visits in Cost Reimbursement • RHC/FQHC visits play an important role in determining cost reimbursement. The number of visits determines the denominator for the calculation of the All-Inclusive Reimbursement Rate (AIRR). Either the actual number of visits is used in this calculation or a calculated number of visits, based on minimum productivity, is used. Allowable Costs ----------------------- = AIRR RHC/FQHC Visits

25. RHC and FQHC Collaboration • How RHCs and FQHCs are different • Program • RHCs must be in non-urbanized areas; FQHCs can be urban or rural • RHCs must be in a Medically Underserved Area (MUA), Health Professional Shortage Area (HPSA) or Governor’s Certified Shortage Area; FQHCs must serve patients from a MUA or Medically Underserved Population (MUP) • RHCs must employ a Physician Assistant (PA), Nurse Practitioner (NP) or Certified Nurse Midwife (CNM); FQHCs do not have this requirement

26. RHC and FQHC Collaboration • How RHCs and FQHCs are different (continued) • Program (continued) • RHCs are certified by CMS; FQHCs are designated by HRSA • RHCs are site specific (each location must be certified); FQHCs are entity specific (the entity may have multiple service locations)

27. RHC and FQHC Collaboration • How RHCs and FQHCs are different (continued) • Scope of Services • FQHCs must provide care for all lifecycles; RHCs can focus on single groups (pediatrics, women’s health) • FQHCs must provide x-rays; RHCs can do so through referral • FQHCs must provide pharmacy, preventive health, preventive dental, transportation and case management; RHCs are not required to do so

28. RHC and FQHC Collaboration • How RHCs and FQHCs are different (continued) • Scope of Services (continued) • RHCs must provide first response emergency care onsite; FQHCs can provide such care through arrangements • FQHCs must be open at least 32 hours/week; RHCs do not have this requirement

29. RHC and FQHC Collaboration • How RHCs and FQHCs are different (continued) • Scope of Services (continued) • RHCs are not required to have after hours coverage by its staff; FQHCs are • RHCs are not required to have a quality assurance program (yet); FQHCs are • RHCs are required to have written clinical protocols; it is recommended for FQHCs but not required

30. RHC and FQHC Collaboration • How RHCs and FQHCs are different (continued) • Management • FQHCs must be governed by a nonprofit Board of Directors or a publicly elected Board (such as a County Board of Supervisors); RHCs can be governed by any structure allowed by state law

31. RHC and FQHC Collaboration • How RHCs and FQHCs are different (continued) • Finances • FQHCs must make services available to all regardless of their ability to pay; RHCs do not have this requirement • FQHCs must have a sliding fee scale; RHCs may have one, but are not required to do so • RHCs must state that the practice has not declared bankruptcy nor is such action pending; FQHCs must demonstrate that their revenues equal at least 90% of their expenditures

32. RHC and FQHC Collaboration • How RHCs and FQHCs are different (continued) • Finances (continued) • RHCs are not required to have an independent financial audit; FQHCs are • FQHCs have access to 340B drug pricing; RHCs do not

33. RHC and FQHC Collaboration

34. RHC and FQHC Collaboration

35. RHC and FQHC Collaboration

36. RHC and FQHC Collaboration • More advocacy for RHCs is necessary – most people think that RHCs and health centers are the same thing. • Invite FQHC representatives to RHC meetings and events • Attend FQHC meetings • Find common ground • It’s about the patients not the organizations!

37. Questions? Comments?

38. Contact Information Gail Nickerson Board President CARHC P.O. Box 2344 Granite Bay, CA 95746 916/774-7308 NickerGW@ah.org