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Rural Health: Remote health facilities find ACA rules especially challenging

Working through complexity

Nurses Laci McEnany (left) and Laura Bohr check up on Mert Steva of Waterloo, who is rehabilitating following a stroke at the Waverly Health Center in Waverly on Tuesday, June 16, 2015. (Adam Wesley/The Gazette)
Nurses Laci McEnany (left) and Laura Bohr check up on Mert Steva of Waterloo, who is rehabilitating following a stroke at the Waverly Health Center in Waverly on Tuesday, June 16, 2015. (Adam Wesley/The Gazette)
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The passage of the Affordable Care Act in 2010 threw new pieces into an already complex health care puzzle — moving the health care system from a fee-for-service payment model to a value-based system, and requiring hospitals to report quality measures to the Centers for Medicare and Medicaid Services

And today rural hospitals still are figuring out how they fit into that puzzle.

The smaller populations that rural hospitals treat can make participating in some of these new initiatives — such as Accountable Care Organizations and submitting certain quality measures — difficult, expert say.

“We definitely want the quality known, it’s just coming up with metrics that are workable for them,” said Kirk Norris, president and chief executive officer of the Iowa Hospital Association, which represents the state’s more than 100 hospitals.

For example, hospital are supposed to submit metrics relating to ventilator-associated pneumonia, a lung infection that develops when a person is on a ventilator. But most rural hospitals don’t have intensive care units, which means they wouldn’t deal with that type of illness.

“They’d have nothing to report,” Norris said. “A lot of measurements don’t apply to them, but if they were to put ‘not reportable’ that could raise questions.”

Low volume

Critical access hospitals are rural facilities that provide short-term care and have no more than 25 beds that are given a special Medicare designation. This designation means Medicare reimburses them at a higher rate to help offset their low patient volumes.

These very low patient volumes can make obtaining the necessary data for certain designations or measurements, difficult, said Jim Atty, chief executive officer of Waverly Health Center, a 25-bed critical access hospital.

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“There seems to be a movement from volume to value, but the rules are not necessarily written to play the game,” he said.

The hospital, which Atty describes as one of the larger critical access hospital in the state, has a birthing center, emergency department, physical therapy, cardiac rehabilitation services and specialty clinic among other services more unusual for smaller hospitals, including a spa and psychiatrist on staff.

It has worked hard on patient satisfaction, he said, pointing out that it was one of about a dozen Iowa hospitals to get the full five-star rating from the Centers for Medicare and Medicaid Services, which rated 3,500 of the country’s hospitals on patient experience.

Waverly Health Center also has its Planetree designation, which measures the level of patient-centered care and looks at everything from patient education to providing a healing environment.

But Atty said that, as the hospital has undergone the redesignation process, he’s realized there are many areas in which it doesn’t have enough patients to submit.

“We’re working with Planetree to work through it,” Atty said, “because we don’t always have the statistically significant numbers.”

ACOs

Another big piece of the ACA jigsaw puzzle is Accountable Care Organizations, or ACOs.

ACOs are groups of physicians, hospitals or other health care providers that come together to coordinate care and share savings.

But again, low patient volumes can present a problem. For instance, to be part of the Medicare Shared Savings Program — a federal program that helped Medicare fee-for-service providers become an ACO — hospitals must have 5,000 Medicare patients. That’s something a rural hospital typically doesn’t have.

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Atty said Waverly Health Center is focusing on achieving the Triple Aim, which he said should make the hospital attractive to an ACO. The Institute for Healthcare Improvement nationwide initiative focuses on improving the patient experience, improving the health of the population and reducing the cost —

“Just because we’re a smaller hospital, doesn’t mean we don’t have to hold ourselves to the same standards,” he said.

Meanwhile, Iowa Specialty Hospital-Belmond is taking a different approach. The hospital, along with Iowa Specialty Hospital-Clarion, joined the National Rural ACO, a California-based ACO made up of nine rural health systems from across the country.

Joining the National Rural ACO gives the hospitals access to Medicare claims data as well as help analyzing that data to identify trends and coverage gaps, said Amy McDaniel, chief executive officer of Iowa Specialty Hospital-Belmond, an 18-bed critical access hospital. The facility shares staff and operates clinics with Clarion, a 25-bed hospital about 15 minutes away.

Participating in the ACO also made the hospital eligible for a grant, which allowed it to hire a care coordinator. The coordinator’s job is to identify patients who haven’t had a checkup in awhile, said Dr. Michael Hurt, the hospital’s chief medical officer.

“We can get them to come in, take their blood pressure and, if it’s high, put them on medication so they don’t have a stroke later on,” he said.

The hospitals together pay a fee of $10,000 a month and in return get access to training, data and analytics as well as guidance on what to do as next steps.

“We’re just figuring out which patients to reach out to,” McDaniel said. “When you look at 2,200 Medicare patients, where do you even start? It can be overwhelming. ... The ACO provides that guidance.

“It’s another tool in our toolbox.”

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