Tim Size, Executive Director Rural Wisconsin Health Cooperative Sauk City, Wisconsin

1. Rural Health Advocacy 24 hours a day 7 days a week Tim Size, Executive Director Rural Wisconsin Health Cooperative Sauk City, Wisconsin

2. Outline of Presentation • Myths About Rural Are Alive & Well • “Almost Worst Rural Health Policy” Awards for 2005 • Cross Section Public-Private Rural Health Issues • Medicare Advantage • Physician Supply • Healthcare Costs • Population Health • Becoming More Effective & Active Advocates

3. MYTHS ABOUT RURAL

4. Myths that Mislead Public & Private Policy • Rural is west ( TX, NC, PA, OH, MI, NY top rural pop ) • Rural Americans are naturally more healthy • Rural economy is mostly about agriculture • Rural health care costs less than urban care • Rural health care is inordinately expensive • Rural health care is lower quality; urban is better • Rural hospitals are just band-aide stations • Rural hospitals & clinics are poorly managed/governed • Rural residents don’t want to get care locally * U.S. 2000 Census, Non-Metro Population By State

5. 2005 “Almost Worst Rural Health Policy” Awards  First Draft of June MedPAC Report  1st Launch of “Hospital Compare” Web Site  Proposed CMS Rural Hospital Building Ban  Federal Appropriations Bill for FFY 2006

6. Medicare Payment Advisory Commission • CAH payment designation ended two decades of failed attempts to retro-fit to rural the PPS Medicare payment methodology designed for large urban hospitals • MedPAC is an advisory commission to Congress • The initial draft of the June MedPAC report was seen as inaccurate, hostile review of the CAH program • Draft framed CAH designation as Federal charity with recipients having to prove they were “deserving poor” • The pushback from Commissioners, with technical help from the field, was substantial and effective

7. Hospital Compare Labled CAH as 2nd Class

8. NRHA Responded with Reporting Guidelines • Need to actively prepare for future when payers and consumers pay attention to public reporting • Rural hospitals should fully engage in the quality improvement and public reporting movement • CAHs and PPS are both “acute care hospitals” • CAH or PPS difference not relevant to quality report • Compare service outcomes, not institution size • Consumers should be able, at a minimum, to readily compare all hospitals in their “hospital referral region” NRHA Policy Brief Approved 5/20/06

9. Proposed Building Ban

10. Appropriations Fight in 2005 for 2006 • President proposed to eliminate 8 programs worth $232 million and dramatically cut 3 others. • House of Representatives followed many of those recommendations; the Senate did not. • The first Conference Report eliminated 6 programs worth $134 million and dramatically cut several others. But it was defeated 209 to 224 in the House! • The final bill restored funding for research and policy and AHECS, and added money for outreach and community health centers. Some programs still cut. Jennifer Friedman, VP Government Affairs and Policy National Rural Health Association

11. President’s Again Slashes Rural Health Does not include $29 million cut from eliminating AHECs; total cuts are over $160 million. Jennifer Friedman, VP Government Affairs and Policy National Rural Health Association

12. Cross Section Rural Health Issues

13. Challenges of a Privatized Medicare

14. Strong Access Standards Are Key • Beneficiary rights to local access, even if “out of network,” is key for beneficiaries and for local providers to have any clout in plan negotiations • “Plans must… ensure that services are geographically accessible and consistent with local community patterns of care.” * • Need to open up current “black-box” which limits beneficiary awareness and evaluation of CMS enforcement of consistency of access standards across plans, markets and time * CMS Medicare Managed Care Manual, Chpt. 4, page 57

15. Protecting CAH/RHC Reimbursement • HR 880 (Ron Kind): pay for CAH & RHC at a rate that is > 101 percent traditional Medicare • SB 2819 (Coleman/Durbin) is comparable to HR 880; adds option of “103 percent of the applicable interim payment rate” • Right to local access still key; payment rates are meaningless if patients can be steered elsewhere • AHA & NRHA Supporting

16. Other Needed Medicare Advantage Improvements • Major increase beneficiary decision-making assistance • Immediate on-line verification beneficiary coverage • Restore State’s Rights to question plan behavior • Regional CMS Office role as source of definitive info • Regional CMS Office handle provider complaints • Plan applications on-line within 30 days of approval • Full/timely transparency re enrollment and quality data • Encourage collaboration amongst rural providers to level playing field re contract development/review DHHS National Advisory Committee on Rural Health & Human Services, Medicare Advantage Sub-Committee, 6/13/06

17. PHYSICIAN SUPPLY

18. Wisconsin Academy of Rural Medicine • Builds on pioneering work of Howard Rabinowitz at Jefferson Medical College in Philadelphia. • Result of 25 years asking land grant UW be true to roots • Goal: rural focused medical school within the Madison based University of Wisconsin medical school • Recruit students with rural background and career goals • Locate education and training programs in rural areas of WI during 3rd and 4th years of Med School • Use rural appropriate curriculum

19. HEALTHCARE COSTS

20. Health Care Costs - Review of Reality • In 2005, employer-based health insurance premiums rose by 9%, the fifth consecutive year over 9% • HMOS, PPOs and POS plans all showed this increase • Annual premium charges an employer for a health plan covering a family of four averaged $10,800 in 2005 • Gross earnings, full-time, minimum-wage = $10,712 • Since 2000, premiums have increased 73%, vs 14% cumulative inflation & 15% cumulative wage increase • The average employee contribution has increased more than 143% since 2000 National Coalition on Health Care http://www.nchc.org/

21. What To Do About Unsustainable Cost Trends? • Most agree that health care costs must be controlled but disagree on the best ways to address rapidly escalating health spending and health insurance premiums: • Price controls and imposing strict budgets on health care spending? • Free market competition solves the problem? • With healthier lifestyles, less medical care required? • Cost of inaction will severely affect employer's bottom lines, business location and consumer's pocketbooks • How do different approaches effect rural health care? National Coalition on Health Care http://www.nchc.org/

22. POPULATION HEALTH

23. Health Outcomes Driven By Multiple Determinants • Access to Health Care (est 10%) • Health Behaviors (est 40%) e.g. smoking, physical inactivity, overweight, sexually transmitted disease, motor vehicle crashes • Socioeconomic factors (est 40%) e.g. education, poverty, divorce rates • Physical environment (est 10%) 2005 Wisconsin County Health Rankings, University of Wisconsin Population Health Institute

24. Critical Link Population & Economic Health “Businesses will move to where healthcare coverage is less expensive, or they will cut back and even terminate coverage for their employees. Either way, it's the residents of your towns and cities that lose out,” Thomas Donohue
President & CEO, U.S. Chamber of Commerce “If we can change lifestyles, it will have more impact on cutting costs than anything else we can do,” Larry Rambo, chief executive officer of Humana’s Wisconsin and Michigan health insurance markets.

26. Initial Local Hospital & Community Steps • Devote a periodic Board meeting to review available population health indicators • Add Board members with specific interest in population health measurement and improvement • Create a “population health” subcommittee of the hospital board to explore opportunities for hospital partnerships with other community organizations • With local employers, develop interventions to improve employee health; expand experience to the larger community “Population Health Improvement & Rural Hospital Balanced Scorecards” by Size T, Kindig D, MacKinney C., Journal of Rural Health; 3/06

27. Strong Rural Communities Initiative • Sponsored by state’s Rural Health Development Council embedded in Wisconsin Department of Commerce • Acquired $700K from 3 sources with 4th looking good • The goal: improve health of rural communities and reduce healthcare cost inflation by accelerating use of collaboration among medical, public health and business organizations that enhance preventive health services • Six local community projects chosen from 22 proposals • Variety approaches to modifying poor fitness, nutrition habits through wellness programs at work/community RWHC Eye On Health Newsletter, 7/06

28. ADVOCACY SKILLS

29. Besides Funding, What Drives Advocacy? • Need to Correct Bias - MedPAC Report • Opportunity to Reframe - Hospital Compare • Short-term Fix Needed/Possible - Building Ban • Broad Coalition Possible - R.H. Appropriations • Address Core Need - Physician Supply • Anticipate Problems - Medicare Advantage • Can’t Be Avoided - Healthcare Costs • Long-term Significance - Population Health

30. Your Advocacy Behaviors Matter • Be Brief • Be Accurate - NEVER false or misleading info • Personalize Your Message - cite examples • Be Prepared - know your issue • Be Aware Every Issue Has Two Sides - there are voters on other side • Be Courteous/Don’t Threaten • Be Patient - long process; be in for long haul Wisconsin Hospital Associations Grass Roots Handbook

31. NRHA’s Three Prong Advocacy Strategy Make your best case: Develop concise, credible, persuasive, fiscally responsible, but emotive arguments. Make friends and form alliances: Find Congressional champions, develop agency contacts, form alliances with a diverse set of groups. Make it happen: Use some or all of your advocacy tools – government relations, grassroots and media advocacy – based on your level of engagement. Jennifer Friedman, VP Government Affairs and Policy National Rural Health Association

33. Rural Health Needs Your Advocacy 24/7 • Rural advocates have an ongoing challenge, an attitude in parts of Washington, and around the country (including CMS) that is frequently ill informed, about rural health and the reality of improving rural health and health care • Rural advocates must not become complacent, all of us must become more skilled and more active.

34. Questions/Discussion? For a free electronic subscription of the RWHC Eye On Health monthly newsletter, send an email to office@rwhc.comwith “subscribe” on the subject line.