Tim Size Executive Director RWHC Sauk City, Wisconsin

1. Rural Health Trends: • Opportunities/Threats Tim Size Executive Director RWHC Sauk City, Wisconsin

2. Overview • Why Should You Care? • Ongoing Myths Undermine Rural Health • Medicare Modernization - Gorilla Wakes Up? • Health Insurance Changes Makes Price Matter • Quality Accountability/Transparency For Real • Workforce Problems Drive Education Reform • Community Collaboration Gets Real • “Say ‘Yes, if …’ rather than ‘No, because…’ ”

3. Keeping Care Local Makes Healthier Local Economy • Over 90 percent of Sauk County providers receive the majority of their revenue from payers outside of Sauk County – primarily private and public insurance companies. • Re hospital services, 66 percent of Sauk County inpatients use local services and 71 percent of outpatients using local services. • �Every two dollars of revenue generated by the health care will generate an additional 80 cents of revenue in other Sauk County industries. • �Every two jobs created (or lost) in Sauk County health care will cause the number of jobs in other sectors to increase (or decrease) by one job. The Economic Value of the Health Care Industry In Sauk County, Wisconsin, Center for Community Economic Development, University of Wisconsin-Extension, November 2000

4. Old Myths Continue To Undermine Rural Health • Rural health care should be cheaper than urban health care. • Bigger is better; urban healthcare quality is better. • Rural residents don’t care/need local healthcare • Rural America is a homogenous healthy agrarian society • Rural populations are disappearing Medicare Reform, A Rural Perspective, The 2001 NACRH Report to the Secretary U.S. Dept. of Health and Human Services.

5. Medicare Is By Far The Major Payer • The Medicare Modernization Act of 2003 had more $ to address historic inequities in rural health than in the history of Medicare. • But also big changes: a pharmacy benefit that could eliminate rural pharmacists and a major push to move Seniors into private plans. • Caused “health care fatigue” re any additional changes in 2005* • Fight against remaining anti-rural biases in Medicare is NOT over. *Lisa Kidder, AHA Fed. Relations at NRHA Annual Conference, 5/27/04

6. Medicare HMOs/PPOs: The Big Sleeper Issue • If providers do not accept what they are offered by Medicare Advantage private health plans (HMOs, PPOs), beneficiaries will be incented or steered away from area hospitals and physicians. • KEY RURAL STRATEGY-ISSUE: Assure that Medicare strongly enforces current access rule that plans must “reflect usual medical travel times within the community.”

7. Consumers: Shift To Focus On Provider Charges • Increased overall health care costs leading to concern re hospital charges being “transparent,” i.e. easily available.* • Increased number of uninsured leading to law suits re hospital collection & billing practices* • Increased overall scrutiny leading to concern re community benefit & not for profit status* *Lisa Kidder, AHA Fed. Relations at NRHA Annual Conference, 5/27/04

8. Health Insurance: Current Cost Trend Unsustainable • Average health care insurance premium headed to $12,000 per capita in 2006. • Responses: shift costs to employees, more low-wage workers uninsured, abandon health benefits for employees or to cut employee positions. • Some saying it will be impossible to sustain the employer-based health care system in the future. Wisconsin Economic Summit IV, Health Care Workgroup, 10/03

9. Shift from Defined Benefit to Defined Contribution • Important addition to mix of insurance products available. • But not a silver bullet for health care costs. • Problem is 80% of population uses only 20% resources while the 20% who use 80% of care “blow” past high deductibles and still may not get needed case management. • Poorly designed plans may discourage preventive care, actually increasing costs over time.

10. Quality: Growing Consensus Re Public Accountability • Rural confronts same quality challenges as urban; health care quality is seen as too variable and falling short of what is possible. • Lower quality seen as cost driver. • Quality infrastructure needed: (1) leadership and quality improvement knowledge, (2) practice guidelines and local protocols, (3) standardized performance measures, (4) measurement, data feedback and (5) quality improvement programs

11. Quality: Information Technology • IT is critical element of quality reporting to public. • Move from episodic-institutional care treating illnesses to greater consumer involvement in the prevention and management of illness across the life-span. • IT provides immediate access to clinical knowledge, specialized expertise, and services not readily available.

12. Quality: Health Literacy • Nearly half of all American adults, 90 million, have difficulty understanding and using health information causing significant demand for preventable care. • Increasing consumer role makes this issue increasingly critical. • Responsibility for improving health literacy must be borne not only by the health system, but also by educators, employers, community organizations… Health Literacy: A Prescription to End Confusion, IOM, 4/04

13. Workforce: Shortage & Maldistribution • Recruit, enroll and train in schools individuals likely to practice in underserved areas • Develop care models that enhance, leverage practitioner resources • Create policy/practices to encourage retention, return to WI • Provide adequate/targeted funding for education. • Develop statewide Council to guide WI medical education policy. WARM hopefully on the way! Wisconsin Academy of Rural Medicine WHA/SMS 2004 Task Force on Wisconsin’s Future Physician Workforce

14. Community Focus: Population Health • Growing awareness that we need to reduce future need for services • Health outcomes (mortality and general health status) are driven by health determinants as follows: • Access to Health Care (10%)* • Health Behaviors (40%)* e.g. smoking, physical inactivity, overweight, sexually transmitted disease, motor vehicle crashes. • Socioeconomic factors (40%)* e.g. education, poverty, divorce rates. • Physical environment (10%)* *Wisconsin County Health Rankings 2003, Wisconsin Public Health and Health Policy Institute

15. Community Focus: Collaboration • Increasingly limited resources make it more appropriate than ever. • It is the only way to address population health threats • It a traditional approach in many rural communities • Basis of most major rural health grant opportunities

16. “Say ‘Yes, if …’ rather than ‘No, because…’ ” * *Anne Woodbury, Chief Health Advocate for Newt Gignrich’s Center for Health Transformation in her keynote address at the WHA 2004 Annual Conference