rural wisconsin health cooperative tim size executive director rwhc sauk city, wisconsin rural...

Rural WisconsinRural WisconsinHealth CooperativeHealth Cooperative


Tim SizeTim Size

Executive DirectorExecutive Director

RWHCRWHC

Sauk City, WisconsinSauk City, Wisconsin

Rural Health Trends:Rural Health Trends:Opportunities/ThreatsOpportunities/Threats



OverviewOverviewOverviewOverview

1.1. Why Should You Care?Why Should You Care?

2.2. Ongoing Myths Undermine Rural HealthOngoing Myths Undermine Rural Health

3.3. Medicare Modernization - Gorilla Wakes Up?Medicare Modernization - Gorilla Wakes Up?

4.4. Health Insurance Changes Makes Price MatterHealth Insurance Changes Makes Price Matter

5.5. Quality Accountability/Transparency For RealQuality Accountability/Transparency For Real

6.6. Workforce Problems Drive Education ReformWorkforce Problems Drive Education Reform

7.7. Community Collaboration Gets RealCommunity Collaboration Gets Real

8.8. ““Say ‘Yes, if …’ rather than ‘No, because…’ ”Say ‘Yes, if …’ rather than ‘No, because…’ ”

1.1. Why Should You Care?Why Should You Care?

2.2. Ongoing Myths Undermine Rural HealthOngoing Myths Undermine Rural Health

3.3. Medicare Modernization - Gorilla Wakes Up?Medicare Modernization - Gorilla Wakes Up?

4.4. Health Insurance Changes Makes Price MatterHealth Insurance Changes Makes Price Matter

5.5. Quality Accountability/Transparency For RealQuality Accountability/Transparency For Real

6.6. Workforce Problems Drive Education ReformWorkforce Problems Drive Education Reform

7.7. Community Collaboration Gets RealCommunity Collaboration Gets Real

8.8. ““Say ‘Yes, if …’ rather than ‘No, because…’ ”Say ‘Yes, if …’ rather than ‘No, because…’ ”



The Economic Value of the Health Care Industry In Sauk CountyThe Economic Value of the Health Care Industry In Sauk County , Wisconsin, Center for , Wisconsin, Center for Community Economic Development, University of Wisconsin-Extension, November 2000Community Economic Development, University of Wisconsin-Extension, November 2000

Keeping Care Local Makes Healthier Local EconomyKeeping Care Local Makes Healthier Local EconomyKeeping Care Local Makes Healthier Local EconomyKeeping Care Local Makes Healthier Local Economy

• Over 90 percent of Sauk County providers receive the majority of Over 90 percent of Sauk County providers receive the majority of their revenue from payers outside of Sauk County – primarily their revenue from payers outside of Sauk County – primarily private and public insurance companies.private and public insurance companies.

• Re hospital services, 66 percent of Sauk County inpatients use Re hospital services, 66 percent of Sauk County inpatients use local services and 71 percent of outpatients using local services.local services and 71 percent of outpatients using local services.

• ��Every two dollars of revenue generated by the health care will Every two dollars of revenue generated by the health care will generate an additional 80 cents of revenue in other Sauk County generate an additional 80 cents of revenue in other Sauk County industries.industries.

• ��Every two jobs created (or lost) in Sauk County health care Every two jobs created (or lost) in Sauk County health care will cause the number of jobs in other sectors to increase (or will cause the number of jobs in other sectors to increase (or decrease) by one job.decrease) by one job.

• Over 90 percent of Sauk County providers receive the majority of Over 90 percent of Sauk County providers receive the majority of their revenue from payers outside of Sauk County – primarily their revenue from payers outside of Sauk County – primarily private and public insurance companies.private and public insurance companies.

• Re hospital services, 66 percent of Sauk County inpatients use Re hospital services, 66 percent of Sauk County inpatients use local services and 71 percent of outpatients using local services.local services and 71 percent of outpatients using local services.

• ��Every two dollars of revenue generated by the health care will Every two dollars of revenue generated by the health care will generate an additional 80 cents of revenue in other Sauk County generate an additional 80 cents of revenue in other Sauk County industries.industries.

• ��Every two jobs created (or lost) in Sauk County health care Every two jobs created (or lost) in Sauk County health care will cause the number of jobs in other sectors to increase (or will cause the number of jobs in other sectors to increase (or decrease) by one job.decrease) by one job.



Old Myths Continue To Undermine Rural Health Old Myths Continue To Undermine Rural Health Old Myths Continue To Undermine Rural Health Old Myths Continue To Undermine Rural Health

Rural health care should be cheaper Rural health care should be cheaper than urban health care.than urban health care.

Bigger is better; urban healthcare Bigger is better; urban healthcare quality is better. quality is better.

Rural residents don’t care/need Rural residents don’t care/need local healthcarelocal healthcare

Rural America is a homogenous Rural America is a homogenous healthy agrarian societyhealthy agrarian society

Rural populations are disappearingRural populations are disappearing

Medicare Reform, A Rural Perspective,Medicare Reform, A Rural Perspective, The 2001 NACRH Report to the The 2001 NACRH Report to the Secretary U.S. Dept. of Health and Human Services.Secretary U.S. Dept. of Health and Human Services.

RWHC Eye On Health

Rural?Pay them less.

They grow their own vegetables.



Medicare Is By Far The Major PayerMedicare Is By Far The Major PayerMedicare Is By Far The Major PayerMedicare Is By Far The Major Payer

The Medicare Modernization Act The Medicare Modernization Act of 2003 had more $ to address of 2003 had more $ to address historic inequities in rural health historic inequities in rural health than in the history of Medicare.than in the history of Medicare.

But also big changes: a pharmacy But also big changes: a pharmacy benefit that could eliminate rural benefit that could eliminate rural pharmacists and a major push to pharmacists and a major push to move Seniors into private plans. move Seniors into private plans.

Caused “health care fatigue” re any Caused “health care fatigue” re any additional changes in 2005* additional changes in 2005*

Fight against remaining anti-rural Fight against remaining anti-rural biases in Medicare is NOT over.biases in Medicare is NOT over.

*Lisa Kidder, AHA Fed. Relations at NRHA Annual Conference, 5/27/04*Lisa Kidder, AHA Fed. Relations at NRHA Annual Conference, 5/27/04

H H H H H H H H H HH H H H H H H H H HH H H H H H H h H HH H H H H H H H H HH H H H H H H H H HH h H H H H H H H HH H H H H H H H H HH H H H H H H H H HH H H H H H H H H HH H H H H H H H H H

RWHC Eye On Health

Equitable rural payments don't threaten or distort Medicare's primary PPS focus.



Medicare HMOs/PPOs: The Big Sleeper IssueMedicare HMOs/PPOs: The Big Sleeper IssueMedicare HMOs/PPOs: The Big Sleeper IssueMedicare HMOs/PPOs: The Big Sleeper Issue

• If providers do not accept If providers do not accept what they are offered by what they are offered by Medicare Advantage private Medicare Advantage private health plans (HMOs, PPOs), health plans (HMOs, PPOs), beneficiaries will be incented beneficiaries will be incented or steered away from area or steered away from area hospitals and physicians.hospitals and physicians.

• KEY RURAL STRATEGY-KEY RURAL STRATEGY-ISSUE: Assure that Medicare ISSUE: Assure that Medicare strongly enforces current strongly enforces current access rule that plans must access rule that plans must “reflect usual medical travel “reflect usual medical travel times within the community.”times within the community.”

• If providers do not accept If providers do not accept what they are offered by what they are offered by Medicare Advantage private Medicare Advantage private health plans (HMOs, PPOs), health plans (HMOs, PPOs), beneficiaries will be incented beneficiaries will be incented or steered away from area or steered away from area hospitals and physicians.hospitals and physicians.

• KEY RURAL STRATEGY-KEY RURAL STRATEGY-ISSUE: Assure that Medicare ISSUE: Assure that Medicare strongly enforces current strongly enforces current access rule that plans must access rule that plans must “reflect usual medical travel “reflect usual medical travel times within the community.”times within the community.”

RWHC Eye On Health

"Why is it legal for our only doctors to be denied payment from our only insurance?"

HometownRural Clinic



Consumers: Shift To Focus On Provider ChargesConsumers: Shift To Focus On Provider ChargesConsumers: Shift To Focus On Provider ChargesConsumers: Shift To Focus On Provider Charges

RWHC Eye On Health

"He's a third generation Conservative but his firm's health care costs just outstripped payroll."

Increased overall health care costs Increased overall health care costs leading to concern re hospital leading to concern re hospital charges being “transparent,” i.e. charges being “transparent,” i.e. easily available.*easily available.*

Increased number of uninsured Increased number of uninsured leading to law suits re hospital leading to law suits re hospital collection & billing practices*collection & billing practices*

Increased overall scrutiny leading Increased overall scrutiny leading to concern re community benefit & to concern re community benefit & not for profit status*not for profit status*

*Lisa Kidder, AHA Fed. Relations at NRHA Annual Conference, 5/27/04*Lisa Kidder, AHA Fed. Relations at NRHA Annual Conference, 5/27/04



Health Insurance: Current Cost Trend UnsustainableHealth Insurance: Current Cost Trend UnsustainableHealth Insurance: Current Cost Trend UnsustainableHealth Insurance: Current Cost Trend Unsustainable

Average health care insurance Average health care insurance premium headed to $12,000 premium headed to $12,000 per capita in 2006.per capita in 2006.

Responses: shift costs to Responses: shift costs to employees, more low-wage employees, more low-wage workers uninsured, abandon workers uninsured, abandon health benefits for employees health benefits for employees or to cut employee positions.or to cut employee positions.

Some saying it will be Some saying it will be impossible to sustain the impossible to sustain the employer-based health care employer-based health care system in the future.system in the future.

Wisconsin Economic Summit IV, Health Care Workgroup, 10/03Wisconsin Economic Summit IV, Health Care Workgroup, 10/03

RWHC Eye On Health

PrivateMarkets

PublicControl

WishfulThinking



Shift from Defined Benefit to Defined ContributionShift from Defined Benefit to Defined ContributionShift from Defined Benefit to Defined ContributionShift from Defined Benefit to Defined Contribution

Important addition to mix of Important addition to mix of insurance products available.insurance products available.

But not a silver bullet for health But not a silver bullet for health care costs.care costs.

Problem is Problem is 80% of population uses 80% of population uses only 20% resources while the 20% only 20% resources while the 20% who use 80% of care “blow” past who use 80% of care “blow” past high deductibles and still may not high deductibles and still may not get needed case management.get needed case management.

Poorly designed plans may Poorly designed plans may discourage preventive care, discourage preventive care, actually increasing costs over time.actually increasing costs over time.

RWHC Eye On Health

"He says our insurance this month only allows him to treat body parts in the first half of the alphabet."



Quality: Growing Consensus Re Public AccountabilityQuality: Growing Consensus Re Public AccountabilityQuality: Growing Consensus Re Public AccountabilityQuality: Growing Consensus Re Public Accountability

Rural confronts same quality Rural confronts same quality challenges as urban; health care challenges as urban; health care quality is seen as too variable and quality is seen as too variable and falling short of what is possible.falling short of what is possible.

Lower quality seen as cost driver.Lower quality seen as cost driver.

Quality infrastructure needed: Quality infrastructure needed: (1) leadership and quality (1) leadership and quality improvement knowledge, (2) improvement knowledge, (2) practice guidelines and local practice guidelines and local protocols, (3) standardized protocols, (3) standardized performance measures, (4) performance measures, (4) measurement, data feedback and measurement, data feedback and (5) quality improvement programs(5) quality improvement programs

RWHC Eye On Health

"I'll drop 'don't let perfection be the enemy of the good' when you stop saying 'just trust me.' "

Quality & Cost Data



Quality: Information TechnologyQuality: Information TechnologyQuality: Information TechnologyQuality: Information Technology

IT is critical element of IT is critical element of quality reporting to public. quality reporting to public.

Move from episodic-Move from episodic-institutional care treating institutional care treating illnesses to greater illnesses to greater consumer involvement in consumer involvement in the prevention and the prevention and management of illness management of illness across the life-span.across the life-span.

IT provides immediate IT provides immediate access to clinical access to clinical knowledge, specialized knowledge, specialized expertise, and services not expertise, and services not readily available.readily available.

RWHC Eye On Health

The Information Technology (IT) highway needs to improve quality, not digital monopolies.



Quality: Health LiteracyQuality: Health LiteracyQuality: Health LiteracyQuality: Health Literacy

RWHC Eye On Health

"Don't tell me, but we really don't have the least idea what each other is saying, do we?"

Nearly half of all American Nearly half of all American adults, 90 million, have difficulty adults, 90 million, have difficulty understanding and using health understanding and using health information causing significant information causing significant demand for preventable care.demand for preventable care.

Increasing consumer role makes Increasing consumer role makes this issue increasingly critical.this issue increasingly critical.

Responsibility for improving Responsibility for improving health literacy must be borne not health literacy must be borne not only by the health system, but only by the health system, but also by educators, employers, also by educators, employers, community organizations…community organizations…

Health Literacy: A Prescription to End ConfusionHealth Literacy: A Prescription to End Confusion , IOM, 4/04, IOM, 4/04



Workforce: Shortage & MaldistributionWorkforce: Shortage & MaldistributionWorkforce: Shortage & MaldistributionWorkforce: Shortage & Maldistribution

RWHC Eye On Health

"The 'rurals' have a point, we should just callourselves a Med School for suburban specialists."

Recruit, enroll and train in schools Recruit, enroll and train in schools individuals likely to practice in individuals likely to practice in underserved areasunderserved areas

Develop care models that enhance, Develop care models that enhance, leverage practitioner resourcesleverage practitioner resources

Create policy/practices to Create policy/practices to encourage retention, return to WIencourage retention, return to WI

Provide adequate/targeted funding Provide adequate/targeted funding for education.for education.

Develop statewide Council to guide Develop statewide Council to guide WI medical education policy.WI medical education policy.

WHA/SMS 2004 Task Force on Wisconsin’s Future Physician WorkforceWHA/SMS 2004 Task Force on Wisconsin’s Future Physician Workforce

WARM hopefully on the way!WARM hopefully on the way!Wisconsin Academy of Rural MedicineWisconsin Academy of Rural Medicine



Community Focus: Population HealthCommunity Focus: Population HealthCommunity Focus: Population HealthCommunity Focus: Population Health

Growing awareness that we need to Growing awareness that we need to reduce future need for servicesreduce future need for services

Health outcomes (mortality and Health outcomes (mortality and general health status) are driven by general health status) are driven by health determinants as follows:health determinants as follows:

Access to Health Care (10%)*Access to Health Care (10%)* Health Behaviors (40%)* e.g. Health Behaviors (40%)* e.g.

smoking, physical inactivity, smoking, physical inactivity, overweight, sexually transmitted overweight, sexually transmitted disease, motor vehicle crashes.disease, motor vehicle crashes.

Socioeconomic factors (40%)* e.g. Socioeconomic factors (40%)* e.g. education, poverty, divorce rates.education, poverty, divorce rates.

Physical environment (10%)*Physical environment (10%)*

*Wisconsin County Health Rankings 2003, *Wisconsin County Health Rankings 2003, Wisconsin Public Health and Health Policy InstituteWisconsin Public Health and Health Policy Institute

RWHC Eye On Health

"Your test results confirm that you are more careful about what you put in your car than your mouth."



Community Focus: CollaborationCommunity Focus: CollaborationCommunity Focus: CollaborationCommunity Focus: Collaboration

RWHC Eye On Health

"The collaboration makes sense, but it will take a while to understand them."

Increasingly limited Increasingly limited resources make it more resources make it more appropriate than ever.appropriate than ever.

It is the only way to address It is the only way to address population health threatspopulation health threats

It a traditional approach in It a traditional approach in many rural communitiesmany rural communities

Basis of most major rural Basis of most major rural health grant opportunitieshealth grant opportunities



““Say ‘Yes, if …’ rather than ‘No, because…’ ” *Say ‘Yes, if …’ rather than ‘No, because…’ ” *““Say ‘Yes, if …’ rather than ‘No, because…’ ” *Say ‘Yes, if …’ rather than ‘No, because…’ ” *

RWHC Eye On Health

"OK. I understand a lot is going to change. But how do I stay the same?"

*Anne Woodbury, Chief Health Advocate for Newt Gignrich’s Center for Health *Anne Woodbury, Chief Health Advocate for Newt Gignrich’s Center for Health Transformation in her keynote address at the WHA 2004 Annual ConferenceTransformation in her keynote address at the WHA 2004 Annual Conference

rural wisconsin health cooperative tim size executive director rwhc sauk city, wisconsin rural...

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