Rural Health Advisory Committee Meeting Minutes

Friday, January 13, 2012
9 - 11:30 a.m.

Members Present: John Baerg, Tom Boe, Ray Christensen, Tom Crowley, Ellen Delatorre, Jeff Hardwig (chair), Rep. Larry Hosch, Tom Vanderwal.

Members Absent: Jode Freyholtz-London, Rep. Steve Gottwalt, Margaret Kalina, Sen. Tony Lourey, Diane Muckenhirn, Sen. Julie Rosen, Nancy Stratman.

RHAC Staff: Paul Jansen, Mark Schoenbaum, Kristen Tharaldson.

MDH Staff: Craig Baarson, Doug Benson, Judy Bergh, Katharine Franken, Tim Held, Chris Kimber, Tom Major, Nitika Moibi, Diane Rydryk, Anne Schoegel, Karen Welle.

Guests: Virginia Barzan (Minnesota Academy of Family Physicians), Mallory Car (TSP Architecture), Bryan Carlson (Lakeview Hospital, Two Harbors), Rick Failing (Kittson Memorial Hospital, Hallock), Karen Miller (Office of Congresswoman Bachmann), Kim McCoy (Stratis Health), Ira Moscovice (Upper Midwest Research Center), Rebecca Radcliffe (Essentia Health).

Welcome and Introductions

The chair welcomed Rural Health Advisory Committee (RHAC) members and guests. Members of Flex program advisory committee were invited to this meeting because of their interest in rural health system and consolidation issues. A joint RHAC/Flex meeting will be held in the future to continue discussions on this topic.

RHAC Chair Elect

Current chair Jeff Hardwig and recent chairs Tom Crowley and Margaret Kalina served as the nominating committee for the 2012 RHAC chair position. The committee nominated John Baerg. Members voted to pass the motion and John Baerg accepted his new position.

Rural Health System Growth and Consolidation

The issue of rural health system growth and consolidation is one of the top priority issues on the current RHAC work plan. RHAC staff provided an overview of data about health system affiliations and trends over the past 20 years. Fifteen systems constitute the majority of statewide hospital affiliations. The first trends toward system affiliation occurred in 1996-1998, followed by another rise in the mid-90s, with the most recent trends toward system affiliation starting in 2008. Historical data was used to compare the total numbers of hospitals versus the number of independent hospitals over time. These trends were also analyzed by region showing hospitals in northeast and northwest Minnesota had less movement to affiliation compared to other parts of the state. Definitions need to be clarified as hospitals use many overlapping terms to describe their affiliations, such as affiliated, managed, owned or leased.

Guest speaker, Ira Moscovice, shared his insights and reactions to these trends. These trends toward system affiliation seen in Minnesota are not unique and are happening all over the country. Over 50 percent of rural hospitals nationwide have various affiliation agreements. The age-old assumptions are local control is maintained with independence, with the gain for system affiliation being greater stability. A question to consider is “Do you believe health reform will lead to a transformed health care system and the game will change?” Minnesota is moving ahead with health reform almost independent of national health reform. The big picture is focused on insurance reform. Can true reform be accomplished without addressing the health care delivery side? Concepts like bundled payments and accountable care organizations move health reform forward, but it boils down to a need for established mechanisms to achieve health reform outcomes.

The independent rural hospital may have a difficult time over the next decade unless hospital leaders figure out network or other affiliations. Looser networks are really important. Some system hospitals are also in these loose networks, and they get different things from system affiliation than focus area affiliations. Health information technology and public reporting are very important. Hospitals will succeed if they can demonstrate to payors they will provide quality care at a local level. Around 73 percent of rural hospitals in Minnesota submit quality information through Hospital Compare and other voluntary quality measurement systems, but there is room for improvement. Data collection and transparency are important and hospitals within systems are more likely to do quality reporting. Problems are created when data is submitted by system instead of by facility, but this is being addressed. Hospitals may have a hard time maintaining quality reporting efforts, or implementing and making the best use of health information technology (HIT), so system affiliations can be beneficial in these areas.

Mechanisms to achieve accountability and care coordination are the next act in health reform. Hospital ownership is an important issue, but more important is the relationship between hospitals and physicians/specialists. The federal government just announced 32 accountable care organization (ACO) pioneers. All three chosen in Minnesota are in the metro area. Nationally, of the 32 ACO projects, five to six have a strong rural component.  The majority of those selected had well-defined organizational relationships between hospitals and physicians. In rural areas, provider-hospital relationships are less formal or structured. To develop rural ACOs, hospitals need to consider joining formal and informal systems, as well as linking with nursing homes or other local health care sectors. Isolated hospitals will face difficulties in the near future unless they are locally organized and set up to be successful. This is true for system affiliated as well as independent hospitals. Incentives are not likely to go to smaller rural hospitals because payments will be dictated by ACOs, which will likely be metro dominated. Rural health care systems will need to document quality care at a reasonable price.

Dramatic changes will take place in health care over the next decade. The challenge is for rural hospitals to determine the kinds of linkages that will be important. When the health maintenance organizations (HMO) movement occurred 30-40 years ago (which was really similar to ACOs or managed care), researchers predicted there would be five or six national HMOs. It would likely hurt rural health care to have small numbers of ACOs nationwide. What is needed is to have rural demonstration projects for ACOs, but it is a real challenge to achieve. It would be foolish to do nothing. In closing, rural hospitals do not need to join systems, but they do need to think through hospital-physician relationships or hospital-nursing home relationships.

Discussion

Small providers/safety net hospitals need to get ready with a solid foundation: networking and partnerships, HIT, cost control, health care homes, care coordination, quality reporting and improved outcomes. This will enable them to be prepared for ACOs and health information exchanges. Can unaffiliated hospitals achieve integrated care coordination? It may be more challenging, but what hasn’t been tested is virtual integration or other vehicles, both in legal and HIT terms. In Minnesota, that is where groups like SISU come in.

For those who are independent, what are reactions to this data and conversation? The hospital in Wabasha is part of a system based in Wisconsin. The local clinic is part of the Mayo system. They have good working relationships and benefit from cost control and quality efforts. The hospital in Wabasha reports quality data as required and is implementing HIT. Staff accomplished a lot of internal work on culture, employee support, and community buy-in and support. How do they take the next step to test an ACO model? With payment alignment, where would a rural hospital start? How do they get local physicians on board? Leadership has considered working with the Medicaid model as a good place to start. At the federal level, there is insurance expansion through state exchanges. From the perspective of serving a vulnerable population base near Wabasha (rural, isolated and elderly), there will be more insurance coverage for the population than in the past, so it will be a logical place to start.

In southeast Minnesota, what are impacts of rural consolidation and growth on the patient side? There is mostly confusion from the patient side. Staff does a lot of educating about what the changes mean. Patients and the community need to understand that quality health care services are still in place. This work was needed with the patient base at the Madelia Community Hospital. It had been affiliated with Mayo, but became independent. Now staff has a close working relationship with the Mankato clinic, which is also independent, so it is a good partnership. What system changes mean for them and their care is still confusing for patients.

The emergency medical services (EMS) perspective is important as it may serve as the entry for patients into health care systems. Northwest Minnesota has a mix of provider relationships as well as independent and affiliated hospitals. Volunteer EMS benchmarks currently measure process outcomes (number of people at meetings) versus quality outcomes. How do we ensure that we can provide services and keep up with health reform measurement trends? With many affiliations and qualifications (ALS, BLS, etc.) that lie outside of health reform efforts, how will our state ensure availability of EMS? Now it is a combination of big players (North and Mayo) and independents providing EMS in the region. There used to be lot more competition, but larger systems no longer take on communities with a small a number of runs because it is not cost effective for them. Down the road, consolidation and regionalization of EMS will need to modify first responder and volunteer components to ensure EMS remains viable.

What happens to rural locations that are too small for a system to be interested, but still need access to essential services like EMS? There are huge barriers to integrating EMS with other parts of the health care system. With voluntary squads, it is even more difficult. Flex Monitoring Team papers show how CAHs need to be major players to ensure EMS services. Gary Wingrove has been trying to stimulate discussions on a national level regarding so little data collection in EMS and integration of EMS issues into health care reform efforts. To date, EMS leaders have not been invited to take part in national health care reform discussions or pilot projects.

Regarding system affiliation, some rural hospital boards cannot see any advantage for their patients, so at this time, they will remain independent. Kittson has a fully integrated local health care system. It includes the clinic, hospital, nursing home, assisted living, home care services, contracts with local public health, fitness center, and ambulance service. A number of rural hospitals in Minnesota are already locally integrated. To gather current information on rural system growth and consolidation, a statewide study of rural hospital administrators/board members may be needed to determine their motivation for choosing system or other formal or informal affiliations. What were the major incentives? What did they perceive as most important? Part of the study’s analysis would target hindsight on system affiliation decisions. Would you do it again? For what reasons? Did it work the way you anticipated? Are system affiliation benefits outweighing unintended consequences? Do you have defined quantifiable advantages for local patients, providers or communities?

From a county commissioner perspective, county government has problems that are different and unrelated to hospital system affiliation. It would make sense for hospitals and county government to communicate about local issues. In Watonwan County, two hospitals operate differently. There is still a long way to go to deliver all the necessary health services, especially mental health.

In the world of dentistry, we are not seeing large group practices in rural areas. Dental care is so important to patients, but how does it fit into federal health reform plans or ACO arrangements? The new dental therapist providers are having a hard time finding jobs, which is a problem for underserved populations/Medicaid patients. The clinic at the dental school in Moorhead sees Medicaid patients. They could hire a dentist or dental therapist and have them work full time to cover Medicaid needs. This may be controversial, but without dental care, it can lead to cardiac issues, diabetes and other health problems. At the county-level, there are problems accessing dental services. Local dentists do not serve Medicaid populations because of high rates of no shows.

Where should RHAC go on the topic of rural health system growth and consolidation? Options are to continue the discussion at a joint Flex meeting this spring, develop a fact sheet or brief, or complete a full analysis through a workgroup in the future. Tom Crowley is interested in getting support for a pilot project to bring in someone familiar with the Medicaid model to develop a demo project or model for small rural hospitals. The pilot can emphasize finding common ground with local public health and physicians to work on Medicaid population access. Models are out there, so staff can identify and share these with the committee as first step. We can discuss how partnerships or affiliations have tried to respond to underserved populations. We can determine if there are opportunities to disseminate success stories. Is the Medicaid population the easiest model to test, or are there other rural models? Staff can inform the RHAC committee about what is already being done or planned to see if there are promising approaches or gaps that need to be addressed.

Future health reform efforts will focus on outcomes, but it is noted that physicians may be somewhat resistant or fearful of change. To assume risk for the health of a population ignores the portion of health outcomes that is dependent on individual decision making. Physicians assuming risk for health outcomes ignores this, which is especially important when a population is small. Describing this phenomenon and the challenges of serving small populations is an important part of this analysis. When talking about accountability, providers need a way to put some back on the patient side. There are a variety of ways to do this. For example, patients who exercise and do not smoke could have lower insurance premiums. Clearly we need to engage patients in making better health decisions to improve population health. A reason hospital readmissions are not a good measure is many times readmissions are due to patient behavior or how primary care manages their patients. Health reform is coming, so how do rural communities best prepare and get informed? This is part of a larger discussion and focus for RHAC. More education and identification of successful models is good first step.

Minnesota Community Transformation Grants

The Community Transformation Grant (CTG) program was created by the Patient Protection and Affordable Care Act of 2010. CTG will be a five-year project from 2011-2016. CTG strategic directions include:

  • tobacco-free living
  • active living
  • evidence-based quality, clinical and prevention measures
  • social and emotional wellness (optional)
  • healthy and safe physical environments (optional).

MDH received a grant award to work statewide. Hennepin County also received an award to do county-based work. The MDH grant award amount is $3.6 million. A specific rule requires that 37 percent of the funding goes to rural areas. This will be fulfilled through local grants totaling $1.4 million. Rural focus areas will target rural-urban health status disparities as well as high need populations. Recent health status reports show rural residents are more likely to be obese, less likely to exercise, and more likely to be smokers. American Indian communities will also be a target population for the local grants in rural areas. The MDH grant will be coordinated with existing health improvement initiatives including the Statewide Health Improvement Program (SHIP), Eliminating Health Disparities Initiative (EHDI), and tobacco control efforts. MDH and Hennepin County will coordinate efforts, particularly around metro health care settings.

The CTG framework is to distribute local grants, support regional systems and provide statewide coordination. Local grants will be given to approximately four SHIP grantees to target communities of high need based on population health indicators. In rural areas, the plan is to award two local public health agencies and two tribal health agencies. To determine the four grantees, staff will look at where CAHs are located and where regional systems are ready to move ahead with these efforts. CTG will also target impoverished populations, which are highest in northern regions of Minnesota.

CTG staff will work with community measurement and clinical prevention measures for this project. CTG regional systems will be developed through:

  • evaluation, legal and policy development contractors and consultants
  • tobacco-free living contractors
  • active living contractors
  • healthy eating contractors in various settings
  • clinical preventative services consultants to do clinical-community coalition building to strengthen links for people to access existing local resources.

Minnesota’s CTG project has a “twin approach” to maximize impact and effectiveness. This implies responsibility for jurisdiction-wide impacts (statewide without Hennepin or Ramsey Counties) AND targeted community impacts. The project is currently in the initial planning stages of developing training and technical assistances to grantees and other communities in the state. State and regional systems will help disseminate lessons learned and best practices. There will be an active exchange between local level and state level findings. Evaluation components are also under development. MDH staff is working closely to coordinate SHIP evaluation plans and strategies to have common metrics throughout state. Federal CTG program officers have high expectations and want to reduce the population burden of disease overall by 5 percent in three areas.

Minnesota CTG staff would like to understand how best to approach rural communities and gather information to make the program a success. They hope to identify rural communities by mid-February and go through a grant negotiation process. Communities that do not receive CTG grant funds will still have access to technical assistance. Key contacts for this project are the community health boards and tribal governments. RHAC staff will be available for information dissemination through the rural health conference and newsletters. RHAC members may contact the presenters to facilitate conversations with community health boards in their region.

ORHPC Updates

Six open slots for 2012-2016 are currently posted through the Secretary of State website. RHAC staff has been in contact with the Governor’s Office, which received at least one application for every opening except for the mid-level provider. This candidate could be PA, NP or CNM. ORHPC is doing some recruiting for that slot and invites RHAC members to send in contact information of willing candidates.

ORHPC staff changes include Karen Welle moving to Assistant Director of Health Policy Division and Tim Held moving to Deputy Director of Office of Rural Health & Primary Care. Two new staff include Nikita Moibi, supervisor for the Workforce Analysis unit, and Diane Reger, administrator for the MERC program. The MERC program was moved into ORHPC recently and it is a great fit with loan repayment and other workforce development and analysis work.

The May 2012 RHAC meeting will be held jointly with the Flex committee. Topics include further discussion of rural health system development and rural EMS leadership. The date for this meeting is yet to be determined.

The Minnesota Legislative session starts shortly. The NRHA policy institute is coming up at the end of January. Eighteen rural health leaders from Minnesota will visit congressional offices to discuss rural health issues.

Adjourn

The meeting adjourned at 11:30 a.m. The next RHAC meeting will be held via videoconference on March 30, 2012 from 9 - 11:30 a.m.

Updated Wednesday, 04-Apr-2012 11:00:03 CDT