Rural Health Advocacy
24 hours a day
7 days a week
Tim Size, Executive Director
Rural Wisconsin Health Cooperative
Rural Wisconsin
Sauk City,
Wisconsin
Health Cooperative
Outline of Presentation
• Myths About Rural Are Alive & Well
• “Almost Worst Rural Health Policy” Awards for 2005
• Cross Section Public-Private Rural Health Issues
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Medicare Advantage
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Physician Supply
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Healthcare Costs

Population Health
• Becoming More Effective & Active Advocates
Rural Wisconsin
Health Cooperative
MYTHS
RURAL
RWHC ABOUT
Eye On Health
Rural?
Pay them less.
They grow their
own vegetables.
Rural Wisconsin
Health Cooperative
Myths that Mislead Public & Private Policy
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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
Rural Wisconsin
Health Cooperative
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
Rural Wisconsin
Health Cooperative
Medicare Payment Advisory Commission
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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
Rural Wisconsin
Health Cooperative
Hospital Compare Labled CAH as 2nd Class
Rural Wisconsin
Health Cooperative
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
Rural Wisconsin
Health Cooperative
RWHC
EyeBuilding
On Health
Proposed
Ban
"No need to rebuild old rural hospitals when
we have Army Surplus MASH Tents."
Rural Wisconsin
Health Cooperative
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
Rural Wisconsin
Health Cooperative
Dollars in Millions
President’s Again Slashes Rural Health
$200
$160
$150
$100
Does not include $29 million
cut from eliminating AHECs;
total cuts are over $160 million.
$27
$50
$0
FY06
Jennifer Friedman, VP Government Affairs and Policy
National Rural Health Association
FY07
President's
Request
Rural Wisconsin
Health Cooperative
Cross Section Rural Health Issues
Rural Wisconsin
Health Cooperative
RWHC Eye of
OnaHealth
Challenges
Privatized Medicare
Hometown
Rural Clinic
"Why is it legal for our only doctors to be denied
payment from our only insurance?"
Rural Wisconsin
Health Cooperative
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
Rural Wisconsin
Health Cooperative
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
Rural Wisconsin
Health Cooperative
Other Needed Medicare Advantage Improvements
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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
Rural Wisconsin
Health Cooperative
PHYSICIAN SUPPLY
Rural Wisconsin
Health Cooperative
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
Rural Wisconsin
Health Cooperative
RWHC Eye On Health
HEALTHCARE
COSTS
"He's a third generation Conservative but his
firm's health care costs just outstripped payroll." Rural Wisconsin
Health Cooperative
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/
Rural Wisconsin
Health Cooperative
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/
Rural Wisconsin
Health Cooperative
POPULATION
HEALTH
RWHC Eye On Health
"Your test results confirm that you are more careful
about what you put in your car than your mouth."
Rural Wisconsin
Health Cooperative
Health Outcomes Driven By Multiple Determinants
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Access to Health Care (est 10%)
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Health Behaviors (est 40%) e.g. smoking, physical
inactivity, overweight, sexually transmitted disease,
motor vehicle crashes
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Socioeconomic factors (est 40%) e.g. education,
poverty, divorce rates
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Physical environment (est 10%)
2005 Wisconsin County Health Rankings, University of Wisconsin
Population Health Institute
Rural Wisconsin
Health Cooperative
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.
Rural Wisconsin
Health Cooperative
Rural Wisconsin
Health Cooperative
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
Rural Wisconsin
Health Cooperative
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
Rural Wisconsin
Health Cooperative
ADVOCACY SKILLS
Rural Wisconsin
Health Cooperative
Besides Funding, What Drives Advocacy?
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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
Rural Wisconsin
Health Cooperative
Your Advocacy Behaviors Matter
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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
Rural Wisconsin
Health Cooperative
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
Rural Wisconsin
Health Cooperative
Rural Wisconsin
Health Cooperative
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.
Rural Wisconsin
Health Cooperative
Questions/Discussion?
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RWHC Eye On Health monthly newsletter,
send an email to office@rwhc.com with
“subscribe” on the subject line.
Rural Wisconsin
Health Cooperative