Rural health providers alarmed by regulatory changes #ahcj14

Attend AHCJ’s free Rural Health Journalism Workshop for a better understanding of what’s happening – or will be happening – in rural regions, and return to work with dozens of story ideas you can pursue.

Compared with city dwellers, people in rural America have higher rates of cancer, diabetes, disabling injuries, and other life-shortening health problems.

Among the less talked about aspects of the Affordable Care Act are measures intended to help reduce rural health disparities. But health professionals working in remote small towns aren’t convinced that the well-intentioned steps will bring enough relief – and do it quickly enough – to reverse problems that many fear are getting worse, such as lack of economic opportunity for rural residents, and limited access to high-quality medical clinics and hospitals.

“There’s definitely joys, but right now the change is huge. It’s going to make it hard for many of us to survive,” said Dean Bartholomew, M.D., a family medicine physician in Saratoga, Wyo., a town with 1,700 residents that is nearly an hour’s drive away from the nearest hospital. Bartholomew was among the panelists at the Health Journalism 2014 session on rural health.

Rural health difference

For Bartholomew, the joys include the rich relationships he’s been able to build with patients and the community. He’s found himself serving as the volunteer team physician for the local high school, for instance, and taking care of sick pets on occasion.

But practicing in a tiny rural community also means that every friend and relative is also a potential patient, he said. The crash of a four-seater aircraft presents a mass casualty situation when the local medical team consists of three people.

“A small town doc is not a job,” he said. “It is your life.”

Certain technological advances are making work easier for rural practitioners: accessing patient medical records electronically, say, or consulting with distant specialists via video and high-speed data connections.

“We can do things we wouldn’t have dreamed of three years ago,” said Chrysanne Grund, project director for Greeley County Health Services in Kansas.

Regulatory burdens fall hard

But Grund and Bartholomew said rural practices remain alarmed by what they see as dramatic changes in regulatory requirements. Grund said small town clinics and hospitals tend to scrape by with lower operating margins than urban health systems, and lack the cash reserves to update computers, hire new staff and train employees to comply with new regulations.

Most ominous, Bartholomew said, is the looming requirement to adopt an entirely new billing code. “Imagine in your line of work, that on Oct. 1, 2014, you all have to write in German,” he said.

While the deadline for the switch to the so-called ICD-10 billing code remains fluid, Bartholomew said it could eventually cost tens of thousands of dollars for small practices to comply. He said Medicare has warned practices to expect months of payment processing delays.

“We received a letter advising us to have three to six months of cash on hand or borrowing capability to survive payment delays,” he said.

“How do you survive this?” he said later in response to a question from the audience. “I don’t know.”

Bootstrap solutions

Jack Westfall, M.D., said rural communities are capable of building some of their own solutions. “Asking ‘Hey, how can we bring the city to you poor rural folk,’ doesn’t fly,” he said. Westfall directs the High Plains Research Network, a consortium of rural primary care practices, hospitals, and communities in eastern Colorado.

The network has enlisted hundreds of people in rural communities to help design and implement strategies to improve health, such as a campaign to boost rates of colon cancer screening and another to improve asthma care and reduce preventable hospitalizations.

For colon cancer screening, community members devised an oversized fact sheet in the form a farm auction flier. These posters are eye catching in farm country, Westfall said, because a farm auction is not just a sale, “It’s a cultural event. Somebody is leaving the farm. It’s ‘Wow, the Jones’s are moving from the old home place to town.’” The key to success, he said, is being locally relevant and actionable.

Westfall said rural communities may find they are better served if they develop their own alternatives for health insurance. “What usually happens is a product is developed in Denver and exported to rural towns,” he said.

Westfall last year became chief medical officer for Colorado HealthOP, a cooperatively owned, nonprofit health plan founded in March 2012.

He said the co-op model can be more attuned to the particular challenges of rural communities, with their provider shortages, small risk pools, and more individual market and very small business purchasers. Those challenges aren’t easy for insurers to handle. It’ll be worth watching to see how rural health insurance co-ops fare.

Further reading


3 thoughts on “Rural health providers alarmed by regulatory changes #ahcj14

  1. Robert C. Bowman, M.D.

    I did a comparison of rural Oklahoma Medicare office visits compared to suburban Arizona.


    Pay is more where more physicians are found
    Pay is less where physicians are needed as set in place by the payment design.

    Rural areas have more Medicare, Medicaid, low pay, no pay
    Rural areas have fewer new patient visits – so the result is less revenue due to more repeat visits
    Rural areas have more patients who are older or sicker with higher complexity of patient care billed. This results in relatively less revenue if patients are not steered to more and usual length visits. It is better to see more patients for shorter time periods to generate reasonable revenue but this may not even keep the doors open as the pay is less in states in need of physicians and in areas with lesser pay – by design
    Reductions of pay for NP and PA also limit this non-physician workforce.

    Suburban areas have more insurance, higher, and highest pay patients for more revenue
    Suburban areas have more new patient visits so higher revenue

    Usual office visit 99213
    Rural OK Billed $86 Paid $38
    Suburb AZ Billed $95 Paid $50 or 32% more for the same service
    NYC Billed $215 Paid $44 to $59 (two different payments)

    More extensive office visit 99214
    Rural OK Billed $124 Paid $62
    Suburb AZ Billed $156 Paid $78 or 26% more for the same service

    If the rural doc bills a 99215 for the most extensive office visit, only $7 more for higher complexity. Much better to have shorter visits and more visits – high patient complexity can kill a practice by design

    The rural location has predominantly Medicare, Medicaid, low pay, and no pay patients. The patients are established patients so there are fewer with higher paid new patient visits (or the doctor’s office fails to understand that they can bill more and get paid more).

    The suburban location has a mix of patients and insurance in suburban AZ with other plans paying higher compared to lower Medicare and lowest Medicaid pay.

    A Medicare listing of over $80,000 for a family doc in a zip code short of physicians (40,000 zips) may represent significant revenue from Medicare, Medicaid, low pay, and no pay.

    Docs paid less from Medicare in family medicine are likely to do much better in revenue and in income.

    Practices where fees paid are lower to lowest tend to be thin margin and on the edge of failure.

    Failure of health access is by design – as indicated in the evidence decade after decade for over 30 years.

    The Reagan administration ignored a call by the Oklahoma Legislature for One Zone Medicare or the same payment for the same service provided – in 1985. I was the rural family doctor who worked with the state medical association and the legislature to get this resolution passed – and administrations since this time have ignored the inequity by design.

  2. Bryan Thompson

    Very interesting, Dr. Bowman. I’m curious why your comparison is between rural Oklahoma and urban Phoenix, rather than rural vs. urban Oklahoma, or rural vs. urban Arizona? I was the moderator for this panel discussion, by the way.

  3. Robert C. Bowman, M.D.

    Started practice in Nowata OK and am now in suburban Phoenix so the initial comparisons were convenience based on past experience.

    Best separations are seen in coding by number of hospitals in a county with a clear linear difference – most pay for counties with 10 or more, least pay for those without a hospital.

    Currently working to geocode the Medicare data using zip code. After working to get a good 5 digit zip, I found errors. So I had to clean the database as the zip codes were off on some – makes me hope that they get paid electronically.

    About to look at NP and PA as initial pay looks significantly lower – not a surprise regarding less than expected utilization. Ortiz noted Rural Health Clinics did not demonstrate cost savings with NP.

    Then there is the whole county shortage designation situation – still crazy after all these years and 3 failed attempts at reforms.

Leave a Reply