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Finding compelling stories about a fraying safety net in a fast-changing insurance marketplace Date: 01/13/14

By Jim Doyle

St. Louis is the home of several large health systems and many hospitals, major academic medical institutions, pharmaceutical companies and a leading pharmacy benefit manager. All of these entities depend on insurance payments and each one is affected differently as the insurance marketplace changes radically this year under health care reform. The question I’m trying to answer most often is how can I cover the issues these organizations face most effectively?

Reporting on these organizations demands most of my time, and often I could do my job without leaving the newsroom or the St. Louis metropolitan area. But I've made a point of escaping the confines of the metro area whenever I can. In recent years, I've done a fair amount of reporting on far-flung hospitals in rural areas, including Missouri's impoverished Bootheel region.

Some of the stories I've written about rural health care have been included in my ongoing series, "Health Care Changes and Choices," which tracks the shifting landscape of the health care industry, the insurance marketplace, and the roll-out of the Affordable Care Act.

To assess any hospital or health care system, I like to pop the hood and examine how things work or don't work – and what might be improved. It's important in this endeavor to challenge conventional wisdom – to aim to test everything, including experts' conclusions and my own assumptions and tentative findings.

One of the key issues in rural health care is access to care, including primary care and specialty physicians. Another issue is the degree of competition and consolidation among rural hospitals. But perceptions often differ on how well a hospital or local health system is serving a rural population.

As always, it's helpful to gather subjective observations and anecdotes from a cross-section of stakeholders, everyone from the powerful elites to the unemployed, uninsured, and those who are broke. People with useful facts and opinions also include physicians, hospital administrators, insurers and Medicaid contractors; politicians, community health advocates, academics and health care consultants; federal, state, regional and local health officials; the middle class and the insured.

But perceptions only tell part of the story. It's equally important to assemble indisputable facts. Key statistics about a local population that I've found advantageous include life expectancy (compared with national, state, and county averages); infant mortality; obesity; chronic disease rates; doctors per capita; proximity of hospitals; racial makeup; unemployment; and poverty levels.

Potential sources for these raw statistics include state hospital associations; regional health or economic development agencies; health foundations; the U.S. census; coalitions of employer-sponsored health plans; and the Institute of Health Metrics & Evaluation at the University of Washington.

Some rural hospitals are in financial jeopardy or may be subject to takeover attempts, so it's vital to assess an institution's financing and pricing. To do so, the following sources are useful:

A nonprofit hospital's IRS 990 tax filings will provide useful information about revenue and expenses; employees; executive salaries; advertising and promotion; self-dealing by hospital board members and executives; and technology.

The filings of publicly held corporations and other for-profit hospitals and health systems with the Securities & Exchange Commission provide basic financial and legal data.

Consolidated financial statements also may be available through the Electronic Municipal Market Access bond reporting website.

The American Hospital Directory provides free hospital profiles; revenue and expenses; and billing rates for specific procedures.

State health officials may post detailed profile data on hospitals within their state.

The newly released federal database on Medicare billings offers a guide to inpatient and outpatient "sticker" prices for most common medical procedures.

In addition, it's important to assess a hospital's quality of care, a factor that is becoming more important to health insurers and patients. A quick check of CMS' Hospital Compare website will provide the latest patient satisfaction surveys; mortality rates for heart attack, heart failure and pneumonia; hospital acquired conditions such as infections, falls, injuries, and pressure sores; emergency room wait times; and readmission rates. (AHCJ also has the data in Excel files designed to allow you to compare more than three hospitals at a time.)

If you report on rural hospitals, you'll soon recognize the parallels between the health care disparities the poor face in rural areas and in the inner cities and that health insurance reform only goes so far, causing many safety-net organizations to struggle. These local populations often share socioeconomic and health assessment factors, including high rates of chronic disease and infant mortality. Here are four examples:

In pursuing rural health care stories, it’s useful to become familiar with two federal designations and how they apply to hospitals and areas of your state:

Critical Access Hospitals (CAHs). These facilities receive cost-based reimbursement from the federal Medicare program. (They are rural hospitals that have no more than 25 acute care beds and are located either more than 35 miles away from another hospital or seven miles away from a hospital in mountainous terrain or on secondary roads.) See the Flex Monitoring Team website for more information and this article, “'Critical access' designation may be in danger for hospitals in your area.”

Health Professional Shortage Areas (HPSAs). These areas have shortages of primary medical care, dental, or mental health providers. Look up states and counties.

In writing about rural health care, it's crucial to find ways to humanize these stories with the voices and images of real people. I've only scratched the surface, but there are great narrative stories waiting to be told on these topics for reporters with the time, interest and commitment of their news organizations.

These links to articles I did recently on health care access may be useful:

Jim Doyle covers the business of health care for the St. Louis Post-Dispatch and is working on an ongoing multi-part series on health care access and the fraying safety net. He was a fellow of the 2010-11 class of AHCJ Midwest Health Journalism Program.