Policy analysis brief. W series最新文献

A Joint Publication of The Walsh Center for Rural Health Analysis, National Opinion Research Center, University of Chicago, W Series, No. 6 and the RUPRI Center for Rural Health Policy Analysis, University of Nebraska Medical Center, P2004-6.

Even the smallest, most isolated rural hospitals are now required to have bioterrorism preparedness plans. From the perspective of many rural hospitals, however, there is a disparity between Federal expectations and the realities of small hospitals operating in geographically isolated communities. As part of an effort to better understand how to close this gap, the Walsh Center for Rural Health Analysis convened a panel of representatives of rural hospitals who are responsible for bioterrorism preparedness in their hospitals. Perspectives of rural hospitals on various aspects of preparedness were discussed, in terms of workforce and training, physical capacity and supplies, communication, and coordination with other entities. All of the participants noted the tremendous progress that has been made in the past two years, but also the distance they each need to go. Some of the issues raised by the panelists included the dual benefit of efforts to increase capacity at rural hospitals, the inapplicability of many federal guidelines and directives for small hospitals because of size and less sophisticated infrastructure, the burden of geographic isolation relative to obtaining training and information, and the fragmentation of funding and directives at both the state and federal levels.

The Balanced Budget Act of 1997 dramatically changed the payment environment for institutional providers of non-acute health services by mandating a shift in Medicare reimbursement of outpatient, home health, and skilled nursing services from the traditional cost-based approaches to prospective payment. Although they were designed to slow health care spending, these Medicare payment reforms, particularly the outpatient prospective payment system (OPPS) rules, were projected to have a disproportionately negative impact on many rural hospitals. Subsequent revisions to the Balanced Budget Act (BBA) modified the initial legislation to alleviate or postpone the negative financial impact, including a hold harmless provision for small (100-bed or under) rural hospitals. Due to delays in processing hospital cost reports, sufficient data to assess the impact of the new outpatient payment system on small rural hospitals have only recently become available. We simulated the effect of OPPS on the financial performance of rural hospitals in four states - Iowa, Texas, Washington, and West Virginia. Our findings suggest that the profitability and cash position of small, government-owned, and Medicare-dependent hospitals will be adversely impacted by outpatient PPS. The results also suggest that the number of financially distressed rural hospitals will increase significantly. The small rural hospitals currently protected by the hold harmless provision are those that are likely to be hardest hit by OPPS.

The past decade has brought many changes to the home health care industry, largely as a result of Medicare policy changes. These policy reforms include a new payment system, eligibility restrictions, and stringent fraud and abuse enforcement. In addition, Medicare now pays for home health care based on the location of the beneficiary, not the agency. To examine the impact of these changes on access to care, we evaluated the degree to which beneficiaries are served by agencies outside of their county. We constructed an analytical file by linking the 1997 five percent Medicare Standard Analytical File home health claims file to the Provider of Services file to obtain the characteristics of the beneficiaries' primary agency. This beneficiary-level analytical file included information on 162,241 Medicare home health users - including 43,488 rural residents - of 9,410 home health agencies. We examined the characteristics of rural beneficiaries served by urban agencies as compared with those served by rural agencies. Our findings demonstrate that urban agencies - either directly or through their branch offices - play an important role in providing home health care to rural Medicare beneficiaries.

The transition to Medicare's new prospective payment system for hospital outpatient services has arguable been the most complex and difficult programmatic change in the history of Medicare (Federal Register, 2002). Concern about its adverse effects led to holding rural hospitals with 100 beds or fewer harmless from the financial consequences of the new payment system for the first three years. However, small rural hospitals were not held harmless from implementing the outpatient prospective payment system (OPPS). Many outside observers felt that small rural hospitals would be ill-equipped to handle the immensity of change required, and that claim denials or delays caused by inaccurate claims submissions might have a disproportionate effect on smaller hospitals. There were also reports about difficulties with the interim payment system that had been designed to ensure small hospitals did not lose money during the first three years. This policy brief describes issues that arose in implementing OPPS during the first years of the program, identifies specific implementation concerns for small rural hospitals, and raises issues that may warrant further research or policy action.