Study Examines Use of Telemedicine Among Rural Medicare Beneficiaries

Newswise, May 31, 2016 — Although the number of Medicare telemedicine visits increased more than 25 percent a year for the past decade, in 2013, less than 1 percent of rural Medicare beneficiaries received a telemedicine visit, according to a study appearing in  JAMA.

Medicare limits telemedicine reimbursement to select live video encounters with the patient at a clinic or facility in a rural area. Federal legislation has been proposed to expand Medicare telemedicine coverage. 

Ateev Mehrotra, M.D., of Harvard Medical School, Boston, and colleagues examined trends in telemedicine utilization in Medicare from 2004-2013 using claims from a 20 percent random sample of traditional Medicare beneficiaries.

The researchers found that telemedicine visits among rural Medicare beneficiaries increased from 7,015 in 2004 to 107,955 in 2013 (annual visit growth rate, 28 percent); 0.7 percent of rural beneficiaries received a telemedicine visit in 2013. 

Most visits occurred in outpatient clinics; 12.5 percent occurred in a hospital or skilled nursing facility. Mental health conditions were responsible for 79 percent of visits. 

Rural beneficiaries who received a 2013 telemedicine visit were more likely to be younger than 65 years, have entered Medicare due to disability, have more illnesses, and live in a poorer community compared with those who did not receive a telemedicine visit.

“Proposed federal legislation would encourage greater use of telemedicine through expanded reimbursement. In contrast to others, we found that state laws that mandate commercial insurance reimbursement of telemedicine were not associated with faster growth in Medicare telemedicine use. 

Our results emphasize that nonreimbursement factors may be limiting growth of telemedicine including state licensure laws and restrictions that a patient must be hosted at a clinic or facility,” the authors write.

Editor’s Note: This article was supported by an unrestricted gift to Harvard Medical School by Melvin Hall and CHSi Corporation. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Surgery Surprise: Rural Hospitals May Be Safer and Less Expensive for Common Operations

Critical access hospital study suggests local care works well for straightforward surgical cases in uncomplicated patients

Newswise, May 18, 2016— They may be in small towns. They may only have a couple of surgeons. But for common operations, they may be safer and less expensive than their larger cousins, a new study finds.

“They” are critical access hospitals – a special class of hospital that’s the closest option for tens of millions of Americans living in rural areas. And according to new findings published in the Journal of the American Medical Association, having surgery at one of them may be a better bet for most relatively healthy patients than traveling to a suburban or city hospital.

A University of Michigan-led team carried out the analysis of data from 1.6 million hospital stays for four common operations: gallbladder removal, colon surgery, hernia repair and appendectomy.

They compared what happened to patients covered by Medicare who had their operations at 828 critical access hospitals with data from patients treated at more than 3,600 larger hospitals.

The analysis yielded several surprises:

• The risk of dying within 30 days of the operation was the same whether a patient had surgery at a critical access hospital or a larger hospital.
• The risk of suffering a major complication after surgery, such as a heart attack, pneumonia or kidney damage, was lower at critical access hospitals.
• Patients who had their operation at a critical access hospital cost the Medicare system nearly $1,400 less than patients who had the same operation at a larger hospital, after differences in patient risk and pricing were accounted for.
• The patients who had these operations at critical access hospitals were healthier to begin with than patients treated elsewhere, suggesting that critical access hospital surgeons are appropriately selecting surgical patients who can do well in a small rural setting, and triaging more complex patients to larger centers.
• But even after the researchers corrected for differences in pre-operation health, the critical access hospitals still had equal or better outcomes.

Critical eye on critical access

The findings are timely because of a current debate over whether to change the national policies that designate critical access hospitals, and determine how much they get paid for medical and surgical services. Hundreds are these hospitals are in danger of closing, threatening local access to care for millions of Americans.

Currently, the Medicare system essentially subsidizes them by paying them slightly more than the total cost of care, in order to ensure they can stay financially afloat to serve rural areas. Even still, dozens have closed in recent years.

Recent studies of common medical conditions like heart attacks and pneumonia at critical access hospitals have raised questions about how well they care for patients with these conditions. The new study is the first comprehensive look at the surgical care they provide.

“From a surgical standpoint, these hospitals appear to be doing exactly what we would want them to be doing: common operations on appropriately selected patients who are safe to stay locally for their care,” says Andrew Ibrahim, M.D., first author of the new study and a VA/Robert Wood Johnson Clinical Scholar at the U-M Medical School.

Ibrahim and senior author Justin Dimick, M.D., MPH, worked on the study with Tyler Hughes, M.D., one of two surgeons at the critical access McPherson Hospital in McPherson, KS and a director of the American Board of Surgery.

Says Hughes, “The goal of the rural surgeon is best care nearest home. Data to assure that the care in rural centers is both safe and cost effective is critical in the decisions the profession faces in providing care to the 20 percent of the U.S. population living in truly rural environments.

This study gives credence to what rural surgeons long suspected -- that well-done rural surgery is safe and cost effective.” Hughes helped the U-M team understand the triage process that surgeons at critical access hospitals use to decide whether to take a case or refer the patient to a larger center.

Says Dimick, “For many years, surgeons have debated whether we should concentrate surgery in a subset of our larger hospitals. The downside of this approach is that patients have to travel far from home for surgery, especially those living in remote areas.

“While it may make sense to travel to a higher volume hospital for a few of the most complex operations, this study shows that having surgery locally is safe for many of our most common surgical procedures.” Dimick, a professor of surgery, leads the Center for Healthcare Outcomes and Policy at U-M and is a member of the U-M Institute for Healthcare Policy and Innovation. 

Other findings from the study:

• Less than 5 percent of surgery patients at critical access hospitals got transferred to larger hospitals, compared with more than a quarter of patients treated for non-surgical issues and studied by other teams.
• Critical access hospital surgery patients were less likely to use skilled nursing facilities after their operations.
• Complex operations such as esophagus or pancreas removal were performed so rarely at critical access hospitals they were not included in the study.

More about critical access hospitals

Under the original provision established by the Medicare Rural Hospital Flexibility Program, hospitals were eligible for critical access designation if they have less than 25 inpatient beds and are more than 35 miles away from another hospital. By meeting these criteria and undergoing critical access designation, hospitals are paid 101 percent of reasonable costs.

They are also exempt from certain other limits on Medicare payment that non-critical access hospitals are subject to. Physicians who practice at critical-access hospitals are also able to receive 115 percent of the usual payment for traditional Medicare patients.

The new research is based on data from the Medicare Provider Analysis and Review file from 2009 to 2013, after nearly all of the current 1,332 critical access hospitals underwent designation.

In addition to Ibrahim, Hughes and Dimick, the study team included U-M statistician Jyothi Thumma, MPH. The research was funded by Ibrahim’s support from the Robert Wood Johnson Foundation and U.S. Department of Veterans Affairs, and by National Institute on Aging grant AG039434. Reference: JAMA Vol. 315, No. 19, DOI:10.1001/jama.2016.5618

Grassley’s REACH Act would increase access to Emergency Care in Rural Areas

April 13, 2016--The Medicare Payment Advisory Commission (MedPAC), an independent congressional agency that advises Congress on issues affecting the Medicare program, has begun to discuss an issue important to Sen. Chuck Grassley: new methods of “improving efficiency and preserving access to emergency care in rural areas.”  

The commissioners discussed a possible new payment option for critical access hospitals in which the hospitals would shift to outpatient services only with emergency room services.  

Grassley is the sponsor of the Rural Emergency Acute Care Hospital (REACH) Act that would allow such hospitals to shift from offering inpatient care to outpatient care with emergency room services.

 Grassley’s bill is meant to recognize that inpatient beds are hard to fill in many small communities but emergency room care is critical.  Grassley made the following comment on MedPAC’s discussion.

“It’s good news to hear a discussion about hospital needs in rural communities.  MedPAC notes that rural hospitals have closed, and more are in danger of closing, so a discussion of whether to shift away from inpatient beds to outpatient care and emergency services is timely and necessary.  

"I look forward to more discussions among policy experts and the enactment of policies that keep rural hospitals open and serving their communities in a flexible, updated way.”
 

Rural Residents Seek Farmers Markets, UF/IFAS study shows

Newswise, April 5, 2016--People who buy their produce from farmers markets love the freshness and nutritional value of the product. Not only that, rural residents seek out such markets more than urban residents, a University of Florida Institute of Food and Agricultural Sciences researcher says.

The latter finding surprised the researchers, led by Alan Hodges, an Extension scientist in the UF/IFAS food and resource economics department.

“We interpret this effect as due to greater awareness of farming and farm-fresh foods in rural areas,” Hodges said. 

“The finding also suggests that rural households may be seeking out farmers’ markets as a travel destination rather than as part of a multi-stop shopping trip, as would often be the case with urban consumers. In addition, there is greater competition among food retailers in urban areas, simply due to the larger number of venues available.”

If you establish farmers markets within about three miles of someone’s home, it will increase the chances urban residents will go to the market, but only by about 3.7 percent, the UF/IFAS study showed.

The findings are published in the journal Renewable Agriculture and Food Systems and come from the master’s thesis of former UF/IFAS graduate student Ruoding Shi, now a doctoral student at Virginia Tech.

Hodges and Shi surveyed 7,500 randomly selected households in Florida and obtained 1,599 valid responses from the primary food shopper in the residence. They asked consumers about shopping frequency and value of foods purchased through multiple local food distribution channels – in this case, farmers markets, U-pick operations and roadside stands.

Several questions asked consumers their perceptions of local food attributes, such as freshness, nutrition, food safety, food security, organic certification and more. Questions also asked about limiting factors such as unavailability, seasonality, not knowing if the produce was truly local, high price and more.

Of those surveyed, 62 percent said they had bought locally grown foods at a farmers’ market, roadside stand or U-pick operation. Of those respondents, 90 percent rated freshness as very important; 78 percent mentioned food safety and 67 percent noted the produce’s nutrition as very important.

“The main takeaway from this study for local economic development is that consumer perceptions about local food attributes affect the likelihood of shopping at farmers’ markets,” Hodges said.

 “These favorable attributes, such as freshness and nutrition, can be emphasized by market managers to increase business volume. In addition, accessibility of farmers’ markets to consumers in terms of distance from home is just one factor among others that should be considered for locating markets.”

As Rural Hospitals Struggle, Some Opt To Close Labor And Delivery Units

By Michelle Andrews 

February 23, 2016--

About 500,000 women give birth each year in rural hospitals, yet access to labor and delivery units has been declining. Comprehensive figures are spotty, but an analysis of 306 rural hospitals in nine states with large rural populations found that 7.2 percent closed their obstetrics units between 2010 and 2014.

A few years ago, when a young woman delivered her baby at Alleghany Memorial Hospital in Sparta, North Carolina, it was in the middle of a Valentine’s Day ice storm and the mountain roads out of town were impassable.

The delivery was routine, but the baby girl had trouble breathing because her lungs weren’t fully developed. Dr. Maureen Murphy, the family physician who delivered her that night, stayed in touch with the neonatal intensive care unit at Wake Forest Baptist Medical Center in Winston-Salem, a 90-minute drive away, to consult on treatment for the infant.

“It was kind of scary for a while,” Murphy remembered. But with Murphy and two other family physicians trained in obstetrics as well as experienced nurses staffing the 25-bed hospital’s labor and delivery unit, the situation was manageable, and both mother and baby were fine.

Things are different now. Alleghany hospital — like a growing number of rural hospitals — has shuttered its labor and delivery unit, and pregnant women have to travel either to Winston-Salem or to Galax, Virginia, about 30 minutes away by car, weather permitting.

“It’s a long drive for prenatal care visits, and if they have a fast labor” it could be problematic, said Murphy, who teaches at the Cabarrus Family Medicine Residency Program in Concord, North Carolina. (Although not essential, women typically see the physician they expect will handle their delivery for prenatal care.)

About 500,000 women give birth each year in rural hospitals, yet access to labor and delivery units has been declining. Comprehensive figures are spotty, but an analysis of 306 rural hospitals in nine states with large rural populations found that 7.2 percent closed their obstetrics units between 2010 and 2014.

“The fact that closures continue happening — over time that means the nearest hospital gets further and further away,” said Katy Kozhimannil, an associate professor at the University of Minnesota School of Public Health, who coauthored the study published in the January issue of Health Services Research.

There are many factors that contribute to the decline in rural hospital obstetrics services. For one thing, obstetrics units are expensive to operate, and a small rural hospital may deliver fewer than 100 babies a year.

 “A labor and delivery unit is functionally no different than an intensive care unit,” said Dr. Neel Shah, an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School.

Staffing levels are high in obstetrics, often one nurse for every patient, and the rooms are cluttered with monitors, infusion pumps and other equipment.

It can be difficult to staff the units as well. Small rural hospitals may not have obstetricians on staff and rely instead on local family physicians, but it can be difficult to get enough to fully provide services for a hospital, too. Nurses with obstetrics experience also can be scarce.

Meanwhile, bringing in the revenue needed to cover the costs involved in maintaining the units can be difficult because insurance payments are often low. Medicaid pays for slightly under half of all births in the United States, but in rural areas the proportion is often higher, said Kozhimannil.

Since Medicaid pays about half as much as private insurance for childbirth, “the financial aspect of keeping a labor and delivery unit open is harder in rural areas,” she said.

Advocates say there are a number of initiatives that could help bolster labor and delivery services in rural areas.

Encouraging medical professionals to move to rural areas is key, they say. A bipartisan bill introduced in Congress last year, for example, would require the federal government to designate maternity care health professional shortage areas.

Such designations exist for primary care, mental health and dental care. The National Health Services Corps awards scholarships and provides loan repayment to primary care providers who commit to serving for at least two years in designated shortage area. Once they get to a community and put down some roots, the hope is they’ll stay.

Expanding the use of midwives and birthing centers could be cost effective since they are generally less expensive than physicians and hospital obstetric units. 

Although birthing centers and home births are on the rise, more than 98 percent of the 4 million babies that were born in 2014 made their arrival at a hospital.

“You can deal with lower volume and still be sustainable,” said Shah.

“Finding strength in numbers, small rural hospitals are increasingly banding together to share resources, said Kozhimannil. For example, since it’s difficult to keep rural staff trained in rare complications, small rural hospitals sometimes pool resources to buy a mobile simulation unit to train people on handling postpartum hemorrhage, the leading cause of maternal mortality.

Kozhimannil sees great opportunity in the ongoing national dialogue about health reform but says much of the research to date has focused on reforming health care in urban settings.

“That’s why it’s crucial to have rural people at the table,” she said.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Palliative Approach to Care Especially Fitting for Rural Hospitals

Article in Critical Care Nurse discusses how nurses at critical access hospitals can use palliative approach to care for rural residents and families

Newswise, February 1, 2016 — Nurses at critical access hospitals are well positioned to provide high-quality palliative care close to home for millions of Americans in rural communities, according to an article in the February issue of Critical Care Nurse (CCN).

The United States has 1,332 critical access hospitals located in rural communities, providing mostly acute inpatient services, ambulatory care, labor and delivery services, and general surgery.

With fewer than 25 beds each and a mean daily census of 4.2 patients, these hospitals may frequently have a single registered nurse as the only healthcare professional on duty.

The article “Palliative Care in Critical Access Hospitals” uses a case report to illustrate the role that critical access hospitals play in meeting the need for high-quality palliative care in rural settings.

Palliative care provides psychological, spiritual, goal-setting and decision-making support not only to patients with life-threatening illnesses but to their families as well.

The benefits of such care include early initiation of comfort-focused treatment goals, decreased length of stay, continuity of care and reduced cost of care without an increase in mortality.

Unlike hospice care, palliative care is appropriate early in the course of illness, and patients can be simultaneously treated for their condition, including therapies intended to prolong life.

Millions of patients are living with serious, complex and potentially life-threatening conditions, increasing the need for palliative and end-of-life care.

Co-authors Dorothy “Dale” M. Mayer, RN, PhD, and Charlene A. Winters, PhD, APRN, ACNS-BC, are on the faculty of the College of Nursing, Montana State University, Missoula.

“As expert generalists, rural nurses are well positioned to provide support and promote quality of life close to home for patients of all ages and their families,” Mayer said.

“In sparsely populated areas, nurses are not strangers to their patients, often providing care to their neighbors, friends and relatives.”

The healthcare system is increasingly moving away from the consultative model of palliative care, in which clinicians bring in specialists to advise on individual cases.

The authors advocate for a different model, in which frontline staff, including physicians, nurses, social workers and chaplains, incorporate a palliative approach into patient care, especially with patients who have complex health conditions.

This approach is especially suited for rural area and critical access hospitals, in part because of an inherent sense of community between friends and neighbors.

“With limited personnel and resources, healthcare providers can no longer rely on specialized palliative care teams as the only clinicians to provide palliative care,” Winters said.

 “Working together, rural nurses and their urban nursing colleagues can provide palliative care across all healthcare settings to meet the needs of rural residents and their families.”

The American Association of Critical-Care Nurses, which publishes CCN, offers resources and tools to help nurses care for patients and their families at the most difficult times of their lives, including an e-learning course and a free, online self-assessment tool.

For more information on palliative and end-of-life care, please visit www.aacn.org/palliativeedu.

As AACN’s bimonthly clinical practice journal for high acuity, progressive and critical care nurses, CCN is a trusted source for information related to the bedside care of critically and acutely ill patients.

Access the article abstract and full-text PDF by visiting the CCN website at http://ccn.aacnjournals.org/.

About Critical Care Nurse: Critical Care Nurse (CCN), a bimonthly clinical practice journal published by the American Association of Critical-Care Nurses, provides current, relevant and useful information about the bedside care of critically and acutely ill patients.

The journal also offers columns on traditional and emerging issues across the spectrum of critical care, keeping critical care nurses informed on topics that affect their practice in high acuity, progressive and critical care settings. CCN enjoys a circulation of more than 106,000 and can be accessed at http://ccn.aacnjournals.org/.

About the American Association of Critical-Care Nurses: Founded in 1969 and based in Aliso Viejo, California, the American Association of Critical-Care Nurses (AACN) is the largest specialty nursing organization in the world. AACN represents the interests of more than 500,000 acute and critical care nurses and includes more than 225 chapters worldwide.

The organization’s vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution. www.aacn.org; www.facebook.com/aacnface; www.twitter.com/aacnme

Many Aging Farmers don’t plan to retire and lack strategies to keep Family Farms going in the future…Rural Culture at stake

(Reposted January 31, 2016)  Newswise — Farming is less a job than it is a way of life for the Kansas farmers who watch their peers retire from office and factory jobs without intentions of quitting themselves.

They also often don't have plans for the farms after they're gone.

That's what a Kansas State University sociologist has found in a study of farmers in Rush County. 

Although such a work ethic and commitment may be admirable, it leaves the future of family farming and the culture surrounding it up in the air, said Laszlo Kulcsar, a K-State associate professor of sociology and director of the university's Kansas Population Center.

"Farming is really an essential component of the local culture, and many farmers think that local culture simply cannot exist without farming," he said. "At the same time, farming is a core element only as long as it's a family farm or a medium-sized operation. Once the big companies take over, the economic activity remains the same but the culture is going to change."

Kulcsar's study of aging Kansas farmers began by examining 2007 U.S. Census Bureau statistics showing that more than one-third of U.S farmers -- about 550,000 of them -- are 65 years old or older. Kulcsar and two graduate students wanted to see how Kansas farmers fit in. 

They made Rush County their model because of the greater significance of farming on the local economy compared with other Kansas counties, and Rush County's large number of older farmers. Kulcsar said that 30 percent of the county's farmers are 70 or older.

Beyond extended life expectancies, Kulcsar said that several cultural and technological shifts explain why there are so many older farmers in Rush County, as well as elsewhere in Kansas and the country. Thanks to more sophisticated equipment, farm labor is less demanding than it once was. In addition, some farmers are not farmers in the traditional sense but rather retirees who took up farming activities as a pastime.

Another significant cultural change, Kulcsar said, has been in family structure. Many farmers inherited their farms from their parents but now find that their own children are not interested in farming.

The second part of Kulcsar's research involved asking these farmers about their strategies for transitioning their farms if they ever do retire or after death.

"They don't even think about retirement whatsoever," he said. "Their take on farming is one that you'd expect. It's a way of life. It's not just making money, it's a culturally important thing

."

Kulcsar said that from a demographic standpoint, the problem that arises from increased corporate farming is long-term sustainability, for which family farming is better suited.

"It is expensive and difficult to enter the profession as a farmer who didn't inherit a family farm," Kulcsar said. "The land is expensive, the equipment is expensive, and for that reason there really is no other way to enter the family farming business."

He said this poses another problem in that farmers just entering the profession are more likely to adopt technology and innovations that could improve profit margins and help them compete with the economies of scale that corporations have.

"Family farming creates certain values and a work ethic that corporate farming just can't have," Kulcsar said. "The farmers we talked to said that their advantage over corporate farming is that they're going to do the right thing and care about people."

Kulcsar presented the research in August at the annual meeting of the Rural Sociological Society in Madison, Wis. The students participating in the research are Benjamin Bolender and Albert Iaroi, both K-State doctoral students in sociology. 

The project is funded by K-State's Center on Aging.

Kulcsar said that the future of the research could involve extending the study to other farming-dependent counties in Kansas, as well as working with the Center on Aging and with K-State Research and Extension on ways of getting farmers involved in transition plans for their farms.