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.

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.

To Survive, Rural Hospitals Join Forces

WILLCOX, Arizona, August 17, 2015—Ask Sam Lindsey about the importance of Northern Cochise Community Hospital and he’ll give you a wry grin. You might as well be asking the 77-year-old city councilman to choose between playing pickup basketball—as he still does most Fridays—and being planted six feet under the Arizona dust.

Lindsey believes he’s above ground, and still playing point guard down at the Mormon church, because of Northern Cochise. Last Christmas, he suffered a severe stroke in his home. He survived, he said, because his wife, Zenita, got him to the hospital within minutes. If it hadn’t been there, she would have had to drive him 85 miles to Tucson Medical Center.

There are approximately 2,300 rural hospitals in the U.S., most of them concentrated in the Midwest and the South. For a variety of reasons, many of them are struggling to survive. 
In the last five years, Congress has sharply reduced spending on Medicare, the federal health insurance program for the elderly, and the patients at rural hospitals tend to be older than those at urban or suburban ones. Rural hospitals in sparsely populated areas see fewer patients but still have to maintain emergency rooms and beds for acute care. They serve many people who are uninsured and can’t afford to pay for the services they receive.

Several months ago, Northern Cochise sought to strengthen its chances for survival by joining an alliance with Tucson Medical Center and three other rural hospitals in southwestern Arizona. Together, the Southern Arizona Hospital Alliance is negotiating better prices on supplies and services. And the Tucson hospital has promised to help its rural partners with medical training, information technology and doctor recruitment.

“We are committed to remaining autonomous for as long as we can,” said Jared Wilhelm, director of community relations at Northern Cochise. “We think this gives us the best leverage to do so.”

Northern Cochise and the other rural hospitals in the alliance, which is similar to ones in Kansas, Mississippi, Washington state and Wisconsin, hope that by joining they will avoid the fate of 56 rural hospitals that have closed since 2010. Another 283 rural hospitals are in danger of closing, according to the National Rural Health Association (NRHA).

Right now, some Arizonans in the region are learning what it’s like to lose a hospital. Cochise Regional Hospital, in Douglas, near the Mexican border, closed earlier this month, following Medicare’s decision to terminate payments because of repeated violations of federal health and safety rules. 

The hospital was part of a Chicago-based chain and its closing leaves Arizona residents in the far southeastern portion of the state up to 75 miles away from the closest hospital emergency room.

Sam Lindsey shudders to think what a long drive to Tucson would have meant for him last Christmas.

“If I’d have had to go 85 miles,” he said, “I don’t think I’d be here today.”

Multiple Advantages

The alliance offers the rural members multiple advantages. One of the most important is in purchasing. Their combined size will enable them to get discounts that are beyond them now. 

For example, instead of being a lone, 49-bed hospital with limited bargaining leverage, alliance member Mount Graham Regional Medical Center, in Safford, is suddenly part of a purchasing entity with more than 700 beds.

“If I’m just Mount Graham and I’m going to buy one MRI every seven years, the sales people will say, ‘Oh, that’s very nice,’ ” said Keith Bryce, Mount Graham’s chief financial officer. “But as part of this alliance that they want to do regular business with, they are going to give us a much better price.”

Bryce said that he expects the added purchasing power alone will save Mount Graham “in the six figures” every year.

Similarly, the hospitals expect the combined size of the alliance to result in lower costs for employee benefits, workers’ compensation and medical malpractice insurance.

The alliance also helps the rural hospitals recruit doctors and other medical providers, many of whom are reluctant to work, let alone live, in isolated areas. 

Rural hospitals rarely have the contacts and relationships that help urban hospitals find doctors. “We’ve been trying to recruit another primary care doctor to this community for the last year with no success,” said Rich Polheber, CEO of Benson Hospital, another alliance member.

Tucson Medical Center has pledged to use its own recruiting muscle to help its rural partners find providers who are willing to live in rural areas, or at least regularly see patients there. As an incentive, Tucson will offer interested doctors help in managing the business aspects of their practices.

The rural alliance members also want Tucson’s help with medical training and IT. Some have dipped into telemedicine, which is particularly valuable for rural hospitals underserved by specialists, and are looking to expand those efforts. 

Copper Queen Community Hospital, in Bisbee, the fourth rural member of the alliance and probably the rural hospital in the best financial shape, is the most advanced user of telemedicine. Its networks in cardiology, neurology, pulmonology and radiology can connect doctors and their patients to specialists at major institutions such as the Mayo Clinic and St. Luke’s Medical Center, in Phoenix.

The alliance also will make it easier for patients who have surgery in Tucson to be transferred back to their home hospitals for recovery and rehabilitation, saving them and their families from traveling long distances.

A Defensive Strategy 

Despite the numerous advantages for the rural partners, the idea for the alliance began with the Tucson hospital, which approached the others with the proposal last spring. At the outset, some of the rural hospitals were skeptical.

“At first, we were like, ‘OK, so why are they doing this? What’s in it for them? Do they want to absorb us?’ ” said Bryce, the Mount Graham CFO.

But after a series of meetings, the suspicions disappeared and the rural hospitals eagerly signed on.

The Tucson hospital was frank about its motivation: to remain independent in an industry moving toward consolidation. As a result of acquisitions in the last few years, it is the last locally owned, independent hospital in Tucson.

“All of a sudden, we were in a situation where [Tucson Medical Center] found itself isolated and facing its own competitive market pressures because the environment had so dramatically changed,” said Susan Willis, executive director of market development at the hospital and president of the new alliance.

Nearly a quarter of Tucson’s patients come from outside the city, many from the areas served by the rural hospitals in the new alliance. Cementing the relationship with those hospitals, Willis said, will help Tucson maintain a flow of patients who need medical services that are beyond the capabilities of the rural hospitals. 

The rural members have laboratories, diagnostic equipment and therapeutic services, but some have little or no surgical or obstetrical services. Not one is equipped to perform complicated surgeries.

“Certainly you could describe it as a defensive strategy,” Willis said.

Decades of Pressure

Many of the problems plaguing rural hospitals date to 1983, when Medicare began paying hospitals a set fee for medical services and procedures rather than reimbursing them for the actual costs of providing that care. 

From 1983 to 1998, 440 rural hospitals closed in the U.S., according to the NRHA. That prompted Medicare to begin reimbursing certain rural hospitals for their actual costs, which helped stabilize them.

But the recession hit rural hospitals especially hard, as did 2011 budget cuts that reduced Medicare payments by 2 percent. 

Because the rural population tends to be older, rural hospitals rely heavily on Medicare payments. The pressure increased in 2012, when the federal government reduced by 30 to 35 percent its reimbursements to hospitals for Medicare patients who don’t cover their share of the bill.

“That’s an example of how a little policy change that seems insignificant in Washington can have profound effects in the rural areas,” said Brock Slabach, NHRA’s senior vice president for member services.

Finally, more insurance plans are increasing copayments and other out-of-pocket costs. Many of the patients at rural hospitals have low incomes. And when they can’t cover their costs, the hospitals have to pick up the tab. 

“We don’t have cash reserves,” said Polheber, the Benson Hospital CEO. “We live on the edge, day to day, week to week. [The alliance] seemed like the best way to keep us going.”

Given the threats to the nation’s rural hospitals, many are eager to learn from any models that work, which is why the Arizona alliance has attracted notice.

Slabach, for one, calls it a promising model, although one that may not be replicable everywhere. 

“You have to have willing partners willing to collaborate and provide assistance to each other,” he said. “You need partners that share a cultural fit with you.”

The rural members of the alliance are major employers in their communities and assets in attracting other employers and residents, including the snowbirds, who flock to the area every winter. 

But hospital leaders, workers and patients say saving lives is the main reason the hospitals must remain open.

“In medicine, distance lessens the chances of survival,” said Pam Noland, director of nursing at Northern Cochise. “Even if a patient has to be transferred to [Tucson Medical Center] or somewhere else, stabilizing them here is the difference between life and death.”

Rural Medicare Beneficiaries Receive Less Follow-Up Care

August 14, 2015- Medicare patients in rural areas have lower rates of follow-up care after leaving the hospital—which may place them at higher risk of emergency department (ED) visits and repeat hospitalizations, according to a study in the September issue of Medical Care.

The journal is published by Wolters Kluwer.

"This study provides evidence of lower rates of post-discharge follow-up care, and higher ED use for Medicare beneficiaries in rural settings," comments lead author Matthew Toth, PhD, MSW. The research was conducted while Dr. Toth was at University of North Carolina at Chapel Hill; he is now at RTI International. 

Especially with new "pay-for-performance" programs tying reimbursement to hospital performance on patient outcomes, the results highlight the need for policies to improve follow-up care for patients in rural areas.

Differences in 30-Day Outcomes for Patients at Rural versus Urban Hospitals

Using data from the nationally representative Medicare Current Beneficiary Survey, the study included approximately 12,000 Medicare-eligible patients with hospital admissions between 2000 and 2010. About 4,000 patients lived in rural areas; this group was further divided into patients living in large, small, and isolated rural areas (based on a standard coding system).

The rural and urban groups were compared on three key outcomes during the first 30 days after hospital discharge: follow-up healthcare visits, ED visits, and unplanned hospital readmissions. The comparisons were adjusted for a wide range of demographic, health-related, and hospital characteristics.

The results suggested that patients living in isolated areas were less likely to receive a follow-up visit within 30 days after leaving the hospital. Compared to those in urban areas, patients in isolated rural settings were 19 percent less likely to receive follow-up care.

The study also found a higher risk of ED visits within 30 days for patients living in large or small rural areas, compared to urban patients. This risk was 44 percent higher for patients who lived in small rural settings and 52 percent higher for those in large rural settings.

The overall risk of unplanned hospital readmissions was not significantly different for rural versus urban residents. However, this difference became significant when patients were classified by the location of the hospital where they were treated, rather than where they lived. 

Thirty-day readmission risk was 32 percent higher for patients discharged from hospitals in large rural settings and 42 percent higher for hospitals in small rural settings, compared to urban settings.

In addition to their impact on patient care, the findings may have important implications for rural healthcare providers at a time of changes in healthcare delivery and payment. 

These include a recently introduced Medicare program seeking to improve post-discharge outcomes by penalizing hospitals with higher-than-expected 30-day readmission rates.

"Consistent with previous [research] on safety-net and low-volume hospitals, our study finds that rural hospitals serving elderly Medicare beneficiaries may be disproportionately penalized under this program," Dr. Toth and coauthors write. "If so, poor readmission outcomes among these hospitals may be exacerbated."

The researchers believe their findings highlight the need for measures to improve access to care and reduce unplanned acute events for rural patients. That may include investment in programs such as telehealth, care management, transitional care, and policies to enhance primary care services.

 "A greater understanding of the reasons for these differences would help inform efforts to improve care," Dr. Toth adds. "For example, are patients of rural hospitals more likely discharged to under-resourced settings, or are there more likely gaps in post-discharge instructions in the inpatient setting?"

Click here to read "Rural Medicare Beneficiaries Have Fewer Follow-up Visits and Greater Emergency Department Use Postdischarge."

Article: "Rural Medicare Beneficiaries Have Fewer Follow-up Visits and Greater Emergency Department Use Postdischarge" (doi: 10.1097/MLR.0000000000000401)

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