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NPR SHOTS | April 7, 20197:33 AM ET | Heard on  Weekend Edition Sunday

When a rural community loses its hospital, health care becomes harder to come by in an instant. But a hospital closure also shocks a small town's economy. It shuts down one of its largest employers. It scares off heavy industry that needs an emergency room nearby. And in one Tennessee town, a lost hospital means lost hope of attracting more retirees.

Seniors, and their retirement accounts, have been viewed as potential saviors for many rural economies trying to make up for lost jobs. But the epidemic of rural hospital closures is threatening those dreams in places like Celina, Tenn.. The town of 1,500, whose 25-bed hospital closed March 1, has been trying to position itself as a retiree destination.

"I'd say, look elsewhere," says Susan Scovel, a Seattle transplant who came with her husband in 2015.

Scovel's despondence is especially noteworthy given that she leads the local chamber of commerce effort to attract retirees like herself. She considers the wooded hills and secluded lake to hold comparable scenic beauty to the Washington coast — with dramatically lower costs of living; she and a small committee plan getaway weekends for prospects to visit.

When she first toured the region before moving in 2015, Scovel and her husband, who had Parkinson's, made sure to scope out the hospital, on a hill overlooking the sleepy town square. And she's rushed to the hospital four times since he died in 2017.

"I have very high blood pressure, and they're able to do the IVs to get it down," Scovel says. "This is an anxiety thing since my husband died. So now — I don't know."

She says she can't in good conscience advise a senior with health problems to come join her in Celina.

The closure adds delays when seconds count

Celina's Cumberland River Hospital had been on life support for years, operated by the city-owned medical center an hour away in Cookeville, which decided in late January to cut its losses after trying to find a buyer. Cookeville Regional Medical Center explains that the facility faced the grim reality for many rural providers.

"Unfortunately, many rural hospitals across the country are having a difficult time and facing the same challenges, like declining reimbursements and lower patient volumes, that Cumberland River Hospital has experienced," CEO Paul Korth said in a written statement.

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AzHHA Blog | April 5, 2019

Today’s blog comes to us from Robert Seamon, CEO of  Copper Queen Community Hospital.  Here he shares his thoughts on the success, challenges and the future of healthcare in Arizona. Once you’ve had a chance to read it, we’d love to hear your thoughts. Generating meaningful conversations around the health issues facing us here in Arizona is another way we are working to make our state the Healthiest State in the Nation!

AzHHA: What are the biggest hurdles to providing care?

Mr. Seamon: While I am always optimistic about the future, there are many challenges facing rural hospitals. I believe the greatest hurdle to providing patient care centers on a rural facility’s ability to remain financially viable and open for business. Financial margins in rural healthcare can be razor thin.  Cuts from Federal and State funding programs such as Medicare and Medicaid are devastating.

Many rural communities also face significant economic challenges, including the loss of valuable industries.  As a result, populations decline causing a significant decrease in volume and revenue for the hospital. Operating cash then becomes insufficient to cover the high fixed costs. As a result, many rural hospitals have been forced to close.

Another significant hurdle is the ability to attract qualified professionals to isolated areas, when the nation as a whole, is facing critical workforce shortages. In addition, hospitals large and small throughout the country are scrambling to develop effective strategies to address cyber threats, regulatory burden, escalating operating costs, social determinants of health affecting patient care outcomes and a national opioid epidemic that continues to kill thousands of Americans on an annual basis.

AzHHA: What are the greatest health needs in your community?

Mr. Seamon: Behavioral health services and addiction medicine programs are in desperate need. Moreover, many rural communities have a high prevalence of chronic conditions including hypertension, diabetes, heart failure and chronic obstructive pulmonary disease. The availability of specialty physicians is often severely limited in rural communities. Social determinants of health, including a lack of transportation to and from medical appointments, the inability to pay for prescription medications and lack of safe, affordable housing are all critical needs.

AzHHA: When you think about the future, what are you most hopeful for?

Mr. Seamon: My dream is to work with other healthcare facilities and community leaders to implement effective strategies that dramatically improve the overall health of our population. My goal is for every resident of the communities we serve to have access to the care they need, provided in the safest possible way, in alignment with the most recent evidence-based standards of care. When patients are discharged, I want them to have a safe place to live, hot food, access to needed medicine, a social support system and transportation to their medical appointments. We service three separate communities, and I want them all to be ranked the healthiest communities in Arizona. That’s my vision!

AzHHA: What is your facility’s greatest recent success?

Mr. Seamon: Copper Queen Community Hospital has been blessed with tremendous success. We are seeing solid growth in every service line. In large part, our success is due to the size of the communities we serve. Having a steady volume of patients is critical. Moreover, we have an incredible Board of Directors made up of volunteers who truly care about the communities we serve. We have the best medical staff. Our providers are exceptional and provide safe, quality care to our patients. We have over 300 employees who commit themselves to our success on a daily basis. We are fortunate to have several specialty physicians, including the recent addition of a gastroenterologist. We also have a robust telemedicine program that helps connect our patients to the care they need for good health.

AzHHA: What keeps you up at night?

Mr. Seamon: Interestingly, it’s not the challenges. I’ve spent my entire career in healthcare. There are always serious problems to face; it’s just part of the job. What keeps me up at night is quite positive. I think about my dream. I think about who I can partner with and how I can make it happen. At the end of my career, I don’t want my name on a building. I want to look back and know that my work was meaningful and impactful on the health of my community.

From AzHHA Newsletter | April 10, 2019 

Though much of the work on the state budget is happening behind closed doors, a recent op-ed in The Arizona Republic is keeping the effort to provide state funding for graduate medical education (GME) out in the open.  Yesterday, State Senator Heather Carter and prominent local economist Jim Rounds made the case that GME funding benefits Arizona’s economy as well as its health. Read the full article below.

Arizona's doctor shortage isn't just hurting our health. It hits our wallets, too

By: Heather Carter and Jim Rounds, opinion contributors

Anyone who has been or will be a patient should be concerned about Arizona’s severe shortage of doctors and nurses. They should also be concerned that the shortage may be limiting the state’s economic potential.

In most discussions about building a stronger Arizona economy, policymakers and economists discuss tax rates, economic development programs and regulations. But the provision of a quality health-care system is just as fundamental to economic growth.

Our concern is the current shortage of doctors and nurses across the state will eventually translate into slower economic growth. This would mean fewer new jobs being created in every county, lower levels of income for many, and a declining quality of life for residents.

How bad is Arizona's doctor shortage?

Arizona is one of the fastest-growing states for overall population growth and at the same time, a leader in elderly population growth. This demographic, which brings retirement money to communities and buys second homes and cars and other things, will require quality health-care services.

The state is also a leader in attracting new businesses and encouraging new ones to be formed. Many will locate to the bigger cities, but others will prefer a more rural lifestyle. These businesses and entrepreneurs examine a long list of community attributes, health-care quality among them, before growing roots.

The people in the trenches are seeing the same things that we are seeing as policy professionals. According to the University of Arizona Center for Rural Health, every county is experiencing a severe shortage of doctors and nurses, as well as increases in costs and decreases in quality.

That same policy brief indicates that Arizona ranks 44th nationally in primary care physicians at 77.9 per 100,000 population and meets just 41% of its primary care physician need.

How SB 1354 addresses the shortage

The Arizona Legislature is considering Senate Bill 1354 to alleviate the state’s health-care workforce shortage. The bill provides support for five programs — Graduate Medical Education, the University of Arizona Medical School, primary care provider loan repayment, medical student loan repayments, and nurse training. All of these programs will move the needle on the shortage.

Graduate Medical Education, commonly known as physician residencies, has not been state-funded in a decade, thus leaving matching federal funds on the table. Senate Bill 1354 will contribute $20 million, matched by approximately $47 million in federal funds — a total of $67 million would become available to the GME account.

We know the vast majority of doctors practice where they do their residency. The problem is that Arizona simply doesn’t have enough medical residencies. Only 42 percent of Arizona’s medical students remain in the state after graduation, as reported by the Association of American Medical Colleges.

But when they train in Arizona, they stay in Arizona. According to Dr. Bharat Magu, chief medical officer at Yuma Regional Medical Center, nearly all medical students who finish the hospital’s post-graduate training stay in-state, and 67% stay in Yuma.

We often need to be reminded how the smallest changes in our overall rate of growth, both in income and job counts, can have a dramatic impact on state and local finances.

This issue matters.

If passed, this initiative will improve the well-being, both economic and physical, of all Arizonans.

Sen. Heather Carter represents Legislative District 15 in north Phoenix. Reach her at hcarter@azleg.gov. Jim Rounds is an economist and president of Rounds Consulting Group. On Twitter: @_jimrounds.

Stephanie Innes | Arizona Republic| April 1, 2019 

Lauren Klinkhamer of Tucson speaks during a protest in Sen. Jeff Flake’s Capitol Hill office. Klinkhamer said she has 16 chronic medical conditions, but fears the current Senate plan to replace Obamacare will cost her health insurance. 

A bill that would expand access to “association” health-insurance plans in Arizona would put into state law elements of a Trump administration rule that was just rejected by a federal judge.

Senate Bill 1085, which is moving through the Arizona Legislature, expands the ability for small businesses, including sole proprietors, to band together and purchase health insurance as an “association.”

The bill codifies into state law elements in a final rule issued by the U.S. Department of Labor in June that loosened some of the regulations on association health plans to make them more attractive to businesses that have not previously used them. It also added sole proprietors into the category of people who could join associations and buy health insurance.

The federal judge’s ruling Thursday casts some uncertainty on the proposed Arizona legislation. The judge's opinion says the Trump administration's final rule is an intentional “end-run” around the federal Affordable Care Act.

“I would think associations looking to form plans would need to think twice about doing so, given this uncertainty,” said Larry Levitt, vice president of the Kaiser Family Foundation. “If this ruling stands, it would limit states’ ability to open the door to more association health plans.”

Debbie Hann, chief operating officer for the Arizona Small Business Association, said her organization remains positive, in spite of the ruling, and is moving forward with plans to offer health insurance to members.

Hann said her association began taking steps to offer health insurance after Trump issued an executive order in October 2017, calling for expanded access to association health plans.

What is an association health plan?

Under SB 1085 and the federal rule, an association of people working in a similar trade, for example, would have negotiating power to get its members cheaper insurance options. Associations could purchase insurance as a large-group employer, and some may choose to self-insure, which critics fear will increase the risk for insolvency. The Arizona Department of Insurance did not take a position on SB 1085.

Proponents say broadening access to the plans will allow everyone from self-employed millennials in the tech industry to small-business owners access to insurance that is otherwise unaffordable for them. Association plans may charge higher rates based on factors such as age and gender, but the association cannot use health status to determine eligibility, premiums, or benefits. 

“This is going to be a game-changer for our members. It will level the playing field for recruitment and retention,” said Hann of the Arizona Small Business Association.

Supporters include Blue Cross and Blue Shield of Arizona, the Arizona Association of Health Underwriters, and the Arizona Technology Council.

Trump has called association health plans “tremendous insurance at a very low cost.” 

“I think we are all supportive of things that are more affordable for consumers and choice is always great. But you have to read the fine print,” said Swapna Reddy, a clinical assistant professor at Arizona State University's College of Health Solutions. 

» Read the full article at link below or download PDF.

A University of Arizona Doctor is using a $10,000 HRSA prize to fine-tune an mHealth platform designed for people dealing with substance abuse to help pregnant women and new mothers.

By Eric Wicklund | mHEALTH INTELLIGENCE

March 25, 2019 - A University of Arizona physician is modifying an mHealth platform to give new and expecting mothers a digital health connection to substance abuse treatment.

Maria Manriquez, MD, director of the Addiction Medicine curriculum and professor in the Department of Obstetrics and Gynecology at the University of Arizona College of Medicine-Phoenix, is using a $10,000 prize from the US Health Resources and Service Administration to modify the connected care platform developed by iTether Technologies, a Phoenix-based telehealth company.

iTether had developed the mHealth app for people dealing with substance abuse disorder (SUD). Manriquez’ goal is to personalize that app for pregnant women and new mothers.

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In a growing number of states, patients who get opioids for serious pain may leave their doctors’ offices with a second prescription — for naloxone, a drug that can save their lives if they overdose on the powerful painkillers.

New state laws and regulations in California, Virginia, Arizona, Ohio, Washington, Vermont and Rhode Island require physicians to “co-prescribe” or at least offer naloxone prescriptions when prescribing opioids to patients considered at high risk of overdosing. Patients can be considered at high risk if they need a large opioid dosage, take certain other drugs or have sleep apnea or a history of addiction.

Such co-prescribing mandates are emerging as the latest tactic in a war against an epidemic of prescription and illegal opioids that has claimed hundreds of thousands of lives over the past two decades.

The Food and Drug Administration is considering whether to recommend naloxone co-prescribing nationally (an FDA subcommittee recently voted in favor), and other federal health officials already recommend it for certain patients. And the companies that make the drug are supportive of the moves. It’s not hard to see why: An FDA analysis estimated that more than 48 million additional naloxone doses would be needed if the agency officially recommended co-prescribing nationally.

Most states have limited the volume of opioids doctors can prescribe at one time and dramatically expanded access to naloxone. In California, for example, pharmacists can provide naloxone directly to consumers who are taking illegal or prescription opioids or know someone who is.

In the states with co-prescribing rules, patients aren’t required to fill their naloxone prescriptions, and those with cancer or who are in nursing homes or hospice typically are exempted.

» Full article at link below:

By Patty Machelor | March 18, 2019 | Arizona Daily Star

Arizona residents in Maricopa, Yuma and Greenlee counties have better overall health scores and easier access to health services than those living in Pima County, a new study shows.

The study, County Health Rankings, was released Monday by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. It compares Arizona counties to one another as part of a nationwide study. The study looks at more than 30 factors including education, housing, jobs and access to medical care to see how these influence how long, and how well, people live.

It shows Pima County’s fourth-place ranking within Arizona is driven by its rates of obesity and related chronic diseases, such as diabetes, as well as problems people have accessing health and behavioral-health services. It’s also tied to a lack of affordable housing, which the report says is a barrier to accessing health care.

Overall, Arizona has a substantial number of people who are underserved living in both urban and rural areas, said Dr. Daniel Derksen, associate vice president for health equity and outreach at the University of Arizona who did not take part in the study.

Some Arizona residents live in areas where they have to travel 30 or 40 miles to get basic health care, he said. The state ranks 44th out of 50 states when it comes to physician shortages, according to a recent study by the UA’s Mel and Enid Zuckerman College of Public Health’s Center for Rural Health.

“We really need to address our primary care shortages,” Derksen said. “We need to strengthen our primary and preventive services, and make them more readily accessible both in rural areas, where it’s quite alarming, but also in underserved urban areas.”

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