In rural communities across the country, health care is becoming an increasingly scarce commodity. More than 50 rural hospitals have closed nationwide since 2010, and hundreds more teeter on the brink of bankruptcy. It’s a trend driven by falling revenues and decreased federal funding, and it could have dire implications for small-town America’s future. Sarah Varney of Kaiser Health News reports.
March 2, 2016 Bill Buckmaster: Dr. Daniel Derksen, director of the University of Arizona-based Center for Rural Health discusses the critical care needs facing Arizona’s rural hospitals and clinics.
KVOI AM Radio 1030. Tucson’s Voice. The Bill Buckmaster Show.
From 32:40 to 40:45 at: http://www.buckmastershow.com/shows/2016/3-2-16.mp3
Arizona Illustrated with Tom McNamara, Episode 222, Arizona Public Media, PBS, KUAT Television.
Dan Derksen, Director of the Arizona Center for Rural Health is featured, starting at 9min, 0 sec; 10:20-11:40 and 17:00-17:45 (min:sec).
Video link below.
The Center for Rural Health at the University of Arizona Mel and Enid Zuckerman College of Public Health was awarded a $1.5 million grant to provide training and information to Arizona's 14 Critical Access Hospitals, 21 Rural Health Clinics, and a statewide network of primary care, trauma and EMS workers.
The Health Resources and Services Administration (HRSA) awarded the Center for Rural Health (CRH) at the University of Arizona Mel and Enid Zuckerman College of Public Health, a three-year $1.5 million grant to support Arizona Medicare Rural Hospital Flexibility Program (AzFlex) which provides quality, operational and performance improvement in Arizona’s rural hospitals and affiliated outpatient services.
Arizona’s 14 Critical Access Hospitals and 21 Rural Health Clinics play crucial roles in assuring access to quality health care, improving population health outcomes and contributing to a community’s overall economic health and development. The AzFlex program provides technical assistance, training and information resources for Arizona’s Critical Access Hospitals, Rural Health Clinics and a statewide network of rural primary care, trauma and Emergency Medical Services providers.
The AzFlex work plan for the next three years has four program areas: Quality Improvement; Financial and Operational Improvement; Population Health Management and EMS Integration; and Critical Access Hospital Designation in Arizona.
“The Center for Rural Health is ideally suited to carry out this important work in Arizona’s rural communities,” said Daniel Derksen, M.D., director of the CRH and principal investigator for the grant.
The CRH also also houses the Navigator Consortium, the Small Rural Hospital Improvement Program and the State Office of Rural Health.
“While our Critical Access Hospitals fiscal performance improved in 2014, we face new threats,” said Jill Bullock, CRH associate director and AzFlex Program Manager. Some of the threats Bullock cites include the 5% Medicaid hospital payment cut; lower participation rates in Medicaid and Marketplace coverage in rural, Hispanic and American Indian populations served by Arizona’s Critical Access Hospitals and Rural Health Centers; new state and federal regulations; and requirements to report on quality, satisfaction and other performance measures.
“Those threats are ominous. Over the last five years, 58 rural hospitals have closed, including one in Douglas, Arizona where 70 people lost their jobs,” said Dr. Derksen who testified on the issues challenging rural hospitals and health services before the health subcommittee of the U.S. House Committee on Ways and Means in July of 2015.
Ken Alltucker, The Republic | azcentral.com
4:32 p.m. MST January 13, 2016
With her husband's life fading from a stab wound to the head, Laura Brown's only thought was how quickly she could get to his side.
She was in Scottsdale. He was at a Yuma hospital.
On the road to Yuma, she got a call. Her husband, Bruce, was being flown by medical helicopter to St. Joseph’s Hospital and Medical Center in Phoenix. His brain stem had been severed. A day later, he was pronounced dead.
In the days and weeks after the March attack, Brown mourned the loss of her husband. She also lost her son, Blake, 25, who is mentally ill and was responsible for his father's fatal injury. Blake has been placed in long-term confinement at the Arizona State Hospital.
Then, the devastated wife and mother faced a new and lingering pain: a costly and unexpected air-ambulance bill.
While Brown's case appears to be headed toward a satisfying resolution, other consumers around the nation routinely face sticker shock when confronted with air-ambulance bills.
Brown's husband’s health insurer largely covered the cost of his hospital care, and she paid the portion that the insurer did not.
But that wasn't the case with the air-ambulance company. Tristate Care Flight’s transport, which her husband could not consent to and she was not made aware of before takeoff, resulted in a $64,620 bill.
Brown’s insurance company, Ameriben, has already paid Tristate Care Flight $19,909. Ameriben told Brown that the Bullhead City-based air-ambulance company was not part of the insurer's network of providers with set, negotiated rates, but it agreed to pay about twice the rate that Medicare would have paid for a similar trip.
Tristate Care Flight wanted Brown to pay the rest of the bill: $44,711.
Though Brown's appeal to her late husband’s insurance company to pay a larger portion of the bill so far has been unsuccessful, this story appears to have a happy ending for Brown.
After The Arizona Republic contacted John Cole, chief operating officer of Tristate Care Flight, to discuss the company's billing practices, he began investigating the case. On Wednesday, Brown said, he notified her that if the company is unable to secure additional insurance payments, it would write off the balance of the bill and that she would owe nothing.
Cole would not divulge details of his conversation with Brown, but said, "I am helping her out with her situation. She is very happy."
Air-ambulance billings are complicated. According to Brown's bill, Tristate Care Flight charged a base rate of $17,325 for the one-way helicopter transport. It also charged $289 for each mile of the 163-mile trip. The base charge and per mile charge made up the bulk of the bill, which included four other minor charges.
Brown isn't the only consumer surprised by air-ambulance bills.
In 2014, the National Association of Insurance Commissioners (NAIC) issued a consumer alert about the cost of and coverage for air-ambulance bills, in part, due to consumer complaints and feedback from state insurance commissioners, an NAIC spokeswoman said.
The NAIC alert said that the average air-ambulance trip is 52 miles and costs from $12,000 to $25,000 per flight.
Other estimates suggest that these emergency medical trips may cost more. FAIR Health, a database of nationwide insurance claims that provides a search tool for consumers, estimates that a Phoenix resident can expect to be billed $25,678 for a one-way air ambulance trip, plus a charge of $283 per mile.
These bills can catch consumers off guard because health insurers may not cover all charges and may require consumers pay a significant portion. Consumers often are not in a position to refuse service or negotiate rates because these medical helicopters typically are dispatched only for medical emergencies.
Some experts say that air-ambulance bills raise an important health-policy question: Who is financially responsible when a health provider seeks to recoup full, charged rates, even beyond what an insurance company is willing to pay?
"There is a lot of discussion about balance billing," said Dr. Daniel Derksen, director of the Arizona Center for Rural Health at the University of Arizona.
Derksen said consumers need to read and understand what their insurance policies cover, but he added that it can be difficult in an emergency, when a medical helicopter is required.
"You can't say, 'Let's see if this is a covered benefit or not,' " Derksen said. "When you are making decisions that can affect someone’s health outcomes, normally you do what's in the best interest of the patient and you sort through the details of who is going to pay for it later."
Perhaps anticipating resistance from Bruce Brown's insurer, Tristate Care Flight mailed a letter to the Browns' Scottsdale home within two weeks of the emergency transport. Tristate offered to help file an appeal to compel the insurance company to pay a larger share of the bill.
Cole said billing complaints are common in the air-ambulance industry.
“This happens all the time,” Cole said. “It is something we work with each individual patient. It is not our goal to put anybody in a position where they are unable to pay. We just want to provide good care.”
Cole added that operating an aircraft with pilot and a trained crew available 24/7 is an expensive proposition. Crews and an aircraft must be available at a moment's notice to respond to car crashes and other medical emergencies across the company's four-state territory. And a medical aircraft may cost as much as $6 million, according to the NAIC bulletin.
Tristate outsources its billing to a third-party company, and Tristate often writes off bills that it is unable to collect, Cole said.
Tristate Care Flight was founded in 2002 by Bullhead City orthopedic surgeon Blake Stamper, also a pilot, who saw the need for a quick response for injured patients, according to the company's website.
Last November, Tristate Care Flight agreed to sell the business to Air Methods Corp. in a $222.5 million deal. A news release announcing the merger said that Tristate had revenue of $81.5 million in 2014.
Brown questioned why the air-ambulance company was able to charge her even though her husband could not provide consent. His brain stem had been severed and he showed little evidence that he would survive the injury. Brown was not made aware of the transport until the helicopter was on its way to Phoenix.
Cole said that such discussions rarely happen during an emergency. The top priority of the flight crew is to make sure the patient gets proper care.
"We just get going, that's the bottom line," Cole said.
After Bruce Brown was discovered stabbed at his home in Yuma, he was transported to Yuma Regional Medical Center. Yuma doctors determined he needed to be treated at a hospital that offered more-advanced care, so they called for an air-ambulance transport.
The hospital typically does not investigate whether a patient's insurer has a negotiated contract with an air-ambulance company. The hospital's priority is to find a transport company with an available aircraft, pilot and crew that can respond quickly, said a Yuma Regional spokesman.
Although Ameriben has negotiated contracts with other air-ambulance companies, the hospital called Tristate Care Flight that day. Ameriben uses Blue Cross Blue Shield's network of providers. Air Methods, the company that is purchasing Tristate Care Flight, has a contract with Blue Cross.
For Brown, the air-ambulance bill capped a heartbreaking scenario. With Wednesday's news, she hopes she can now move on.
"This could have been life-altering," Brown said of the bill. "I'm thankful."
By Jessica Swarner | Cronkite News | POSTED: Jan 19, 2016
WASHINGTON – A new report says that Arizona had the 10th-highest percentage of uninsured Hispanic children in the nation in 2014 – the third-highest among states with the largest numbers of Hispanic children.
The report by Georgetown University’s Center for Children and Families and the National Council of La Raza, released Friday, looked at Census data to show that 12.7 percent of Arizona’s Hispanic children were uninsured, well above the national average rate of 9.7 percent.
The report said one factor behind Arizona’s relatively high rate may be its 2010 decision to freeze enrollment in KidsCare, the state’s children’s health insurance program, or CHIP. Arizona is the only state without an active CHIP program.
“In effect, this enrollment freeze limited eligibility for children in Medicaid to 152 percent of the FPL (federal poverty level), the lowest income eligibility level in the country,” the report stated.
Dr. Daniel Derksen, a professor at the University of Arizona’s Mel and Enid Zuckerman College of Public Health, said he is not surprised by the state’s high uninsured rate.
“This is one of those things that would be a relatively easy legislative fix,” he said. “The biggest barrier we face in Arizona – we are the only state in the country that has eliminated the CHIP program.”
Joe Fu, the director of health policy at Children’s Action Alliance in Arizona, agreed that the lack of a CHIP program is what’s holding the state back.
“Without that program, we have seen that Arizona lags behind its neighboring and peer states in its ability to protect children’s health,” Fu said.
Arizona’s ranking came despite the fact that the state did well in terms of gains for the number of Hispanics under age 18 with health care coverage: Uninsured kids in the state fell 2.4 percentage points between 2013 and 2014, the fifth-best increase in the country.
The report said one characteristic of states with lower uninsured rates for Hispanic children is the expansion of Medicaid coverage. Arizona expanded its Medicaid coverage in 2013 as part of the Affordable Care Act, better known as Obamacare.
Expanding coverage options for parents can create a “welcome mat” effect, the report said, that leads parents to enroll their children in insurance programs when they sign up for their own.
Derksen said that while both Medicaid and KidsCare were frozen at the beginning of the recession, only Medicaid has been restored and then expanded under Obamacare. He said continued inaction on the children’s program is a disservice to the state.
“It’s irrational that we continue on this path,” he said.
Nationally, the number of uninsured Hispanic children is decreasing at a rate much faster than that of all kids. But Latino children still make up 40 percent of all uninsured kids, while they only account for 24 percent of the children in the country.
The report pointed to two possible barriers for Hispanics seeking coverage, including a lack of access to materials in Spanish, as well as a fear of providing information due to the immigration status of themselves or their family members.
Fu agreed that fear can be a hurdle and said advocates need to focus on “creating a safe space where parents can take their kids to apply” for coverage.
In an interview last week before the report was released, a spokesman for Cover Arizona, a coalition working to increase health insurance enrollment in the state, also cited those barriers and added that many people are unaware of their eligibility for Medicaid or tax credits that can help subsidize a marketplace plan.
“Neighbors say it is expensive, so they go by that,” said Cover Arizona’s David Aguirre, referring to potential enrollees.
Aguirre said that to combat those barriers, Cover Arizona works very closely with local media to get the message out to the community. Partnerships with Telemundo and print media help it specifically target the Hispanic population, he said, as do opportunities for one-on-one assistance in order to quell fears of deportation.
“That’s where the trust comes in,” Aguirre said. “They confide in us so they don’t have to go through a government agency.”
Calls seeking comment from the Arizona Health Care Cost Containment System, the agency that runs the state’s Medicaid program, were not immediately returned Tuesday.
TUCSON, AZ (Tucson News Now) - By Craig Reck
The potential closure of a nursing home in Willcox is the latest example of ongoing struggles for health care providers to remain open and above the red in rural areas of southern Arizona.
Administrators at Northern Cochise Community Hospital met with the community Thursday morning to hear concerns and address any questions.
The event had a good turnout, according to Dan Douglas of Charles William Leighton Jr. Hospice. He said he is worried that closing the hospital’s nursing home would hurt his business and negatively impact families in the area.
Jared Wilhelm, Director of Community Relations for the hospital, said the hospital has always operated on a very thin budget. He said the administration learned about severe losses after a line-by-line breakdown of the services offered at the hospital.
Preliminary numbers were complete by late September and the hospital’s board learned in early October that NCCH was losing close to $2 million a year, according to Wilhelm.
He said closing the nursing home would save almost $750,000 annually, so departments would have to cut their budgets in order to make up the remaining $1.25 million.
Part of the problem, according to Wilhelm, is the drop in collections. The hospital used to collect 51 percent of its money owed, but he said that number has dropped to 37 percent, causing the administration to miss out on approximately $6 million.
The hospital’s district board will make a decision Wednesday, Oct. 28 on the nursing home’s future. It could be part of the solution to keep NCCH from closing like other critical access hospitals before it in southern Arizona.
“We don’t want to be the next one,” Wilhelm said.
Tubac Regional Health Center closed its doors earlier this year, but a new facility opened up farther away in Sierra Vista. Cochise Regional Hospital shut down less than three months ago, but there is now an urgent care in operation with plans to open an emergency room as well. All of these closures are on the radar of the Arizona Center for Rural Health, according to Executive Director Dr. Daniel Derksen.
Do you have a healthcare provider in your state that exemplifies a "Real Doc Hollywood"? NOSORH would like to use National Rural Health Day to honor "Real Doc Hollywoods" or other healers who have made a positive impact on their local community, brought services that may not have been there before, has shown local leadership, or has been a dependable partner that has helped made a change for the better. We welcome you to showcase that individual and help NOSORH promote all of the amazing Real Doc Hollywoods and other Healers around the nation. Please take the time to fill out to provide the following information, showing what makes your choice. You may enter as many individuals as you would like, this is not limited to one submission per person. If all goes well we'll work on media stories and a publication to honor their work. To make your submission, click here.
By Mark Brodie | Aug. 28, 2015
This week’s ruling by a Maricopa County Superior Court judge that the assessment used to pay for part of Arizona’s Medicaid expansion is constitutional has set the stage for an appeal to the state Court of Appeals.
It also brought at least temporary sighs of relief from expansion supporters, including Dan Derksen. He’s director of the Center for Rural Health at the University of Arizona. Derksen said small towns face big health care challenges.
Listen to full audio broadcast at link below:
- Report credits accountable care organizations with more care coordination
by Shannon Firth
WASHINGTON -- Medicare Accountable Care Organizations (ACOs) continue to improve care quality and to lower costs, according to a new report from the Centers for Medicare & Medicaid Services (CMS).
Eligibility is open to medical students (allopathic or osteopathic) in their final year of a U.S. accredited school who are planning to pursue a career in primary care, and are committed to working in underserved communities with limited access to care.
Students to Service loan repayment award recipients receive up to $120,000 (tax free) for three years of full-time service or six years of half-time service. Upon completion of residency, recipients serve as primary care providers in an NHSC-approved site in a Health Professional Shortage Area (HPSA) of greatest need. The 2016 Students to Service application cycle closes on October 22, 2015 at 7:30 pm, ET.
There are two Students to Service infographics that help explain the benefits of this program. One shows how the award can greatly reduce a medical school student’s debt by more than 45 percent, and the other shows overall benefits of the award, such as training and financial support.
The program is expected to be competitive. Please note that applicants who have federally-serviced loans will need to create a FSA ID before beginning the application process. The FSA ID replaced the Federal Student Aid PIN on May 10, 2015. Additional instructions can be found in the 2016 NHSC Students to Service Application and Program Guidance.
Also, please encourage applicants to join us on Thursday, September 17 from 7:00 pm – 8:30 pm ET for the Students to Service Technical Assistance Webinar, to get questions answered about the application process, program eligibility, and service commitment. The login information is below:
Access link: https://hrsa.connectsolutions.com/s2sapplication/
Dial-In Number: 1-888-566-6151
Participant Passcode: 4221465
Thank you for your continued support in helping us spread the word about the opening of the Students to Service Loan Repayment Program.
National Health Service Corps
HRSA Awards $2.7 Million to Improve Rural Health
The Health Resources and Services Administration (HRSA) announced $2.7 million in grants for two pilot programs to increase access to and improve health care in rural communities. These 3-year grants will provide rural communities an opportunity to collaborate in training allied health professionals and expanding health insurance coverage.
The Rural Network Allied Health Training Program, funded at $1,994,150, will support 10 awards for budget requests up to $200,000 in each of eight states to develop networks for improving rural health care through the recruitment, clinical training, and retention of allied health professionals. Emphasis is on integrated rural health networks that can partner with local community colleges and other accredited educational institutions to develop formal clinical training programs for allied health professional students. The program is in response to the Administration’s Job-Driven Training Initiative, which calls for effectively placing ready-to-work Americans in jobs that are available now, or training them in the skills needed for better jobs.
“The strength of this program is its collaborative approach to training allied health professionals,” said HRSA Acting Administrator Jim Macrae. “This program builds on HRSA’s efforts to help those living in rural communities have access to the comprehensive care they need.”
The Rural Outreach Benefits Counseling Program is funded at $749,915 to support 10 projects in nine states with budget requests up to $75,000 each. The program is designed to expand health insurance outreach, education and enrollment efforts to eligible uninsured individuals and families; help educate the newly-insured about their benefits; and connect these individuals to primary and preventive services to which they now have access. Both programs are managed by the Federal Office of Rural Health Policy (FORHP) at HRSA.
“With the large number of uninsured individuals living in rural areas, this program addresses a critical need,” said Tom Morris, FORHP director. “It will help us identify the creative and effective models that are reaching the rural underserved.”
tucson.com | The Arizona Daily Star | June 26, 2015
By Stephanie Innes
After the U.S. Supreme Court’s decision on the Affordable Care Act Thursday, Tucson insurance broker Raymond E. Magnuson had one reaction — a huge sigh of relief.
By Associated Press | June 25, 2015
The U.S. Supreme Court on Thursday upheld the nationwide tax subsidies under President Barack Obama's health care overhaul, in a ruling that preserves health insurance for millions of Americans.
The justices said in a 6-3 ruling that the subsidies that 8.7 million people currently receive to make insurance affordable do not depend on where they live, under the 2010 health care law.
The decision means the 126,000 Arizonans receiving tax subsidies won’t have to find another means of paying for health insurance.
The outcome is the second major victory for Obama in politically charged Supreme Court tests of his most significant domestic achievement.
Dan Derksen, director of the Arizona Center for Rural Health at the University of Arizona, said this will likely be the last time the ACA will be challenged in the Supreme Court.
"I think at this point we’ll be seeing efforts to try to fine tune the patient protection and affordable care act there may be efforts to try to change the way it’s financed and budgeted certain portions," Derksen said.
Earlier this year, lawmakers in Arizona passed a law barring the state from setting up it’s own exchange. Arizona is one of 34 states that don't run their own marketplace for health insurance.
Chief Justice John Roberts again voted with his liberal colleagues in support of the law. Roberts also was the key vote to uphold the law in 2012. Justice Anthony Kennedy, a dissenter in 2012, was part of the majority on Thursday.
"Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them," Roberts wrote in the majority opinion.
Nationally, 10.2 million people have signed up for health insurance under the Obama health overhaul. That includes the 8.7 million people who are receiving an average subsidy of $272 a month to help pay their insurance premiums.
Of those receiving subsidies, 6.4 million people were at risk of losing that aid because they live in states that did not set up their own health insurance exchanges.
The challenge devised by die-hard opponents of the law, often derided by critics as "Obamacare," relied on four words — established by the state — in the more than 900-page law.
The law's opponents argued that the vast majority of people who now get help paying for their insurance premiums are ineligible for their federal tax credits. That is because roughly three dozen states opted against creating their own health insurance marketplaces, or exchanges, and instead rely on the federal healthcare.gov to help people find coverage if they don't get insurance through their jobs or the government.
In the challengers' view, the phrase "established by the state" demonstrated that subsidies were to be available only available to people in states that set up their own exchanges. Those words cannot refer to exchanges established by the Health and Human Services Department, which oversees healthcare.gov, the opponents argued.
The administration, congressional Democrats and 22 states responded that it would make no sense to construct the law the way its opponents suggested. The idea behind the law's structure was to decrease the number of uninsured. The law prevents insurers from denying coverage because of "pre-existing" health conditions. It requires almost everyone to be insured and provides financial help to consumers who otherwise would spend too much of their paycheck on their premiums.
The point of the last piece, the subsidies, is to keep enough people in the pool of insured to avoid triggering a so-called death spiral of declining enrollment, a growing proportion of less healthy people and premium increases by insurers.
Several portions of the law indicate that consumers can claim tax credits no matter where they live. No member of Congress said that subsidies would be limited, and several states said in a separate brief to the court that they had no inkling they had to set up their own exchange for their residents to get tax credits.
The 2012 case took place in the midst of Obama's re-election campaign, when he touted the largest expansion of the social safety net since the advent of Medicare nearly a half-century earlier. But at the time, the benefits of the Affordable Care Act were mostly in the future. Many of its provisions had yet to take effect.
In 2015, the landscape has changed, although the partisan and ideological divisions remain for a law that passed Congress in 2010 with no Republican votes.
The case is King v. Burwell, 14-114.
KJZZ's Carrie Jung contributed to this report.
Updated 6/25/205 at 10:30 a.m.