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An Introduction to the Impact of Triple A (H.R. 1244) and (S. 980) legislation on the DRIS Communities
by Luisa Buada
CIRHM, Executive director
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| Luisa Buada |
The landscape of rural California is amazingly diverse, not only in terms of its people, geography and economy, but also in terms the of availability of health care resources. This diversity poses interesting challenges for the preservation of access to care for rural residents as access to health services may mean very different things for the various population groups that live in the multitude of topographies and cultures that comprise California.
Access to health care is generally defined by the availability of primary care physicians, emergency medical services and basic hospitalization that can be obtained regardless of ability to pay— ideally, this care should also be provided in the first language and in a culturally appropriate manner to the person seeking care. To the extent that current trends in health care delivery and financing continue, particularly system consolidation and managed care, access to health care in rural communities is threatened.
For rural health care to remain viable, a community response - a system response is necessary. This can be achieved through service integration, which is the pooling of provider efforts through a single accountable entity that takes responsibility for managing the health care needs of a rural community through a local provider network. The collaborative efforts of local providers may also focus on healthy communities, prevention, health promotion, a healthy economy, school health and/or dealing with mental health, drug and alcohol issues. The key here is the emphasis on an integrated service approach or the pooling of health care service dollars and community collaboration for the survival of the whole. Rural health policy that ensures access, quality, and reasonable cost needs to support incentives for service integration and community involvement. Policy development that assures ongoing access to care, however, is particularly complex in rural California because of the State’s diversity.
Early this fall, Congress is likely to consider two bills, the Triple AAA Rural Health Improvement Act of 1999 (H.R. 1244) and Promoting Health in Rural Areas Act of 1999 (S. 980), both of which are designed to address some of the existing challenges in the rural health system. Sheldon Weisgrau of Rural Health Consultants has written an article for this newsletter discussing the actual provisions of both the House and Senate bills which will be considered during the upcoming Fall 1999 congressional session. These two bills were developed in order to address some of the provisions of the Balanced Budget Act of 1997 (BBA 97) that have caused or threaten to cause damage to rural health care providers. The following article by Journalist Uriel Heilman, will discuss the potential impact of the bills on the four Developing Rural Integrated Systems (DRIS) sites in California.
In creating a variety of responses to meet the needs of rural constituencies, rather than proposing a congruent policy for strengthening rural health systems the bills ensure access for some members of the population and ensure revenues to support individual providers, but do not provide clear incentives for developing integrated health systems among the full spectrum of providers and across payor sources. Because of the smaller populations in rural areas, the ability to aggregate resources, providers and payors into a single system of care is key to building and maintaining financial strength and viability in the face of external market pressures. Financial incentives that support system integration are ones which result in improving provider revenues when working together to reduce duplication and to increase efficiencies.
Typically, full cost-based reimbursement to health providers does not provide an incentive to integrate. Thus, when a segment of providers such as the FQHCs (Federally Qualified Health Centers), who are the principal providers to the uninsured and Medi-Cal (California’s version of Medicaid) patients are made immune to market pressures through full cost-based reimbursement, the ability of the community to aggregate its health care resources is limited. If the financial incentive to integrate is taken away for those providers that are fully cost-reimbursed, can the remaining rural health care providers serving the commercial and Medicare populations develop and sustain feasible integrated systems? In the case of Critical Access Hospitals (CAHs), Medicare payment provisions under the BBA 97 also covers 100% of allowable cost. However, the legislation requires CAHs to operate within a network for patient transfers and referrals. State Rural Health Plans have gone further to require CAHs to work with a provider network for both primary and tertiary care, thus promoting system integration as part of obtaining CAH designation.
If we take the position that all providers in rural communities are safety net providers, then the preservation of access is a concern to the whole community. The effect of ensuring access to care for one rural population through sustaining its current revenue streams needs to take into account the impact of potential loss of access that may result to another segment of the rural population. A coherent federal policy that preserves access to care in rural communities needs to look at the community of providers and provide a balance of incentives that both promote integration and strengthen rural individual providers through reimbursement mechanisms.
Because the DRIS project has spent the past several years working intimately with four rural California communities, I asked a journalist, Uriel Heilman, to go to the DRIS sites to report on what these bills might mean to the DRIS communities.
© CIRHM