Dr. Dean goes to Washington

Dean Bartholomew, physician at the Platte Valley Medical clinic in Saratoga, told lawmakers in Washington, D.C., about challenges faced by rural healthcare providers.

The discussion was led by Senators John Barrasso (R-Wyo) and Al Franken (D-Minn) of the Senate Rural Health Caucus. The panel discussion brought together lawmakers from both parties and members of the National Quality Forum (NQF) - a non-profit, non-partisan healthcare advocacy group - along with rural healthcare providers and academic experts on healthcare policy. The discussion focused on the challenges facing rural healthcare providers in light of the rapidly changing landscape of health care policy and insurance.

One of the recommendations of the NQF was to have rural providers participate in the healthcare quality assurance programs administered by the Center for Medicare and Medicaid Services (CMS). These quality assurance programs are intended to reduce costs to the Medicare and Medicaid programs by monitoring the quality of care and patient outcomes.

One new quality program is a part of the Medicaid Access and CHIP Reauthorization Act of 2015 (MACRA), the Merit-Based Incentive Payment System (MIPS). MIPS was passed as part of MACRA, and ties payment made to doctors under Medicare to patient outcomes, with better outcomes leading to larger payments.

Bartholomew said that while payment systems that reward physicians for quality of medical outcome are in a general a good thing, he stresses that the cost of collecting data for such schemes impose a disproportionately high burden on smaller health care providers in rural areas.

The cost of the medical records systems that track outcomes for such payment schemes are very expensive, and the problem is compounded when dealing with private insurers who each have their own systems, Bartholomew said.

The biggest issue is the amount of time needed to compile the information required, Bartholomew said. Compiling these records, even with modern computerized medical record software requires a lot of effort and time, and this hits smaller clinics and practitioners much harder than larger ones.

"Big hospitals have full departments that do this, they have compliance officers and IT departments that can do all of that," Bartholomew said. "Here it's just me, and I don't have all of that."

This increased regulatory burden on small clinics and rural hospitals adds to a problem that is not new to rural healthcare. Since 1977, the federal government has had programs in place to encourage physicians to open clinics in underserved areas. The areas, called Health Provider Shortage Areas (HPSA), are defined by the U.S. Department of Health and Human Services as areas where there are not enough primary care physicians to adequately serve the population.

Eastern Carbon County, including Saratoga, is an HPSA according to the department's most recent data.

Even though it is possible for medical professionals working in medically underserved areas to have student loans forgiven and Medicare and Medicaid payments to clinics and providers in these areas are higher, there is some evidence that changes in regulations have exacerbated the problem of lack of healthcare availability in rural areas.

Across the nation, small clinics and hospitals in rural areas are feeling the pinch of regulatory compliance expenses as Medicare switches over to a quality-of-care based payment systems.

Between January 2010 and April 2016, 72 rural hospitals have closed nationwide, according to the North Carolina Rural Health Research Program at the University of North Carolina in Chapel Hill. According to research published by the university, rural hospital closures slowed down in the 1990s and earlier 2000s, but began to accelerate just recently as many of the regulatory changes came into place.

"Right now, it's truly the fact that for rural hospitals and rural clinics, there are many that are not surviving," Bartholomew said.

There are mechanisms that could help reduce the regulatory compliance costs of small clinics, he said. Under one scheme, insurers provide an incentive pay to clinics and providers on a per patient basis to allow providers to hire the staff necessary for the increased workload imposed by regulations, but it is difficult since insurers are reluctant to pay those incentives, he said.

Bartholomew said he felt it was important for him to speak at the meeting so legislators understand the burdens placed on small, rural providers by such regulations, and to try and align the regulations in such a way to reduce the burden on small clinics.

Bartholomew said that he felt there were good suggestions at the meeting in D.C. But, due to the size of the Medicare and Medicaid programs, the dense regulations in place, and the rapidly changing landscape of healthcare provision in the U.S., he's not sure what things will look like in the immediate future, or what improvements rural hospitals and small providers might see.

"I felt that the Senate Rural Health Caucus is open to recommendations from the NQF about needing to simplify, and needing to align the measures and programs," he said. "I'm just not sure what changes are going to be made."