VRHA Weekly Update
In this Issue December 18, 2017

VRHA News Virginia News National News Mark your calendar
Funding Opportunities


December newsletter




VRHA Office Schedule

The VRHA offices will be closed December 22-January 2 for the winter break.

Happy Holidays to all of our members and stakeholders!

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Members in the News

VRHA member Community Health Center of the New River Valley was recently honored by the Montgomery County Chamber of Commerce.  CEO Michelle Brauns was named 2017 Non-Profit Leader and staff member Melissa Stockwell-Gregson was named 2017 Outstanding Community Service.

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More Members in the News

By Mike Bollinger - The Recorder

[VRHA member] Bath Community Hospital and Bath County are in the process of entering into an agreement that would allow BCH to re-establish a clinic in Millboro.  Tuesday, the board of supervisors approved a lease agreement for the former Millboro child care building, commonly called the SEEDS building. The building is across from Millboro Elementary School. 

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Virginia News

Medicaid Expansion

By Matt Delaney - Falls Church News-Press

A push to expand Medicaid coverage throughout Virginia was the focus of a public forum hosted by the Virginia Interfaith Center for Public Policy’s Northern Virginia Chapter at the Columbia Baptist Church by Bailey’s Crossroads on Dec. 1.

Senator George Barker from Virginia’s 39th District was one of the speakers at the event and estimated that Medicaid expansion may not be feasible in the upcoming 2018 legislative session, but by 2019 it should be well within the General Assembly’s reach. However, other members of the legislature are hopeful that expanding Medicaid can be agreed upon once the governing body convenes in early January due to November’s election results.

Friday’s discussion was one of 11 similar events that took place throughout the state. Each location shared a group of prominent figures from religious, medical and political backgrounds. Speaking alongside Barker and Brown was executive director of Neighborhood Health, Dr. Basim Khan, who lamented how most care low-income populations receive is at the hospital, not a primary care physician or a specialist. Their collective presence and comments carried a sense of urgency to grow the government healthcare program that helps people who fall significantly below the federal poverty level.

The inertia for expansion comes on the heels of a new joint report by the Virginia Poverty Law Center (VPLC) and The Commonwealth Institute (TCI) titled, “How Medicaid Works: A Chartbook for Understanding Virginia’s Medicaid Insurance and the Opportunity to Improve It.”

Read the full article.

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Opioid & Mental Health Budget

By Caslee Sims - WDBJ7

Gov. Terry McAuliffe announced that his 2019-2020 biennial budget will include $76 million to combat the opioid epidemic and improve behavioral health treatment, according to a release from the Office of the Governor.

According to the release, the proposed funding will improve behavioral health services through community services boards; expand access to drug courts; establish residential treatment programs for non-violent offenders; hire more parole and probation officers, and pay for six additional forensic scientists to test substances. It also expands access to medically-assisted treatment for people with opioid addictions.

Read the full article, and other stories about the opioid epidemic from WSET, Roanoke Times, and the Martinsville Bulliten.

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No Exchange

By Katie O'Connor - Richmond Times-Dispatch

Nearly six months after syringe services programs, known as needle exchanges, became legal in Virginia in an effort to curb surging rates of hepatitis C, the Department of Health has yet to receive a single application to launch one from any of the 55 eligible districts.

The state health commissioner, Dr. Marissa Levine, told the Board of Health during a recent meeting that law enforcement agencies have been hesitant to provide letters of support, which is a requirement for the applications.

Syringe services programs have been shown through research and data to be effective in hindering the spread of hepatitis C and HIV. Both the Centers for Disease Control and Prevention and the U.S. Department of Health and Human Services call them effective components of a comprehensive approach to HIV prevention.

But the evidence behind the programs — as one of the best ways to stop the spread of drug-related infections — doesn’t always translate among everyone involved in tackling the opioid epidemic. For law enforcement, the idea of giving someone the equipment to illegally use drugs may be too big a pill to swallow.

Read the full article.

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National News

House Tax Bill

By Rachel Roubein - The Hill

Groups representing affordable housing, hospitals, airports and colleges are intensely lobbying House Republicans to defer to the Senate and retain a critical financing tool scrapped in their own tax plan. The groups say eliminating tax-exempt private activity bonds (PAB) would dramatically limit the ability of nonprofit hospitals to perform much-needed renovations, of certain colleges to finance new dorms and heating plants, of developers to build desperately needed affordable housing and much more.

Overall, they argue the changes will be harmful to vulnerable communities, making critical capital projects more expensive and likely resulting in the need to scale them back. Cash-strapped rural hospitals could, in particular, feel the brunt of this provision, sources said.

“It would not be melodramatic to say that rural hospitals will close throughout the United States if this provision becomes law and certainly the necessary upgrades, or sometimes even new hospital construction that’s necessary, will be delayed or restricted,” said Charles Samuels, general counsel for the National Association of Health and Educational Facilities Financing Authorities.

Read the full article.

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Nursing Supply

By Shari Dingle Costantini - Daily Yonder

Nurses are few and far between in rural communities. The Journal of Nursing Regulation reported that by 2020 over 70,000 nurses will be retiring. This decline in staff could affect healthcare facilities in rural areas first, since they already struggle with longer patient wait times, longer shift hours for their nurses and are more at risk for closure than healthcare facilities in metropolitan areas.
In response to the nurse shortage, Rep. Jim Sensenbrenner (WI) introduced H.R.3351 Emergency Nursing Supply Relief Act 2017, which allocates up to 8,000 immigrant visas annually for nurses and physicians who are in critical need and in short supply.

Read the full article.

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FCC Fund Demands

By Steve Rosen - Fierce Healthcare

The Rural Health Care Fund is becoming a victim of its own success, stranding rural healthcare providers (and, subsequently, their patients) that have become reliant on the fund to help support their telemedicine needs. After years of undersubscription, the last two funding years have finally seen healthcare provider demand for these funds outstrip the current $400 million annual cap on grants. The consequences of this oversubscription are just beginning to be felt throughout the healthcare industry. 

For most of the Rural Health Care Fund’s 20-year history, applications were fully funded as they were approved by Universal Service Administrative Company (USAC). USAC opened successive “funding windows” each year in the hope of distributing more grants to worthy rural healthcare providers. 

Things have changed. During the 2017 funding year (July 1, 2017-June 30, 2018) USAC offered only one funding window. And, because demand for the fund’s resources now outstrips supply, grantees are seeing a pro rata reduction in their funding, based on the percentage by which the funds requested in approved applications exceed the fund’s $400 million cap. For the second filing window in the 2016 funding year, the pro rata reduction was 7.5%. Such a pro rata reduction is also likely for funding year 2017. 

Read the full article.

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Rural Research

Rural-Urban Enrollment in Part D Prescription Drug Plans
Rural enrollment in the Medicare Part D program has historically lagged urban enrollment. As of June 2017, the percentage of rural enrollment in Part D plans (69.8 percent), which include stand-alone prescription drug plans (PDPs) and Medicare Advantage with Prescription Drug (MA-PD) plans, lags urban enrollment (73.0 percent). This lag is in spite of significant growth in the overall percentage of Medicare beneficiaries with prescription drug coverage through Medicare Part D plans (72.5 percent in 2017 vs. 55.6 percent in 2008). Rural enrollees continue to have much higher enrollment in stand-alone PDPs than do urban enrollees, though rural participation in MA-PD plans has almost doubled since December 2008. 

Characteristics of Communities Served by Hospitals at High Risk of Financial Distress
Since 2005, there have been 124 rural hospital closures in the United States. Rural hospital closures can intensify already challenging health and economic issues for rural communities. People served by rural hospitals tend to be older, poorer, have access to fewer health care professionals, and have overall worse health outcomes than those served by urban hospitals. To better understand the causes of hospital closure, this brief compares the characteristics of communities served by rural hospitals at high risk of financial distress to those served by rural hospitals that are not at high risk of financial distress. Key Finding: Hospitals at high risk of financial distress serve a more vulnerable population than those not at high risk. Because hospitals at high risk of financial distress are more likely to close or curtail services, these more vulnerable populations are at increased risk of losing access to some types of health care, exacerbation of health disparities, and loss of hospital and other types of local employment. 

Distribution of Disproportionate Share Hospital Payments to Rural and Critical Access Hospitals
This policy brief provides information about the potential impact of scheduled changes in Medicaid Disproportionate Share Hospital (DSH) payment on rural hospitals in 47 states. We found variation across states because of difference in state policies distributing DSH payments to hospitals. For rural hospitals in particular, including critical access hospitals (CAHs), we found variation in the number receiving any DSH payments and in the amount among those who received payment.
Using data from the 2011 Medicaid DSH audits, CMS Provider of Service files, and Medicare Hospital Cost Reports, we found that the percentage of rural hospitals receiving any Medicaid DSH payment ranged among states from 0 percent to 100 percent. In some cases, rural and CAHs realized significant percentages of net patient revenue from DSH payments, which ranged from 0.5 percent to 8.8 percent. States already showing evidence of rural hospitals at greater financial risk are the same states where this analysis shows that rural hospitals are more dependent on Medicaid DSH payments. Changes to Medicaid DSH payment policy, especially if not combined with increased revenue from other sources, should consider the effect on vulnerable rural hospitals. 

ESRD Facility Characteristics by Rurality and Risk of Closure
The purpose of this study was to profile rural end-stage renal disease (ESRD) facilities, focusing specifically on those at greatest risk for closure based on low-volume designation and/or negative Medicare profit margins. Specifically, we examined the characteristics of these facilities, the quality of care they provide, and the distance patients in rural areas would have to travel if these facilities were to close. We found a higher prevalence of facilities designated as low-volume and facilities with negative profit margins in rural areas. Rural facilities, especially those with low-volume designation and/or negative profit margins, are likely to become more vulnerable. Our study also found that rural ESRD facilities (particularly those at risk for closure) offered fewer services (i.e., fewer dialysis stations, fewer late shifts). Despite functioning at a lower scale, these facilities performed similarly to or, in some cases, better than their urban counterparts in terms of quality. Our study found that rural patients will be adversely affected by potential closures of at-risk rural facilities, although travel distances will vary by the type of facility a patient chooses as an alternative venue for care. Should their at-risk facility close, rural patients would have to travel an average of >100 miles to seek care from a facility that is not at risk. It is imperative that CMS recognize and address the potential impacts of bundled payments on facilities in rural areas running on low volumes and/or negative Medicare profit margins. The possible closure and consolidation of such facilities will increase the travel distances faced by rural patients and will likely lead to lower compliance rates and, ultimately, higher mortality. 

Rural Long-Term Services and Supports: A Primer
Focusing on the population of older LTSS users (i.e., age 65+), this paper reviews the fundamentals of the rural LTSS system, examines rural access to and use of LTSS, and discusses opportunities and limitations of current Federal and State LTSS policy for advancing rural health system transformation toward a high-performing rural health delivery system. Ideally, primary care, acute care, post-acute care, and LTSS form a continuum of coordinated services designed to meet individuals’ needs based on their level of clinical, social, behavioral, or other chronic care needs and preferences. In reality, these services tend to be fragmented, with only weak coordinating connections. The effects of fragmentation are exacerbated in rural areas, where the availability of, and access to, LTSS is more limited. The growing population of older adults in rural areas, combined with the more limited capacity of rural LTSS systems, suggests the need for targeted initiatives, including expanded community-based service options, enhanced workforce capacity, and improved care coordination. 

Rural Transportation: Challenges and Opportunities
Transportation, as it relates to health and healthcare, is widely acknowledged to have unique features in rural communities, but there is limited research on specific challenges and potential policy interventions to alleviate them. Six themes emerged from the interviews describing different types of rural transportation challenges: infrastructure (mentioned by 63% of key informants), geography (46%), funding (27%), accessibility (27%), political support and public awareness (19%), and socio-demographics (11%). We describe each of these in detail, along with illustrative quotations, in the policy brief. 

Differences in Community Characteristics of Sole Community Hospitals
In 1983, Congress created the Sole Community Hospital (SCH) program to support small rural hospitals for which "by reason of factors such as isolated location, weather conditions, travel conditions, or absence of other hospitals, is the sole source of inpatient hospital services reasonably available in a geographic area to Medicare beneficiaries." A SCH is often the only source of hospital care for isolated rural residents. As such, the Medicare hospital classification is intended to keep these institutions viable through certain payment enhancements and protections to the hospital. The purpose of this brief is to: 1) present a snapshot of SCHs and the communities served by them in 2015 (cross-sectional analysis) and 2) identify some trends in selected SCH and community characteristics between 2006 and 2015 (longitudinal analysis). 

Diabetes and Forgone Medical Care due to Cost in the U.S. (2011-2015): Individual-level & Place-based Disparities, used 2011-2015 data from the Behavioral Risk Fact Surveillance System. This study identifies trends in diabetes rates and people with diabetes who forgo medical care. It also identifies geographic and other social determinants of health disparities. 

Diabetes Mortality in Rural America: 1999-2015, used data from the Centers for Disease Control and Prevention Wonder Database. This study explores diabetes-related mortality during a 16-year period. It pays particular attention to the what parts race and rurality play in diabetes-related mortality. 

Ambulance Services for Medicare Beneficiaries: State Differences in Usage, 2012-2014
Improved understanding of how Medicare beneficiaries, most of whom are elderly, use ambulance services provides vital information for policymakers who set rules and regulations about access to ambulance services. Using data provided by the Centers for Medicare and Medicaid Services, our work took a state-level look at usage across the United States. We believe policymakers and researchers need to consider differences across the regions of the U.S. when evaluating reimbursement and rules about usage. When looking at changes in the supply of ambulance services in an area, we need to consider the current rate of usage of those services. 

Rural and Urban Differences in Passenger-Vehicle–Occupant Deaths and Seat Belt Use 
Rurality was associated with higher age-adjusted passenger-vehicle–occupant death rates, a higher proportion of unrestrained passenger-vehicle–occupant deaths, and lower seat belt use among adults in all census regions and regardless of state seat belt enforcement type.

Rural-Urban Variations in Medicare Live Discharge Patterns from Hospice, 2012-2013
For the last decade-and-a-half, the proportion of patients discharged from the Medicare hospice program prior to death – known as a “live discharge” – has increased across the country with significant hospice-level geographic variations. Despite clear geographic variations in live discharge rates and known rural-urban disparities (e.g., patients of rural hospices have higher satisfaction), previous studies have not explored differences in live discharging patterns between rural and urban areas in depth. Accordingly, this brief first provides an overview of the geographic distribution of “freestanding” (i.e., rather than those co-located in a hospital, home health agency, or skilled nursing facility) rural and urban hospices and, second, explores live discharge rates for hospices operating in rural versus urban areas. 

Rural/Urban Analysis on Individual Insurance Market Topics
Some special challenges face the development and sustainability of marketplace plans in rural areas. Previous work by the RUPRI Center for Health Policy Analysis and others has brought attention to some of these issues. This data release provides some additional detail on some important topics, with particular importance to rural people, places, and providers. 

Medicare Advantage Enrollment Update 2017
Enrollment in Medicare Advantage (MA) plans, measured either as an overall count or as a proportion of eligible Medicare beneficiaries continues to climb with one in three Medicare beneficiaries enrolled in an MA plan in March 2017. Among non-metropolitan enrollees, nearly one in four (23.5%) beneficiaries is enrolled in an MA plan. The majority of all MA enrollees are in HMO plans but that is largely driven by metropolitan enrollees. The majority of non-metropolitan MA enrollees are in Preferred Provider Organization (PPO) plans, either local PPOs (38.5%) or regional PPOs (17.7%). 

Despair in the American Heartland? A Focus on Rural Health 
This issue of AJPH provides a special focus on the health of rural populations in the United States, with four research articles and accompanying editorials.

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Mark Your Calendar

For more information about these and other events, visit the VRHA Calendar

February 6-8: Rural Health Policy Institute - Washington, DC
March 3: Educational Forum on Prescription Drug Abuse - Martinsville
March 4: Educational Forum on Prescription Drug Abuse - Roanoke
April 15-17: MATRC Annual Telehealth Summit - Hershey, PA
May 8: Health Equity Conference - New Orleans, LA
May 8: Rural Medical Education Conference - New Orleans, LA
May 8-11: Annual Rural Health Conference - New Orleans, LA
May 8-11: Rural Hospital Innovation Summit - New Orleans, LA

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Free one-hour consultation
with the SAMHSA-HRSA Center for Integrated Health Solutions to provide Personalized Technical Assistance on Integration of Behavioral Health in Rural Communities. Rural health care providers working toward integrating behavioral health and primary care are enhancing the health care experience for individuals living with behavioral and physical health conditions. Collaborative care teams providing comprehensive, whole person care also help to alleviate some of the barriers to accessing care in rural communities. These barriers may include provider shortages, limited transportation, and stigma associated with behavioral health concerns. 

Rural Health Disparities
This guide has been updated with new information, including a table on potentially preventable deaths for leading causes of death and new Frequently Asked Questions on regions with high levels of rural health disparities & finding programs that are using best practices to provide health services in disparity areas.

Model Program: "Team Up. Pressure Down." Blood Pressure Medication Adherence Project
The Montana Cardiovascular Health Program conducted an intervention in which pharmacists distributed educational materials and consulted patients with high blood pressure. 

SAMHSA-HRSA Center for Integrated Health Solutions (CIHS)
provides personalized support to primary and behavioral health care organizations in rural communities on a variety of topics such as: 

  • Completing tools to assess organizational readiness for integrated care;
  • Integrating screening for depression, anxiety, and substance use in primary care practice;
  • Learning how to apply Motivational Interviewing techniques in primary care settings;
  • Assessing an organization’s trauma-informed care approach;
  • Addressing burnout and compassion fatigue in the workforce; and,
  • Building a culture of wellness.

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Funding Opportunities

For funding opportunities without a specific deadline, please visit the VRHA Resources page

Sojourns Scholar Leadership Program
Supports innovative clinical, research, education, or policy projects in the field of palliative care and implementation of a leadership career plan for outstanding emerging leaders.
Letter of Intent (Required): Feb 1, 2018
Application Deadline: Jun 1, 2018 

Reducing Health Disparities Among Minority and Underserved Children (R01 and R21 Clinical Trial Optional)
Awards funding for research projects that target the reduction of health disparities among children, including rural, low-income, geographically isolated children.
Application Deadline: Feb 5, 2018 

Prevention and Treatment Research to Address HIV/AIDS Disparities in Women in the U.S. (R01 Clinical Trial Optional)
Grants to support health services, intervention, and implementation research to understand and reduce racial/ethnic, geographic, and socioeconomic HIV disparities in U.S. women.
Letter of Intent (Optional): Jan 28, 2018
Application Deadline: Feb 28, 2018 

Strategies to Increase Delivery of Guideline-Based Care to Populations with Health Disparities (R01 Clinical Trial Optional)
Awards funding for innovative, multi-level studies to test systems, infrastructures, and strategies that will accelerate the adoption of guideline-based recommendations into clinical care relevant to heart, lung, blood diseases, and sleep disorders. Vulnerable populations include medically underserved individuals, racial and ethnic minorities, low income groups, and rural-dwelling patients.
Letter of Intent (Optional): May 21, 2018
Application Deadline: Jun 21, 2018 

Rural Domestic Preparedness Consortium Training
Emergency preparedness training and resources for rural first responders, offered both in-person and online, and provided at no cost.
Applications accepted on an ongoing basis 

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