Sue Lani Madsen: Obamacare remains broken, especially for rural hospitals

Whether you describe the future of health care as repealing or improving the Affordable Care Act, there is no simple solution. But there is agreement on the need for change to an increasingly unaffordable and too often physically inaccessible health care system.

In April 1994, volunteer firefighters and emergency medical technicians surrounded the tiny gas station pay booth along U.S. Highway 2 in Reardan. The attendant had been ousted from her perch and a woman in labor lay on the floor. The ambulance had just arrived and three EMTs squeezed inside the booth were preparing to move her for a little more elbow room.

Baby had other ideas. One caught the healthy boy, a second suctioned and a third cut the cord. His mother had bypassed Lincoln Hospital in Davenport intent on making it to the well-publicized new birthing center at Deaconess Hospital in Spokane.

Easy access to the city is both a blessing and a curse. Physicians at many rural hospitals no longer deliver babies regularly. Lincoln Hospital and its three family practice clinics offered obstetric services until about 15 years ago, when the rising cost of malpractice insurance for a decreasing number of births made it financially impractical.

Without physician insurance for obstetrics, rural clinics also are blocked from providing prenatal care. Without prenatal care in their community, physical access is a challenge and a delayed start of prenatal care is a serious risk factor. Especially for low-income women, the additional costs of time and travel are significant even though they’re not counted as part of the cost of health care. Washington has been similar to the national trends in the link between rural ZIP codes and poor maternal and child health outcomes.

Lincoln Hospital is one of 39 Critical Access Hospital facilities in the state. The CAH program was created in 1997 as a way to protect rural health care by providing cost-based reimbursement from Medicaid and Medicare. Larger facilities rely on volume and a higher ratio of private to public payers to subsidize low reimbursements from government programs. The ACA changed the formula, putting rural health care back over the edge.

Health care is on the border of major changes in payment methods from public and private insurance. Now, payment is made on a fee-for-service basis. It’s a perverse incentive. Clinics and hospitals are only paid when people are sick. It’s a barrier to better value for patients.

Kevin Harris is the senior facilitator for health policy for the William D. Ruckelshaus Center, dedicated to finding collaborative approaches to tough policy challenges. He gave his view from the 10,000-foot level at a recent rural issues conference in Yakima. The current fee-for-service system doesn’t provide an incentive for behavioral change by patients or providers. He emphasized the policy debate needs to focus on how to deliver the right care in the right place at the right time at the right price. He noted hospitals in rural areas have been struggling for a long time, “trying to be all things to all people” and bleeding red ink.

Innovative ideas to provide better health care value usually suffocate against payment barriers in the traditional fee-for-service system. That’s why the Washington Legislature instructed the Health Care Authority to pursue a new financial model, particularly for the most remote and underserved areas. The Washington Rural Health Access Preservation group has been working for two years on a pilot project to test a model that incorporates both cost and value into payments.

The WRHAP group still is negotiating a new payment system with the federal agencies responsible for Medicare and Medicaid. The increasing emphasis on preventive and primary care versus hospital care is not going away, according to Pat Justis, director of the State Office of Rural Health and lead contact for WRHAP. Payment systems, both public and private, will have to change to hold costs down by spending money more wisely on what really matters to good health.

Back along the highway, self-service gas pumps have replaced the clerk. The booth is still available for a mother in labor. The price is right, but it’s not the right place, even if baby decides it’s the right time.