Challenges facing Colorado's nurse practitioners

An article in today's Denver Post highlights the challenges that Colorado's advance practice nurses face in being credentialed and reimbursed by insurance companies.

Calls needed to stop looming Medicare cuts

Congress is back in session and needs to act now to avoid a 23 percent Medicare payment cut that is scheduled for December 1 (with another 2 percent cut following on January 1). These cuts will greatly impact rural residents, as there is a larger portion of elderly living in our rural areas already dealing with provider shortages, and rural healthcare providers who are struggling to cover their costs and care for our communities. The American Medical Association (AMA) and the U.S. Health and Human Services Department are supporting a 13-month halt to any cuts while Congress works on creating a more permanent solution to Medicare funding for physicians.

Please consider contacting Senator Udall, Senator Bennett, and your 2010 member of Congress this week and ask them to avoid these Medicare cuts!

Senator Mark Udall: 202-224-5941; 303-650-7820
Senator Michael Bennett: 202-224-5852; 303-455-7600

Representative Diana DeGette: 202-225-4431; 303-844-4988
Representative Jared Polis: 202-225-2161; 303-484-9596
Representative John Salazar: 202-225-4761; 970-245-7107
Representative Betsy Markey: 202-225-4676; 970-221-7110
Representative Doug Lamborn: 202-225-4422; 719-520-0055
Representative Mike Coffman: 202-225-7882; 720-283-9772
Representative Ed Perlmutter: 202-225-2645; 303-274-7944

You can also use the AMA’s Patient Action Network by calling 888-434-6200 (you will need to submit your zip code). Not sure who represents you in Congress? Click here.

Medicare Updates: 2011 OPPS Final Rule, Physician Payments and the SGR

Earlier this month, the Centers for Medicare and Medicaid (CMS) issued final rules updating Medicare policies and rates for 2011, including several changes relating to physician supervision that impact rural providers. Read more about these changes as well as other components of the final rule. Some of the highlights include:

• Delayed the enforcement of supervision requirements for outpatient therapeutic services in both critical access hospitals (CAHs) and small rural hospitals through calendar year 2011
• Changed definition of “immediately available”
• Finalized a proposal for 16 services requiring direct supervision by a physician or non-physician practitioner during an initiation period, followed by ‘general’ supervision for the reminder of the service
• Announcement that CMS will convene a panel in 2012 to review supervision requirements for all outpatient services

While we’re on the topic of Medicare, as Rural Voice readers recall from last week’s post, Medicare physician payments will be cut by 23% beginning December 1 without congressional action. Why so high? In very oversimplified terms, the formula used to determine Medicare payments, the Sustainable Growth Rate (SGR), ties Medicare physician payments to factors related to the overall national economy. Put another way, SGR says the growth in payments per Medicare beneficiary cannot grow more than the economy as a whole…and slower economic growth requires lowering physician payments to control Medicare costs. Reimbursements were cut in 2002 but since that time payment reductions have been postponed (and been accumulating) while SGR remains in place. Many organizations and individuals will be calling on Congress next week to take action to avert these cuts and create a more stable, sustainable method for determining physician payments. Stay tuned for opportunities to contact your congressperson next week to share your concerns about potential Medicare cuts and what they will mean for rural communities and providers. 

Want to learn more about SGR and how Medicare pays physicians? Check out this policy brief by Health Affairs that summarizes the issues and possible solutions.

Share your ideas and priorities on rural public health for Rural Healthy People 2020

Complete a brief, online survey to assist rural health policy makers and researchers in identifying the most important health issues facing rural residents. The project, Rural Healthy People 2020, is designed to identify the most significant preventable threats to the health of rural people and to establish goals for reducing these threats. The survey should take 5-10 minutes to complete and does not require a professional background in health issues.

Rural Healthy People 2020 is an important companion document and resource to Healthy People 2020, a national framework for health and prevention. You can find a good article on the 2020 initiative written by Kim Krisberg in the American Public Health Association's The Nation's Health.

Federal Health Reform Accounts for Less than 5% of Rate Increases in Colorado

In response to speculation about the effects of federal healthcare reform on health insurance premiums in Colorado, the Division of Insurance, lead by Insurance Commissioner Marcy Morrison, conducted an analysis of recent rates and found that “while federal changes have minimally affected premium costs, numerous other factors are more significant across the board”. Read the news release from the Division of Insurance and learn more about factors which are driving healthcare insurance rate increases.

Looking ahead...but not too far

By now most of us have probably learned about the outcomes of yesterday’s election. In Washington, the House of Representatives will be Republican-controlled beginning January 2011 and Democrats will have a narrower margin in the U.S. Senate. Colorado voters will send Michael Bennett (D) back to the Senate for another term. Re-elected Representatives Mike Coffman (R), Diana DeGette (D), Doug Lamborn (R), Ed Perlmutter (D), and Jared Polis (D) will be joined in January by the newly elected Cory Gardner (R) and Scott Tipton (R).

But there’s work left to be done this year in Washington. Lawmakers will return to D.C. later this month for a post-election “lame duck” session and they will have a lot on their plates. On the agenda are spending bills for most government programs (including important rural and workforce provisions) and addressing a 23.6% Medicare payment cut for physicians that is scheduled to begin on December 1. National organizations are already mobilizing and we will keep you informed of opportunities to contact your member of Congress about these important healthcare issues.  

Back here in Colorado, voters rejected several tax cutting initiatives including Amendment 60, 61, and Proposition 101 as well as Amendment 63. Republicans appear to have taken a majority in the State House, the Democrats have maintained their majority in the State Senate, and John Hickenlooper (D) is the Governor-elect. With our state facing significant revenue shortfalls, FY 2011-12 budget briefings and hearings are scheduled to begin later this month.

Read a complete list of Colorado’s election results. And thanks for voting!

Governor Ritter’s FY2011-12 proposed budget released

In the midst of election activities (more to come on that later), Governor Ritter released his proposed budget plan for fiscal year 2011-2012.  Addressing a shortfall of over $714 million, the proposal includes targeted reductions in Medicaid and Children’s Basic Health Plan (CHP+), payment delays for Medicaid providers, and also a reduction in scheduled provider fee payments to hospitals. No direct cuts to Medicaid provider rates were proposed, however the payment delays and other proposed reductions will negatively impact Medicaid providers. This proposal is not yet final, as the Legislature and Governor-elect John Hickenlooper can make changes to the budget. CRHC will continue to monitor the budget process for opportunities to advocate on behalf of rural healthcare and share updates as they unfold. I welcome your feedback on budget issues—send me an email at ss@coruralhealth.org. 

New report features Colorado clinics using non-physician clinicians

A new report by the Colorado Health Institute provides case studies of clinics throughout Colorado that utilize interdisciplinary collaborative models for the provision of primary care. Working under physician supervision or independently (depending on their training and practice setting), nurse practitioners, certified nurse midwives, and physician assistants are providing a range of primary care services to patients. Read the report "Collaborative Models of Primary Care: Case Studies in Colorado Innovation". 

Family Medicine Residency Training in Rural Locations

A survey of U.S. family medicine residency programs found that 33 rural programs account for over 80% of family medicine training occurring in rural sites. Published by the WWAMI Rural Health Research Center, the report includes responses from family medicine residency programs about their rural training programs and provides policy recommendations to encourage the growth of medical training that supports rural primary care. Read the full report.

Other health clinics need support, too

The Denver Post published Colorado Rural Health Center CEO Lou Ann Wilroy’s letter “Other health clinics need support, too” in response to an article on the state’s rural safety-net clinics.

Health Insurance Exchange Forums this week in Colorado Springs and Greeley

Public forums on health insurance exchanges will be held this week--on Tuesday, October 26 in Colorado Springs at the Pikes Peak Regional Development Center, located at 2880 International Circle and on Friday, October 29 in Greeley at the Panorama Room of the UNC University Center, located at 2045 10th Avenue. Both forums will be held from 10:00 a.m.-12:00 p.m. Information on these meetings as well as materials and minutes from previous forums are available on the state's Exchange Forums website.  

As part of the Affordable Care Act, states are responsible for developing health insurance exchanges. The exchanges will be virtual marketplaces where Coloradans will be able to obtain information to select and purchase health insurance plans and determine eligibility for federal subsidies and tax credits. The Colorado Coalition for the Medically Underserved, the Colorado Consumer Health Initiative, and the state's Health Reform Implementation Board have been hosting a series of community forums across Colorado to discus the options for our state and collect input from stakeholders and communities. 

Governor announces additional cuts to re-balance budget

Facing an shortfall of about $261.7 million in FY 2010-11, Governor Ritter released a budget re-balancing plan totaling $296.5 million. Proposed health-related items in the plan include a three week provider payment delay for fee-for-service Medicaid providers. More information on the proposed provider payment delay, including a provider payment schedule, is available on the Department of Health Care Policy and Financing website. 


More budget news is on the horizon. The Governor will present his FY 2011-12 balanced budget request on November 1, anticipating an estimated $1.1 billion shortfall for the year beginning July 1, 2011. Additional budget cuts for FY 2010-11 may be needed following December’s revenue forecast. 

Impact of Amendment 60, 61, and Proposition 101 on healthcare in rural communities

If passed, Amendment 60, 61, and Proposition 101 will have dire consequences for healthcare across Colorado, especially in rural communities. The Bell Policy Center has written an article on how these ballot initiatives will directly impact three rural hospital districts in Garfield, Huerfano, and Yuma counties, severely limiting their abilities to maintain facilities and provide services. Read the article and download fact sheets for these three counties. For information on how these initiatives will impact other Colorado counties, visit Looking Forward.  

Don't forget to cast your ballot--by early voting, by mail, or at the polls on November 2. Read the Secretary of State's 2010 Voter's Guide for more information. 

Health Reform Hits Main Street

Looking for an easy-to-understand source for learning more about the health reform law? The Kaiser Family Foundation has produced a short, animated movie that explains some of the concerns about the current healthcare system, the changes that are happening now, and the changes to come in 2014. 

California Court Approves CRNA Opt Out

The California Superior Court in San Francisco has upheld Gov. Arnold Schwarzenegger's June 2009 decision to opt out of the federal physician supervision rule for certified registered nurse anesthetists (CRNA).  The presiding judge ruled that California state law does not specifically require CRNAs to be supervised by physicians when administering anesthesia, and therefore Gov. Schwarzenegger was within his rights to opt out of the federal rule.

Colorado’s Governor Ritter opted-out of the CRNA Medicare supervision requirement in rural and Critical Access Hospitals in September, becoming one of fifteen states that have opted out of the requirement. The Colorado Society of Anesthesiologists and the Colorado Medical Society filed suit in Denver District Court to block Governor Ritter’s opt-out decision and this legal challenge is still pending.

CRHC congratulates California on this important victory and applauds the Colorado advocates of CRNA opt-out, including the Colorado Hospital Association, Colorado Nurses Association, Colorado Association of Nurse Anesthetists, and many individuals and healthcare providers who all support this effort. 

Denver Post Article Discusses Amendment 63

The Colorado Rural Health Center (CRHC) is mentioned in an article in today's Denver Post as one of several members of Colorado’s medical community that is opposed to Amendment 63. This confusing and costly amendment would alter the state’s constitution to block Colorado from adopting federal health reform legislation that requires individuals to have health insurance coverage. While not taking a position on the individual mandate issue, CRHC opposes Amendment 63 and does not believe a constitutional amendment is the appropriate way to address this issue. Read more about CRHC’s positions on the November ballot measures. 

CRNA Opt-Out Update

Last month Governor Ritter exercised the option to exempt Colorado’s Critical Access Hospitals and rural hospitals from the Medicare requirement that certified registered nurse anesthetists be supervised by a physician, joining 15 other states that have already opted-out of the requirement. Both the Colorado Board of Nursing and the Colorado Medical Board voted on and supported the CRNA opt-out and a study found that opting out of the oversight requirement did not diminish quality of care or threaten patient safety. The Colorado Society of Anesthesiologists and the Colorado Medical Society filed suit to block Governor Ritter’s decision and this legal challenge is still pending.

CRHC thanks the many individuals and organizations who support this effort to improve access to healthcare in rural Colorado and have worked tirelessly toward the opt-out decision, including the Colorado Hospital Association and the Colorado Nurses Association. The Rural Voice will continue to update readers on this important issue. 

Department of Insurance to Assist on Child-Only Policies

Colorado’s Department of Insurance announced yesterday that it will assist families with finding “child-only” health insurance policies. Federal health legislation that took effect on September 23, 2010 prohibits insurers from denying coverage to children based on pre-existing conditions. Read the Department’s updates on Child-Only policies.  

Navigating Health Reform Implementation

Confused about what is in the Patient Protection and Affordable Care Act of 2010 and how it will be implemented? While the Act’s four major components — market reforms, state health insurance exchanges, Medicaid expansions, and employer and individual responsibility provisions — do not take effect until January 1, 2014, other aspects of the legislation have already taken effect or will be soon. Two resources for information are the Kaiser Health Reform Gateway, sponsored by the Kaiser Family Foundation, and Health Reform GPS, a joint project of the Robert Wood Johnson Foundation and George Washington University's School of Public Health and Health Services. 

Know the Issues for November 2!

Coloradans will be heading to the polls (or mailing in their ballots) in just over a month—get ready. 

The Colorado Legislative Council has published The Blue Book, a detailed analysis of each of the ballot initiatives. CRHC is opposing Amendment 60, Amendment 61, and Proposition 101 along with a growing coalition of organizations. Please visit Don’t Hurt Colorado for more information. CRHC also opposes Amendment 63, Health Care Choice. To learn more about Amendment 63, go to www.NoOnAmendment63.com. 

Don't forget! Voter registration ends on October 4, be sure to register or update your voter registration.