MississippiGovernor’sRuralHealthTaskForce

ReportdeliveredtoGovernorPhilBryantonSeptember30,2019

AboutTheMississippiGovernor’sRuralHealthTaskForcewasformedviaexecutiveorderinMay,2019byGovernorPhilBryantinordertobringtogetherindustryexpertstoresearch,discuss,andsuggestneededpolicyandguidelinesforimprovingMississippi’sruralhealth.

Thetaskforceisfocusedonthreeprincipalareas:

• SustainandEvaluatethestate’scurrenthealthcareinfrastructure,• Growingaccesstoqualityhealthcareservices,and• Transformingcurrenthealthcarepracticesintothosethatprovidemore

efficientcarewithpatientoutcomesin-mind.

Governor’sRuralHealthTaskForceMembers

ChairmanRyanKelly,ExecutiveDirector,MississippiRuralHealthAssociation

SecretaryEdTucker,CPA,CMC,G.EdwardTucker,CPA

TobyA.Butler,ManagingPartner,TrilogyHealthcareSolutions

ShannonCoker,ExecutiveDirector,MississippiDentalAssociation

KevinS.Cook,CEO,UMMCHealthSystem

ThomasE.Dobbs,III,MD,MPH,StateHealthOfficer,MississippiDepartmentofHealth

LarkinKennedy,PresidentandCEO,RushHealthSystems

DianaMikula,ExecutiveDirector,MississippiDepartmentofMentalHealth

TimMoore,PresidentandCEO,MississippiHospitalAssociation

SamPace,MDRetiredPartner/President,DigestiveHealthSpecialists,PA

JoaniePerkins,ChiefComplianceOfficer,SunflowerManagementGroup

CourtneyPhillips,CEO,SouthSunflowerCountyHospital

JaniceSherman,CEO,CommunityHealthCenterAssociationofMississippi

DrewSnyder,ExecutiveDirector,MississippiDivisionofMedicaid

RachelChandlerSprinkle,Director,StateOfficeofRuralHealth,MississippiDepartmentofHealth

Asaresultofnumerousmeetingsandin-depthresearchfromthetaskforce,recommendationshavebeenofferedtoimproveMississippi’sruralhealthlandscape.Thisreportdescribestheproblem,thesolution,andthemeasurebywhichMississippicantrackimprovementineachrespectiveareaoffocus.Afterinitialdiscussions,itwasdecidedthatthetaskforceshouldfocusitseffortsundertheparametersofsustainingandevaluatingthecurrenthealthcareinfrastructure,growingaccess,andtransformingcurrenthealthcarepracticesintothoseofthefuture.TheseareaswereintendedtodeterminetherootcausesofMississippi’sruralhealthissuesandprovidesolutionsspecifictoaddressingthosesolutions.Itdidnotdiscussotherselectconsiderations,includingutilizationofspecificusetaxesandMedicaidreform,amongotheritems,outsideofthisscope.Itshouldalsobenotedthatthisreportistheculminationofdiscussion,research,andmajorityconsensusofthetaskforce.Itdoesnot,however,necessarilyrepresenttheopinionsorviewpointsofeveryindividualmemberofthetaskforce.AsMississippiworkstogrowgreataccesstoqualityhealthcareservicesandtransformintopracticesofthefuture,itmustfirstworktosustainandevaluateitscurrentinfrastructure.OnceMississippiisabletosustainitscurrentinfrastructure,itmaythenmoresuccessfullypivottonewmodelsofcare.TheMississippiGovernor’sRuralHealthTaskForceispleasedtopresentthisreportforconsiderationofdirection,focus,policy,andlegislationtosolveMississippi’sruralhealthchallengesandtoserveasasolutionroadmapforyearstocome.

ExecutiveSummaryTheGovernor’sRuralHealthTaskForcewasabletodiscussthechallengesandopportunitiesavailabletoimproveMississippi’sruralhealth.Asthetaskforcefocusedonthethreeprescribedfocusareas(sustainandevaluatecurrentinfrastructure,growingaccess,andtransformingpractices),itwasunderstoodthatsomeitemswouldtranscendallthreeareas.Inaddition,itwasunderstoodandagreeduponthatselectstrategieswouldbefocusedonshort-termgoalswhileotherswouldallowfacilitiestopivottolong-termstrategiesformeetingfuturehealthcareneeds.Thetaskforceunderstandsandrecognizesthatthereisno“onesizefitsall”solutionforallchallengesthatprovidersandcommunitiesface,butthosediscussedandrecommendedwillhelptosolvemostissuesandallowfordevelopmentofcommunity-centricsolutions.Sustainandevaluatethestate’scurrenthealthcareinfrastructureAsMississippiworkstogrowgreataccesstoqualityhealthcareservicesandtransformintopracticesofthefuture,itmustfirstworktosustainitscurrentinfrastructure.OnceMississippiisabletosustainitscurrentinfrastructure,itmaythenmoresuccessfullypivottonewmodelsofcare.GrowingaccesstoqualityhealthcareservicesAccesstoqualityhealthcareisessentialforqualityhealthoutcomesandhealthequityinMississippi.Ruralhealthfacesavastshortageofprovidersandaccesstospecialtyservices,whichnegativelyaffectsexistingfacilitiesandpatients.Withanincreaseinaccesspointstoqualityhealthcare,includingprimarycare,oralandmental/behavioralhealth,andemergencycare,Mississippian’scanreceiveboththetreatmentandpreventiveservicesneededtoproduceahealthierpopulation.And,asaresult,Mississippiwillenjoyimprovedfamilies,ahealthierworkforce,andlesscostinpreventivetreatment.TransformingcurrenthealthcarepracticesAsMississippiworkstosustainitscurrenthealthcareinfrastructureandprovideadditionalaccesstocare,thestatemustalsotransformitscurrentruralhealthinfrastructureandpracticesintothoseofthefuture-practicesthatprovidemoreefficientcarewithpatientoutcomesinmind.Futuremodelsconsistlargelyofvalue-basedcarethatdelivershigherqualityservicesforpatientswhileleveragingtechnologyandefficiencymodelstoreallocateresourcesandreducecost.Thesenewmodelsaremorestable,meettheneedsoftheircommunities,andprovidegreatercollaborationamongmultiplehealthcaresystems.Mississippimustbegintopivottothesenewmodelsofsupportandcareinordertomeettheneedsofourstate’sfuturehealth.

PolicyandStrategyRecommendationsThefollowingrepresentsrecommendationsforstrategies,policiesand/orlegislationthatwillhelptoresolveMississippi’sruralhealthneeds:KeepingPatientsLocalItisrecommendedthatretainingpatientsinthelocalsettingbecomeacentralstrategyforimprovingruralhealthcareinMississippi.Allhospitalsandclinicsmustmaketheevaluationandtreatmentofpatientsinthelocalsettingapriority,andtheymustonlytransportpatientstotertiarycarecentersifhigherlevelsoftreatmentareneeded.Further,bothhospitalsandclinicsmustworktoidentifyandcreateservicesneededbypatientsthatmaybemissingfromthecommunitybutcouldbereasonablyadded.ReduceCostThroughTele-EmergencyServicesItisrecommendedthatruralhospitalsstronglyconsidertele-emergencyservicesasasupportingcomponentforoperationalintegrityandcostefficiencyintheemergencydepartment.TransitionEmergencyDepartmentstoCapacity-BasedReimbursementItisrecommendedthattheMississippilegislatureinvestigateanddiscussamechanismbywhichthestatemayadjustcurrentfundingorsupplyfundingspecificallytosupportthesustainabilityofhospitalemergencydepartmentsforthefixedcostsofoperations.ConvertMHAPtoaLowIncomePoolWaiverItisrecommendedthattheMississippiDivisionofMedicaidpursueaCMS1115waivertoestablishalowincomepoolwaiverfortheStateofMississippi,pursuantthatthestatecanestablishtherequiredbudgetneutralityofthewaiver.ReimbursementChallengesfromMedicaidManagedCareItisrecommendedthattheMississippiDivisionofMedicaidchangeitsCCOagreementstoalignwithMississippilawandstringentlyenforcetimelypaymentcontractrequirements.ItisrecommendedthattheMississippiDivisionofMedicaidestablishacollaborativeworkgroupwiththeDivision,theCCOs,theHealthcareFinancialManagementAssociation,theMississippiHealthInformationManagementAssociationandothersasdeemednecessarytomonitorandreconcileclaimpaymenterrorsreportedbyprovidersandpursueprocesscorrections.TheDivisionofMedicaidshoulddelegatetotheworkgroupauthoritytorecommendtotheDivisioncontractualpenaltiesagainsttheCCOsasappropriate.RelaxingMedicaidRuralHealthClinicCominglingRegulationsItisrecommendedthattheMississippiDivisionofMedicaidshouldinvestigatecominglingregulationsandseektofollowMedicareguidelines.

HospitalandClinicStaffingConcernsItisrecommendedthatsignificantworktakeplacetotrainorre-trainstaffinruralclinicsandhospitalstomeettheneedsofthosefacilities.Thisshouldinvolveoutsidecontinuingeducationanddirectconsulting,educationalinstitutionsrevisingcurriculumtomeetmodern“realworld”demands,andasubstantialemphasisonretaininganeducatedworkforceinruralcommunities.IncreasingtheNumberofPhysiciansinRuralCommunitiesItisrecommendedthattheMississippilegislaturecontinuetosupportMississippiRuralPhysicianandDentalScholarshipprogramsaswellasincreasethescholarshipamountfortheMRPSP.ThisincreasedamountwillhelptomakeuptheshortfallcreatedthroughincreasedtuitionatUMMCandWCUCOMandpreventstudentfromgoingintodebtasaresultoftheirpursuitofgoingintoruralpractice.ItisrecommendedthattheMississippilegislaturecontinuetosupporttheMississippiOfficeofPhysicianWorkforceaswellassupportagrowthofadditionalruralresidenciesinMississippi.IncreaseIncentivesforTrainingandHiringParamedicsItisrecommendedthatMississippi’scommunitycollegescontinuetoproducequalityparamedicstofillthepipelineforemployment,andthatambulanceprovidersseektofindfundingtoincreasethesalaryofparamedicsinordertoestablishamorecompetitivefieldofwork.StatewideSingleSourceCredentialingItisrecommendedthattheMississippiDepartmentofInsurancecreateasingle,statewidecredentialingapplicationmeetingNCQAstandardsthatmustbeutilizedbyallinsurancecompanieslicensedintheStateofMississippi.SuchmaybeasingleplatformfordatainputbyprovidersthatwilltransmitNCQA–approvedfieldsdirectlytoinsurersforverificationandapproval.RetainingDentistsinRuralAreasItisrecommendedthatfullfundingandsupportoftheMississippiRuralDentalScholarshipProgramisretainedandmade(formerlyreferencedinthisdocument).SupportingtheDonatedDentalServicesProgramItisrecommendedthatasourceoffundingfortheDonatedDentalServicesProgramisdeterminedinordertocontinuethecoordinationofvolunteerdentalservicesinruralMississippi.Asaresult,coordinationofvolunteerdentalservicesshouldbeprioritizedforruralMississippicounties.LeverageTele-DentistryServicesforGreaterOralHealthOutreachItisrecommendedthatexistingfacilitiesareutilizedtotheirmaximumcapacityinconnectionwithapotentialtele-dentistryprogramstoensurethatruralareasareaddressedinregardstodentistry,andthatconsiderationbemadebytheMississippi

StateBoardofDentalExaminerstoutilizetele-dentistrystatewideforgrowingaccesstopreventivetreatmentandscreeningsfororalhealthneeds.IncreasedMedicaidFundingforDentalServicesItisrecommendedthattheMississippiDivisionofMedicaidconsiderincreasedreimbursementforvitaloralhealthservicesinruralareas.LeverageTele-PharmacyServicesforIncreasedAfter-HoursPharmacyAccessItisrecommendedthatexistingfacilitiesareutilizedtotheirmaximumcapacityinconnectionwithapotentialtele-pharmacyservices,asthattheMississippiBoardofPharmacyconsiderarevisiontopoliciesandrulesthatwillallowtele-pharmacytoprovidebackupcoveragetoexistingpharmacieswishingtoprovideafter-hourscoverageforpatients.StrengthenRuralIntegrationoftheMobileCrisisResponseTeamsItisrecommendedthataformalconnectionismadebytheMississippiDepartmentofMentalHealthandpeerhealthcareassociationstostrengthenthepartnershipbetweenthemobilecrisisresponseteamsandruralfacilities.GrowingAccesstoPsychiatryThroughTele-psychiatryServicesItisrecommendedthatasignificantgrowthintele-psychiatryservicestakeplace,withanemphasisthatruralhealthfacilities,includingclinics,hospitals,andcountyhealthdepartments,shouldconsideradoptionandimplementationofsuchservices.IntensiveCommunityOutreachandRecoveryTeam(ICORT)ItisrecommendedthatacontinuedsupportandgrowthoftheICORTprogramtakeplacethroughtheMississippiDepartmentofMentalHealthforadultswithsevereandpersistentmentalillness.School-BasedTelehealthItisrecommendedthatneededrulesandregulationsarealteredtoallowtheMississippiDivisionofMedicaidtoprovidereimbursementfortelehealthservicesintheschool-basedsetting.CreatingStableFundingforEMSTransportItisrecommendedthatastatewidesystembedevelopedtobetterorganizeMississippi’sambulancesystems.Thismaytakeplacewithmultiplecompaniesofferingservices,butthemeansbywhichtheseservicesarepaidmustbecomemoreefficientandconsistent.ItisrecommendedthatastudybeconductedtoanalyzewhetherasetpropertytaxallocationonthecountylevelcouldfullysubsidizebothEMStruckandhelicoptercoveragestatewide,resultinginnooutofpocketcostforpatientswhileprovidingsubstantiallybetterambulancecoverageinruralMississippi.

ItisrecommendedthattheStateofMississippishouldconsiderleveragingtheEMSserviceslineinthestatetraumafundasaMedicaidmatch.ProvidingAdditionalHealthCoveragewithAmbulance-BasedTelehealthItisrecommendedthatEMSprovidersbegintoequipambulanceswithtelemedicineservicesandtrainparamedicswiththeskillsneededtousesuchservicesinordertocreatemoreefficientandeffectiveemergencytreatmentforimprovingpatientoutcomes.Non-EmergencyMedicalTransportItisrecommendedthatafocusonnon-emergencytransportservicesforallconditionsnotrequiringaccesstoemergencytransportservices,includingthoseaffectingsocialdeterminantsofhealth.Itisrecommendedthatalternativesourcesoffundingshouldbeexplored(i.e.USDAfunds)forgrowingandsustainingnon-emergencymedicaltransportationsystems.AppropriateUtilizationofServicesItisrecommendedthatMississippihealthcareentities,providers,andpeerorganizationscontinuetoeducatethepublicontheappropriateuseandaccessofemergencytransportservices,non-emergencytransportservices,hospitalemergencydepartments,preventiveservices,andotheravailableservicesinthecommunity.MississippiRuralHospitalTransitionandImprovementGrantProgramItisrecommendedthattheMississippilegislaturecreateafundingpoolintheformoftheMississippiRuralHospitalTransitionandImprovementGrantProgramunderthedirectionandadministrationoftheMississippiStateDepartmentofHealth.Thisfundmayincludeacombinationoffederal,state,andlocalmatchingfunds.Coupledwithlong-termdebtfinancing,thesefundscouldtransformstruggling,outdatedruralhospitalsintofacilitiesthatbetterservetheircommunities.Fundingofthisprogramshouldbesubstantial,allowinghospitalstoapplyforfundingtoresolvemajorone-timeinfrastructureimprovementsorfinancialreorganization.DevelopHospital‘CentersofInnovation’AcrossMississippiItisrecommendedthathospitalstransitionfromdeliveringmoderate-levelcareamongallavailableservicestocoordinatingwithneighboringfacilitiesfordevelopmentof“CentersofInnovation”inaregionalformatforgreaterefficiencyandqualityofcare.SuchcoordinationshouldbesupportedbytheMississippiStateDepartmentofHealth,theMississippiDivisionofMedicaid,andpeerhealthcareassociations.LeveragetheStrengthofAccountableCareOrganizations(ACOs)andClinicalIntegratedNetworks(CINs)ItisrecommendedthatruralfacilitiesstronglyconsiderinclusioninthestatewideACOs,andthatfundssuchasthestateFLEXgrantcontinuetobeutilizedtohelpfundACOinfrastructureneeds.

HavetheMississippiDivisionofMedicaidandPrivateInsurersInvestigateIncentivesforParticipationinPatientCenteredMedicalHomesItisrecommendedthatruralfacilitiesmovetoadoptPCMHcertification.Inreturn,itisrecommendedthattheMississippiDivisionofMedicaidandprivateinsurersseektoinvestigatetheimpactofprovidingfundingincentivestofacilitiesforadoptingcertifiedPCMHstatus.ConsiderFinancialStabilizationwithGlobalBudgetingItisrecommendedthataformalcommitteebeestablishedbytheMississippiLegislatureorGovernor’sOfficetospecificallyinvestigatetheGlobalBudgetingmodel,analyzingitseffectonMississippihospitalsandclinics.ThiscommitteeshouldconsistofrepresentativefromallpublicandprivateinsuranceprovidersintheStateofMississippi,aswellasrepresentativesfromthehealthcareindustry.EncourageHealthcareDataMiningandRiskStratificationItisrecommendedthatacommitteebeestablishedtospecificallyinvestigatethecreationofauniversalriskstratificationtooltobeusedonanannualbasisbyallMississippihealthinsurancecompaniesinordertoallowproviderstoimprovedirectedscoresasdictatedbythestratificationtool.ThetaskforceconcludesthatwiththeaforementionedpolicychangesinMississippi,itwillcreateamorestablehealthcaresystemwithafocusonimprovingfacilitiesinfrastructure,carestructure,andefficiency.Mississippiwillmovefastertowardavalue-basedsystemthatrewardspositiveoutcomesandreducescostbyleveragingtechnologyanddata.Itistheanticipationofthetaskforcethatbyfollowingthesepolicyrecommendations,Mississippiwillincreaseinnationalhealthcarerankingsasastateimprovingpatientoutcomesandtheeconomicsuccessofitshealthcaresystem.Bymeasuringsuccesswithdesignatedbenchmarks,Mississippiwillbeabletoensurethatpositiveactionisbeingtaken,anditwillallowthestatetomodifythisplanasenvironmentalorregulatorysituationschangeinthecomingyears.

BackgroundMississippihasanestimated2019populationof2,968,118,accordingtotheU.SCensusBureau.Ofthis,anestimated1,595,263arelivinginruralareas.Mississippihas64ruralhospitals,183federallyqualifiedhealthcenters,181ruralhealthclinics,and90localhealthdepartments.RuralMississippianshavea65%insurancerate,comparedtourbanMississippiansat67%.Thiscomparestothenationalaverageof91.2%.(ratesasof2017)Mississippi’sruralhospitalsarestrugglingfinancially.TherehavebeenfiveMississippihospitalclosuressince2010.AnadditionalfourMississippiruralhospitalsdeclaredbankruptcyin2018.ThistrendsignalsadeclineinaccesstohealthcareservicesforruralMississippians.TheMississippiStateDepartmentofHealth,OfficeofRuralHealthandPrimaryCarehousestheStateRuralHealthPlan.Inthisplan,itidentifiesthestate’shealthcarepriorityareasincludediseaseprevention,healthpromotion,healthprotection,healthcareforspecificpopulationgroups(i.e.,mothers,babies,theelderly,indigent,uninsured,thedisabled,personswithdevelopmentalconditions,andminorities),availabilityofadequatehealthworkforcethroughoutthestate,healthdisparities,mentalhealthneeds,andenhancedcapabilitytorespondtopublichealthemergencies.ThesepriorityareascorrespondwiththerecentlyestablishedstatehealthimprovementplanknownasUpRoot,whichestablishedthepriorityareasofincreasededucationalattainment,creatingacultureofhealth,reducingratesofchronicdisease,andimprovinginfanthealth.Mississippidefinesaruralareaas:1)aMississippicountythathasapopulationlessthan50,000individuals;2)anareathatislessthan500individualspersquaremile;or3)amunicipalityoflessthan15,000individuals.SOURCE:Miss.CodeAnn.§41-3-15ArecentstudypublishedbyNavigantstatedthat48%,or31ofMississippi’s64ruralhospitals,areat“highfinancialrisk,”meaningtheyhaveacombinationofpoorprofits,highdebtandlowcashreserves.InruralMississippicommunities,hospitalstendtoserveasthehubandthecentralpointaroundwhichhealthcareservicesareprovided.Otheressentialaspectstocareincludefederallyqualifiedhealthcenters,ruralhealthclinics,mentalandbehavioralhealthcenters,dentalpractices,pharmacies,andotherclinicalstructuresthatserveruralpatients.

ImpactofRuralHospitalClosuresAsruralhospitalsformthebackboneofacommunitiesaccesstocare,theimpactofruralhospitalclosuresareparticularlydevastatingtoacommunityaswellastheinfrastructuresurroundingthehospital.Thefollowingdetailstheimpactofanunplannedhospitalclosure:

1. Reducedaccesstohealthcare,mostcriticallythereductioninaccesstolifesavingemergencyservices.Losingruralemergencyservicesisexacerbatedbythedistancefromruralcommunitiestolargerfacilitiesinmorepopulatedcommunities.

2. Lossofjobs.Ruralhospitalsareoftenthelargestoroneofthelargestrural

communityemployers.

3. Reducedviabilityoftheemploymentbase,aseachhospitalclosureproduces

decreasedpercapitalincomebyfourpercent(4%),andincreasedunemploymentby1.6%incommunitiesalreadystrugglingeconomically.Thisincludesbothdirecthospital-relatedjobs,andotherjobsrelatedtobusinessesaffectedbythelossofthosedirecthospitaljobsandrelatedbusinessdecline.

FactorsCausingFinancialStress,UltimateBankruptcyand/orClosureofRuralHealthFacilitiesThetaskforcehasidentifiedmultiple“rootcauses”offinancialstressonruralhealthfacilities,including:

1. Decliningruralpopulations.Therearefewerjobsinruralcommunitiestodayversuswhatthecommunitiesenjoyeddecadesago.Thishasledtoyoungcitizensleavingruralcommunitiesforurbanareasresultinginadisproportionatelyolderandunhealthypopulation.

2. Healthcareout-migration,resultingfromalimitedaccesstospecialties,aperceivedhigherqualityofcareinurbanareas,andadifficultyinrecruitinghealthcareprofessionalsinruralcommunities.

3. Regulatoryburden.Thereisanever-increasingnumberofrequirementsfromregulatoryagenciesandinsurers,whichaddssubstantialnon-patient-centriccostinasystemwhereresourcesarealreadyscarce.

4. Risingemergencydepartmentcostanddecliningutilization.Therearefixed

costsassociatedwithoperatinganemergencydepartmentwith24/7/365coverage.Withthesecostsset,reimbursementforservicesisnolongeradequate,especiallywhenconsideringtheeffortstodecreaseERutilization.

5. UnintendedconsequencesofpopulationhealthandAccountableCare

Organizationpaymentmodelsonsmallhospitals.Value-basedpaymentmodelsareconceptuallygood,makingthemostsenseinurbanareas,wherecapacityrestraintsexistsandemergencydepartmentsareoftenover-utilized.Butasstatedabove,movingpatientsfromaruralhospitalERtoaprimarycaresettingcancauseunder-useofERcapacitythatthecommunitystillneeds,thusactuallyduplicatingcostsofcareinmanycasesandjeopardizingsmallhospitals’abilitytosustaincriticalservices

6. Reimbursementdecline.Medicarepaymentsforphysicianshavenot

increasedin10years,despitepracticecostincreases.Further,Medicare“sequestration”withholds2%ofpayments,whichresultsincriticalaccesshospitalsthatarecost-basedreimbursedat101%ofcaretonowonlyreceive99%of“allowable”costforMedicarepatients.Thispaymentmethodcreatesaself-liquidatingbusinessmodel.This,coupledwithreimbursementpenaltiesandstricterinsurercontracts,resultsinsignificantrevenuedecline.

7. RevenueCyclecomplexityandchallenges.TheshifttomanagedMedicare

andMedicaidhaveplacedoftensignificantchallengesfortimelyreimbursement.This,inadditiontotheaforementionedcomplexandever-changingpayerrequirements,makesitmoredifficulttoadjudicateclaimsandreceivetimelypayment.

8. Disproportionateagedandlow-incomepopulations.Thesehigh-riskpopulationstendtohavenegativehealthconditionsandoftenhavemultiplechronicconditions.

9. Limitedaccesstocapitaltomaintainandupdateagingfacilitiesandequipmentandmaintainregulatoryrequirements.Thenumberofregulatoryrequirementsplacedonruralfacilitieshasincreasedsubstantially,includingelectronicmedicalrecords,HIPAA,dataandsecurity,andmanymore.Withdecliningrevenuesandincreasedcosts,hospitalshavelittletonomargintoinvestbackinthefacilityforcapitalimprovements,technologyupgrades,increasedsalariestohireindustry-trainedstaff,trainingforexistingstaff,andavarietyofotherissuesnecessarytocompleteitsmission.

10. Advancesincaredelivery.Healthcarehasseensignificantadvancesin

technologyandcaredelivery,butsuchhascreatedsurgicaltrendsfrominpatienttooutpatient,andpayersarenowdrivingsurgicalpatientdischargesstraighttohomecare,bypassingswingbedservicesandotherhospital-basedservicesthatweretraditionallyrevenue-generatorsforruralfacilities.

11. Providerscarcityanddeclineintraditionalphysicianpractice.Primarycarephysicianshavebeguntoshifttoaclinic-onlypracticemodel,withnoinpatientpracticerequirements.Thislackofavailablehospitalistshascreatedsignificantcoverageissuesforsmallruralhospitals.Thistrendmeansthatruralcommunitiesmustcompeteforprimarycarerecruitswithurbanpracticeswherehospitalsprovidefull-timeinpatienthospitalistcoverage.Smallruralhospitalssimplycannotaffordfull-timehospitalistcoverage.Inaddition,mostruralhospitalsandclinicsrelyonverysmallmedicalstaffs.Thismeansthatthelossofevenoneprovidercreatesadrasticreductioninaccesstocareforruralpatients.

12. Lackofpayingpatients.AsMississippihasaninsuredratewellbelowthe

nationalaverage,alargenumberorruralpatientsdonothaveinsurancetopayforcostlycare.Thisresultsinalargeburdenofuncompensatedcareamonghospitalsandclinicsthatoftenmustbeabsorbedas“charitycare”bythefacility.Mostruralfacilitiesalreadyoperateonverythinmarginswithouttheabilitytoabsorbnon-paypatients.

Sustainandevaluatethestate’scurrenthealthcareinfrastructureAsMississippiworkstogrowgreataccesstoqualityhealthcareservicesandtransformintopracticesofthefuture,itmustfirstworktosustainitscurrentinfrastructuretoensurethatnofurtherlossesoccur.OnceMississippiisabletosustainitscurrentinfrastructure,itmaythenmoresuccessfullypivottonewmodelsofcare.ThefollowingaretopicsofconsiderationandrecommendationonbehalfofthetaskforceforensuringtheSustainandEvaluateofMississippi’scurrenthealthcareinfrastructure.KeepingPatientsLocalHealthcare“out-migration”isasignificantissueinruralMississippitoday.Mississippi’sclinicsandhospitalsmustaddressthisout-migrationandworktokeeppatientslocalifcarecanbedeliveredinthelocalsetting.Ruralclinicsfacechallengedwithkeepingpatientslocallargelyduetospecialtyservicesavailableinurbanareas.Withonlyalimitedspectrumofservicesavailableinruralclinics,patientsoftendrivelongerdistancestoreceivecarewherethesespecialtyservices“may”beneeded.Strategiesforextendingspecialtycareintoruralareasviatelehealthandtravelingspecialistsmusttakeplacetokeepoutpatientserviceslocal,andthereforekeeppatientslocal.Hospitalsfaceasimilarissuewithlocalpatients.Often,patientsthatvoluntarilytransportthemselvestoahospitalwilloptforalarger,urbancenterratherthanalocalfacility.Thisisdueinparttothelackofspecialistsintheruralfacility,butoftenitisduesimplytoaflawedperceptionofthequalityofcaredeliveredinaruralfacility.Inaddition,ruralhospitalsthattriagepatientsareoftenreluctanttotreatpatientsinthelocalsettingduetouncertaintyoftheabilitytotreat,andthisresultsinapatientbeingtransportedunnecessarilytotertiaryfacilities.Thisproblemnotonlycreatesabacklogofpatientsattheurbancenters,butitsubstantiallyreducestheinpatientrevenueopportunitiesatthelocalfacilityandincreasesutilizationofanunderresourcedandover-usedemergencytransportsystem.ArecentstudyfromtheOfficeoftheAssistantSecretaryforPlanningandEvaluationattheU.S.DepartmentofHealthandHumanServices(HHS)showsthatruralhospitalsoutperformtheirurbancounterpartsonMedicare’svalue-basedpurchasingprogramandinreducinghospital-acquiredinfection.Keepingpatients

localnotonlyimprovesthedirectbottomlineofhospitals,butitalsoallowsthemtoleverageprogramssuchas340(b)tocaptureadditionalrevenuethatcanoffsetuncompensateddrugcostsandneededservices.Newandadvancedsystemsofdeliveringcaresuchasthetele-hospitalistprogramandtele-emergencyprogramallowlocalproviderstohaveconsultationservicesandback-upserviceson-demand,givingthemconfidenceintheirdecisionstotreatlocallyortransporttotertiarycaresettings.Hospitalsandclinicsmustfocusonbothincreasingadmissionsfromtheirlocalpatientpopulationaswellasretainingpatientsinthelocalfacilitywherecarecanbedelivered.Bykeepingpatientslocal,hospitalsandclinicsincreaserevenue,decreasetheburdenonemergencytransportation,andincreasetheoverallhealthandoutcomesofthepatient.ItisrecommendedthatretainingpatientsinthelocalsettingbecomeacentralstrategyforimprovingruralhealthcareinMississippi.Allhospitalsandclinicsmustmaketheevaluationandtreatmentofpatientsinthelocalsettingapriority,andtheymustonlytransportpatientstotertiarycarecentersifhigherlevelsoftreatmentareneeded.Further,bothhospitalsandclinicsmustworktoidentifyandcreateservicesneededbypatientsthatmaybemissingfromthecommunitybutcouldbereasonablyadded.EmergencyDepartmentUtilizationandFinancialSupportMosthospitalshavesignificantlossesintheiremergencydepartments(ERs/EDs)duetothehighcostofservices.Ruralhospitalshavesomeoftheworstlossesdueprimarilyhighfixedcostofbeingavailable24/7/365andlownumbersofpatientsutilizingERservicesduetosmallpopulationsize,limitedavailableserviceforseriousproblems,andeffortstotreatpatientsoutsideofemergencysettings.Theseconstraintsareplacingasignificantburdenonhospitalsbywhichtheyareoperatingemergencydepartmentsbysupplementinglossesfromotherrevenue-generatingservices.ReduceCostThroughTele-EmergencyServicesTele-emergencyprogramswithnursepractitionerssubstitutedforphysiciancoveragehavebeenfoundtosignificantlyreducetheaverageERcostinlowacuitysettingsbutprovideanacceptablelevelcare.Thismodelutilizesnursepractitionerstrainedunderemergencyroomphysicians,andleveragestelehealthconnectivitytoconnectthenursepractitionertotheiremergencyroomphysicianswhenanemergencyispresented.Thepatientistreated,stabilized,andtransportedtoafacilityofhighertertiarycareifneeded.

Achallengewiththetele-emergencymodelisworkforcetraining.ItisalsodifficulttoobtainaggregatedERcostdata.Suchdatawouldbehelpfultobenchmarkcostsavings.Itisrecommendedthatruralhospitalsstronglyconsidertele-emergencyservicesasasupportingcomponentforoperationalintegrityandcostefficiencyintheemergencydepartment.TransitionEmergencyDepartmentstoCapacity-BasedReimbursementMostMississippipatientsutilizetheemergencydepartmentofahospitalbecauseofacatastrophicinjuryoremergencyconditionthatresultsinemergencytransportation.Emergencyroomsmustbeprepared24/7/365tohandleemergencypatientswithabuilt-in“surgecapacity”forunexpectedconditionsthatrequiremorebedsandmorecarethanordinarilyneeded.Thiscapacitycomesatacost.AlthoughitisunderstoodthatdeferringpatientsfromtheERispreferred,thefactremainsthatfacilitiesmustcoverthefixedcostofstaffinganERinpreparationoranticipationofaneed.Inordertoproperlycoverthecostofsuchaccess,asolutionisneededtoallowhospitalstoreceivecost-basedpaymentsthatare,atminimum,equivalenttothecostofminimumstaffingandservicedelivery.ThereareseveralmechanismsbywhichMississippimayaccomplishthisgoal.ItisrecommendedthattheMississippilegislatureinvestigateanddiscussamechanismbywhichthestatemayadjustcurrentfundingorsupplyfundingspecificallytosupportthesustainabilityofhospitalemergencydepartments.ConvertMHAPtoaLowIncomePoolWaiverNineUSstatescurrentlyhaveMedicaid-fundeduncompensatedcarepools.Thesepools,whicharetimelimited,arecreatedthroughMedicaidSection1115demonstrationwaivers.Fundsinthesepoolsgodirectlytohealthcareproviders.Thesepoolswerecreatedtohelphospitalswithfundingshortfalls.Threefactorsproducetheseshortfalls:

• Hospitalscoveringthecostofcarewhenuninsuredpeopleseekcareatemergencyrooms

• Hospitalsprovidingcharitycare• Hospitalsabsorbing“baddebt”fromunpaidmedicalbills

ItisrecommendedthattheMississippiDivisionofMedicaidpursueaCMS1115waivertoestablishalowincomepoolwaiverfortheStateofMississippi,pursuantthatthestatecanestablishtherequiredbudgetneutralityofthewaiver.

ReimbursementChallengesfromMedicaidManagedCareTheMississippiDivisionofMedicaidhascurrentlycontractedwiththreeCoordinatedCareOrganizationsor“CCOs”providingmanagedcarefortheMedicaidpopulation.TheseincludeUnitedHealthcare,MagnoliaHealth,andMolina.ProvidershavereportedthatCCOshavefrequentlydelayedpaymentsorprovidedincorrectpaymentsforservicesrendered.AlthoughtheDivisionofMedicaidcurrentlyhasunderwayinternalinvestigationstoidentifyandcorrecttheproblems,theamountofmoneydeniedorincorrectlypaidtoprovidersisreportedtobesubstantial.Thishasledtoastraininthehealthcaresystem.Currently,MedicaidagreementswiththeCCOsallowsforpaymentofclaimswithin30daysof“clean”claimfiling(thosewithallnecessaryinformationpresentonsubmission).However,mostclaimsaresentelectronicallyandStateinsurancelawrequiresthatinsurerspayelectroniccleanclaimswithin25days.ItisrecommendedthattheMississippiDivisionofMedicaidchangeitsCCOagreementstoalignwithMississippilawandstringentlyenforcetimelypaymentcontractrequirements.ItisrecommendedthattheMississippiDivisionofMedicaidestablishacollaborativeworkgroupwiththeDivision,theCCOs,theHealthcareFinancialManagementAssociation,theMississippiHealthInformationManagementAssociationandothersasdeemednecessarytomonitorandreconcileclaimpaymenterrorsreportedbyprovidersandpursueprocesscorrections.TheDivisionofMedicaidshoulddelegatetotheworkgroupauthoritytorecommendtotheDivisioncontractualpenaltiesagainsttheCCOsasappropriate.RelaxingMedicaidRuralHealthClinicCominglingRegulationsCurrently,MedicareallowsexceptionstoCMScominglingrulesforspecialiststorentspacefromexistingruralhealthclinicstoprovideadditionallevelsofcare.However,theMississippiDivisionofMedicaiddoesnotcurrentlyallowcomingling,thereforelimitingtheabilityofspecialiststoprovidecareinoutpatient,clinicalsettingsinruralMississippi.Changingtheseruleswillnotadverselyaffectqualityofcareoraddadditionalcosttothehealthcaresystem.Infact,relaxingcominglingregulationsisestimatedtoslightlyreducetheoverallcostofcarebycreatingfacilityspaceefficiencies.ItisrecommendedthattheMississippiDivisionofMedicaidinvestigateitscominglingregulationsandseektofollowMedicareguidelines.

WorkforceChallengesinRuralHealthSettingsHospitalandClinicStaffingConcernsWorkforceshortagesaremorelikelytoexistinruralareas.Thisshortageofproviders,administrationandstaffhasoftenledtoissueswithhospitalandclinicoperations.Ruralhospitalssufferfromlackof“economiesofscale,”meaningthatallornearlyallservicesrequireacertain“minimumstaffing”leveltoofferevenalowvolumeofservices.Further,hospitalmanagementiscomplexandtrainedhospitalmanagementmanpowerinruralareasisdifficulttofind.Ruralfacilitiesareheldtothesamequalityandefficiencystandardasurbanfacilities,sotheymustbegintomanagethemselvesmoreeffectively.Ruralfacilitiesmusthavethefinancialandworkforceresourcesneededtooperatefacilitiesandtreatpatientsinthemosteffectivemannerpossible.Itisrecommendedthatsignificantworktakeplacetotrainorre-trainstaffinruralclinicsandhospitalstomeettheneedsofthosefacilities.Thisshouldinvolveoutsidecontinuingeducationanddirectconsulting,educationalinstitutionsrevisingcurriculumtomeetmodern“realworld”demands,andasubstantialemphasisonretaininganeducatedworkforceinruralcommunities.IncreasingtheNumberofPhysiciansinRuralCommunitiesTrainingRuralPhysiciansandDentists/MississippiRuralPhysicianandDentalScholarshipProgramIn2007,theMississippiLegislatureauthorizedtheMississippiRuralPhysiciansScholarshipProgram(MRPSP),creatingauniquelongitudinalprogramthatidentifiesruralcollegestudentswhoaspiretoreturntotheirrootstopracticemedicine.Inthisprogram,academicenrichment,facultyandphysicianmentoringandsolidmedicalschoolfinancialsupportenablecapableyoungMississippianstoaddressthechallengeofMississippi'shealthcarecrisis.In2013,theMississippilegislatureauthorizedtheMississippiRuralDentistsScholarshipProgram(MRDSP)aswelltomeetthechallengeofprovidingmoregeneralandpediatricdentistsinruralcommunitiesinMississippi.ManycurrentMississippiprimarycarephysiciansarereachingretirementage,anditappearsthatevenwiththeexpandingclasssizesattheUniversityofMississippiMedicalCenter’sSchoolofMedicine(UMMC)andWilliamCareyUniversity’sSchoolofOsteopathicMedicine(WCUCOM),itmaynotbeenoughtomeetdemandforanticipatedphysicianlossesduetoretirementandattrition.Inaddition,mostgraduatesfromtheseprogramsoptforurbansuburbansettingsratherthanruralsettingsfortheirpractices.

Wemustnotonlyproducemorephysicians,wemustproducephysicianswhoarechoosingprimarycare,whichisthefrontlineofmedicineforourstateandwhereweranklastinthenationforpatienttophysicianratio.Acontinuedfocusontrainingphysiciansanddentistsfromruralareasisneededtoprovideabetteropportunityforthoseproviderstoreturntotheirruralcommunitiestopractice.Currently,theprogramincludes41practicingphysiciansinruralareasofMississippialongwith60physiciansinresidencytraining,64medicalstudentsonscholarshipatUMMCandWCUCOM,and49undergraduatestudents.Injustthenextfewyears,theprogramwillhavemorethan60newprimarycarephysiciansforruralMississippi.Thedentalprogramincludes9practicingdentistsalongwith9dentalstudentsonscholarshipand19undergraduates.ItisrecommendedthattheMississippilegislaturecontinuetosupportMississippiRuralPhysicianandDentalScholarshipprogramsaswellasincreasethescholarshipamountfortheMRPSP.ThisincreasedamountwillhelptomakeuptheshortfallcreatedthroughincreasedtuitionatUMMCandWCUCOMandpreventstudentfromgoingintodebtasaresultoftheirpursuitofgoingintoruralpractice.RuralResidencies/MississippiOfficeofPhysicianWorkforceCreatedbystatelegislatorsin2012,theOfficeofMississippiPhysicianWorkforce(OMPW)isworkingtoreducetheshortageofprimarycaredoctors.Theofficeoverseesthestate’sphysicianworkforcedevelopmentneedsbynurturingthecreationoffamilymedicineresidencyprograms,fosteringthedevelopmentofaphysicianworkforceinallspecialtieswheretheyareneeded,evaluatingtheexistingworkforce,andestablishingthestate’scurrentandfutureworkforcerequirements.Toreachthenationalaverage,Mississippiwillhavetoaddmorethan1,300primarycarephysicians,whosespecialtiesincludefamilymedicine,internalmedicine,pediatricsandobstetrics/gynecology.Mississippicurrentlyhasjust64.4activeprimarycarephysiciansper100,000population,withaU.S.statemedianof90.8.Increasingthenumberofphysicianresidenciesaroundthestate,coupledwiththeworkoftheMRPSPforgraduatingphysiciansfromruralareas,willcreatesignificantimpactintheabilitytoretainruralphysicians.Physiciansintheirresidencyyearswilloften“putdownroots”inthecommunitieswheretheycompletedthatphaseoftheirmedicaleducation.Whenaphysicianisinvestedinacommunity,thereismuchlessdesiretoleavethecommunity.ItisrecommendedthattheMississippilegislaturecontinuetosupporttheMississippiOfficeofPhysicianWorkforceaswellassupportagrowthofadditionalruralresidenciesinMississippi.

IncreaseIncentivesforTrainingandHiringParamedicsAnothermajorworkforcechallengeisinregardtothenumberofparamedicscurrentlyworkinginMississippi’semergencyresponsesystem.Asof2012,theMSDHBureauofEmergencyMedicalServicesreportedatotalof1,906EMTBasicscertifiedinthestate;1,599EMTParamedics;and24EMTintermediates.Currently,obtainingadegreeasaparamedicrequiresatwo-yeardegree,butthesalaryisgenerallylowerthantwo-yeardegree-preparedpeerprofessionssuchasaregisterednurse,withmuchmoredifficultworkingconditions.Thisdifferentialhascausedasignificantshortfallinthenumberofparamedicsrequiredtooperateambulances.Thisshortfallcausesanincreaseincostduetotheneedtoprovideovertimeforthecurrentlyemployedparamedics.This,inturn,leadstomorefrequentburnoutfromthosecurrentlyintheprofession,exacerbatinganalreadydepletedworkforce.ItisrecommendedthatMississippi’scommunitycollegescontinuetoproducequalityparamedicstofillthepipelineforemployment,andthatambulanceprovidersseektofindfundingtoincreasethesalaryofparamedicsinordertoestablishamorecompetitivefieldofwork.StatewideSingleSourceCredentialingCurrently,eachMississippiinsurancecompanyandtheirsecondary/subsidiarypayershaveauniqueprocessforcredentialingandenrollingproviders.EvenwithintheMedicaidprogram,movingtothreeCCOshashadtheunintendedconsequenceofanincreaseincredentialingoverheadforbothprovidersandpayers.Multiplecredentialingprocessesandrequirementshavecausedsignificantadministrativeburdensforfacilitiestocredentialandenrollproviders.ThishascausedasignificantbarriertoentryfornewprovidersintoMississippi.Althoughitisrecognizedthateachinsurershouldhavetherighttoenrollordenyprovidersbasedontheirownsetofcriteria,thereshouldnotbeasystem-wideduplicationincredentialverificationofproviderspriortoenrollment.Delaysincredentialingcanbefinanciallydevastatingtotheproviderandharmfultopatientswhoneedaccesstocare.ItisrecommendedthattheMississippiDepartmentofInsurancecreateasingle,statewidecredentialingapplicationmeetingNCQAstandardsthatmustbeutilizedbyallinsurancecompanieslicensedintheStateofMississippi.SuchmaybeasingleplatformfordatainputbyprovidersthatwilltransmitNCQA–approvedfieldsdirectlytoinsurersforverificationandapproval.

Growingaccesstoqualityhealthcareservices

AccesstoqualityhealthcareisessentialforqualityhealthoutcomesandhealthequityinMississippi.Ruralhealthfacesavastshortageofprovidersandaccesstospecialtyservices,whichnegativelyaffectsexistingfacilitiesandpatients.Withanincreaseinaccesspointstoqualityhealthcare,includingprimarycare,oralandmental/behavioralhealth,andemergencycare,Mississippian’scanreceiveboththetreatmentandpreventativeservicesneededtoproduceahealthierpopulation.And,asaresult,Mississippiwillenjoyimprovedfamilies,ahealthierworkforce,andlesscostinpreventativetreatment.Thefollowingaretopicsofconsiderationandrecommendationonbehalfofthetaskforceforensuringthegrowthofaccesstoqualityhealthcareservices:DentalandOralHealthCoverageRetainingdentistsinruralareasMississippicurrentlyhas835generaldentalpracticesand360specialtydentalpractices.Thisisseenasanadequatenumberofdentistswhencomparedtothestate’spopulation,butduetoscaleandmarketfactors,thesepracticesareheavilylocalizedinurbanareasandarenotadequatelydistributedamongruralpopulations.Significantworkisneededtoretaindentistsinruralareas.ItisrecommendedthatfullfundingandsupportoftheMississippiRuralDentalScholarshipProgramisretainedandmade(formerlyreferencedinthisdocument).SupportingtheDonatedDentalServicesProgramTheMississippiDonatedDentalServicesprogramisacoordinatedvolunteerdentalserviceacrosstheStateofMississippi.MorethanthreemilliondollarsworthofvolunteerservicesareprovidedeachyearthroughthisprograminthemostvulnerablecommunitiesinruralMississippi.However,fundingforastatecoordinatorpositionwasrecentlyeliminatedfromtheMississippiDivisionofMedicaidbudget,resultinginadramaticreductioninthenumberofvolunteerservicesofferedinruralareas.Fundingforthispositionisapproximately$60,000peryear.ItisrecommendedthatasourceoffundingfortheDonatedDentalServicesProgramtocontinuethecoordinationofvolunteerdentalservicesinruralMississippi.Asa

result,coordinationofvolunteerdentalservicesshouldbeprioritizedforruralMississippicounties.LeverageTele-DentistryServicesforGreaterOralHealthOutreachTele-dentistryhasbeenobservedacrossthenationtoprovidedentaloutreachservicesinareaswhereadentistisnotphysicallylocated.Suchcouldhelptoprovidescreeningsforchildreninschools,detectoralhealthconcernsandprovidepreventivetreatmentsasneeded.Mississippicurrentlyhasbarriersinplacethatpreventtele-dentistryfromoccurring,resultinginanunfilledgapincareinruralcommunitieswhereadentistisnotphysicallylocated.ItisimportantthattheBoardofDentalLicensureworktoaddresspotentialintheprogramandtoimplementnewrulesasneededtoincreaseaccesstocare.Itisrecommendedthatexistingfacilitiesareutilizedtotheirmaximumcapacityinconnectionwithapotentialtele-dentistryprogramstoensurethatruralareasareaddressedinregardstodentistry,andthatconsiderationbemadebytheMississippiStateBoardofDentalExaminerstoutilizetele-dentistrystatewideforgrowingaccesstopreventivetreatmentandscreeningsfororalhealthneeds.IncreasedMedicaidFundingforDentalServicesTheMississippiDivisionofMedicaidisgeneroustosupportdentalservicesforbeneficiariesinMississippi,asthisisnotaCMSrequiredservicefordeliveryofthestateMedicaidprogram.Althoughaveryhelpfulserviceforpatients,thereimbursementlevelsforprovidersisoftenlessthanthecostoftheservicesdelivered.ThishascreatedanenvironmentwhereareducednumberofdentistswillenrollasaMedicaidoralhealthprovider.ItisrecommendedthattheMississippiDivisionofMedicaidinvestigateincreasedreimbursementforvitaloralhealthservicesinruralareas.ServicesLeverageTele-PharmacyServicesforIncreasedAfter-HoursPharmacyAccessMississippicurrentlyhas276totalpharmacylocationsinMississippi,providingaccesstoprescriptionmedicationandsuppliesforpatients.Inadditiontophysicalpharmacylocations,alternativeservicessuchasmail-orderdeliveryhashelpedtoprovideneededmedicationtopatientswhentransportationoraccesshasbeenanissue.

Tele-pharmacyservicesarenewservicesthatwouldallowpharmaciestoaccessaremotepharmacistduringafterhourstimesforcontinuingdispensingservices.Suchmaybeutilizedbybothcommercialandfamilypharmacies,allowingthemtoprovideservicesusingamoreefficientstaffingmodelwhenneeded.Thiswillallowpatientstoaccessprescriptionmedicationoutsideoftraditionalofficehours.Mississippicurrentlyhasbarriersinplacethatpreventtele-pharmacyfromoccurring,resultinginabarrierforpharmaciestoreceivebackupservicesbyusingatelehealthcomponent.Itisrecommendedthatexistingfacilitiesareutilizedtotheirmaximumcapacityinconnectionwithapotentialtele-pharmacyservices,asthattheMississippiBoardofPharmacyconsiderarevisiontopoliciesandrulesthatwillallowtele-pharmacytoprovidebackupcoveragetoexistingpharmacieswishingtoprovideafter-hourscoverageforpatients.Behavioral/MentalHealthServicesStrengthenRuralIntegrationoftheMobileCrisisResponseTeamsTheMississippiDepartmentofMentalHealthhasdevelopedmobilecrisisresponseteams,designedtohelppeoplewhoareexperiencingasituationwheretheperson’sbehavioralhealthneedstheavailableresourcestoeffectivelyhandlethecircumstances.Deployedinall82counties,theseteamsconsistofmentalhealthprofessionalswhoprovidesupporttopeopleexperiencingamentalhealth,alcoholanddrug,orintellectualanddevelopmentaldisabilitycrisis.TheseteamshavebecomeproficientathandlingmentalandbehavioralhealthcrisesinruralMississippi.However,theunderstandingoftheirroleinthehospitalandclinicsettingisstillnotwellunderstood.ItisrecommendedthataformalconnectionismadebytheMississippiDepartmentofMentalHealthandpeerhealthcareassociationstostrengthenthepartnershipbetweenthemobilecrisisresponseteamsandruralfacilities.GrowingAccesstoPsychiatryThroughTele-psychiatryServicesMississippicurrentlyhas14mentalandbehavioralhealthcentersand135activelypracticingpsychiatrists,mostofwhichworkinurbanareas.ThiscriticalshortageofavailableprovidersisahugecontributortowardthegapinaccesstomentalandbehavioralhealthcareinruralMississippi.

However,thegrowthoftele-psychiatryservicesoffersaveryefficientandeffectivewaytogrowservicesinareasthatmaynotbeabletosupportafull-timepracticeotherwise.Manypatientshavebeenknowntoreportapreferencetotele-psychiatryservicesoverin-personpsychiatryservicesduetothereducedstigmaofreceivingsuchservicesinaprimarycaresetting.Itisrecommendedthatasignificantgrowthintele-psychiatryservicestakeplace,withanemphasisthatruralhealthfacilities,includingclinics,hospitals,andcountyhealthdepartments,shouldconsideradoptionandimplementationofsuchservices.IntensiveCommunityOutreachandRecoveryTeam(ICORT)TheIntensiveCommunityOutreachandRecoveryTeam(ICORT)focusesonadultswithsevereandpersistentmentalillnessandalignsastreamlinedteamaroundthesepatientsthatismorecosteffectivethanthetraditionalProgramonAssertiveCommunityTreatment,whichismorecostlyandinvolvesmoreprofessionals.TheICORTprogramismoreeffectiveinruralsettingsbyleveragingfewerprovidersandcreatingamoreefficientcareplan.ThereiscurrentlyapilotofthisprograminRegion2.ItisrecommendedthatacontinuedsupportandgrowthoftheICORTprogramtakeplacethroughtheMississippiDepartmentofMentalHealthforhandlingadultswithsevereandpersistentmentalillnessSchool-BasedTelehealthOneofthegreatestopportunitiesthatMississippihastoimproveaccesstocareisthroughtelehealthservices.Asalreadymentioned,telehealthservicesmayextendprovidersintoareaswhereaccessisnotcurrentlyfound.Suchanopportunityisfoundattheschool-basedsetting.Currently,school-basedclinicsarenoteligiblethroughtheDivisionofMedicaidtoprovidetelehealthtostudentsandreceivereimbursementforsaidservicesduetositeofserviceandpresentingproviderregulations.SelectruleandpolicychangeswiththeMississippiDivisionofMedicaidstatecodewillallowahugeincreaseinaccesstoprimarycareservices,whichwouldallowstudentstostayinschool,parentstostayatwork,andprovidequickercarewhichwillhelptoalleviatethespreadofillnessinadensepopulation.SuchwouldcontinueMississippi’spositionasanationalleaderintelehealthdeliveryservices.ItisrecommendedthatneededrulesandregulationsarealteredtoallowtheMississippiDivisionofMedicaidtoprovidereimbursementfortelehealthservicesintheschool-basedsetting.

EmergencyMedicalTransportation(EMS)OneofthegreatestchallengestoMississippi’sruralhealthisreceivingaccesstoambulancetransportation.Thereiscurrentlynostatewideambulanceserviceorcoordinatedambulanceservices,aseachcountymanagesitsownambulancecontractwithoutsignificantcoordinationwithsurroundingcounties.TherearecurrentlyseveralveryrobustambulancecompaniesinMississippithatserveextendednetworksinamulti-countyrange.Thisallowsagreatercoordinationofresourcestocoverareasthathaveahighneed.Atthesametime,somecountieshaveverylimitedcoveragewithlesssophisticatedambulancenetworksthatareunabletoleverageextendedresourcestofillneedsastheyarise,leavingruralpatientswaitingextendedperiodsforlife-savingemergencytransportationtoarrive.CreatingStableFundingforEMSTransportThecostofoneambulance,includingpersonnel,isapproximately$900,000peryear.Ambulanceservicesareusuallypaidbycommercialinsurance,withasmallamountreimbursedthroughMedicare,Medicaid,andwithlimitedcountysupport.Asruralcitizenshavelesscommercialcoveragethanurban,thisplacesanaturalpressureonambulancecompaniesattemptingtosurviveinruralMississippi.Sparsegeographicpopulationsinruralareascreatelongerambulanceruns,thereforeincreasingthecostofeachrunandtyinguptheambulanceteamsforlongerperiods.Theresultisthinnercoverageofmultiplecountiesandthelikelihoodthatpatientswillgoextendedtimebeforeanambulancearrives.Thesedelayscanbethedifferenceinlifeanddeath.Payingforthefixedcostofstandbycoverageisessentialtomaintainingasuccessfulemergencytransportsystem.ItisrecommendedthatastatewidesystembedevelopedtobetterorganizeMississippi’sambulancesystems.Thismaytakeplacewithmultiplecompaniesofferingservices,butthemeansbywhichtheseservicesarepaidmustbecomemoreefficientandconsistent.ItisrecommendedthatastudybeconductedtoanalyzewhetherasetpropertytaxallocationonthecountylevelcouldfullysubsidizebothEMStruckandhelicoptercoveragestatewide,resultinginnooutofpocketcostforpatientswhileprovidingsubstantiallybetterambulancecoverageinruralMississippi.ItisrecommendedthattheStateofMississippishouldconsiderleveragingtheEMSserviceslineinthestatetraumafundasaMedicaidmatch.

ProvidingAdditionalHealthCoveragewithAmbulance-BasedTelehealthServicesareemergingthatprovidespecialtyandemergencycareforparamedicsinambulancestoimprovepatientstabilizationpriortoarrivalatemergencydepartments.Asambulancesareequippedwithgreatertechnology,integratingtelemedicinecapabilitiesintotheambulancemayhelptoimprovepatientoutcomesandbetterallowemergencyproviderstotreatthepatientfasterwhenarrivingatthehospital.ItisrecommendedthatEMSprovidersbegintoequipambulanceswithtelemedicineservicesandtrainparamedicswiththeskillsneededtousesuchservicesinordertocreatemoreefficientandeffectiveemergencytreatmentforimprovingpatientoutcomes.Non-EmergencyMedicalTransportNon-emergencytransportationisfoundinMississippi’surbanareas,andinlimitedcapacityinruralareas.Thelimitedscopeofruralnon-emergencytransportationisnotenoughtofulfillthemanyneedsforsuchservicesbyruralpatients.Mississippimustplaceanemphasisonnon-emergencytransportoptions,wherepatientsneeding“wheelchairtransport”canutilizeanon-emergencyvanratherthanahigher-costambulance.Inaddition,suchserviceswouldhelptoprovidetransportationforthosefacingnegativesocialdeterminantsofhealth.Providingtransportationwhereotherwiseunavailablewouldhelppatientstoaccesshealthyfoods,accesswellnessandpreventativeservices,andbemoreempoweredtocontroltheirownhealthoutcomes.Servicescouldincludetheuseoflocaltransportcompanies,additionalservicesfromEMSproviders,oralternativeoptions.Itisrecommendedthatafocusonnon-emergencytransportservicesforallconditionsnotrequiringaccesstoemergencytransportservices,includingthoseaffectingsocialdeterminantsofhealth.Itisrecommendedthatalternativesourcesoffundingshouldbeexplored(i.e.USDAfunds)forgrowingandsustainingnon-emergencymedicaltransportationsystems.AppropriateUtilizationofServicesAccesstocaredoesnotjustmeantheavailabilityofservices,butalsotheutilizationofappropriateservices.Toooftenpatientsareutilizinghighercostservicessuchasemergencydepartmentswhentheprimarycaresettingisfarmoresuitedfortheirindividualneeds.Theremustbeadistinctfocusoneducatingpatientsastothemosteffectiveandavailablepointsofcarefortheirindividualneeds.Byproviding

bettereducationforpatients,facilitieswillbeabletoreducecostandprovidehigherlevelsofcare.ItisrecommendedthatMississippihealthcareentities,providers,andpeerorganizationscontinuetoeducatethepublicontheappropriateuseandaccessofemergencytransportservices,non-emergencytransportservices,hospitalemergencydepartments,preventiveservices,andotheravailableservicesinthecommunity.

TransformingcurrenthealthcarepracticesAsMississippiworkstosustainitscurrenthealthcareinfrastructureandprovideadditionalaccesstocare,thestatemustalsotransformitscurrentruralhealthinfrastructureandpracticesintothoseofthefuture-practicesthatprovidemoreefficientcarewithpatientoutcomesin-mind.Futuremodelsconsistlargelyofvalue-basedcarethatdelivershigherqualityservicesforpatientswhileleveragingtechnologyandefficiencymodelstoreallocateresourcesandreducecost.Thesenewmodelsaremorestable,meettheneedsoftheircommunities,andprovidegreatercollaborationamongmultiplehealthcaresystems.Mississippimustbegintopivottothesenewmodelsofsupportandcareinordertomeettheneedsofourstate’sfuturehealth.MississippiRuralHospitalTransitionandImprovementGrantProgramMostofMississippi’sruralhospitalswereconstructedusingHill-Burtonfundinginthe1950’s,andmanyofthefacilitieshavereceivedfewvisibleupdatessincethattime.Asaresult,theperceptionofourruralhospitalsisthattheydeliveroutdated,inferiorcaretotheirurbancounterparts.Qualityscoresandpatientoutcomesshowthatthisperceptionisnotreality,andruralhospitalsthathavebeenabletorebuildorrepurposetheirfacilitieshavedemonstratedsignificantincreasesincensus.However,asmostofMississippi’sruralhospitalsarefinanciallydistressed,theydonothaveamarginavailabletoleverageforsignificantfacilityimprovementsorrestructuring.Additionally,ruralhospitalsmustmeetthesameregularityrequirementsforthePromotingInteroperabilityProgramasotherhospitals,yetoftendonotneedtheadditionaltechnologyfunctionalitycontainedinrequired,expensivesystemupgrades,nordotheyhavetheavailableinfrastructuresuchas

adequatebroadbandtosupport.Asaresult,thisoftenleadstoa“piecemeal”solutiontoaruralhospital’stechnologyandelectronicmedicalrecord,whichaffectproductivity,revenuecycleintegrity,access,andqualityofcare.Mississippi’sruralhospitalsneedafundingpoolavailabletothemfordirected,specificconstructionandrepurposingprojects.Suchmayincluderebuildingfacilities,redesigninglayoutsformodernhealthcareservicedeliveryandgreaterefficiencies,or“rightsizing”thefacilityformoderncommunityneeds.Suchmayincludeincreasingordecreasingthesizeofahospital,orinselectcases,convertingastrugglinghospitaltoanafter-hoursclinicwithspecialtyservices.Itisimportantthatanaspectofanyfundingtakeintoaccountthehospitals’abilityanddirectivetotransformintoamorevalue-based,costefficientmodelthatdrivespreventiveservicesandopensnewopportunitiestoaccesstocareinacommunity.Thiswouldlookdifferentforeachcommunityaseachwouldhaveuniqueneedsandpopulationsneedingsuchservices.Anyapplicationforfundingshouldtakeintoaccountbothgreatersustainabilityofthefacilityaswellasafocusonvalue-basedcare.Inaddition,anyapplicationshouldaccountfora5-10yearmasterplanofthefacilitytodetailimplementedchangesandtheimprovementsthatwilloccurasaresult.In2017,Rep.SamMimsandabi-partisandelegationintheMississippiHouseofRepresentativessupportedameasuretocreatetheMississippiRuralHospitalTransitionandImprovementGrantProgram.Thisprogramwouldaccomplishthegoalssetforthinthisdirective.ItisrecommendedthattheMississippilegislaturecreateafundingpoolintheformoftheMississippiRuralHospitalTransitionandImprovementGrantProgramunderthedirectionandadministrationoftheMississippiStateDepartmentofHealth,ortheMississippiDivisionofMedicaidasdeemedappropriate.Thisfundmayincludeacombinationoffederal,state,andlocalmatchingfunds.Coupledwithlong-termdebtfinancing,thesefundscouldtransformstruggling,outdatedruralhospitalsintofacilitiesthatbetterservetheircommunities.Fundingofthisprogramshouldbesubstantial,allowinghospitalstoapplyforfundingtoresolvemajorone-timeinfrastructureimprovementsorfinancialreorganization.DevelopHospital‘CentersofInnovation’AcrossMississippiAsMississippi’shospitalshaveaseverelackofresources,theymustdesignatethoseresourcestowardprogramsthathavethebestopportunityforsuccessandthatmeettheneedsofthemajorityofthepatientsinthecommunity.Tothisextent,ruralhospitalsshouldnotknowinglyduplicateservicesofanearbyfacilitywhenoneofthemcouldbettersupplythoseservicestobothcommunities.

Hospitalsneedtoworkwithpeerfacilities(includingnon-hospitalfacilities)todevelop“CentersofInnovation.”Thiswouldallowfacilitiestofocusonthein-patientandout-patientservicesmostneeded,andcoordinatewithsurroundingfacilitiestotransportpatientstotheservicesofferedthatbestmeettheneedsofthepatient.ThiscoordinationwouldworkbestinaformalorganizationalstructuresuchasanACOorCIN,butmayalsotakeplaceoutsideofsuchastructurethroughinformalagreements.Bydivertingvaluableresourcesintothemostrevenue-generating,community-neededservices,hospitalsmayincreasecapacityandbringahigherlevelofcaretotheirpatients.Thiswillresultingreaterrevenue,increasedpatientoutcomes,andincreasedpatientsatisfaction.Itisrecommendedthathospitalstransitionfromdeliveringmoderate-levelcareamongallavailableservicestocoordinatingwithneighboringfacilitiesfordevelopmentof“CentersofInnovation”inaregionalformatforgreaterefficiencyandqualityofcare.SuchcoordinationshouldbesupportedbytheMississippiStateDepartmentofHealth,theMississippiDivisionofMedicaid,andpeerhealthcareassociations.LeveragetheStrengthofAccountableCareOrganizations(ACOs)andClinicalIntegratedNetworks(CINs)AccountableCareOrganizationsandClinicalIntegratedNetworkshaveshowngreatsuccessinruralstatesbyorganizingfacilitiesandpatientsintomanageablepopulationsforfacilitiestousevalue-basedoutcomesasthedrivingindicatorofsuccess.Thismodelreceivesmostparticipationfromhospitalsandfederallyqualifiedhealthcenters,butitisalsoutilizedbyruralhealthclinicsandotherentities.InMississippi,existingACOsareonlyforMedicarepatients.ItispossibletoextendACOstoMedicaidandcommerciallyinsuredpatientpopulationstofurthereffortsforqualitycare.Facilitiesareincentivizedwithsharedsavingsbonuses,andinsurerspayfewerdollarsincareduetosavingsinthesystem.ThedownsidetoACOsisthehighburdenofreportingandnon-patientcentricservicesandpersonnel,whichrequirealargestart-upinvestmentandstart-upbusinessrisk.ACOsarebeginningtoemergethroughcollaborationamongruralareas.MedicarehasalreadyestablishedseveralACOmethodologiesanditalreadysharespatientdatawithACOstofacilitatesuccess.Commercialandself-insuredemployerACOsaremoredifficultduetothefollowing:

• Thenumberofclaimsdatabasesarescatteredamongmultiplecommercialpayersandthird-partyadministratorswithdisparatedataelementsandformats.

• ThereisnooneACOformatforthecommercialandself-insuredemployermarket,sonegotiationismorecomplex.

• EmployedmembersuselesshealthcarethanMedicarepatients,sotheACOtechniquesthataresuccessfulforMedicarepatientsmayormaynothavebenefitsexceedingtheACOcaremanagementcosts.

AnadditionalbenefitoftheACOandCINisthatnetworksmaybeabletoleveragepurchasingcostandcontractnegotiationforreducedpharmaceuticalcost,improvedinsurercontracts,andotherbundledservices.Inaddition,theseentitiesfocusonthesocialdeterminantsofhealthoftheirdesignatedpatientpopulationsandencourageafocusonkeepingpatientshealthy,whichincludestheirlivingenvironmentandlifestyleissues.TheMississippiHospitalAssociationandtheCommunityHealthcareAssociationofMississippirecentlystartedastatewideACOnetwork,whichincludesmostruralhospitals,FQHCsrespectively.Includingmoreruralprovidersandpatientsunderthesenetworkscanhelptoprovidenetworkdataforpatientoutcomesandallowadministratorsandofficialsto‘drilldown’tothecoreissuesmoreeffectively.ItisrecommendedthatruralfacilitiesstronglyconsiderinclusioninthestatewideACOs,andthatfundssuchasthestateFLEXgrantcontinuetobeutilizedtohelpfundACOinfrastructureneeds.IncentivizeParticipationinPatientCenteredMedicalHomesThePatient-CenteredMedicalHome(PCMH)isacaredeliverymodelwherebypatienttreatmentiscoordinatedthroughthepatient’sprimarycarephysiciantoensurethepatientreceivesthenecessarycarewhenandwhereitisneeded,inamannerthepatientcanunderstand.ThePatientCenteredMedicalHomeisacentralizedsettingthatfacilitatespartnershipsbetweenindividualpatients,andtheirpersonalphysicians,andwhenappropriate,thepatient’sfamily.Careisfacilitatedbyregistries,informationtechnology,healthinformationexchangeandothermeanstoassurethatpatientsgettheindicatedcarewhenandwheretheyneedandwantitinaculturallyandlinguisticallyappropriatemanner.SeveralpayersinotherstateshaveinitiatedincreasedreimbursementforservicesforfacilitiesadoptingthecertifiedPCMHstatus(i.e.AlabamaMedicaid).SuchcanbethesameinMississippi,wherepayerscanrewardqualitycarewithenhancedpaymentsforPCMHfacilityservices.

ItisrecommendedthatruralfacilitiesmovetoadoptPCMHcertification.Inreturn,itisrecommendedthattheMississippiDivisionofMedicaidandprivateinsurersseektoinvestigatefundingincentivestofacilitiesadoptingcertifiedPCMHstatus.ConsiderFinancialStabilizationwithGlobalBudgetingCMSisexploringandpilotinganewconceptcalledtheGlobalBudget.ThisconceptiscurrentlybeingpilotedinPennsylvania,Maryland,andVermont.Theglobalbudgetisathree-yearlook-behindaverageoftheinsurer’s“spend”ateachfacility,andaveragedovertheperiodasapaymentpermonth.Adjustmentsaremadeonanannualbasisforfluctuationsinpatientvolumeandexpense.Theupsidetotheglobalbudgetmodelisthathealthcarefacilitiesenjoyastableincomingstreamthatsimplifiestherevenue-cyclechallenges,andtheyhaveanaturalincentivetoprovidequality,low-costcareinordertosavemoneyandkeepprofits.Fromtheinsurer’sperspective,theycanbetterpredicttheirpaymentscheduleandshifttherisktotheprovider,betterensuringprofitability.Thereshouldbelittledifferenceobservedfromthepatient.Afterlimitedinvestigationfromthetaskforce,itwasundeterminedastowhetherGlobalBudgetingwouldbebeneficialtoMississippi’shealthcaresystem.Itwasseentoshowpromise,butthereareseveralkeyissuesthatneedtobefurtherinvestigatedtodetermineitslong-termimpact.ItisrecommendedthataformalcommitteebeestablishedbytheMississippiLegislatureorGovernor’sOfficetospecificallyinvestigatetheGlobalBudgetingmodel,analyzingitseffectonMississippihospitalsandclinics.ThiscommitteeshouldconsistofrepresentativefromallpublicandprivateinsuranceprovidersintheStateofMississippi,aswellasrepresentativesfromthehealthcareindustry.EncourageHealthcareDataMiningandRiskStratificationThereisaneedinMississippiforsubstantiallymoresystem-widedatafortrackingpatienthealthoutcomes,monitoringpatientmigrationpatternsbetweenfacilities,andprovidingdirectedpreventiontowardthehighestriskpatients.Asystematicdataminingcoordinatedeffortisneededtoallowallfacilitiestohavethedataandtoolstheyneedtodecipherdataintomeasurableperformancemeasuresandstrategiesforimprovementbothpatienthealthandfacilityhealth.Inaddition,theriskstratificationfactorsenforcedbyeachpublicandprivateinsurerinMississippicausehealthcareprovidersandfacilitiestobeforcedtomonitorandreportnearlyhundredsofpointsofdata.Itbecomesnearlyimpossible

forallbutthelargesthealthcaresystemstotrackandimprovedatascoreswhensomanyareenforcedbyinsurancecompanies.ItisrecommendedthatacommitteebeestablishedtospecificallyinvestigatethecreationofauniversalriskstratificationtooltobeusedonanannualbasisbyallMississippihealthinsurancecompaniesinordertoallowproviderstoimprovedirectedscoresasdictatedbythestratificationtool.ItisfurtherrecommendedthattheMississippiStateDepartmentofHealthbecometheclearinghouseforobtaininganddistributinghealthcaredataforhospitalsandclinicsinordertoallowthemtoimprovefunctionalityandpatienthealthimprovement.

TrackingProgressThetaskforcefeelsstronglythatMississippishouldtracktheprogressoftheaforementionedpolicyrecommendationstoensurethesuccessofthisplan.TrackingshouldtakeplacethroughtheMississippiStateDepartmentofHealthandMississippiDepartmentofMentalHealthforapplicablecategories.Theseagencieswillnotbetaskedwithleadingtheseefforts,butrathertrackinganydata-drivenprogressasaresultoftheeffortsinaccordancewiththeirindividualdatatrackingeffortscurrentlyinplace.Thefollowingarerecommendedpointsofdatawithsuggestedlevelsofimprovement.FinancialstabilityImproveeachMississippihospital’stotaloperatingmarginabove1.4%ThisisaMoody’sBaamedian/lowestinvestmentgrade,astrackedbyseveralfinancialstudiesanalyzingfinancialhealth.Beginimmediately,completebyDecember2021Improveeveryhospitalandclinic’sdailycashonhandtomorethan78.5daysThisfigurerepresentshalfofMoody’sBaamedian,astrackedbyseveralfinancialstudiesanalyzingfinancialhealth.Beginimmediately,completebyDecember2021

Improvehospitaldebttocapitalizationratiotolessthan49.8%ThisfigurerepresentsMoody’snoninvestmentgradegroupingmedian,astrackedbyseveralfinancialstudiesanalyzingfinancialhealth.Beginimmediately,completebyDecember2021InvestigatetheglobalbudgetingconceptforMississippiAtaskforcededicatedtoglobalbudgetingshouldbeestablishedtoinvestigatetheimpactofthestreamlinedrevenuecycleprocessinMississippi.Establishin2020,withfindingspresentedbyDecember2020LowerthecostofEmergencyDepartment’sHospitalsshouldleverageopportunitieswithtele-emergencyorbyothermeanstoreducecost.Hospitalsshouldworktoreducethecostofoperationofemergencydepartmentsupto25%.Beginimmediately,completeby2022MississippiRuralHospitalTransitionandImprovementGrantProgramThisgrantprogramshouldbepassedbytheMississippilegislatureandplacedintoadministrationatfullfundingthroughtheMississippiStateDepartmentofHealth.Hospitalsmaythenbegintoapplyforfundingtoenactcapitalimprovements,undergoorganizationalandstructuralimprovements/changes,etc.Upto5applicationsshouldbereceivedeachyeardetailingthehospital’sdesiredimprovementwitha5-10yearimprovementplanoutlinedaspartoftheapplication.BeginJuly2020,continueongoingGrowingRuralAccessEstablishschool-basedtelehealthprogramsEstablishaminimumofthreeschool-basedtelehealthprogramsBeginimmediately,completebyDecember2020ReduceUrbanvsRuralDisparitiesLeveragepopulationhealthandpreventivescreeningsthroughvalue-basedhealthtoreduceurbanvs.ruralhealthdisparitiesby25%Beginimmediately,completebyDecember2022TransitionHospitalsandClinicstoValue-BasedCarePrepareaminimumof75%ofMississippi’shospitals,ruralhealthclinics,andfederallyqualifiedhealthclinicstoparticipateineitheranAccountableCareOrganization(ACO),aClinicallyIntegratedNetwork(CIN),oraPatientCenteredMedicalHome(PCMH)Beginimmediately,completebyDecember2022

Increasinglocally-deliveredservicesRuralhealthcareservicesshouldbecomingincreasinglyavailableandutilized.Byanalyzingclaimsdata,Mississippishouldseea25%increaseinavailableruralservices.Beginimmediately,completeby2022EstablishasustainablestatewideEMSnetworkMississippishouldworktobuildastatewideEMStransportationnetworkusingcurrentEMSproviderswiththecapacitytogrow.Fundingforthisprogramshouldoccurasapartnershipbetweencountiesandinsurers,withfullfundingprovidedforbothtruckandairtransportationatnocosttothepatient.Beginimmediately,completeby2024EducationandOutreachTrainruralproviderstoscreenforsuicideriskTrainatleast50providerstoscreenforsuicideriskusingMSDepartmentofMentalHealthtoolkits.Beginimmediately,completebyDecember2020PartnerhospitalsandMobileCrisisResponseTeamsStrengthenthepartnershipbetweenruralhospitalsandlocalmobilecrisisresponseteamsinordertoimprovepatients’health.Thisshouldresultaminimumof100newcallstotheresponseteams,50face-to-facevisits,and100diversionsfromamorerestrictiveenvironmentincludingemergencyrooms,jails,etc.Beginimmediately,completebyDecember2021ProvideConsultingandSupportforRuralHospitalsDuetothecomplexityofrevenuecycleoptimization,reimbursementprograms,contractsandservices,documentation,andutilizationneeds,itisrecommendedthatMississippi’sfivemoststrugglinghospitalsareidentifiedandreceivedirectconsultingservicestoassistwithhands-on,holisticimprovementstostructureandfunction.ThisconsultingshouldbecoordinatedthroughtheMSDHStateOfficeofRuralHealth.Beginidentificationimmediately,completebyDecember2021Developaleadership/boardtrainingsystemToprovideadditionalC-suiteandproviderleadershiptraining,acourseorcurriculumshouldbeestablishedtotrainatleast50ruralhospitalandclinicleadersinMississippi.Beginimmediately,completebyDecember2021

RegulatoryCreationofastatewidesinglesourceforcredentialingservicesTheMississippiDepartmentofInsuranceshouldcreateafully-functionalstatewideonlinetoolforcredentialingproviders,thatshouldbeusedbyallinsurancecompanies(bothpublicandprivate)operatingintheStateofMississippi.Beginimmediately,completebyDecember2022.

References

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