Critical Access Hospitals (CAHs) have long played an important role in the provision of Skilled Nursing Facilities (SNF), swing bed, and other long term care (LTC) in rural communities and are more likely than other rural and urban hospitals to offer these services. The implementation of the Medicare SNF prospective payment system (PPS) in 1998 and subsequent exemption of CAH-based swing bed services from the SNF PPS in July, 2002 created financial incentives from CAHs to close their SNF units in favor of providing skilled level care using swing beds. During the period 2004 through 2007, 42 CAHs closed their SNF units. Despite the changing financial incentives related to the operation of SNF units by CAHs, 42% of CAHs (456) in 2010 continued to operate SNF units. Little is known about the reasons CAHs decide to close or retain their LTC services. This briefing paper and associated policy brief address this gap by examining the factors related to operation of skilled nursing services by CAHs, and specifically the factors related to closure of skilled nursing units by some CAHs and the continued provision of these services by others.

Key Findings:

• Critical Access Hospitals (CAHs) that closed Skilled Nursing Facility (SNF) units cited a range of financial challenges related to payer mix, operating costs, cost allocation methods, and service utilization patterns.
• The availability of alternative local long term care services, including swing beds, often contributed to hospitals’ decisions to close their SNF units.
• CAHs that continued to operate SNF units were driven primarily by community need, despite the financial disincentive for doing so.
• Hospitals reported substantial variation in their strategies for using swing beds for SNF, rehabilitation, and post-acute services.
• Given ongoing concerns about financial viability and low census rates among some CAHs, further research on the ability of CAHs to expand patient services and revenues through swing bed use is warranted.
• Additional research on the quality and outcomes of skilled care delivered by CAHs in SNF and swing beds is also recommended.

Suggested citation: Gale JA, Croll ZT, Coburn AF, et al.  Why Do Some Critical Access Hospitals Close Their Skilled Nursing Facilities While Others Retain Them?  Portland, ME: Flex Monitoring Team; December 2012.

Key Findings:

• Among those with the highest levels of mental health need, rural children are more often identified with an ADHD diagnosis than urban children (24.7% vs. 19.8%; p<.05).
• The higher prevalence of ADHD diagnosis and stimulant prescribing in rural areas likely results from a greater need for such treatment, based on scores from the Columbia Impairment Scale.
• Among those with a possible mental health impairment, rural children are less likely to be diagnosed with a psychiatric illness other than ADHD and are less likely to receive counseling.
• Higher rates of poverty, public coverage, and mental health impairment among rural children explain their greater likelihood of a mental health prescription and stimulant use.

Suggested citation: Anderson, N., Neuwirth, S., Lenardson, J.D., & Hartley, D. (2013, April). Rural children experience different rates of mental health diagnosis and treatment. (Research & Policy Brief). Portland, ME: University of Southern Maine, Muskie School of Public Service, Maine Rural Health Research Center.

The Muskie School of Public Service hosted two health policy colloquia this April to promote informed discussion throughout the state regarding MaineCare coverage options under the ACA and the implications of Vermont’s move toward a single-payer system.The series, sponsored by the Muskie School Board of Visitors, offers community conversations in which experts from various disciplines and perspectives inform and engage the broader public to explore and debate critical policy issues. On April 22, community and sector leaders joined for Global Budgets, Payment Reform, and Single Payer: Understanding Vermont's Health Reform. Participants discussed Vermont's recent movie toward single payer health care and how the state is cutting costs and improving how health care is delivered, as well as the implications for Maine.

Anya Rader Wallack, chair of the Green Mountain Care Board, presented on ways in which the state is seeking to make heath care a public good, creating an integrated delivery system, and moving to a single system where access to health coverage is not linked to employment.

Read the brief authored by Trish Riley of the USM Muskie School.

The Affordable Care Act (ACA) requires Health Insurance Exchanges (HIEs) to specify network adequacy standards for the Qualified Health Plans (QHPs) they offer to consumers. This article, authored by research staff at the Maine Rural Health Research Center, USM Muskie School, examines rural issues surrounding network adequacy standards, and offers recommendations for crafting standards that optimize rural access.

The authors review ACA requirements for QHP network adequacy standards, considering Medicaid managed care and Medicare Advantage (MA) standards as models, and analyze the implications of stringent vs flexible access standards in terms of how choices might affect health plans' participation in rural markets and rural enrollees' access to care. The authors propose strategies for designing standards with the degree of flexibility most likely to benefit rural consumers, including adjusting standards according to degrees of rurality and rural utilization norms; counting midlevel clinicians toward fulfillment of patient-provider ratios; and allowing plans to ensure rural access through delivery system innovations such as telehealth.

Suggested Citation: Talbot, J. A., Coburn, A., Croll, Z. and Ziller, E. (2013), Rural Considerations in Establishing Network Adequacy Standards for Qualified Health Plans in State and Regional Health Insurance Exchanges. The Journal of Rural Health. doi: 10.1111/jrh.12012