A proposed rule that would have kept cigarette smoke away from infants in foster care was tabled Wednesday during a meeting of the House Health Committee at the North Carolina General Assembly. This is the fourth time Rep. Tricia Cotham (D-Matthews) has proposed a rule to protect foster children from smoke, and the fourth time she has faced pushback by her fellow representatives.
Rep. Tricia Cotham (D-Matthews) Photo courtesy N.C. General Assembly
“While I believe the bill’s sponsors have the absolute best intentions,” said Rep. Nelson Dollar (R-Cary), “I really have serious, serious problems with this bill.”
Dollar said that a bill to limit tobacco-smoke exposure would also restrict parents’ freedom within their homes. He worried about how the state would regulate such a plan, and whether friends of the family or grandparents would also have their smoking habits restricted.
Some studies have connected exposure to smoke with Sudden Infant Death Syndrome.
Many foster children suffer from one or more health issues, with asthma or other disorders of the airway being common complaints. Cotham said she believes strongly that North Carolina should be the 19th state in the U.S. to restrict smoking near foster infants.
“We don’t allow prison guards to smoke because we don’t want inmates to breathe in smoke,” she said. “I think we should protect babies as well.”
No Doctor’s Note Needed for Handicap Parking Pass
If passed, House Bill 434 would reduce the paperwork requirements for people who are 100 percent permanently disabled to get a handicap parking pass.
By Hyun Namkoong
House Bill 434 received a favorable report in a transportation committee meeting Wednesday. If passed, the law would no longer require people who are 100 percent permanently medically disabled to get recertified by a doctor every five years to acquire a handicap parking pass.
Rep. Susan Martin (R-Wilson), one of the bill’s primary sponsors, said a veteran in her district asked her to do something to remove the requirement of having a doctor’s note to renew the handicap parking pass. She said recertification can be overly expensive for many individuals.
Martin said the Department of Motor Vehicles supported the proposed legislation, but asked to have until 2016 to institute the changes.
Tax-time Tribulations: Health Law Complicates Filing Season For Many
This tax season, for the first time since the health law passed five years ago, consumers are facing its financial consequences. Whether they owe a penalty for not having health insurance or have to reconcile how much they got in premium tax credits against their incomes, many people have to contend with new tax forms and calculations. Experts say the worst may be yet to come.
When Christa Avampato, 39, bought a silver plan on the New York health insurance exchange last year, she was surprised and pleased to learn that she qualified for a $177 premium tax credit that is available to people with incomes between 100 and 400 percent of the federal poverty level. The tax credit, which was sent directly to her insurer every month, reduced the monthly payment for her $400 plan to $223.
A big check from a client at the end of last year pushed the self-employed consultant and content creator’s income higher than she had estimated. When she filed her income taxes earlier this month she got the bad news: She must repay $750 of the tax credit she’d received.
Avampato paid the bill out of her savings. Since her higher income meant she also owed more money on her federal and state income taxes, repaying the tax credit was “just rubbing salt in the wound,” Avampato said. But she’s not complaining. The tax credit made her coverage much more affordable. Going forward, she said she’ll just keep in mind that repayment is a possibility.
It’s hard to hit the income estimate on the nose, and changes in family status can also throw off the annual household income estimate on which the premium tax credit amount is based.
Like Avampato, half of people who received premium tax credits would have to repay some portion of the amount, according to estimates by The Kaiser Family Foundation. Forty-five percent would get a refund, according to the KFF analysis. The average repayment and the average refund would both be a little under $800. (KHN is an editorially independent program of the foundation.)
Tax preparer H&R Block has also looked at the issue. It reported that 52 percent of people who enrolled in coverage on the exchanges had to repay an average of $530 in premium tax credits, according to an analysis of the first six weeks of returns filed through tax preparers. About a third of marketplace enrollees got a tax credit refund of $365 on average, according to H&R Block.
The amount that people have to repay is capped based on their income. Still, someone earning 200 percent of the poverty level ($22,980) could owe several hundred dollars, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. People whose income tops 400 percent of poverty ($45,960 for an individual) have to pay the entire premium tax credit back.
Experts say the message for taxpayers is clear: If your income or family status changes, go back to the marketplace now and as necessary throughout the year to adjust them so you can minimize repayment issues when your 2015 taxes are due.
Many people are learning about what the health law requires and how it affects them for the first time when they come in to file their taxes, said Tara Straw, a health policy analyst at the Center on Budget and Policy Priorities. For the past 10 years, Straw has managed a Volunteer Income Tax Assistance site in the District of Columbia as part of an Internal Revenue Service program that provides free tax preparation services for lower-income people.
Some of the recently initiated owe a penalty for not having health insurance. For 2014, the penalty is the greater of $95 or 1 percent of income. The H&R Block analysis found that the average penalty people paid for not having insurance was $172. Consumers who learn they owe a penalty when they file their 2014 taxes can qualify for a special enrollment period to buy 2015 coverage if they haven’t already done so. That would protect them against a penalty on their next return.
People may be able to avoid the penalty by qualifying for an exemption. Tax preparers rely on software to help them complete people’s returns, including the forms used to reconcile premium tax credits and pay the penalty for not having insurance or apply for an exemption from the requirement. For the most part, the software is up to the task, Straw said, but it comes up short with some of the more complicated calculations.
Case in point: applying for the exemption from the health insurance requirement because coverage is unaffordable. Under the health law, if the minimum amount people would have to pay for employer coverage or a bronze level health plan is more than 8 percent of household income they don’t have to buy insurance. That situation is likely to be one of the most common reasons for claiming an exemption.
But to figure out whether someone qualifies, the software would have to incorporate details such as the cost of the second lowest-cost silver plan (to calculate how much someone could receive in premium tax credits) and the lowest-cost bronze plan in someone’s area. The software can’t do that, so tax preparers must complete the information by hand.
“That one in particular has been vexing,” said Straw.
The gnarliest filing challenges may yet come from people with complicated situations, such as those who had errors in the IRS form 1095A that reported how much they received in premium tax credits, experts say.
Take the example of a couple with a 20-year-old son living at home who bought a family policy on the exchange. If midway through the year the son gets a job and is no longer his parents’ dependent, the family’s premium tax credit calculation will be off. The family needs to work together to figure out the optimal way to divide the credit already received between the two tax returns. The goal is to maximize the benefit to the family and minimize any tax credit repayment they may face.
“A lot of tax software is just not designed for that kind of trial and error,” said Straw.
This story originally appeared inKaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.
Welcome to Play
By Hyun Namkoong
Sen. Louise Pate (R-Mount Olive) spoke Wednesday in a legislative education committee meeting about encouraging children to move away from computer and television screens and go out outdoors to play. He is one of three primary sponsors of Senate Bill 315, legislation that would allow children to use school playgrounds after school hours.
“In this day of getting kids to put down their iPads and iPhones and get out and do some exercise, I think we’re missing a great area of resources that can be used for that very thing after school hours. And that is the outside playgrounds of our public schools,” Pate said.
“If they’re not used for other purposes after school hours are over, with certain conditions, they should be open to the kids. After all, the taxpayer paid for the facilities,” he said.
Sen. Angela Bryant (D-Rocky Mount) spoke in favor of the bill, saying it would be a positive step in fighting the state’s obesity epidemic, especially for small towns and counties that don’t have the money to build recreational departments.
The bill passed out of the Senate Education Committee and now goes to the Senate floor for consideration.
WNC Rural Health Symposium Underscores Issues, Offers Solutions
Health care providers, educators and students gathered in Asheville last week to discuss the region’s health care needs.
By Taylor Sisk
Visits to a doctor, nurse practitioner or dentist’s office are obviously critical elements of maintaining overall health. But the effectiveness of those visits is determined to a large extent by what happens outside of those offices – in the home, the workplace, the community.
Rural Rx: NC Health News coverage of rural health issues. This week: Western NC
This was a recurring theme at Friday’s first annual Western North Carolina Rural Health Symposium, hosted by Western Carolina University’s School of Nursing and held at the Holiday Inn Biltmore West in Asheville.
Creative approaches to helping people maintain or restore good health are critical in rural areas with fewer resources. This point was underscored by a number of symposium speakers.
Judith Long, executive director of The Free Clinics of Henderson County, which provides free health care services to low-income, uninsured residents, described the clinic’s caseload: “the hardest patients with the most complex medical conditions, exacerbated by procrastination of care, lack of financial means and all the life issues this encompasses.”
Among these issues, Long said, are illiteracy, transportation barriers, transient living situations and mental health and substance abuse concerns.
Several speakers stressed the need for “culturally congruent” services – figuring out what works best for a particular community – and the importance of going “upstream” to better understand the causes of health and health care deficiencies.
Lisa Harmon, chair of the nursing department at the State University of New York’s College of Technology at Alfred and a specialist on rural health nursing, was keynote speaker and a facilitator for discussions.
What’s needed, Harmon said, echoing what she was hearing from the audience, is collaborative engagement and innovative strategies. That audience of some 100 included a number of students in a variety of health care fields, and exchanges were lively.
Lisa Harmon, chair of the nursing department at the State University of New York’s College of Technology, served as the WNC Rural Health Symposium’s keynote speaker. Photo credit: Taylor Sisk
Those with the most critical needs
Public health officials from throughout Western North Carolina reported issues with health care access, particularly behavioral health care, and high rates of diabetes, obesity, heart disease and mental health and substance abuse issues. They also reported an increasing incidence of opioid overdose.
These concerns reflect national concerns.
Rural residents generally receive fewer preventive services than urban residents, leading to more chronic diseases and conditions according to the Rural Policy Research Institute.
According to a report from the federal Agency for Healthcare Research and Quality, 1 percent of patients accounted for 21 percent of the nearly $1.3 trillion spent on health care in this country in 2010. Five percent of patients accounted for 50 percent of costs.
These patients are found disproportionately in rural areas, Long said.
What do our patients need? she asked. Certainly, a “tremendous amount of clinical intervention and care.” But perhaps most significantly, Long said, they need “recognition of their challenges, not punishment for bad behavior. They need empathy.”
“Life happens sometimes,” she said. “And with your patients, life happens more often than not, and dramatically.”
The symposium’s afternoon sessions involved breaking off into groups to discuss the primary issues rural Western North Carolina communities face and to suggest solutions.
Topics included the importance of knowing your patient’s social history and what they’ll be facing when they return home, and arranging supports accordingly.
Karen Cochran is director of WCU’s Rural Education and Support Scholarship Program. Photo credit: Taylor Sisk
A number of participants emphasized the urgency of addressing the stigma around mental health and substance abuse issues, which tends to be greater in rural areas.
Karen Cochran, director of WCU’s Rural Education and Support Scholarship Program and the symposium’s coordinator, said an idea that came out of the afternoon group discussions that particularly grabbed her attention was student-run community health fairs offering screenings, with educational booths that provide information related to the risks these screenings reveal. They could also offer, for example, gardening and cooking tips.
Such events could serve as students’ capstone or service learning projects, would be relatively easy to implement and would “have a lot of impact,” Cochran said.
Bill Filing Deadline Brings Flurry of Proposed Health Care Legislation
Senators filed more than 300 bills this week as they bumped up against their filing deadline.
By Rose Hoban
Everyone has deadlines: Taxpayers plan ahead for April 15, reporters need to file stories for publication by a certain time and lawmakers have deadlines to file bills for consideration during legislative sessions.
On Thursday, the North Carolina Senate had a deadline for bills that are not finance bills (those can be filed later) or local bills (those also can be filed later). Originally, the drop-dead time was 3 p.m. Then it was pushed until later in the afternoon. Finally, the bills stopped flying somewhere around 5 p.m.
By the time it was all done, 194 bills had been filed on Thursday alone. And at least 52 of the total 351 bills filed just this past week have health care implications, from proposals to oversee donations of venison to charities to defining sexual consent, to regulating opticians, to remaking the state’s Medicaid program.
Not every bill that’s filed will become law, and many are simply desires put down on paper or statements made to be used in the next campaign. But a look at the bills gives an idea of what lawmakers are thinking about.
Dueling Medicaid plans
Senators filed at least four different Medicaid reform bills on Thursday, laying bare the philosophical differences over how to change the program that persist despite close to two years of discussion.
Medicaid provides health care for close to 1.8 million low-income children, some of their parents, pregnant women and low-income elderly.
Chairs of the Senate Health Care Committee have their bills, with Sens. Louis Pate (R-Mt. Olive) and Tommy Tucker (R-Waxhaw) supporting a bare-bones bill with general language that has its origins in the Medicaid reform subcommittee process that took place last fall. That measure has a companion bill in the House with the same language and is sponsored by leaders from the House Health Committee.
Another co-chair from the Senate Health Care Committee, Ralph Hise (R-Spruce Pine), has filed his own version of a bill to “Modernize Medicaid”. Hise’s bill pulls administration of the Medicaid program out from the Department of Health and Human Services and creates a separate Health Benefits Authority with appointed members to oversee the program. That bill would move doctors, clinics and hospitals from getting paid on a fee-for-service system to one that places providers at “full financial risk” for managing costs, while improving their patients’ health care outcomes.
Hise calls for implementation of the new system over a four-year time period.
Hise has also filed a companion bill that would forbid the state from contracting with Community Care of North Carolina. That organization currently manages the care for many of the state’s Medicaid children and non-disabled adults using the medical-home model that has been found to save the state money and has been emulated in a number of states.
Yet another member of the same committee, Jeff Tarte (R-Cornelius), has filed a bill that would “Modernize Health Care,” containing a broad brush plan for Medicaid’s makeover. Tarte’s plan includes retaining Community Care of North Carolina but also includes creating “At-Risk Provider-Led Organizations,” which, similar to Hise’s plan, would expose doctors and hospitals to financial risk in organizations led by the health care providers themselves.
Different from Hise’s plan, though, Tarte’s plan would keep Medicaid administration within DHHS. Instead, his plan would create a legislative oversight committee to monitor the budgeting, finance, administrative and operational issues in the program.
In what is perhaps a reflection of the difficulty of designing a new governmental program within a bill proposal, Tarte’s bill retains parenthetical notes such as: “not clear who picks them or how they are regulated” and “suggest a more specific entity to report to, like HHS Oversight Committee or Fiscal Research.”
Finally, Senate President Pro Tempore Phil Berger (R-Eden) filed his own “Medicaid Transformation” bill that would change the program from the current fee-for-service payment system to one run by commercial managed care companies.
That bill is one of only six sponsored by Berger during this session.
The bill also institutes an regimen of annual inspection of abortion clinics.
Another bipartisan bill seeks to define rape, including the stipulation that “a person may withdraw consent to engage in vaginal intercourse in the middle of the intercourse, even if the actual penetration is accomplished with consent.”
A number of bills are reappearing from prior legislative sessions, including a bill first introduced last year to reduce the copay for cancer drugs administered on an outpatient basis to be more comparable to intravenous drugs administered in hospitals and clinics.
Families who have children with autism could benefit from a bill that would require insurers to cover up to $40,000 worth of intensive therapy. That bill was first introduced in 2013, passed the House and was sent to the Senate, where no action was taken on it during the 2014 short session. Advocates say they are hopeful the bill will be successful this year, given that one of the Senate co-sponsors is the powerful chairman of the Senate’s Rules and Operations committee, Tom Apodaca (R-Hendersonville).
Docs Raise Familiar and New Issues with Legislators
The return of doctors in white coats on Wednesday brought issues new and old to the General Assembly.
By Hyun Namkoong
Familiar topics such as Medicaid reform and expansion and improving access to care were on physicians’ agendas when they met with lawmakers Wednesday at the General Assembly.
Diane Hanke, Miriam Schwarz and Robert Henderson traveled from Asheville to advocate for better access to care in the west, higher Medicaid reimbursements and Medicaid expansion. Photo credit: Hyun Namkoong
Newer topics such as cuts to Medicaid reimbursement and reform of the rules that govern hospitals also floated around during their conversations with legislators.
Diane Hanke and Robert Henderson are physicians who drove from Asheville to meet with representatives. They said the western part of the state is often overlooked when it comes to ensuring access to care.
Both said high levels of poverty, geographic barriers such as mountainous terrain and a disproportionate number of residents who rely on Medicaid negatively impact care.
“We really need to have resources and reimbursement to keep people [in the west] engaged in helping the community,” she said. Hanke estimated that some 80 percent of residents in the western region rely on Medicaid or Medicare. She added that most counties in Western North Carolina don’t have community clinics, putting a strain on emergency departments.
Physicians who receive Medicaid payments face a 3 percent retroactive cut from the state going back to January 2014, something that High Point physician Ric Leinbach said would be especially detrimental to small rural practices. “Not everyone’s going to make it,” Henderson added. “We already lose money on Medicaid patients.”
Hanke and Henderson said inadequate reimbursement for Medicaid patients is causing many physicians in Western North Carolina to stop accepting Medicaid or to retire early because they can’t afford to practice.
Henderson said fewer health care providers in a region of the state that already faces physician shortages could result in worse health outcomes and even higher inappropriate utilization of the emergency department.
Eileen Raynor, a pediatric surgeon at Duke Children’s Hospital, said low Medicaid reimbursement rates affect private hospitals too.
“I see a lot of Medicaid patients because they can’t get services in their home county [due to] problems with Medicaid reimbursement,” she said.
Certificate of Need
Raynor said House Bill 200 and the certificate of need issue brought her to the General Assembly to meet with legislators.
The certificate of need statute requires providers or hospitals to first get approval from the Department of Health and Human Services to add or upgrade facilities so that services aren’t unnecessarily duplicated in the same area. The rationale behind a certificate of need is to control the costs and utilization of services.
But some providers disagree.
“We have the most restrictive rules in the United States,” Raynor said. “[We’re] trying to allow access to drive down costs so that patients can have choices.”
“House Bill 200 is a relatively nice middle-of-the-road [compromise], where it loosens restrictions without completely eliminating certificate of need, because I think that would be detrimental to North Carolina,” she said.
HB 200 would exempt certain health care centers such as ambulatory surgical facilities and psychiatric hospitals from the certificate of need statute. It would also prohibit the state from restricting the number of operating rooms and gastrointestinal endoscopy rooms.
Vaccine Exemption Bill Draws Objections
By Rose Hoban
In the wake of legislators filing a new bill that would all but remove religious exemptions from childhood vaccinations for schoolchildren, several dozen opponents of vaccine mandates descended on Jones Street Tuesday to protest the measure.
Standing in front of the General Assembly Tuesday morning with a sign reading “Stop Medical Terrorism,” Lisa Jillani, who heads a Charlotte-based organization called People Advocating Vaccine Education, called the bill “draconian.”
Anti-vaccine advocates Lisa Jillani (r) and Michael Horwin (l), who both said they both believed parents had the right to choose vaccines for their children, came to the General Assembly to protest on Tuesday. Photo credit: Rose Hoban
“I have religious exemption to vaccinations, and contrary to what Jeff Tarte says it’s not a bogus exemption; it is my personally held religious belief that I should not vaccinate myself or my children,” Jillani said.
When asked her religious denomination, Jillani said she had none. She said she has a “very, very close relationship with God. I pray every day. I see God’s guidance in everything. And there is no way… I will go to any lengths to keep myself and my children unvaccinated.”
Bill sponsor Sen. Jeff Tarte (R-Cornelius) said he understood that people have their personal beliefs and that those can be the basis for not getting a child vaccinated. But he also said the state has an interest in seeing that schoolchildren get vaccinated.
“You have a loud vocal group who has a position and you have others who have other positions,” Tarte said. “There’s probably multiple positions in this particular issue. But it’s also important [to ask], ‘How do we balance individual rights with the greater good in the case of the whole population?’”
Jillani was not so sure about the obligations of parents with regard to the rest of the population.
“It will probably sound cold to say this, but it’s each parent’s responsibility to protect their child,” she said. “If my child were immune-compromised, I would never expect another parent to have a procedure performed that might risk their child just to protect mine.”
The issue of parents’ rights was on the mind of Kerri Pechin, who came to the legislature from Youngsville with most of her eight children. Only the oldest two of her children are vaccinated, and one of her children was holding up a sign reading: “Don’t confuse the real issue, it’s not about safety, it’s about a parent’s right to choose.”
“I gave birth to these children and I believe in God,” Pechin said. “He made human beings. He gave these children to me, he did not give them to the state.”
She pointed at the grassy field behind the legislative building and said, “As far as I know, they were not born in the middle of this field by the state.”
Pechin also said she doesn’t try to tell others not to vaccinate their children, that the decision should be a parent’s choice.
But according to civil libertarians, the issue is murkier, said Sarah Preston, the governmental affairs representative for the ACLU of North Carolina, which has not taken a position for or against the bill.
“While parents have wide leeway in how they bring up their children, the state unquestionably has a compelling interest in protecting children from dangerous diseases,” Preston said.
She said the ACLU is monitoring the bill closely for changes in the language that might alter her organization’s stance.
“At the moment, we think that the bill as written appropriately balances those interests,” Preston said.
She said things that might alter the ACLU’s position would be changes to the number of diseases vaccinated against, how effective those vaccines are and how dangerous the diseases vaccinated against are.
She also said her organization would have an issue if the bill attempted to extend the vaccine requirement to people who homeschool their children.
Sen. Terry Van Duyn (D-Asheville), another of the bill’s sponsors, said she had expected opposition to the bill. She said she’s sympathetic to people’s fears, as she has a son who is autistic, that she is firm on the public health issues.
“In the county where I live, we have pockets of the population where vaccination opt-out rates are as high as 30 percent,” she said. “[Public health officials] talk about how as a state we have 95 percent vaccination rates, but that’s the average. That doesn’t tell the whole story.”
Van Duyn also said she’s heard from many of her constituents who are unhappy with her sponsorship of the bill.
“I understand that they’re concerned, but I’m hoping that they’re willing to stick it out with me as we get more information and find a way to thread the needle,” she said. “It’s not my intention to make people do anything; it’s my intention to get more people vaccinated to protect our kids.”
Both Van Duyn and Tarte said the hearing process would be deliberate and transparent. Tarte said hearings would take place in the coming weeks, and that they were lining up experts to speak on the bill.
“We want sunlight on the process. I’m hoping when we’re all done, that [people] will be happy with the process,” Van Duyn said, “even if they may or may not be happy with the outcome.”
Rural Hospitals, One of the Cornerstones of Small-town Life, Face Increasing Pressure
Despite residents’ concerns and a continuing need for services, the 25-bed hospital that served this small East Texas town for more than 25 years closed its doors at the end of 2014, joining the ranks of dozens of other small rural hospitals that have been unable to weather the punishment of a changing national health care environment.
For the high percentages of elderly and uninsured patients who live in rural areas, closures mean longer trips for treatment and uncertainty during times of crisis.
“I came to the emergency room when I had panic attacks,” said George Taylor, 60, a retired federal government employee. “It was very soothing and the staff was great. I can’t imagine Mount Vernon without a hospital.”
The Kansas-based National Rural Health Association, which represents around 2,000 small hospitals throughout the country and other rural care providers, says that 48 rural hospitals have closed since 2010, the majority in Southern states, and 283 others are in trouble. In Texas alone, 10 have changed.
“If there was one particular policy causing the trouble, it would be easy to understand,” said health economist Mark Holmes, from UNC-Chapel Hill, whose rural health research program studies national trends in rural health care. “But there are a lot of things going on.”
Experts and practitioners cite declining federal reimbursements for hospitals under the Affordable Care Act as the principal reason for the recent closures. Besides cutting back on Medicare, the law reduced payments to hospitals for the uninsured, a decision based on the assumption that states would expand their Medicaid programs. However, almost two dozen states have refused to do so. Other Medicare cuts caused by a budget disagreement in Congress have also hurt hospitals’ bottom lines.
But rural hospitals also suffer from multiple endemic disadvantages that drive down profit margins and make it virtually impossible to achieve economies of scale.
These include declining populations; disproportionate numbers of elderly and uninsured patients; the frequent need to pay doctors better than top dollar to get them to work in the hinterlands; the cost of expensive equipment that is necessary but frequently underused; the inability to provide lucrative specialty services and treatments; and an emphasis on emergency and urgent care, chronic money-losers.
Rural health care experts caution that national and state officials need to address the problems for rural hospitals or they could face a repeat of the catastrophic closings that followed changes in the Medicare payment system 30 years ago. That 1983 change, called the “prospective payment system,” established fixed reimbursements for care instead of payments based on a hospital’s reported costs. The change rewarded large, efficient providers, but 440 small hospitals closed before the system was adjusted in 1997 to help them. Those adjustments created the designation of critical access hospitals for some small, isolated facilities, which are exempted from the fixed-payment system.
“And now, beginning in 2010, we’ve had another series of cuts that are all combining to create another expansion of closures just like we saw in the ‘90s,” said Brock Slabach, senior vice president of the Rural Health Association. “We don’t want to wake up with another disaster.”
The current surge in closures means federal officials need to come up with new legislation to halt the recent cuts to small hospitals in order to “buy time” to figure out how rural hospitals should effectively operate in the future, said the association’s chief lobbyist, Maggie Elehwany. “It is important to stop the bleeding right now.”
In Mount Vernon, a town of 2,678 people nestled in grassland and dairy country about two hours east of Dallas, family practitioner Jean Latortue has taken out a lease on the now-vacant hospital building to convert it into an outpatient and urgent care clinic at his own expense. Reopening may be a risky move, he acknowledged, but the need is there.
“The community went into panic mode,” he said. “I figured I had to step up.”
The nonprofit ETMC Regional Healthcare System, based in Tyler, Texas, closed the Mount Vernon hospital and two others of its then-12 rural hospital affiliates because it could no longer sustain operating losses that had persisted for five years.
“There was no ill will,” Franklin County Judge Scott Lee said in an interview from his Mount Vernon office. “They were losing money. We had a good working relationship for years, and they had a business decision to make.”
Mount Vernon’s issues
Perry Henderson, senior vice president of affiliate hospitals for ETMC, a major health care provider in East Texas, noted that rural hospitals have many uninsured patients, and Medicare accounts for “60 to 70 percent of the business,” while in “Dallas or Houston it’s a fraction of that.”
Mount Vernon, with lakefront properties that are attractive to retirees, has its share of elderly patients. Henderson also noted that many rural hospitals also have to deal with large numbers of agricultural accidents. Farming, another Mount Vernon staple, is one of the country’s most dangerous occupations. Finally, he added, country roads bring large numbers of traffic accidents. When there’s no hospital, emergencies mean longer trips to get help.
Henderson and other experts cite three reasons for the rash of closures nationally. Sequestration, the across-the-board federal budget cut that arose out of the legislative impasse between the Obama administration and congressional Republicans, has resulted in a 2 percent reduction in Medicare reimbursements since 2013.
“If Medicare is 50 percent of your revenue and you lose two points,” UNC’s Holmes said, “it can be a killer.”
Rural hospitals took a second hit from the federal health law’s reductions in “disproportionate share hospital” payments to hospitals with large numbers of indigent and uninsured patients. Federal officials made the cuts assuming that the law would assure that more patients had insurance.
It hasn’t worked well in rural areas, the Rural Health Association’s Elehwany said, because annual deductibles for the new insurance plans, which come out of consumers’ pockets, “are running between $2,500 and $5,000,” and people can’t pay them.
And in communities such as Mount Vernon, this problem is exacerbated because Texas, along with 22 other states, has refused to expand Medicaid, a key provision of the Affordable Care Act.
“That’s a big deal,” ETMC’s Henderson said. “That’s when we had the hurt.”
Latortue, who came to Mount Vernon as an ETMC hospital doctor in 2008, appears undaunted by the challenges of reinventing the hospital, which was treating an average of eight inpatients a week when it closed. Still, he said, “I’m very busy, and patients need to be seen. We’ll be all right.”
He intends to provide both outpatient services, including lab work, at the new clinic, and emergency care, stabilizing patients until they can be transferred to the Titus Regional Medical Center in Mt. Pleasant, 16 miles away, or to a smaller facility in Winfield, eight miles away. He also plans a wellness clinic to treat obesity and will offer Botox and laser cosmetic services. A cardiologist and a gastroenterologist will make weekly visits, and he is also looking for an ob-gyn.
Latortue got a favorable lease from the town of Mount Vernon and inherited an X-ray machine and other equipment from ETMC. But he still took out $150,000 in loans for remodeling and needs another $60,000 to $70,000 for equipment.
Still, none of this will replace the hospital, and his patients know it.
“I live right behind the building,” said Mary Hunter, a very fit grandmother of 73. “I’ve had very good health until my blood pressure spiked last week. We retired in 2006 and moved here, partly because of the hospital. And now it’s gone.”
Nurse Practitioners Ask Lawmakers to Ease Restrictions for Practice
A wave of 115 nurse practitioners flooded the General Assembly to meet with lawmakers about easing practice restrictions.
By Hyun Namkoong
Nurse practitioners from across North Carolina came to the General Assembly on Tuesday to advocate for loosening the grip on the way they are allowed to practice.
In light of a new study conducted by Duke University economist Chris Conover and commissioned by the North Carolina Nurses Association, nurse practitioners swarmed the legislature with optimism that they’d be able to convince lawmakers on the positive economic and health care impacts of allowing nurse practitioners to practice without license restrictions.
Nurse practitioners Katerina Jones, Stephanie Limesand and Jan Disantostefano came to the General Assembly with more than 100 other NPs to advocate for fewer restrictions on their practice. Photo credit: Rose Hoban
If lawmakers lift some of the restrictions on nurse practitioners, nurse midwives, nurse anesthetists and other “advanced practice” nurses, it could fill gaps in access to primary care providers, create at least 3,800 jobs statewide, and generate more than $20 million in income tax revenues annually, according to the study.
Nurse practitioners are trained to perform advanced care beyond that of a registered nurse. For example, nurse practitioners can write prescriptions, diagnose straightforward conditions like colds and perform routine check-ups. But in North Carolina, they have to do that under the “supervision” of a physician.
Under state law, physicians don’t have to be physically present to supervise. They are only required to have a two-times per year review of patient standards and the delivery of care. The nurse practitioner should be able to contact a physician for questions.
Brunswick county nurse practitioner Angela Bertsch said at her own health department clinic, which she recently retired from, their supervising physician lived 25 miles away.
“His requirement is that we would see him once a month,” Bertsch said. “The state statute only requires twice a year contact. Right now the supervisory agreement is a piece of paper in a drawer.”
But, physicians aren’t always willing to supervise and some nurse practitioners find themselves unable to work.
Tay Kopanos, vice president of state government affairs of the American Association of Nurse Practitioners said the bureaucracy limits patients’ ability to get direct access to care.
“Nurse practitioners can’t find a physician to do collaborative agreement or pay money to [for the supervision],” she said. “The laws for nursing here are decades old and they really haven’t kept pace with changes.”
Bertsch said one of her colleagues in a nearby clinic has been compelled to pay a physician about $16,000 for her supervision agreement.
Time for change
Kopanos said North Carolina is at a crossroads to implement some solutions that can address health care needs across the state.
She said legislation will be introduced in the coming weeks to match the educational and professional expertise of nurse practitioners to the legal limits of care they can provide in the state.
“Here in North Carolina, licensure laws limit the amount of care [nurse practitioners] can provide to patients, unless they have a mandated agreement with the physician,” Kopanos said. “This legislation will look at retiring that so that patients get full and direct access.”
Rep. Gale Adcock (D-Cary) said many nurse practitioners want to work in rural, underserved areas, something that could help ease the primary care provider shortage in the state.
Adcock acknowledged that any legislation giving nurse practitioners more autonomy would likely be met with resistance and that change is hard to implement.
“When you do the same thing over and over you get the same result,” Adcock said. “And the result we’re getting in this state are huge pockets of people who have no access to health care.”
Access to primary care is important because it’s more cost-effective and easier to treat illnesses when they’re caught early on and not in advanced stages that require intensive treatment. The primary care provider shortage has led 18 states to grant full autonomy to nurse practitioners.
“If you catch diabetes early on, you may not end up on dialysis,” said Stephanie Limesand, a nurse practitioner from Gastonia who works in urgent care. “There’s such a shortage of primary care providers. We can help fill that gap.”
Gordon said the nurse practitioners met with the legislators from their own district and with members of the health and human services committee to tell them how nurse practitioners are trained, educated and experienced in providing safe and quality care.
Where do Nurse Practioners in NC Work?
Group Medical Practice/Physician Office
Group Nursing Practice
Home Health Care
Hospital (Other than In-Patient, Emergency, Out-Patient)
Long Term Care
Self Employed NP
About NC Health Beats
National stories with a Tarheel twist, keeping up with emerging trends, keeping our fingers on the pulse of North Carolina health.