Recently, a lot has been done to attempt to fix healthcare, hospitals, and public health. With somewhat noble intentions, new laws like HIPAA have been passed, along with innovations in the way hospitals do business, treat patients, and promote themselves. One thing is missing, however, is that the public still lacks faith in hospitals and the healthcare system in general, says Heather Johnson in this posting on Hospital Impact.

The American Hospital Association is right to raise concerns about proposed rule changes that could adversely affect payments for rural health clinics and federally qualified health centers.

In an Aug. 22 letter to Kerry N. Weems, the Centers for Medicare & Medicaid Services' acting administrator, AHA singled out for criticism the proposal to implement section 1833(a)(3) of the Social Security Act, which requires that beneficiaries' deductibles and coinsurance be subtracted from reasonable costs to determine the amount of the Medicare payment. The proposal would also limit payments to no more than 80% of an amount deemed to be "reasonable and related to the cost of furnishing such services."

Currently, CMS pays RHCs 80% of their all-inclusive rate with a payment limit, but does not factor in coinsurance and deductibles.

In the letter to Weems, AHA Executive Vice President Rick Pollack says that the rule change "will have serious negative implications for the financial viability of RHCs, which will experience substantial reductions in Medicaid payments."

In addition, Pollack notes, the cuts would come at a time when RHCs are already being required to implement mandatory quality assessment and performance improvement, which will drive up operational costs.

What's odd about all of this is the timing. The fact is, the Social Security Act provision has been around for more than 30 years and is as old as the act that created RHCs in the first place. Why has CMS suddenly decided to implement section 1833(a)(3)? In a vaguely worded press release that announced the proposed rule change last June, Weems said: "The flexibilities we are proposing will help to ensure that beneficiaries and Medicare get the best value from RHC providers." The press release also said something about putting RHC reimbursements "in line with statutory requirements."

Well, that answers all our questions!

The fact is, RHCs have proven themselves to be desperately needed, cost-efficient, effective healthcare providers in chronically underserved areas. As Pollack points out, nobody is raising concerns about the growing costs of operating RHCs—not federal advisory committees, nor oversight agencies, nor Congress.

AHA is asking CMS to scrap the idea, or at least to define reasonable costs as those derived from the RHCs' Medicare cost report, rather than blanket-impose the Social Security Act's payment caps.

The rule changes proposal has prompted other concerns. Despite reassurances from CMS, the AHA is concerned that new language used to define the requirements for essential provider exceptions are subjective and ambiguous. AHA is also calling for an explanation and a timeline for the appeals process for RHCs that are denied essential provider status. Additionally, there is concern that a provision requiring a 48-hour window for authentication of patients' health records is unrealistic and would be difficult to enforce for weekend admissions. AHA wants the window pushed back to 72 hours.

CMS is not the bad guy here. The agency oversees massive and vitally important programs and has an obligation not only to its beneficiaries, but to taxpayers as well. But cutting funding for RHCs or bogging them down with vague verbiage or unreasonable timeframes seems counterproductive at a time when rural America is already struggling to find healthcare.

Seinfeld fans will remember the episode when Jerry and sidekick George Costanza filmed their pilot for NBC. As a writer of a new television show, it looked like sad-sack George was finally going to make something of himself.

But then fate handed George yet another blow. He discovered a white growth on his lip, and worried that it was cancer.

A doctor performed a biopsy and told George the results were "negative." The news sent George into hysterics. How could he be struck down just when he was ready to enjoy success, he lamented. His mood quickly changed, though, when he realized the doctor was telling him good news—he did not have cancer.

If George Costanza has trouble understanding a diagnosis, think about the 60% of Medicare enrollees who are at either a basic or below-basic literacy level. Will they know that negative is actually positive?

Low health literacy costs the country between $106 billion to $236 billion annually, according to a 2007 University of Connecticut study, yet many in healthcare continue to ignore the problem.

This issue can lead patients to avoid the doctor or simply not follow directions. Just think of the barrier if a patient can't follow a doctor's instructions, and the potential impact that has on health.

Health literacy's impact was evident in two articles that recently appeared in the Washington Post and The Boston Globe.

Both of these articles show how a person's literacy (both health literacy and general literacy) can erect barriers.

In the first article, a study showed that a majority of seniors who visited the Medicare Web site was frustrated by the experience (anyone who visits CMS' site could surely relate. I often feel like I'm in that maze in "The Shining" when I'm on that site.)

A study by the University of Miami reported that Medicare beneficiaries found the Medicare site difficult to navigate and they were not able to gain the information they wanted. They also told researchers that some of the language was too complex.

Then, there's the news from Massachusetts. The state's healthcare program has experienced highs (more insured residents) and lows (skyrocketing costs), but news this past week showed that tens of thousands of previously uninsured residents who enrolled in the state's Commonwealth Care were bounced out of the program because of errors on member forms and mistakes by the state.

Advocates say the state's eligibility documents are too complex, and that complexity is confusing residents who are losing their insurance.

This has led some patients to pay for medical bills while not getting reimbursed. There is no data as to whether patients have put off care because of being removed from the program, but that could be another problem.

Barbara Anthony, executive director of Health Law Advocates, a nonprofit that has sued the state on behalf of some Commonwealth Care members who were mistakenly terminated, told The Boston Globe that there has been a "steady stream" of people dropped by accident.

Anthony was quoted in the paper sounding like a health insurer: "I think there would be a huge outcry by state government if a private insurance plan behaved that way." These cases show how health literacy plays a role in healthcare. Medicare's Web site is not user-friendly enough to provide useful information and Massachusetts' forms are not easy enough to follow.

So, what can a health insurer, managed care company, or anyone in healthcare do to remove these barriers? I recently moderated an audio conference on the topic of health literacy.

One of the leaders on the health literacy issue is Gloria Mayer, EdD, RN, FAAN, president and CEO of the Institute for Healthcare Advancement, a nonprofit that works to improve health literacy.

Mayer provided two ways that healthcare providers and payers could connect with patients and members:

• Avoid medical jargon. For this tip, think back to George Costanza's dilemma. Think about how terms like terminal, immunization, and contraception sound to a patient, and whether there is a more basic way to say it. Mayer said rather than using medical terms, healthcare should use "living room language" to connect with patients. For instance, rather than saying "insomnia," say "can't sleep," and rather than "benign," say "no cancer."
• Use the teach back technique. Rather than simply informing a patient or member about what needs to be done and asking if he understands, Mayer said the healthcare representative should ask the person to actually relay what he is going to do.

As we transfer more healthcare decisions onto the individual, properly reaching members with understandable communication will play a larger role in healthcare. Health insurers may puff out their chests and brag about the latest personal health record or their outreach efforts, but if literacy levels are not taken into account, insurers are wasting their money and just placing barriers to healthier living.

A Malaysia-based hospital operator run by Seattle residents and backed by Seattle-area investors says there's money to be made by treating India's upwardly mobile to American-style healthcare. Columbia Pacific, a Seattle investment firm, said it has raised $135 million to go after the Indian market. Its Asian venture, Columbia Asia, has 13 facilities in Malaysia, India, Indonesia, and Vietnam—and expects to have 39 by the end of the decade. The latest investment brings the total equity raised by Columbia Asia to $325 million.