Of the eight University of Kansas Medical School graduates, just three chose to go where the shortages are most evident.

This article was first published on Wednesday, October 9, 2019 in Kaiser Health News.

By Lauren Weber

SALINA, Kan. — The University of Kansas School of Medicine-Salina opened in 2011 — a one-building campus in the heart of wheat country dedicated to producing the rural doctors the country needs.

Now, eight years later, the school's first graduates are settling into their chosen practices — and locales. And those choices are cause for both hope and despair.

Of the eight graduates, just three chose to go where the shortages are most evident. Two went to small cities with populations of fewer than 50,000. And three chose the big cities of Topeka (estimated 2018 population: 125,904) and Wichita (389,255) instead.

Their decisions illustrate the challenges facing rural recruitment: the lack of small-town residencies, the preferences of spouses and the isolation that comes with practicing medicine on one's own.

But the mission is critical: About two-thirds of the primary care health professional shortage areas designated by the federal Health Resources and Services Administration in June were in rural or partially rural areas. And it's only getting worse.

As more baby boomer doctors in rural areas reach retirement age, not nearly enough physicians are willing to take their place. By 2030, the New England Journal of Medicine predicts, nearly a quarter fewer rural physicians will be practicing medicine than today. Over half of rural doctors were at least 50 years old in 2017.

So Salina's creation of a few rural physicians a year is a start, and, surprisingly, one of the country's most promising.

Only 40 out of the nation's more than 180 medical schools offer a rural track. The Association of American Medical Colleges ranked KU School of Medicine, which includes Salina, Wichita and Kansas City campuses, in the 96th percentile last year for producing doctors working in rural settings 10 to 15 years after graduation.

"The addition of one physician is huge," said Dr. William Cathcart-Rake, the founding dean of the Salina campus. "One physician choosing to come may be the difference of communities surviving or dissolving." 

The Draw Of Rural Life
 

By placing the new campus in Salina (population: 46,716), surrounded by small towns for at least 50 miles in every direction, the university hoped to attract and foster students who had — and would deepen — a bond to rural communities.

And, for some, it worked out pretty much as planned.

One of the school's first graduates, Dr. Sara Ritterling Patry, lives in Hutchinson (population: 40,623). Less than an hour from Wichita, it isn't the most rural community, but it's small enough that she still runs into her patients at Dillons, the local grocery store.

"Just being in a smaller community like this feels like to me that I can actually get to know my patients and spend a little extra time with them," she said.

After all, part of the allure of a rural practice is providing care womb to tomb. The doctor learns how to deliver the town's babies, while serving as the county coroner and the public health expert all at once, said Dr. Robert Moser, the head of the University of Kansas School of Medicine-Salina and former head of the state health department.

He would know — he worked for 22 years in Tribune, Kan. (population: 742).

For another of the original Salina eight, Dr. Tyson Wisinger, that calling brought him back to his hometown of Phillipsburg (population: 2,486) after his residency. His kids will go to his old high school, where his graduating class was all of 13 people, and he'll take care of their baseball teammates. Plus, they'll grow up living minutes away from generations of extended family.

"I can't have imagined a situation that could have been more rewarding," Wisinger said.

The Rural Challenge
 

The Original Salina Eight

Three went the urban route:

Dr. Erik Dill decided to be a pathology specialist in more urban Wichita.

Dr. Claire Hinrichsen Groskurth, who intended to practice in a more rural area, is now in Wichita working as an OB-GYN.

Dr. Rany Gilpatrick wanted a more flexible, outpatient schedule as a pediatrician instead of the on-call in-patient life, so she works in Topeka.

Two work in smaller towns:

Dr. Sara Ritterling Patry practices internal medicine in Hutchinson, Kan., to help accommodate her husband's farming business.

And Dr. Kayla Johnson stayed in Salina as a pediatrician. 

And the final three might as well be poster children for the movement:

Dr. Tyson Wisinger returned to his Kansas hometown of Phillipsburg to practice family medicine.

Drs. Daniel Linville and Jill Corpstein Linville married each other and were recruited to Lakin, Kan., by a rural practice to work in family medicine.

But the road to rural family medicine also includes a thing called "windshield time" — the amount of time needed to travel between clinics or head to the closest Walmart.

Then there's figuring out just how far their patients will need to drive to get to the nearest hospital — which for Drs. Daniel Linville and Jill Corpstein Linville is a solid four hours for more advanced care from their new practice in Lakin, Kan. (population: 2,195).

Their outpost in southwestern Kansas can feel a little bit like a fishbowl. "We do life with some of our patients," Corpstein Linville said.

Already, the Linvilles have delivered babies and handled a variety of ailments there.

The pair met and married during their four years in Salina — they jokingly call it a "full-service med school." They completed a family medicine residency in Muncie, Ind. Then they were recruited by a rural practice that helped them avoid what Moser calls the most dreaded words in rural medicine: "solo practice."

New doctors don't want to practice alone, especially as they develop their sea legs, due to the strains of constantly being on call and having singular responsibility for a town. Telemedicine, where doctors can easily consult with other physicians around the country via web video or phone, is helping, as are physician assistants.

Diverging From The Path
 

Dr. Claire Hinrichsen Groskurth, another member of the first graduating class, always intended to return to a small town similar to where she grew up.

"The first thing that threw me off was I fell in love with surgery and OB-GYN," she said. "Then the second thing that threw me off was marrying another doctor," whose life goals headed in a different direction.

She'd been a member of the Scholars in Rural Health program at Kansas University that seeks out rural college students who are interested in medicine. She also had committed to the Kansas Medical Student Loan program, which promises to forgive physicians' tuition and gives a monthly stipend if they agree to work in counties that need physicians, or in other critical capacities.

But when she realized she might specialize, she decided to take out federal loans for her final years. She had to pay back the first year of the special loan with 15% interest.

Plus, her now-husband, who went to Kansas University's Wichita campus, needed to be in a large enough city to accommodate further training to become a surgeon. So Hinrichsen Groskurth delivers babies as she thought she would — but in Wichita.

The spousal coin can flip both ways: Ritterling Patry needed to find a place that worked for her husband's farming of corn, sorghum, soybeans and wheat. So the smaller city of Hutchinson it was.

Flaws In The Pipeline
 

Most medical school students come from urban areas and are destined to stay there, said Alan Morgan, the head of the National Rural Health Association. Producing doctors for the vast swaths of rural America needs to be more of a priority at every step in the education pipeline, experts said.

Many academic centers sell students on the party line that they'll be overworked, underappreciated and underpaid, according to Dr. Mark Deutchman, director of the University of Colorado School of Medicine's rural program. "They take people who are interested in primary care or rural and beat it out of them throughout their training," he said.

And that kind of rhetoric often influences the opinion of their medical school peers, which those in rural health might resent.

"Small does not mean stupid," Moser said.

Medical students everywhere should be exposed to rural options, according to Dr. Randall Longenecker, who runs Ohio University Heritage College of Osteopathic Medicine's rural programs.

"If a medical student never ever goes to a rural place, they never find out," he said. "That's why students need to meet rural doctors who love what they do."

The federal government recently allocated $20 million in grants to help create 27 rural residency programs — programs where newly minted doctors go for practical training before they can be fully licensed. That's a big jump from the 92 programs now active.

For Jill Corpstein Linville, the pipeline also needs to start at more schools like Salina that are promoting rural medicine from Day One.

"So when you hear rural medicine, you know that it's a thing and don't kind of cringe," she said. "You don't think it's someone taking care of a cow."

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

Hospitals cannot discharge patients if they have no safe place to go, so patients who are homeless, frail, living alone, or experiencing an unstable housing situation, can occupy hospital beds long after their acute medical problem is resolved.

This article was published by Kaiser Health News on October 4, 2019.

By Markian Hawryluk, KHN

DENVER — One patient at Denver Health, the city's largest safety net hospital, occupied a bed for more than four years—a hospital record of 1,558 days.

Another admitted for a hard-to-treat bacterial infection needed eight weeks of at-home IV antibiotics, but had no home.

A third, with dementia, came to the hospital after being released from the Denver County Jail. His family refused to take him back.

In the first half of this year alone, the hospital treated more than 100 long-term patients. All had a medical issue that led to their initial hospitalization. But none of the patients had a medical reason for remaining in the hospital for most of their stay.

Legally and morally, hospitals cannot discharge patients if they have no safe place to go. So patients who are homeless, frail or live alone, or have unstable housing, can occupy hospital beds for weeks or months—long after their acute medical problem is resolved. For hospitals, it means losing money because a patient lingering in a bed without medical problems doesn't generate much, if any, income. Meanwhile, acutely ill patients may wait days in the ER to be moved to a floor because a hospital's beds are full.

"Those people are, for lack of a better term, stranded in our hospital," said Dr. Sarah Stella, a Denver Health physician.

To address the problem, hospitals from Baltimore to St. Louis to Sacramento, Calif., are exploring ways to help patients find a home. With recent federal policy changes that encourage hospitals to allocate charity dollars for housing, many hospitals realize it's cheaper to provide a month of housing than to keep patients for a single night.

Hospital executives find the calculus works even if they have to build affordable housing units themselves. It's why Denver Health is partnering with the Denver Housing Authority to repurpose a mothballed building on the hospital campus into affordable senior housing, including about 15 apartments designated to help homeless patients transition out of the hospital.

"This is an experiment of sorts," said Peg Burnette, the hospital's chief financial officer. "We might be able to help better their lives, as well as help the financials of the hospital and help free up capacity for the patients that need to come to see us for acute care."

Spending To Save Money
 

Denver Health once used the shuttered 10-story building for office space but opted to sell it to the housing authority and grant a 99-year lease on the land for a minimal fee.

"It really lowers the construction costs for us," said Ismael Guerrero, Denver Housing Authority's executive director. "It was a great opportunity to build additional housing in a location that's obviously close to the hospital, close to public transit, near the city center."

Once the renovation is complete in late 2021, the housing group will hire a coordinator to assist tenants with housing-related issues, including helping those in the transitional units find permanent housing. The hospital will provide a case manager to help with their physical and behavioral health needs, preparing them for life on their own. Denver Health expects most patients will be able to move on from the transitional units within 90 days.

The hospital will pay for the housing portion itself. That will still be far cheaper than what the hospital currently spends.

It costs Denver Health $2,700 a night to keep someone in the hospital. Patients who are prime candidates for the transitional units stay on average 73 days, for a total cost to the hospital of nearly $200,000. The hospital estimates it would cost a fraction of that, about $10,000, to house a patient for a year instead.

"The hospital really is like the most expensive form of housing," Stella said.

Growing Interest
 

A recent report from the Urban Institute found that while most hospital officials are well aware of how poor housing affects a patient's recovery, they were stymied about how to address the issue.

"It's on the radar of almost all hospitals," said Kathryn Reynolds, who co-authored the report. "But it seemed like actually making investments in housing, providing some type of financing or an investment in land or something that has a good amount of value seems to be less widespread."

The report found housing investment has been more likely among hospitals with their own health plans or other types of arrangements in which they were receiving a fixed amount of money to care for a group of patients. Getting patients into housing could lower their costs and increase their operating margins. Others, particularly religiously affiliated and children's hospitals, sought housing solutions as part of their charitable mission.

Reynolds said the trend is due in part to the Affordable Care Act, which requires hospitals to perform a community needs assessment to help guide their charitable efforts. That prompted more hospitals to consider the social needs of their patients and pushed housing concerns up the list. Additionally, the Internal Revenue Service clarified in 2015 that hospitals could claim housing investments as charitable spending required under their tax-free status. And provisions included in the 2017 tax cut bill provided significant tax savings for investors in newly designated opportunity zones, increasing their interest in affordable housing projects.

Some hospitals, she said, may use their cash reserves to invest in housing projects that generate a lower return than other investment options because it furthers their mission, not just their profits.

In other cases, hospital systems play a facilitator role—using their access to cheap credit or serving as an anchor tenant in a larger development—to help get a project off the ground.

"Housing is not their business," Guerrero said. "It's not an easy space to get into if you don't have the experience, if you don't have a real estate development team in-house to understand how to put these deals together."

Cutting Costs
 

In the southwestern corner of Colorado, Centura Health's Mercy Regional Medical Center has partnered with Housing Solutions for the Southwest to prioritize housing vouchers for frequent users of the emergency room.

Under a program funded by the Catholic Health Initiatives, Mercy hired a social worker and a case manager to review records of frequent emergency room patients. They quickly realized how big an issue housing was for those patients. Many had diabetes and depended on insulin—which needs refrigeration. Kidney failure was one of the most costly diagnoses for the hospital.

Once patients received housing vouchers and found stable housing, though, costs began to drop.

"We now knew where they were. We knew that they had a safe place to live," said Elsa Inman, program coordinator at Mercy Regional. "We knew they would be more effective in managing their chronic conditions."

The patients with stable housing were more likely to make it to their primary care and specialist appointments, more likely to stay on top of medications and keep their chronic conditions in check.

The combination of intensive case management and patient engagement helped to halve ER visits for the first 146 patients in the program, saving nearly $495,000 in Medicaid spending in less than three years.

"Hospitals are businesses and nonprofits are businesses," said Brigid Korce, program development director for Housing Solutions. "They are bottom-line, dollars-and-cents people."

Inman acknowledged that the hospital might have missed out on some revenue by reducing ER use by these patients. Hospitals are still largely paid by the number of patients they treat and the number of services they provide.

But most of those patients were covered by Medicaid, so reimbursements were low anyway. And the move freed up more ER beds for patients with more critical needs.

"We want to be prepared for life-threatening conditions," Inman said. "If you've got most of your beds taken up by someone who can be receiving patient care outside in the community, then that's the right thing to do."

That was less of an issue for the inpatients at Denver Health. Because hospitals are generally paid a fixed amount for a given diagnosis, the longer a patient stays in the hospital, the more money the hospital loses.

"They've basically exhausted their benefit under any plan because they don't meet medical necessity anymore," Burnette said. "If they had a home, they would go home. But they don't, so they stay in the hospital."

Conservatives have pursued Medicaid block grants for decades to give states more power over the program.

This article was first published on Thursday, October 3, 2019 in Kaiser Health News.

By Phil Galewitz

Tennessee wants to be the first state to test a radical approach for federal financing of Medicaid, the federal-state health care program for low-income people.

The proposal, Tennessee Medicaid Director Gabe Roberts said, would increase the federal government's contributions by millions of dollars and allow Tennessee to improve care for enrollees, perhaps offering additional services such as limited dental care for some people. But critics fear the plan will harm the poor.

Tennessee, controlled by a Republican governor and legislature, has not expanded its Medicaid program as allowed under the Affordable Care Act.

The federal government pays each state a percentage of the cost of caring for anyone eligible for Medicaid ― varying from 50% to 77%. And all who qualify get covered.

Tennessee has proposed altering its federal funding (66% of its total Medicaid budget) into an annual lump sum. (Drug expenses would be excluded from the new program.) The state said the change would give it more flexibility to run the program ― which serves 1.4 million people ― and would save money.

Conservatives have pursued Medicaid block grants for decades to give states more power over the program. But Democrats oppose such efforts, arguing block grants could result in less coverage and limit enrollment. They also stress that states, over time, could see significant drops in federal Medicaid funding because it would not be based specifically on the number of enrollees.

Tennessee's plan, which was submitted last week to the Centers for Medicare & Medicaid Services, would not change benefits or eligibility levels.

KHN senior correspondent Phil Galewitz sat down with Roberts last week to talk about the issue. His answers have been edited for clarity and length.

Q: Why are you seeking to turn Medicaid into a block grant now, especially as your state has been experiencing a budget surplus?

This isn't a traditional block grant. We are calling it a modified approach. Tennessee Gov. Bill Lee has been a fan of the block grant idea for a while but also cares deeply about making sure that any approach isn't going to reduce enrollment or services or people that we serve.

A state law passed this year instructing our administration to file a block grant waiver that would have a floor for federal dollars coming. So if enrollment fell, the money wouldn't decrease. But if enrollment increased, the amount of federal payments would be indexed to account for that.

Q: Can you discuss the shared-savings element that Tennessee is proposing?

Any savings from this program would be split in half with the federal government.

We have routinely underspent what the federal government projects for our costs by billions of dollars. So what this proposal does is to ask CMS to reimagine the state-federal funding mechanism as a value-based one, so that states that operate well and serve their populations well ― but also contain costs ― are rewarded with additional federal dollars to invest in that population without the requirement to come up with a state match. Right now, we don't keep any of the money we save.

Q: As one of the poorer states, are you willing to risk getting less money from the federal government for Medicaid?

We believe the way the waiver is designed mitigates any concerns around a traditional block grant program. We do not believe this will result in fewer federal dollars coming to the state. This is an opportunity to bring more federal dollars to spend to enhance services or perhaps to provide services to additional people we are not serving today.

Q: Some experts question the legality of the Trump administration approving a type of Medicaid block grant without congressional authority. Why do you believe this is legal?

There are a variety of ways we can reach a mutually agreeable solution with CMS on this that clearly comports to federal law.

Q: Why is turning Medicaid financing into a block grant a better idea for the poor than expanding Medicaid under the Affordable Care Act, which would provide coverage to nearly additional 300,000 residents? The federal government pays 90% of the cost of these new enrollees, bringing billions of additional federal funding into the state.

These are two different and not mutually exclusive goals. This is an approach that rewards Tennessee for a well-run program, providing high-quality care to members with high member satisfaction and underspending CMS projections. This allows us to get access to some of those federal savings. Medicaid expansion requires a significant amount of money that the state has to come up with on an ongoing basis. I don't know that it's fair to pit the two approaches against each other.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Of the 3,129 general hospitals evaluated in the Hospital Readmission Reduction Program, 83% received a penalty.

This article was first published on Tuesday, October 1, 2019 in Kaiser Health News.

By Jordan Rau

Medicare cut payments to 2,583 hospitals Tuesday, continuing the Affordable Care Act's eight-year campaign to financially pressure hospitals into reducing the number of patients who return for a second stay within a month.

The severity and broad application of the penalties, which Medicare estimates will cost hospitals $563 million over a year, follows the trend of the past few years. Of the 3,129 general hospitals evaluated in the Hospital Readmission Reduction Program, 83% received a penalty, which will be deducted from each payment for a Medicare patient stay over the fiscal year that begins today.

Although Medicare began applying the penalties in 2012, disagreements continue about whether they have improved patient safety. On the positive side, they have encouraged hospitals to focus on how their patients recuperate, and some now assist them in procuring medications and follow-up appointments.

But the hospital industry and some academics have raised concerns that some hospitals may be avoiding readmitting patients who require additional inpatient care out of fear of the financial repercussions, while others have said the program is not showing major benefits.

"A lot of hard work has gone into trying to reduce readmissions, and the needle has not moved very far," said Dr. Karen Joynt Maddox, co-director of the Center for Health Economics and Policy at Washington University in St. Louis, who has been skeptical of the initiative. "It's been a huge investment by hospitals but not very much in outcomes, but some good things have come out of it."

A few studies have even found an increase in mortality since the penalties took effect, but other studies, including a recent one by the Medicare Payment Advisory Commission (MedPAC), an independent body that helped devise the approach for Congress, identified no such link.

"I don't believe the HRRP kills people," David Grabowski, a commission member and health policy professor at Harvard Medical School, said at the commission's meeting last month, using the acronym for the penalty program.

The MedPAC staff's preliminary analysis, made public last month, found that the frequency of Medicare patients being readmitted within 30 days of discharge dropped from 16.7% in 2010 to 15.7% in 2017. However, the analysis said the decrease was more significant once it took into consideration that the average patient was frailer in 2017 than in 2010 and thus more likely to end up back in the hospital, with all other things being equal.

"On a risk-adjusted basis, it appears that readmissions have declined in 2010 to 2018 without causing a material increase in mortality," Jeff Stensland, a MedPAC analyst, told the commission.

The penalties are based on the frequency of readmissions of Medicare patients who had originally been treated for heart failure, heart attack, pneumonia, chronic lung disease, hip and knee replacement or coronary artery bypass graft surgery. Readmissions that were scheduled to occur are not counted.

Medicare counts the readmission of patients who returned to a hospital within 30 days even if that hospital is not the one that originally treated them. In those cases, the penalty is applied to the first hospital. This year's penalties are based on discharges from July 1, 2015, to June 30, 2018.

"This is like driving your car by looking in the rearview mirror of the car three cars behind you," Dr. Jonathan Perlin, the chief medical officer of HCA Healthcare in Nashville and a MedPAC commission member, said at last month's meeting. "It's very difficult to operationalize."

The average penalty will be a 0.71% decrease in payment for each Medicare patient who leaves the hospital over the next year, according to a Kaiser Health News analysis. The KHN analysis also found:

• 1,177 hospitals received a higher penalty than they did last year.
   
• 1,148 hospitals received a lower one than last year.
   
• 64 hospitals received the same penalty as last year.
   
• 194 hospitals that had not been penalized last year are being punished this year.
   
• The maximum penalty — a 3% reduction in payments — was assessed against 56 hospitals.
   
• 372 hospitals avoided penalties in both years.

These figures do not include 2,142 hospitals that Medicare exempted from the program this year, either because they had too few cases to judge; served veterans, children or psychiatric patients; or were critical-access hospitals, which are the only hospitals within reach of some patients.

Also, Maryland hospitals were excluded because Congress lets that state set its own rules on how to distribute Medicare money and handle readmissions.

The Centers for Medicare & Medicaid Services determines its penalties by looking at national averages for each of the conditions, so hospitals that have reduced their readmissions from previous years can still take a hit. The hospital industry argues it may be approaching the limits of how much it can do to prevent readmissions. A repeat stay, hospitals say, is sometimes necessary no matter what precautions are taken.

Akin Demehin, director of policy at the American Hospital Association, said: "It raises the question: Is the value of the program to improve care or just to enact penalties on hospitals?"

Look Up Tool
Here are the hospitals hit with readmissions penalties for 2020. You can filter by location, hospital name or year.

Historical Data
Here are links to articles and data since 2015.

Jordan Rau: jrau@kff.org, @JordanRau