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Chronic Care Management and Medicare Requirements for Chronic Care Management


Held Live On Thursday, July 21 at 10:00-11:00 am


Presented by:

                   Care 24/7 (Knoxville, TN)

                   ARHA Sponsor, HealthMed  (Alabaster, AL)

                   The Alabama Rural Health Association



Audience:  Rural Health Clinics

                   Federally Qualified Health Centers

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recording of RHC and FQHC demo 7-21-16.m[...]
MP4 video/audio file [70.7 MB]





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Without Fully Funding Medicaid, Patient Care at Risk

With the passing of the General Fund budget, lawmakers appropriated $700 million for Medicaid next year, $85 million short of what is needed to fully fund Medicaid. Now the Medicaid Agency is left with the tough decisions of which programs to cut, and how deep to reach into the pockets of Alabama’s citizens who can already barely afford their medications and health treatments. Services at risk of being cut are prescription drug coverage for adults, eyeglasses for adults, outpatient dialysis, prosthetics and orthotics, hearing programs, Program of All Inclusive Care for the Elderly (PACE), among other programs and services that patients across Alabama need to survive.

Medicaid is a critical component of our health care system, covering the young and elderly. More than half the births in Alabama and 47 percent of our children are covered by Medicaid, as well as 60 percent of Alabama’s nursing home residents. Without full funding, the Medicaid program will collapse, leaving these individuals without coverage. While uncompensated care is delivered every day in all 67 counties of this state, without Medicaid, charity care needs could skyrocket, crippling the health care delivery system and potentially placing the burden on those with private health insurance through higher premiums and co-pays.

Alabama Medicaid is the backbone of our state, supporting the health and welfare of the young and elderly citizens that physicians have pledged to protect during their medical careers. Consequently, we cannot support any solution other than fully funding a program that touches so many lives. Allowing Alabama Medicaid to continue with adequate funding is a smart investment in Alabama and her citizens. The current appropriated budget will have dire consequences.

Physician practices, hospitals and nursing homes are among the economic engines driving many Alabama communities. Closure of these health care providers will have a devastating impact on the state of Alabama and the health and prosperity of its citizens. The ripple effect will be felt from Mobile to Huntsville.

Therefore we call on the legislature and the Governor to work toward a permanent revenue solution to fully fund Medicaid.

Our organizations strongly believe that Medicaid matters … to all Alabamians.

For more information or comment, please contact:

  • Mark Jackson, Medical Association of the State of Alabama, (334) 954-2500
  • Linda Lee, Alabama Chapter, American Academy of Pediatrics, (334) 954-2543
  • Jeff Arrington, Alabama Academy of Family Physicians, (334) 954-2570

ARHA Board Approves Health Policy "Rural" Definition

The ARHA Board of Directors approved an official definition of "rural" for Alabama's health policy purposes at the meeting on March 18, 2016.  This definition was recommended through research by ARHA President, William H. Coleman, M.D. and his team of researchers at the Office of Family Health, Education and Research at the UAB Huntsville Regional Campus.


This definition is very simple, considering areas designated as "Urbanized Areas" by the U.S. Census Bureau as being "urban" and all other areas including those designated by the Census Bureau as "Urban Clusters" as being "rural".


This definition is used in currently introduced legislation that corrects several problems in Alabama's Rural Physician Tax Credit Law.  Several important health related organizations have expressed favor for this definition.


This same definition is used by the federal government for determining locations where Certified Rural Health Clinics can be located.  

Alabama Rural Health Conference

Friday, March 18 and Saturday March 19, 2016


Conference Received Outstanding Evaluations

Thank You to Everyone Involved

Small Rural Hospitals – Can These Provide Part Of The Solution In Rural Alabama?

Alabama currently has eight counties (Chilton, Cleburne, Coosa, Henry, Lamar, Lowndes, Macon, and Perry) with no hospital.  Over the past six years, Alabama has had five rural hospitals close.  This is tied with Georgia for the second highest number of rural hospital closings among all 50 states.  Texas, with nine, has had the most rural hospital closings.  Unfortunately, the fact that more rural Alabama hospitals are experiencing threatening financial difficulties is well known. 


Many rural residents and others interested in rural health care are asking if there is a model of health care facility that can provide care similar to that received in a hospital in counties with no hospital.  This need is being studied by the Alabama Hospital Association and widely discussed by many others, including the Alabama Rural Health Association.


One possibility is the Freestanding Emergency Department which is a new type of health care facility that is now authorized in Alabama.  This is basically a hospital emergency department that is not attached to the hospital.  Two requirements for this facility limit its possibilities in meeting the needs in rural counties.  It cannot be located more than 35 miles from the parent hospital and must be directed by an Emergency Medicine physician.


A second possibility is the Critical Access Hospital (CAH) which was first authorized under federal law in 1997.  A CAH is certified under Medicare conditions that differ from those for acute care hospitals.  A CAH cannot have more than 25 inpatient beds; must maintain an annual average length of stay of no more than 96 hours for acute inpatient care; must offer 24-hour, 7-day-a-week emergency care; and must be located in a federally-recognized rural area. 


Critical Access Hospitals are encouraged to focus on providing care for common conditions and outpatient care, while referring patients with other conditions to larger hospitals.  In return, this type of hospital receives cost-based reimbursement from Medicare, instead of standard fixed reimbursement rates.  This can enhance the financial status of many rural hospitals with larger percentages of Medicare patients.


Critical Access Hospitals have not been as financially feasible in Alabama as in many other states.  Alabama currently has only four critical access hospitals:  Red Bay Hospital in Red Bay, Choctaw General Hospital in Butler, Washington County Hospital in Chatom, and St. Vincent’s Blount in Oneonta. There are 30 Critical Access Hospitals in Georgia and 32 in Mississippi.


Currently, there is a state requirement in Alabama that acute care hospitals must have a minimum of 15 beds.  Given current restrictions on inpatient stays, many rural hospitals do not have a daily census of patients that would require 15 inpatient beds.  The federal requirement for critical access hospitals is that there be 25 or fewer authorized beds.  There is no required minimum number of beds. 


There is a federal requirement that a critical access hospital must first be an acute care hospital and then convert to a critical access hospital. A new hospital cannot be opened as a critical access hospital.  With Alabama’s requirement that acute care hospitals must have 15 or more authorized beds, a new hospital must be constructed with a minimum of 15 beds, even if there is no need for so many beds.


The current financial crisis among many of Alabama’s rural hospitals may make the time right for Alabama to take a look at our regulatory requirements for acute care hospitals to consider allowing our rural areas to have hospitals with fewer than 15 beds.  These facilities could operate as acute care hospitals or convert to critical access hospitals without being required to have more beds than they can realistically expect to need.  This could be done as a change in regulatory requirements for acute care hospitals or by authorizing a new type of hospital – the Small Rural Hospital.  Either of these approaches would require approximately a year to complete the legal procedure if there is no opposition, possibly more time if there is opposition.


Several states already have rural hospitals with small numbers of authorized beds, including Tennessee and Mississippi.  The Johnson County Community Hospital in Mountain City, Tennessee is a 2-bed critical access hospital with 78 employees that operates at a profit when the annual critical access hospital payment is received.  The emergency department at this facility treats patients with minor conditions and sends then home, stabilizes patients with more serious conditions for transfer to a larger hospital, or keeps those who should be observed overnight.  The emergency department utilizes tele-medicine and an emergency department staffing service.  There is a certified rural health clinic affiliated with this hospital.  Major services such as radiology, other scanning, laboratory, and therapy is provided.  This small hospital even provides obstetrical service.


The Greene County Hospital in Leakesville, Mississippi is currently a 3-bed critical access hospital that is being expanded to seven beds in a county that does not have a single physician, like Coosa County here in Alabama.  This hospital has 55 employees and is also operating at a profit.  There is a 60-bed nursing home attached to this hospital and it has a certified rural health clinic.  The services provided at this hospital are quite similar to those in Mountain City except that tele-medicine is not being utilized and the emergency department is staffed by four advanced practice nurses (Certified Registered Nurse Practitioners) who commute from Mobile, Alabama to provide this coverage.  Advanced practice nurses cannot provide this coverage in Alabama, though there is some discussion about considering this coverage to hold down costs during early morning hours when patient traffic is light.


Can small rural hospitals like these provide part of the solution to our rural hospital crisis in Alabama?  One thing for certain is that continuing to allow rural hospitals to close is not part of the solution.

Telemedicine:  Ready or Not, Here It Comes!

The provision of health care is constantly changing to meet the varying needs of those it serves and to take advantage of ever changing technology.  Another dramatic change in the provision of and receiving of health care may be on the horizon in Alabama, especially in rural areas.  This involves the availability of telemedicine.


What is telemedicine?  There are currently three major types of telemedicine:  store and forward, remote (or high-risk) patient monitoring, and live video.  Store and forward technology has been available and widely used for some time.  An example of this technology is having technicians in many of Alabama’s rural hospitals complete x-rays, various types of scans, etc. and transmit these electronically to services staffed by radiologists and other professionals, some even in other countries, where there is a rapid analysis and reporting of findings.


Remote or high-risk patient monitoring has been tested in rural Alabama and is in current use.  An example of this technology is the current monitoring of vital signs for over 700 home care consumers by the Alabama’s Department of Public Health’s Bureau of Home and Community Services.  Regularly scheduled telephone calls are made to or received from these consumers with special needs.  They have selected vitals monitored using special equipment and the telephone to identify whether special attention is needed or not.  This can help in avoiding unnecessary travel for patients in remote areas or with difficult transportation concerns.  This can also identify potentially serious conditions requiring fast intervention or treatment.


Live video is an emerging and rapidly advancing technology that involves a health care provider in one location examining or providing other care for a patient in another location – possibly thousands of miles away.  This is done through the use of special equipment, sometimes located on a cart, including a screen and phone connection allowing the provider and patient to see and communicate with each other.  There are numerous attachments such as a digital stethoscope, otoscope, etc., depending upon the specialty or sub-specialty of care that is being provided, that can be used with this equipment in examining patients or specific conditions. 


With the use of high quality broadband connectivity, the services of another health care provider who is with the patient to follow the provider’s instructions in using the equipment, and high technology medical instrument attachments, a health care provider can examine the patient and offer instruction on the required treatment.  The special attachments allow the provider to see images that can sometimes provide much greater detail than is seen in face-to-face visits.  This explanation of telemedicine is very basic and offers limited detail in comparison to all services which are currently possible using this technology.


Georgia is a leader in adopting the use of telemedicine.  Patients in Georgia can currently receive care involving more than 40 specialties or sub-specialties through telemedicine.  Primary care is available in many retirement facilities, often avoiding unnecessary transport by ambulance for basic care.  Children who may rarely or even never see a physician have the ability to receive care through school based clinics.


Georgia, Tennessee, and Mississippi have all passed legislation mandating that private insurance companies reimburse for telemedicine services.  Private insurance reimbursement is not being mandated through legislation in Alabama.  This has been a major barrier to the use of this promising technology.  A second barrier is the need for high quality broadband access throughout Alabama.  High quality broadband access is a critical need for the expansion of remote patient monitoring.


The lack of reimbursement by private insurance companies in Alabama is being decreased as a barrier.  Alabama’s largest private insurance company, Blue Cross and Blue Shield, has announced that it will voluntarily start reimbursing for selected services involving cardiac care, neurological care or stroke, dermatology, infectious diseases, and behavioral health on December 1.  Medicare already reimburses for telemedicine services nationally.  Alabama’s Medicaid program currently provides reimbursement for some telemedicine services.


Even without private insurance reimbursement, several types of telemedicine are already being practiced in Alabama.  Alabama currently has tele-stroke care available in several rural emergency departments where patients are examined by a distant neurologist with local providers being instructed in what time-sensitive care should be administered.  Tele-wound care is being provided at the Washington County Hospital in Chatom to help local patients possibly avoid having to travel more than 70 miles one-way for this care.  Tele-anesthesiology, tele-cardiology, tele-HIV medicine, tele-psychiatry, and tele-child psychology are all being utilized in Alabama. 


The Alabama Department of Corrections is utilizing telemedicine in several prison clinics to avoid transporting expenses for general care.  The Alabama Department of Public Health is providing strong support for the expansion of telemedicine by placing telemedicine carts in nine county public health departments that can be used by local providers.  Tele-HIV medicine is being provided in some of these locations.  Others locations are being considered for telehealth applications such as tele-prenatal care.


Positive potential abounds for all involved parties.  This technology can allow health care providers to be more like other businesses by exporting their health care services.  Insurers have the potential to reimburse for earlier and lower cost care administered through telemedicine, possibly avoiding greater expenses for treatment received later.  Consumers have the option of receiving care more conveniently and earlier.   


What the future of telehealth and telemedicine will become is yet to be seen.  However, the current utilization is very exciting and promising, especially for such needs as providing specialty and sub-specialty care to patients in our rural areas.  Talk with your health care providers and encourage them to utilize this very promising technology.

 Alabama's Obstetrical Crisis 

More Bad News


East Alabama Medical Center - Lanier in Valley (Chambers County) ended the providing of obstetrical service as of the end of December 2015.  This unfortunate loss in obstetrical service leaves only 16 of the 54 counties considered rural by the Alabama Rural Health Association with hospitals providing this most basic and important health care service.  In 1980, 45 of the 54 counties currently considered rural had hospitals that provided obstetrical service.  This loss has been much greater in the Black Belt Region counties.  In 1980, 10 of the 12 Black Belt Region counties had hospitals that provided obstetrical service.  Today, only one of the 12 Black Belt Region counties has a hospital providing this service.


                                                     Good News


Bibb Medical Center in Centreville (Bibb County) has returned obstetrical service to this medical center.  Being able to absorb the financial loss of offering obstetrical service to the residents in its service area is being accomplished by enhancing financial stability in other service areas.


With the returning of this service to the residents in the Bibb Medical Center service area, a disturbing trend has been interrupted.  ARHA has researched as far back as 1970 and has found only a short time in Pickens County during the 1990s where a county lost this service and had it later return.  Bibb Medical Center administrator, Joseph Marchant; John Waits, M.D.; and Lacy Smith, M.D. are to be applauded for their leadership roles in returning this service.  Mr. Marchant is a former Director of ARHA.  Drs. Waits and Smith are members of ARHA.    

ARHA Announces Drive to Establish Student Chapters

      First Community College Chapter of ASRHA Being Established at Northeast

                                Alabama Community College in Rainsville


   Initial UAB Chapter Meeting Requires Larger Room to Accomodate Attendance


                       Additional Student Chapter Information To Follow


Your Alabama Rural Health Association has initiated an aggressive campaign to establish student chapters of the Alabama Student Rural Health Association (ASRHA) on all 54 public and private university, college, and community college campuses in Alabama.  A partnership proposal has been submitted to another Alabama organization to assist in funding this promising program.


Student membership in ASRHA is a bargain at a cost of only $25 per school year.  Included in this membership is annual membership in the campus ASRHA chapter (on campuses with ASRHA chapters), a full annual membership in the Alabama Rural Health Association, and a school year student membership in the National Rural Health Association.  For additional information on student memberships and benefits, select "Join ARHA".


Student members can also seek election as an officer in their campus chapter or seek election to the student position on the ARHA Board of Directors.


Campus ASRHA chapters will have regular meetings during which information of value to students pursuing health related careers will be provided.  A listing of possible program topics and speakers is currently being developed.  Chapters will also conduct health related community projects.  Each campus chapter must have a faculty/staff sponsor to oversee the chapter activities.  


To assist in establishing campus chapters of ASRHA, the following are being sought:

     Students with an interest in helping to establish a chapter at their school.

     Faculty/staff at Alabama schools interested in serving as a campus sponsor.

     Potential speakers on topics of interest to health related program students.


Please contact ARHA to assist with this program or if you have questions or recommendations.