1. HEALTH REFORM MEETING THE NEEDS OF RURAL COMMUNITIES Brief History Great Plains Health Alliance Hill Burton Program Government Financed Health Care Evolution of the Rural Hospital o Meeting Community Needs  Community Expectations  Development of Hospital Based Long Term Care  Swing Bed Programs  Critical Access Hospitals  Rural Health Clinics Hospital Employed Medical Staff Provision of Emergency Medical Services Home Health Wellness Centers

2. HEALTH REFORM MEETING THE NEEDS OF RURAL COMMUNITIES Impact of Health Care Services in Rural Communities Access to Health Care in a Rural Environment o Demographics o Transportation o Aging Population o Out Migration o Volunteer Based Emergency Medical Services Quality Of Life Return on Investment o Return of Insurance Dollars to the Community o Choosing Services that will Provide the Best Return of Dollars Back to the Community o Contribution to the Community’s Economic Engine o Financial Penalties from Medicare when Critical Access Hospitals Provide Services Beyond Traditional Hospital Services

3. HEALTH REFORM MEETING THE NEEDS OF RURAL COMMUNITIES Challenges Financing o Local Tax Support o Government Payment Models  Critical Access Hospital Payment Methodology Strengths and Weaknesses Regulations (Congress and CMS) o Lack of Understanding of Rural Environments and Their Impact on the Total Medicare Expenditures o Development of Regulation that Exceed Congressional Intent o Unintended Consequences o Transition to the New Medicare Administrative Contractors o Recovery Audit Contractors  Retroactive Enforcement  Focus on Short Stays  Evaluate Appeals Process

4. HEALTH REFORM MEETING THE NEEDS OF RURAL COMMUNITIES Challenges – Cont’d Manpower o Physicians (Especially Primary Care Physicians) o Allied Health  PA/ARNP ‘s  Nurses  Physical Therapists  Lab/X-rays Aging Facilities Technology o Diagnostic o Electronic Medical Records o Electronic Information Exchange o Telemedicine

5. HEALTH REFORM MEETING THE NEEDS OF RURAL COMMUNITIES Policy Issues Dysfunctional Federal Government Technology o Medicare Advantage Programs o Specialty Hospitals o Self Referrals Stabilize Physician Payment Methodology o Incentivize Primary Care o Impact of Rural Hospitals when Physician Payments are Uncertain or Reduced Improve Impact Analysis Prior to Implementation of Regulations