1. Rural Health Advocacy Missouri Rural Health Conference November 18, 2015 Tim Wolters, Director of Reimbursement Citizens Memorial Hospital, Bolivar Lake Regional Health System, Osage Beach

2. Rural Advocacy Overview Meeting with legislators – tell your story – What makes rural different Fluctuating volume Higher Medicare volume Lower commercial volume to subsidize Medicare cuts Lower overall volume over which to spread fixed costs Fewer resources to deal with complex, ever-changing government programs Don’t forget the regulatory side – comment on proposed regulations

4. FY13 Medicare and Medicaid Discharges by Hospital Type Number of Hospitals Medicare Discharges Medicare Discharge Percent Medicaid Discharges Medicaid Discharge Percent Total Discharges All Hospitals4,6839,583,41631.5%3,872,80712.7%30,425,687 Urban2,5658,035,72530.0%3,354,04112.5%26,786,587 All Rural2,1181,547,69142.5%518,76614.3%3,639,100 CAH1,202298,66649.4%64,82510.7%604,217 MDH192171,97448.5%50,78414.3%354,279 SCH377533,74241.4%182,65814.2%1,289,173 Other Rural347543,30939.0%220,49915.8%1,391,431 Source: FY2013 Medicare cost report data from CMS HCRIS file, 1 st quarter 2015 update. Note the ‘CAH’ category includes rural CAHs only – urban CAHs are in the urban category. The ‘Other Rural’ category includes only rural hospitals with no special payment status (i.e., non-SCH, non-MDH, non-CAH).

6. Medicare Programs CMH Operates Inpatient acute care PPS Inpatient psychiatric PPS Inpatient skilled nursing PPS Outpatient PPS Home health PPS Hospice PPS

7. Medicare Programs CMH Operates Physician fee schedule Outpatient rehabilitation fee schedule Outpatient laboratory fee schedule, for tests not bundled under outpatient PPS Ambulance fee schedule Durable medical equipment fee schedule Pharmacy fee schedule

8. HR 3225- Save Rural Hospitals Act Eliminates Medicare sequestration cuts for rural hospitals Permanently extends low-volume and Medicare dependent hospital programs Reinstates sole community hospital hold harmless program for outpatient services Eliminates rural Medicare & Medicaid disproportionate share funding reductions

9. HR 3225- Save Rural Hospitals Act Reforms RAC program Extends rural ambulance base rate increases Reduces CAH outpatient coinsurance rates Eliminates 96-hour inpatient certification requirement for CAHs Revises physician supervision requirements Establishes community outpatient hospital program

10. Regulations - Evaluate & Comment Annual proposed rules for IPPS, OPPS, etc. Special CMS rules – EHR (meaningful use), CCJR initiative, discharge planning HRSA proposed mega-guidance on 340B TRICARE rules for sole community hospitals MO HealthNet rules – Medicaid DSH funding, NDC coding requirement

11. Thank you for your efforts! Tim Wolters tim.wolters@citizensmemorial.com 417-328-7286