Sub-Goal: Strengthen health systems to support the delivery of quality health care services
Measure FY Target Result
27.1: Reduce the proportion of rural residents of all ages with limitation of activities caused by chronic conditions.1
(Outcome)
(Baseline – FY 2000: 14.67%)
Out-Year
Target 13% (FY 2013) Oct 31, 2015 2010 13.9% Oct 31, 2012 27.IV.A.2: Increase the number of people
receiving direct serves through Outreach Grants. (Outcome) 2012 390,000 Oct 31, 2013 2011 385,000 Oct 31, 2012 2010 380,000 Oct 31, 2011 2009 N/A 375,000 (Baseline) 2008 N/A N/A 2007 N/A N/A Goal: Improve Access to Quality Health Care and Services
Sub-Goal: Strengthen the financial soundness and viability of HRSA-funded health organizations
Measure FY Target Result
27.2: Increase the proportion of critical access hospitals with positive operating margins. 1
(Baseline – FY 1999: 10%)
(Outcome)
Out-Year
Target 60% (FY 2013) Dec 31, 2015
27.V.B.1: Increase the average operating margin of critical access hospitals.
(Outcome)
2012 0.5% point below FY 2011 Dec 31, 2013
2011 0.5% point below FY 2010 Dec 31, 2012
2010 0.5% point below FY 2009 Dec 31, 2011
2009 0.5% point below FY 2008 -3.3%
(Target Not Met)
2008 0.5% point below FY 2007 -1.9% (Target Exceeded) 2007 -8.3% -6.7% (Target Exceeded) 1
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Efficiency Measure FY Target Result
27.E: Increase the return on investment of funds by the Rural Hospital
Flexibility (FLEX) grant program, as measured by change in total operating margin of critical access hospitals in relation to FLEX dollars invested
(Efficiency) 2012 30% Oct 31, 2014 2011 29% Oct 31, 2013 2010 28% Oct 31, 2012 2009 27% Oct 31, 2011 2008 26% -383%
(Target Not Met)
2007 25% 68% (Target Exceeded)
Measure Data Source Data Validation
27.1 Centers for Disease Control and Prevention (CDC), "Health in the United States."
Data validated by CDC
27.IV.A.1 Reported by grantees through the Program’s Performance Improvement Measurement System.
Validated by project officers
27.2 27.V.B.1 27.E
Medicare Cost Reports Validated by Centers for Medicare and Medicaid Services
INTRODUCTION
The goals and measures are used to assess the Office of Rural Health Policy’s (ORHP) performance. (This does not include the Black Lung, Radiation Exposure Screening, and Telehealth programs, which are presented later.)
ORHP’s goals and objectives support HRSA’s Strategic Plan goal to improve access to quality health care and services and sub-goals to strengthen health systems to support the delivery of quality health services and strengthen financial soundness and viability of HRSA-funded health organizations. This is done through improving the health and wellness in rural communities as well as increasing the financial viability of small rural hospitals. Strategies include making revisions to program guidance to assure that performance expectations and goals are clear and to focus the attention of grantees on performance improvement and efficiency. DISCUSSION OF RESULTS AND TARGETS
Goal: Improve Access to Quality Health Care and Services
Sub-Goal: Strengthen health systems to support the delivery of quality health care services 27.1. Reduce the proportion of rural residents of all ages with limitation of activities caused by chronic conditions.
(Baseline – FY 2000: 14.67%)
This long-term measure was chosen because rural residents experience greater limitation of activity caused by chronic conditions than urban residents. A reduction of activity limitation is an indicator of improvement of health status and wellness. According to the Centers for Disease Control and Prevention (CDC) the proportion of rural residents of all ages with limitation of
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activities caused by chronic conditions in FY 2000 was 14.67%. By 2013, the goal is to reduce this proportion to 13%.
27.IV.A.2. Increase the number of people receiving direct services through Outreach grants.
This revised performance measure will examine the increase in the number of people receiving direct services through Outreach Grants. This new measure will focus on only direct patient care such as screenings and treatment which is clearer, easier to interpret, easier to quantify and, thus, more accurate. The baseline for this measure is 375,000in FY 2009. The targets for FY 2011 and FY 2012 are 385,000 and 390,000, respectively.
Goal: Improve Access to Quality Health Care and Services
Sub-Goal: Strengthen the financial soundness and viability of HRSA-funded health organizations
27.2. Increase the proportion of critical access hospitals with positive operating margins. (Baseline – FY 1999: 10%)
This long-term measure is used to monitor efforts to increase the financial viability of small rural hospitals. Medicare cost-report data for CAHs shows that progress toward this goal is being
made. In FY 2009, the number of CAHs with positive operating margins had increased to 54%. As these facilities become more economically viable, they will be more likely to survive long
term and therefore continue serving as a key access point for health care in rural communities. 27.V.B.1. Increase the average operating margin of critical access hospitals.
An increase in the average operating margin of CAHs can contribute to these hospitals’ financial viability. CAHs serve as key access points for Medicare beneficiaries in rural areas and also act as the focal point for expanded health care services in rural communities by helping to attract physicians and other health care personnel. Therefore, the focus on operating margin helps determine the long-term viability of CAHs to continue to perform that access role. A large representative sample of Medicare cost reports show that CAHs had a -14.05% average operating margin in 1999. Since that time, Congress has enacted three laws that have included provisions increasing administrative flexibility for CAHs. It is expected that these changes in the law will help address some of the financial challenges and barriers facing CAHs. Analysis of the sample representation of Medicare cost report data shows positive progress toward this goal. In
FY 2005, CAHs had an average operating margin of -9.6%. In FY 2006, the average operating margin improved to -8.8%. This figure improved to -6.7% in 2007, which was better than the FY 2007 target of -8.3%. The FY 2008 result is -1.9% which exceeded its target of a 0.5 percentage point improvement from FY 2007. This improvement is mostly associated with the increase in the number of CAHs that have submitted a full year of cost report data. The FY 2009 operating margin is -3.3%, not meeting the target. This decrease from last year could be attributed to the economic downturn beginning in 2008, which impacted the number of insured patients within hospitals’ patient mix. The FY 2012 target is to show a 0.5 percentage point improvement as compared to the FY 2011 operating margin.
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27.E. Increase the return on investment of funds by the Rural Hospital Flexibility (FLEX) grant program, as measured by change in total operating margin of critical access hospitals in relation to FLEX dollars invested.
This efficiency measure indicates the return on investment of funds by the Rural Hospital Flexibility grant program as measured by the change in total operating margin of critical access hospitals in relation to the investment of Flex program dollars. The measure looks at the change in total operating margin for all CAHs from one year to the next relative to the programmatic investment that is specifically focused on finance-related activities to yield a percentage that quantifies return on investment annually. The return on investment in FY 2006 was 13.4% which was below the target but still indicative of a positive return on investment for the program.
The return on investment in FY 2007 was 68% which considerably exceeded the target of 25%. The return on investment for FY 2008 was -383%, a significant decline from the previous year.
The return on investment may fluctuate year to year as rural hospitals experience significant variability in their patient volume and revenue, but these factors tend to balance out to some degree over time. The FY 2008 number captures the struggles hospitals faced during the economic downturn, with decreased insurance coverage of the patients in the catchment areas. In addition, there have been changes in the way some hospital systems are reporting costs for their CAHs which are impacting the CAHs return on investment percentage. Given the outside factors beyond the control of the Flex grant program and the difficulties caused by changes in hospital reporting, the Office of Rural Health Policy will be proposing alternatives to this measure. The FY 2012 target is 30%.
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Measure FY Target Result
27.IV.A.1: Increase the number of people served through Outreach Grants.
(Outcome) 2012 N/A N/A 2011 980,000 Oct 31, 2012 2010 950,000 Oct 31, 2011 2009 930,000 2,451,969 (Target Exceeded) 2008 635,000 828,360 (Target Exceeded) 2007 777,000 923,003 (Target Exceeded) 27.IV.A.1. Increase the number of people served through Outreach Grants.
The Outreach grant program demonstrates an effective way to provide services to rural communities in order to improve the health and wellness of people served. In FY 2008, the number of individuals served was 828,360, exceeding its target of 635,000. In FY 2009, the number of individuals served was 2,451,969, exceeding its target of 930,000. This increase was due to two reasons: 1) an increase in the number of awards made and 2) a new method that ORHP is using to collect more accurate data. Grantees currently collect the direct and indirect services they provide through the Outreach grants which can be a very large number. This new data collection method may help to explain the large increase in the number of individuals served in FY 2009 over the previous year. Accurately accounting for persons receiving indirect
services, which includes such things as handing out brochures and flyers and making radio and television announcements, is very challenging to grantees. This impacts the consistency and reliability of this data, despite Program efforts in providing guidance to grantees. More important, the measure, which includes such a hodgepodge of services, is difficult to interpret and lacks sufficient meaning for grantees and for Program management.
This performance measure has been discontinued and replaced with a revised performance measure that will examine the increase the number of people receiving direct services through Outreach Grants. This new measure will focus on only direct patient care such as screenings and treatment which is clearer, easier to interpret, easier to quantify, more accurate, and more
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RURAL HEALTH POLICY DEVELOPMENT