Form CMS-10508 Data Collection Protocols

Evaluation of the Rural Community Hospital Demonstration

Contract Number: HHSM-500-2011-00013I

Data Collection Protocols

Information Collection Request for Paperwork Reduction Act Clearance

Prepared for:

The Center for Medicare & Medicaid Services

U.S. Department of Health and Human Services

Prepared by:

IMPAQ International

Berkeley Policy Associates

Mission Analytics Group

Protocols

Round 1 Interview Discussion Guide: New Hospitals, 2013 1

Round 2 Interview Discussion Guide: All Hospitals, 2015 9

Interview Information Sheet 15

Annual Progress Report (Template) 16

RCHD Evaluation

Round 1 Interview Discussion Guide: New Hospitals, 2013

Introduction

My name is [ ___ ], and I am a researcher from [Berkeley Policy Associates/Mission Analytics Group]. As you know, Berkeley Policy Associates, BPA, and its partner Mission have been contracted to serve as the independent evaluator for the Rural Community Hospital Demonstration – the RCHD. The evaluation team includes a group of researchers who led the previous RCHD evaluation. This evaluation builds upon the earlier evaluation work with the goals to (a) assess the effects of the demonstration on participating hospitals and their communities and (b) develop a report to Congress at the end of the demonstration.

In preparation for our interview today, we have reviewed your hospital’s application. We hope to use this interview as a way for you to update the information in the application and provide more detail about your hospital. We’ve scheduled about 1.5 hours for this conversation – does that still work for you? We plan to record this interview if that is Ok with you. In addition, we will send you our notes in about a month for your review. You can let us know if we misinterpreted anything you said or if there is anything else you would like to add.

To start, please tell me a little bit about yourself. How long have you been serving as [job title] in your hospital? What are your current responsibilities? What did you do before?

Environment

Now, I’d like to make sure I understand the environment your hospital operates in. From what I have read, I understand that [summarize information on economic and social environment from ARF and Census data]. Is that right? What else can you tell me about:

1. The economy of the region (or service area)

1. What types of jobs or industries are prevalent (e.g., tourism, agriculture, etc.) in your market area? Do these jobs tend to be seasonal or stable throughout the year? Are any industries growing or declining?

2. Who are the major employers? What proportion of the employment in your market area does the hospital account for?

3. Are there any other important characteristics of the local economy that affect your hospital? In what ways has the recent recession impacted the local economy?

4. Are there other ways the economy is changing? Are any of these changes affecting hospital operations and/or service use?

2. The social environment of the area

   1. Are there any other important characteristics of the local population in terms of their racial or ethnic backgrounds, incomes, or age that affect your hospital?

   2. Is the population changing in any important way? How has changing demographics affected the hospital’s operations, or how might they affect them in the future?

3. Is there anything else we should know about the environment you operate in that makes it unique or creates particular challenges?

Hospital Profile

Now, I’d like to focus on [________] Hospital, in particular. Again, based on what I’ve read, I understand that [summarize information from other sources about hospital structure, size, operations]. Is that accurate? What else can you tell me about:

1. Your hospital’s ownership, governance, or structure

1. Are you a free-standing facility, or are you owned or operated by a larger hospital or health care system/network?

2. Are you a not-for-profit or for-profit hospital? Are you owned or operated by a public/governmental entity, such as a county, township, municipality, or borough?

3. Do you have a management contract with another organization? If so, what services does that organization provide?

4. Are you part of a formal or informal network of rural healthcare providers?

5. Are there any other partnerships that are a key part of your operations?

6. Has your hospital’s ownership or structure changed to improve financial viability?

2. Your hospital’s service lines

1. What types and levels of inpatient services do you provide? What services do you refer elsewhere?

2. What services are your primary generators of revenue? Which ones operate at a loss?

3. How important are outpatient services as a source of revenue? Probe: What percent of revenues comes from outpatient services?

4. Have you recently added or dropped service lines, or do you plan to? Why?

3. Your hospital’s staffing

1. How large is your workforce? How would you describe the skill mix of your workforce?

2. To what extent do you rely on temporary, transient, or contract labor?

3. Do you employ your own physicians (e.g., emergency/trauma care, hospitalists, intensivists, or others)? Do you own any physician practice groups?

4. How would you describe staff recruitment/retention at your hospital? What kind of turnover do you have?

4. Your hospital’s technology infrastructure

   1. Does your hospital use advanced IT resources such as telehealth or electronic medical records?

   2. Do you plan on applying for EHR meaningful use payments?

   3. What high-tech medical equipment does your hospital operate? What are your recent purchases? What equipment would you like to acquire?

5. Your hospital’s key strategic challenges

1. What do you see as the 2-3 top strategic challenges for the hospital?

2. How are you responding to these challenges?

6. Do you have a strategic plan? If so, could we get a copy? What were the key forces shaping the hospital’s strategic plan?

Health Care Market

Based on what I have read, I understand that [summarize information from other sources about health care market and environment]. Is that accurate? What else can you tell me about:

1. The health care providers in the area and the health care services available (e.g., availability of primary care physicians and specialists)

   1. What kind of competition for patients does your hospital face from other providers of outpatient care (e.g., physician-owned ambulatory surgery centers, diagnostic tests)?

   2. What kind of competition for patients does your hospital face from other providers of inpatient care?

   3. Is competition putting pressure on your hospital to update and expand its facilities?

   4. Is competition changing in any important way?

   5. What makes you competitive in your health care market? What do you feel would make you more competitive relative to the other providers in your market?

2. The health insurance market in the area

   1. Are there a large number of people who are uninsured? Roughly, what share of the individuals in your market is uninsured?

   2. What share of the population in your market is covered under Medicare? What share is covered under Medicaid? What share is covered by a private insurance company?

   3. What share of Medicare beneficiaries in your market are enrolled in a Medicare HMO or PPO? What share of commercially insured patients is enrolled in an HMO or PPO?

   4. Are most individuals with commercial insurance in your market enrolled under a particular insurer such as Blue Cross Blue Shield or Aetna? What percent of the commercial insurance market is held by the top 1-3 commercial insurers? What is your hospital’s relationship with these managed care plans and your process of remaining with a plan’s network?

3. The labor market for health care professionals in your area

1. Are there shortages of key professionals?

2. Is the labor market for hospital or health care professionals changing in any important way?

4. The health needs of the population

1. Are there particular health care needs that characterize the population of your service area (e.g., prevalence of chronic disease, disability, aging population)?

2. Are these needs changing in any important way?

Financial Performance

We have been reviewing [__________] Hospital’s Medicare Cost Reports and HCRIS data as part of this evaluation, but I’d also like to get your perspective on the hospital’s financial situation. Let’s first talk about what is generally influencing your hospital’s financial viability. Then, we can move on to the effects of the demonstration. Based on what I have seen, I understand that [summarize information from other sources about the hospital’s financial situation and influential factors prior to the demonstration]. Is that accurate?

1. What are the major positive and negative forces affecting your financial condition? Have any of these forces changed since joining the demonstration?

2. What is your payer mix for inpatient care and/or outpatient care? Have you noticed any changes since the demonstration?

3. How much of your caseload did uncompensated care account for before the demonstration started?

   1. Are you designated as a DSH for purposes of Medicare reimbursement? Medicaid? [Note that hospitals do not receive DSH payments while in the demonstration]

   2. Do you receive any compensation from local government authorities or other sources for free care?

   3. Have you noticed any changes in uncompensated care delivery since the demo started?

4. What non-operating sources of revenue have you relied on (e.g., local government subsidy, investments, donations, rent)?

5. How would you describe your hospital’s access to capital? Are capital projects funded in part through local bond issues?

6. [If financial viability is a concern] How would you describe your hospital’s strategy for achieving long-term financial viability?

Now, let’s talk about how the demonstration has affected your hospital’s financial viability. Based on what I have seen, I understand that [summarize how hospital margins have changed during the years of the demonstration]. Is that accurate?

7. Please describe the process of receiving interim payments.

   1. When did you start receiving payments?

   2. How much are they?

   3. How often does your hospital receive them?

8. What about the auditing, adjustment, or settlement process? Have you submitted a cost report? Have your payments been reconciled? If so,

   1. How big are adjustments?

   2. How does this affect your financial management?

   3. Has this changed your reporting requirements or your relationship with your FI or MAC?

9. How has the demonstration’s payments affected your financial bottom line (e.g., margins, liquidity)?

10. Has the impact of the demonstration changed over time?

11. Is the demonstration’s financial impact what you expected?

12. What might happen to your hospital’s financial viability when the demonstration ends?

I’d like to understand how your hospital has been affected by the demonstration’s methodology to calculate the target amount. Are you pretty familiar with the equation or would you like some additional information?

7. What parts of the equation for calculating the target amount have helped or hurt your hospital?

8. If the demonstration were to become a permanent program, do you have any suggestions on how the equation or payment process should be changed based on your experience?

To help us better understand the financial circumstances that rural hospitals face, we’re asking all of the hospitals participating in this demonstration to provide us with copies of their audited financial statements.

15. Would you be able to provide us with these statements, or let me know who else we can contact to obtain copies?

16. If we have clarification questions about the financial statements, who should we contact?

Community Benefits

Now, I’d like to focus our conversation on how your community may have been impacted by the demonstration. Based on what I have read, I understand that [summarize the programs and projects the hospital has implemented with demonstration funds]. Is that accurate?

1. Are you using the additional payments from the demonstration to generally improve the financial health of the hospital or are you channeling them to specific programs or activities (e.g., capital improvement, community programs)?

2. How did you expect to use the additional payments from the demonstration to benefit the community? What were your initial goals for the demonstration funds?

3. How are the additional payments actually used (e.g., capital improvement, community programs)? [If the expected and actual use of funds is different],why was there a change in how you expected to use the funds and how you actually used them?

4. Were these projects or activities already planned or underway before you participated in the demonstration, or were they new?

5. What barriers to implementing these projects or activities have you encountered?

6. Did you have other sources of funding to support these projects, apart from added revenues from the demonstration?

7. Overall, how important would you say the revenues from the demonstration were to these projects or activities?

8. What have been the community impacts of these projects? How many Medicare and non-Medicare beneficiaries have been impacted?

9. How do you track the impact of activities designed to benefit your community?

10. What do you expect will happen to these projects when the demonstration ends? Are there any plans to improve or develop the sustainability of these projects?

11. Is there anything else about your hospital’s community benefit projects that you feel is important for us to understand? Also, is there anything else about how your participation in the demonstration may affect one or more of these community benefit projects?

The Demonstration Compared to Other Payment Options

Now, we’d like to talk about why you chose to apply for the demonstration and its tradeoffs compared to other payment strategies, such as CAH or SCH.

1. Why did you apply for the RCHD?

2. Did the 2012 expiration of Medicare Dependent Hospital (MDH) payments affect your decision?

3. Why didn’t you apply during the first solicitation (e.g., not eligible)? Did you know about the demonstration? If your hospital had been eligible, would you have applied? [Modify the question based on the hospital’s state, which triggered eligibility for the initial solicitation.]

4. Why did you decide not to apply for CAH designation instead? [Modify the question based on the hospital’s bed size or distance to another hospital, which trigger eligibility for CAH.]

5. [If applicable] As we understand it, your hospital had been designated as a sole community hospital, which entitled you to cost-based reimbursement based on 1982, 1987, 1996 or 2006 costs for Medicare inpatient services. Is this correct?

   1. If so, were your payments based on current IPPS rates, or base year costs per discharge updated to the current year?

   2. What impact did the SCH designation have on your hospital’s Medicare reimbursement and overall financial performance?

6. Have you ever considered withdrawing from the Rural Community Hospital Demonstration? Why?

7. With what you now know about this demonstration, is there anything you would have done anything differently?

8. Is there anything else that you’d like to add?

In addition to interviewing officials from hospitals participating in the demonstration, we plan to interview one or two other people from each state who are knowledgeable about rural community hospitals and the communities they serve. Is there someone from your state or your community that you would recommend we talk to?

Thanks for taking the time to talk to us today. This has been very helpful. We will send you our notes in about a month for your review. You can let us know if we misinterpreted anything you said or if there is anything else you would like to add. We look forward to talking to you further down the road to see how things are going.

RCHD Evaluation

Round 2 Interview Discussion Guide: All Hospitals, 2015

1. Introduction

My name is [ ___ ], and I am a researcher from [Berkeley Policy Associates/Mission Analytics Group]. As you know, we have been working with BPA on the evaluation of the Rural Community Hospital Demonstration, or RCHD. We really appreciate your hospital’s contribution to this evaluation by participating in an interview and completing annual progress reports.

In preparation for our interview today, we have reviewed all materials related to your hospital, including your application, annual reports, and notes from the previous interview(s). We want to use this interview as a way to update information about your hospital’s operating environment and the impact of the demonstration. We are particularly interested in how your hospital is doing in light of health care reform. We’ve scheduled about an hour for this conversation – does that still work for you? We plan to record this interview if that is Ok with you. In addition, we will send you our notes in about a month for your review. You can let us know if we misinterpreted anything you said or if there is anything else you would like to add.

1. When we spoke to you last, your main responsibilities were [summarize]. Is that still true?

Or

2. To start, please tell me a little bit about yourself. How long have you been serving as [JOB TITLE] in your hospital? What are your current responsibilities? What did you do before?

2. Health Care Reform

First, we’d like to understand how your hospital has been impacted by health care reform and what this might mean for the demonstration.

1. We see that your state [participates in or does not participate in] Medicaid expansion. Do you know how this decision was made? What were the main factors behind the decision-making process?

2. We also see that your state [developed its own health insurance exchange or uses the federal health insurance exchange]. Do you know how this decision was made? What were the main factors behind the decision-making process?

3. Does your state participate in any other Affordable Care Act programs (e.g., accountable care organization, health care innovation award, Balancing Incentive Program)?

4. How has health care reform impacted your state’s population (e.g., more people have health insurance)?

5. How has health care reform impacted your hospital (e.g., less charity care)?

6. Has your hospital been able to take advantage of enhanced payments available through ACA (e.g., based on meaningful use) or has it been hurt by reductions in payment based on performance (e.g., hospital readmissions)?

7. Given health care reform, how reliant is your hospital on the demonstration for maintaining financial viability?

8. Do you see the importance of the demonstration changing as more aspects of health care reform are implemented?

3. Financial Performance

Now, I’d like to focus our conversation on what has changed since the last annual report. Let’s start with financial performance. Based on what I have seen, I understand that [summarize most recent hospital margins].

1. How have demonstration payments changed over the last couple of years?

2. What do you attribute to the increase or decrease of payments?

3. How important is the demonstration to your hospital’s financial viability?

4. What might happen to your hospital’s financial viability when the demonstration ends?

5. Please comment on the auditing, adjustment, or settlement process. How large are adjustments to your payments? Has this affected financial management decisions?

6. Have you considered withdrawing from the demonstration? Why? Why did you decide to stay?

7. What would you change about the demonstration so it better supports your hospital?

1. What parts of the equation determining the target amount have helped or hurt your hospital?

2. If the demonstration were to become a permanent program, should the equation or payment process be changed?

Now, let’s talk about other factors that are influencing your hospital’s financial performance. Based on what I’ve read [summarize other financial factors]. Is that still accurate? What has changed regarding:

8. Compensation from local government

9. Non-operating sources of revenue you rely on (e.g., local government subsidy, investments, donations, rent)

10. Access to capital

11. Your hospital’s strategy for achieving long-term financial viability

4. Community Benefits

Please comment on how programs and projects implemented using demonstration funds have affected your community. Based on what I have seen, I understand that [summarize the programs and projects the hospital has implemented with demonstration funds]. Is that still accurate?

1. Have you implemented any new projects since the last interview?

2. Overall, how important would you say the revenues from the demonstration were to these projects or activities?

3. What have been the community impacts of these projects? Have there been changes in the community impact of these projects since the last interview? How many Medicare and non-Medicare beneficiaries have been impacted?

4. Please note whether the method used to track the impact of activities designed to benefit your community has changed since the last interview.

5. What do you expect will happen to these projects when the demonstration ends? Are there any plans to improve or develop the sustainability of these projects?

6. Is there anything else about your hospital’s community benefit projects that you feel is important for us to understand? Also, is there anything else about how your participation in the demonstration may affect one or more of these community benefit projects?

5. Environment

Now, I’d like to go over some background information on your hospital and its operating environment. You have already provided a lot of information in the past, so we can just talk about what has changed. Let’s start with the economy and population. From what I have read, I understand that [summarize information on economic and social environment from ARF and Census data]. Is that right? Tell me about what has changed regarding:

1. The economy of the region (or service area)

   1. What types of jobs or industries are prevalent (e.g., tourism, agriculture, etc.) in your market area? Do these jobs tend to be seasonal or stable throughout the year? Are any industries growing or declining?

   2. Who are the major employers? What proportion of the employment in your market area does the hospital account for?

   3. Are there any other important characteristics of the local economy that affect your hospital? How has the economy been affected by the recent recession? Have things begun to pick up?

   4. In what other ways is the economy changing? Are any of these changes affecting hospital operations and service use?

2. Population demographics and impact on hospital operations

   1. Are there any other important characteristics of the local population in terms of their racial or ethnic backgrounds, incomes, or age that affect your hospital?

   2. Is the population changing in any important way? How has changing demographics affected the hospital’s operations, or how might they affect them in the future?

6. Hospital Profile

Now, I’d like to focus on ________ Hospital, in particular. Again, based on what I’ve read, I understand that [summarize information from other sources about hospital structure, size, operations]. Is that accurate? Let’s talk about what has changed regarding:

1. Your hospital’s ownership, governance, or structure

1. Are you a free-standing facility, or are you owned or operated by a larger hospital or health care system/network?

2. Are you a not-for-profit or for-profit hospital? Are you owned or operated by a public/governmental entity, such as a county, township, municipality, or borough?

3. Do you have a management contract with another organization? If so, what services does that organization provide?

4. Are you part of a formal or informal network of rural healthcare providers?

5. Are there any other partnerships that are a key part of your operations?

6. Has your hospital’s ownership or structure changed to improve financial viability?

2. Your hospital’s service lines

1. What types and levels of inpatient services do you provide? What services do you refer elsewhere?

2. What services are your primary generators of revenue? Which ones operate at a loss?

3. How important are outpatient services as a source of revenue?

4. Have you recently added or dropped service lines, or do you plan to? Why?

3. Your hospital’s staffing

1. How large is your workforce? How would you describe the skill mix of your workforce?

2. To what extent do you rely on temporary, transient, or contract labor?

3. Do you employ your own physicians (e.g., emergency/trauma care, hospitalists, intensivists, or others)? Do you own any physician practice groups?

4. How would you describe staff recruitment/retention? Turnover?

4. Your hospital’s technology infrastructure

1. Does your hospital use advanced IT resources, such as telehealth or electronic medical records?

2. Do you plan on applying for EHR meaningful use payments?

3. What high-tech medical equipment does your hospital operate? What are your recent purchases? What equipment would you like to acquire?

5. What are the biggest strategic/operational challenges your hospital faces?

7. Health Care Market

From the background information on your hospital, I understand that [summarize information from ARF and Census data about health care market]. Is that accurate? Let’s talk about what has changed regarding:

1. The health care providers in the area and the health care services available (e.g., availability of primary care physicians and specialists)

   1. What kind of competition for patients does your hospital face from other providers of outpatient care (e.g., physician-owned ambulatory surgery centers, diagnostic tests)?

   2. What kind of competition for patients does your hospital face from other providers of inpatient care?

   3. Is competition putting pressure on your hospital to update and expand its facilities?

   4. Is competition changing in any important way?

   5. What makes you competitive in your health care market? What do you feel would make you more competitive relative to the other providers in your market?

2. The health insurance market in the area

   1. Are there a large number of people who are uninsured? Roughly, what share of the individuals in your market is uninsured?

   2. What share of the population in your market is covered under Medicare? What share is covered under Medicaid? What share is covered by a private insurance company?

   3. What share of Medicare beneficiaries in your market are enrolled in a Medicare HMO or PPO? What share of commercially insured patients is enrolled in an HMO or PPO?

   4. Are most individuals with commercial insurance in your market enrolled under a particular insurer such as Blue Cross Blue Shield or Aetna? What percent of the commercial insurance market is held by the top 1-3 commercial insurers? What is your hospital’s relationship with these managed care plans and your process of remaining with a plan’s network?

3. The labor market for health care professionals in your area

1. Are there shortages of key professionals? How do you attract and retain staff to your hospital?

2. Is the labor market for hospital or health care professionals changing in any important way?

4. The health needs of the population

1. Are there particular health care needs that characterize the population of your service area (e.g., prevalence of chronic disease, disability, aging population)?

2. Are these needs changing in any important way?

Thanks for taking the time to talk to us today. This has been very helpful. We will send you our notes in about a month for your review. Your contribution has been essential to understanding the role of the demonstration in your hospital’s financial viability and community benefits.

RCHD Evaluation

Interview Information Sheet

The information sheet will be provided to respondents prior to interviews. This is not a data collection instrument, and is provided for information purposes only.

Evaluation of the Rural Community Hospital Demonstration

Interview Information Sheet

The Centers for Medicare and Medicaid Services (CMS) has contracted with Berkeley Policy Associates (BPA), in partnership with Mission Analytics Group (Mission), to evaluate the Rural Community Hospital Demonstration (RCHD). The goals of the evaluation are to assess how participating hospitals progress during the RCHD and to develop a Report to Congress at the end of the demonstration. As part of the evaluation, BPA and Mission are conducting telephone interviews with one person at participating hospitals to learn about the impact of the RCHD on hospital finances, community benefits of the RCHD, and hospital environments and challenges.

We anticipate that the interview with BPA/Mission staff will run for approximately [1.5 hours (Round 1) or 1.5 hours (Round 2] ] and may include participation by CMS staff. Some things we want you to know about participating in the interview:

• We will work with you to find a mutually convenient time to schedule the interview.

• Your responses are confidential. Your name will not be used in any reports, and no quotes will be attributed to you personally. We will document that the information is from your hospital.

• We would like to record the interview with your consent. Recordings will be used internally to verify information; they will not be shared with anyone outside of the research team.

• After the interview, we will prepare summary notes. You will be provided an opportunity to review and make modifications to the summary notes.

• A Report to Congress that describes the study, its findings, including those that emerge from hospital interviews, and recommendations will be prepared at the end of the demonstration.

• We are happy to answer any questions you may have about the study at any time.

Any further questions can be directed to [name ] at [email address/phone number].

RCHD Evaluation

Annual Progress Report (Template)

Reporting Period: __ / __ /2012 — __ / __ /2013

Note: To minimize the burden on respondents, Annual Progress Reports will be pre-populated using data available from other sources and previous reports. Respondents will be asked to provide only the missing information and correct or update if the pre-populated information is not accurate.

Hospital Environment

1. Service areas

Primary service area counties:__________________

Estimated percent of patient population from primary service area: ____%

Secondary service area counties:___________________

Estimated percent of patient population from secondary service area: ____%

2. Please describe the major industries in your area, and if they are changing, why:

3. Who are the major employers in your area?

4. What is the unemployment rate? ____%

5. If your unemployment rate is changing, why?

6. Please describe your area’s population:

   1. Growing Why?

   2. Shrinking Why?

   3. Stable Why?

Hospital Operations

1. Which ownership structure(s) best describes your hospital? (You may choose more than one.)

1. Independent non-profit

2. Multi-hospital non-profit: Name:________________

3. Independent for profit

4. Multi-hospital for profit: Name:________________

5. Public

   1. City

   2. Borough

   3. County

   4. Tribal

2. How many FTEs does your hospital employ?

3. How many represent temporary or contracted labor?

4. Based on HCRIS data, in 201X, your hospital employed the following FTEs:

Physician, Nurse Practitioner (NP)/Physician Assistants(PA), and Registered Nurse (RN) Staffing Levels and Trends, 201X
Clinician	FTEs (201X)	What are FTEs currently?	If growing or shrinking, why?
Physician	[Populated from HCRIS]
NP/PA	[Populated from HCRIS]
RN	[Populated from HCRIS]

5. What specialists does your hospital employ?

6. How many unfilled positions does your hospital have?

   1. Clinical _____

   2. Administrative _____

7. On a scale of 1 to 5, how difficult is it to fill the following positions (with 5 being very difficult to fill)?

   1. Physicians (1, 2, 3, 4, 5)

   2. NPs/PAs (1, 2, 3, 4, 5)

   3. RNs (1, 2, 3, 4, 5)

   4. High level administrators (1, 2, 3, 4, 5)

8. What is your hospital’s rate of staff turnover?

9. Comments regarding questions 2-9:

10. Please describe your hospital’s staff recruitment strategy:

11. Please indicate the approximate insurance breakdown of clients.

Hospital Patient Payer Mix, 201X
Insurance type	Percent
Medicare FFS	%
Medicare managed care	%
Medicaid FFS	%
Medicaid managed care	%
Private insurance	%
Private insurance managed care	%
Charity care/self-pay	%

12. Is the distribution of insurance types of changing? Why?

13. Inpatient utilization

Bed Type	Number of Staffed Beds	Number of Inpatient Days	Number of Inpatient Discharges
Adult/Pediatric (non-swing)
Swing
Intensive Care/Critical Care Unit
Nursery
Other (please explain)
Total

14. Please list major information technologies your hospital currently utilizes or plans to purchase, including electronic medical records (EMR), electronic health records (EHR), telehealth technology, eprescribing, picture archiving and communication systems (PACS), etc.:

Information Technology	Added since joining the RCHD?	If “yes”, describe the importance of demonstration funds
	☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed
	☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed
	☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed
	☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed
	☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed
	☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed

15. Has your hospital received or does your hospital plan to receive meaningful use payments?

1. Yes, year:______________

2. No

16. Please list major medical technologies your hospital currently utilizes or plans to purchase, including CT scanners, mammography machines, blood chemistry analyzers, nuclear imaging cameras, etc.:

Medical Technology	Added since joining the RCHD?	If “yes”, describe the importance of demonstration funds
	☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed
	☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed
	☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed
	☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed
	☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed
	☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed

17. Please describe any new capital expansion projects planned or underway.

18. What are your sources of funding for these new capital expenditures?

19. Service lines

Hospital service lines			Change	Added since joining the RCHD?	If “yes”, describe the importance of demonstration funds	Common services referred out	Main competitors	If you are trying to expand the service line, what are your strategies?	Discussion
☐	General medicine	☐Growing ☐Shrinking ☐Stable		☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed		☐Local hospital ☐Local outpatient center ☐Regional hospital ☐Other	☐ Adoption of technology ☐ Staff recruitment ☐ Marketing ☐ Other
☐	Labor and delivery	☐Growing ☐Shrinking ☐Stable		☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed		☐Local hospital ☐Local outpatient center ☐Regional hospital ☐Other	☐ Adoption of technology ☐ Staff recruitment ☐ Marketing ☐ Other
☐	Diagnostic imaging	☐Growing ☐Shrinking ☐Stable		☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed		☐Local hospital ☐Local outpatient center ☐Regional hospital ☐Other	☐ Adoption of technology ☐ Staff recruitment ☐ Marketing ☐ Other
☐	ER/trauma	☐Growing ☐Shrinking ☐Stable		☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed		☐Local hospital ☐Local outpatient center ☐Regional hospital ☐Other	☐ Adoption of technology ☐ Staff recruitment ☐ Marketing ☐ Other
☐	Intensive care	☐Growing ☐Shrinking ☐Stable		☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed		☐Local hospital ☐Local outpatient center ☐Regional hospital ☐Other	☐ Adoption of technology ☐ Staff recruitment ☐ Marketing ☐ Other
☐	Critical care	☐Growing ☐Shrinking ☐Stable		☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed		☐Local hospital ☐Local outpatient center ☐Regional hospital ☐Other	☐ Adoption of technology ☐ Staff recruitment ☐ Marketing ☐ Other
☐	Orthopedic services	☐Growing ☐Shrinking ☐Stable		☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed		☐Local hospital ☐Local outpatient center ☐Regional hospital ☐Other	☐ Adoption of technology ☐ Staff recruitment ☐ Marketing ☐ Other
☐	Cardiac rehabili-tation	☐Growing ☐Shrinking ☐Stable		☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed		☐Local hospital ☐Local outpatient center ☐Regional hospital ☐Other	☐ Adoption of technology ☐ Staff recruitment ☐ Marketing ☐ Other
☐	Mental & behavioral health	☐Growing ☐Shrinking ☐Stable		☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed		☐Local hospital ☐Local outpatient center ☐Regional hospital ☐Other	☐ Adoption of technology ☐ Staff recruitment ☐ Marketing ☐ Other
☐	Physical & occupa-tional therapy	☐Growing ☐Shrinking ☐Stable		☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed		☐Local hospital ☐Local outpatient center ☐Regional hospital ☐Other	☐ Adoption of technology ☐ Staff recruitment ☐ Marketing ☐ Other
☐	Infusion, chemo-therapy	☐Growing ☐Shrinking ☐Stable		☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed		☐Local hospital ☐Local outpatient center ☐Regional hospital ☐Other	☐ Adoption of technology ☐ Staff recruitment ☐ Marketing ☐ Other
☐	Surgery	☐Growing ☐Shrinking ☐Stable		☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed		☐Local hospital ☐Local outpatient center ☐Regional hospital ☐Other	☐ Adoption of technology ☐ Staff recruitment ☐ Marketing ☐ Other
☐	Other: _________	☐Growing ☐Shrinking ☐Stable		☐ Yes ☐ No	☐ Essential ☐ Helpful ☐ Not needed		☐Local hospital ☐Local outpatient center ☐Regional hospital ☐Other	☐ Adoption of technology ☐ Staff recruitment ☐ Marketing ☐ Other

20. Please describe any service lines that have been dropped in the reporting period:

21. Please describe how your hospital takes into account competitors when planning to expand or drop services:

Hospital Finances

1. Hospital margins

Hospital Revenues, Expenditures, and Margins by Medicare Inpatient, Medicare Outpatient, Total Medicare and Total Services, 201X
	Revenues	Expenditures	Margin*
Medicare inpatient			%
Medicare outpatient			%
Total Medicare			%
Total			%

*Margin = (Revenues-Expenditures)/Expenditures

2. Amount of uncompensated care:__________$

3. Uncompensated care as a percent of total costs:_________%

4. If any, what factors are improving your hospital’s bottom line?

   1. Private donations Describe

   2. Support from public entities Describe

   3. Increased utilization due to:

      1. Growing population Describe

      2. Improved quality of care Describe

      3. Expanded services Describe

      4. Other Describe

   4. Other Describe

5. If any, what factors are hurting your hospital’s bottom line?

   1. Cost of maintaining facilities and equipment Describe

   2. Cost of maintaining high quality staff members Describe

   3. Cost of adopting new equipment Describe

   4. Low utilization due to:

      1. Shrinking population Describe

      2. Competition Describe

      3. Other Describe

   5. Other Describe

6. What strategies has your hospital implemented to improve financial viability?

7. What strategies does your hospital plan on implementing to improve financial viability?

Use of Demonstration Funds

	Use Type	Describe	Importance of demonstration funds	Number of Medicare beneficiaries affected	Total number of patients affected
☐	Facility upgrades/expansion		☐Essential ☐Very important ☐Important ☐Somewhat
☐	New medical equipment (e.g. diagnostic imaging)		☐Essential ☐Very important ☐Important ☐ Somewhat
☐	New IT equipment, including IT (e.g. EMRs and telehealth)		☐Essential ☐Very important ☐Important ☐ Somewhat
☐	Care coordination and chronic condition management programs		☐Essential ☐Very important ☐Important ☐ Somewhat
☐	New service lines, such as behavioral health		☐Essential ☐Very important ☐Important ☐ Somewhat
☐	Recruitment		☐Essential ☐Very important ☐Important ☐ Somewhat
☐	Salary increases		☐Essential ☐Very important ☐Important ☐ Somewhat
☐	Other		☐Essential ☐Very important ☐Important ☐ Somewhat

Demonstration Payments

1. Describe the role of the demonstration funds in your hospital’s bottom line:

2. Were your hospital’s reasonable costs for acute care during the most recent year for which you have settled cost reports above or below your target amount under the terms of the demonstration? For post-acute care (swing beds)?

3. If above the target, why did your hospital’s costs exceed the expected target?

4. How often do you receive payments?

5. What is (on average) the amount of each payment?

6. Are your interim payments adjusted or reconciled?

   1. Yes

   2. No

7. If so, by how much?

   1. Adjusted

   2. Reconciled

8. Please describe the payment reconciliation/adjustment process:

9. Have you considered withdrawing from the demonstration?

   1. Yes

   2. No

10. If your hospital has considered withdrawing from the demonstration for an alternative payment arrangement, please note which alternative arrangement is being considered.

    1. Sole Community Hospital

    2. CAH

    3. IPPS

    4. Other

11. If yes for question 10, why did your hospital decide to stay in the demonstration?

12. Comments about the payment methodology:

13. Has the demonstration met your expectations? Why or why not?

Thank you for completing the progress report.