Thursday, October 27, 2016

Oregon PCMH Saved 240 Million But Spent Over 250 Million

The latest headlines spout 250 million saved for Oregon in the movement to Primary Care Medical Home. Claims of savings often fail to consider the additional costs of an intervention or the supplemental government or foundation funding required. Based on $105,000 additional cost per primary care physician per year the following table demonstrates $250 million to 1 billion dollars more in cost for primary care medical home across Oregon. It is important to consider not just the savings, but also the higher costs of new models.

Specifics are not given but the impact of the primary care medical home can be estimated across the number of clinics that could participate and the doctors per clinic over a 2 or 3 year period. The number of doctors may be small compared to actual. The high and low levels are shown along with a possible average cost. If studies involved less than 2 years they should not have gained print.

The limitations in new studies with new measurements as measured and analyzed and reported by personnel in agencies that need to demonstrate improvements are many.

Oregon Also Demonstrates Little Change in Costs in Other Studies

We do know more from Oregon in areas such as Medicaid because of the randomization experiment. We know that Medicaid costs for emergency room care have not gone down. The cost savings predicted have not been demonstrated in this area.

The limitations of of managed care or managed cost are many. 

The Congressional Budget Office indicated that the cost of these programs was about as much as was saved. The lessons are many such as patients and patient factors set consumption

The limitations of comprehensive efforts are many. 

Robert Wood Johnson spent 300 million over 10 years in the best ways that their sites and leaders could thing of to change clinics and physicians toward quality focus and the result was little or no change across population health and quality measures.
  • Higher cost and no change is the opposite of value. 
  • Improvements in the controls and likely overall, were as great (or as limited) as in sites with interventions
My estimates of the primary care medical home obtained from studies in 2 other states could be off. Oregon could be spending less. Or Oregon could be spending more in time, talent, and treasure to do much more while accomplishing less.

All states should be working in a comprehensive way to improve basic care. The Oregon effort is admirable. But it is still clinical intervention and dollars spent in low yield clinical intervention areas - dollars that might be better spent for housing, nutrition, legal aid, child development, early education, transportation, healthier environments, behavior change, jobs, and other social determinant and people factor changes.

Health care is about changing people - not changing practices. Health care leaders, innovators, and designers need to remember this most of all.

The limitations of the claims regarding interventions are many.

Which intervention resulted in improvements in cost or quality? How can savings in a comprehensive effort be assigned to as smaller portion such as Primary Care Medical Home? Why do headlines exaggerated the various claims?
The limitations of the primary care medical home are many. 

There are impacts in the clinical areas, in the local/Social Determinant areas, and on the clinician/team areas.

Clinical Impact
  • Increased cost of delivery
  • Continued need to train due to turnover of clinicians and team members
  • Diversion of funds from team members to PCMH expenses with the potential to impact higher turnover and greater costs of recruitment and retention
  • What happens when supplemental funds for PCMH run out?
  • Incentives were paid from funding that was taken away and almost everyone recovered the funding that was taken away - minus cost of administration.
 Local/Social Determinant People Factor Impact
  • Social Determinant/Local Impact - Dollars shipped from local to outside for training, certification, software, practice management consultants
  • Losses of local jobs and cash flow 
  • Clinic viability may be impacted by higher cost of delivery
Clinician/Team Impact
  • Rapid change is stressful
  • Can outside advisors comprehend local situations, populations, team issues?
  • Emphasis increased upon quality measures, certification
  • How do we meet the higher volume of patients and the increasing complexity without more team members?
  • What about our raises and improvements in benefits such that my take-home pay increases rather than decreases (especially in sites with lower viability)?
  • Investing in us vs investing in them concerns

Most Visited Early Blogs

Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care  

Finance-me-cratic Constants in the Bureaucratic Universe  

Meeting Primary Care Needs in the Last Half of the 21st Century 

Exploring the Health Consequences of Disease Focus  

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
Martin Luther King, Jr. 

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.

Copyright 2016

Wednesday, October 26, 2016

Blood Clots or How Dr. House Breaks Down the United States

A recent study from Italy is making the media rounds indicating that doctors should screen more for blood clots in the lungs. Now that this is pushed by the media and the social media, there will be more pressure on doctors to screen for blood clots. More patients will come in to urgent care and emergency care about what they think represents blood clots. The cost will be enormous with little change in outcomes - a representation of much that is wrong with the most costly health care in the world.

And, by the way, doctors have long known about clots as a hidden cause of health problems inside and outside of formal health care. The truth is that the incidence of clots is actually much higher and the body handles these challenges well. And those that tend to have the worst symptoms (faints, falls) and worst clots are often closest to death.

Some reflections
  • Do we really want doctors pressured by the government and insurance companies to do less or by the media (academic media, news media, social media) or patients to do more?
  • Decades of manipulations have not resulted in improvements of care and have substantially worsened costs and have resulted in no improvements in health outcomes.

Review what NPR represents to the public, with my comments
  • "When A Fainting Spell Is Caused By A Serious Blood Clot" - The errors made by journalists start with the title. Elderly people averaging 76 years and with chronic conditions have many different reasons for fainting. This may or may not be due to a blood clot, even when a clot can be found. And it is possible for a clot to have already dissolved into smaller pieces such that the clot caused the "faint" but there is no evidence of a clot - such is the ability of the body to address clots although aging and other conditions can impact this ability.
  • "Blood clots are on the list of conditions that doctors are supposed to consider when figuring out the cause of a fainting spell, but physicians don't routinely do full work-ups to look for them....The doctors screened for blood clots among 560 elderly patients (average age 76). And they report in the latest issue of the New England Journal of Medicine that 17 percent of the patients with fainting spells also had blood clots in the lung."   Full work ups cost thousands of dollars. Excluding every condition on every list (The Dr. House Approach) would result in thousands more dollars in some fairly common presentations across emergency rooms, urgent cares, and primary care settings.
No Smoking Gun
It is well known that we throw blood clots throughout our lives. Some are too small to detect or are too small to cause problems. Some can be detected and cause problems. Some cause problems and cannot be detected. Other clots are just present when people faint but this was not the reason for the fainting.

No Baseline for Comparison

The research survey design has problems. The population that was surveyed was the most likely age of all to have conditions that lead to clots. There is not even a reference population to indicate how many have clots "normally" for the age and other conditions present (matched controls).  

Treatment Consequences

The treatment for clots involves anticoagulation. Thousands have complications from anticoagulation or die. This is the riskiest of all treatments which many should realize given the number of lawyer commercials. 

Government design made it more difficult to care for patients with clots. The government design for payment (Diagnosis Related Groups) has forced hospitals to send patients out of the hospital faster. The design has also made it more difficult to get follow up.

Does More Treatment in the Oldest of the Elderly Add to Life?

The study population is closest to the last year of life. This is the time period that results in 30% of Medicare costs and this proportion continues to increase - not surprising given journal, media, and other promotions. Having a fainting episode or a clot indicates patients even closer to death. The treatment adds to costs and results in some who die from complications.

Costly Training That Results in Higher Costs and Must Be Unlearned By Physicians

Doctors are taught by the Dr. House approach. In this approach, medical students are taught to form a differential diagnosis of every different condition that could cause the symptoms. They tend to think in organ systems (cardiac, respirator, GI) with one or more conditions reviewed for each organ system. This can result in 50 - 100 reasons for a patient's condition. Faculty have "pimped" students and residents to spout forth all of these different possibilities as a condition of "looking good" during medical rounds. 

A major reason given for the high cost of graduate medical education is the need for those in training to do more testing. But as we are learning more and more, the higher costs are more about the patients and their conditions and how they present than what is done by physicians impacting a few minutes of the life of a patient.

Many require expensive tests or technologies that may or may not identify the condition. Sometimes a test that is suggestive requires more tests. Even though doctors are taught to approach patients in the most costly way, they change during residency and practice.

Experienced physicians spend a lifetime unlearning this Dr. House method to be more relevant and choose the most likely reason for a patient to come to care and the most likely tests to confirm a diagnosis - if such a test exists - and if such a test is able to detect the condition reliable.

The Diagnostic Dilemma of the Mammogram

Mammograms have changed detection of breast cancer, but not necessarily the outcomes. Mammograms were switched to digital for no improvement in quality but higher cost. Mammograms still miss cancers and also still result in patients being sent for biopsy. Biopsy has an error rate too. About 7% of biopsies are positive for presence of cancer but actually there is no cancer as demonstrated by surgical removal. Substantial amounts problems are caused for no gain.

Now there is a more balanced approach to breast cancer - less guided by media, promotions by those who profit, and less guided by advocacy groups or by relatives or friends of those who died of breast cancer. It has only taken 20 years to get to a reasonable balance. Even so, not all benefit because many still have problems with lack of access or avoid screening due to attitudes or behaviors or poor health literacy.

Even so, the major groups that recommend screening cannot always agree on what is best.

A Return to Scientific Decision-Making

The scientific process must proceed through all stages in an iterative process to come to balance. External pressures due to misguided advocacy groups, media, corporations, and journal articles do not help. Drug company advertising may contribute to the problem of costs too high and uses too much as well as distractions from care delivery.

How Many More Trillions for Health Care?

Constant promotion of the Dr. House method of patient care could easily result in acceleration of health care costs past 3.5 trillion to 4 trillion or more. There is little doubt that this would result in even more squeezed from basic services with the worst impact where most people already have the least local workforce and the least access.

More trillions spent on clinical interventions, the most costly with little gain, would not improve outcomes because clinical interventions involve so few and impact so little of life lost. The long shot tests and other interventions for few conditions impact care so little - like 2 trillion of the 3 trillion we already spend. Other nations that choose to invest in children and people have one-third to one-half the cost of the US that has chosen to invest in the most costly impacting the least at huge cost of administration getting worse. 

Most Visited Early Blogs

Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care 

 Finance-me-cratic Constants in the Bureaucratic Universe  

Meeting Primary Care Needs in the Last Half of the 21st Century 

Exploring the Health Consequences of Disease Focus  
Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
Martin Luther King, Jr. 

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.

Copyright 2016

Friday, October 21, 2016

Seeds of Health Improvement Fail on Barren US Soil

From the 1960s to the 1970s, many efforts to improve health, education, and community efforts were successful. Since 1980 the successes have been limited. The US soil appears to be unable to sustain the necessary growth and development to help make interventions in health, education, nutrition, and other areas more effective.

In many ways the progress of recent decades has been about lasting impact from the previous decades. A generation with greater investment will benefit and will also benefit the next generation. The past investments have run their course.

War on poverty, the creation and increased funding of Medicaid and Medicare, support for the National Health Service Corps, Community Health Centers, and other investments have been followed by decades of cost cutting and austerity focus. Funding for humans has been diverted to other areas and the moonshot focus continues. Once it appeared that numerous interventions worked. Even the medical education efforts seemed to work for primary care and rural practice. But national changes in investment have resulted in changes in outcomes.

It is really difficult to see how health policy designers think that primary care can be made better when the dollars are too few to support the teams to deliver the care and the new designs make teams less productive, more distracted, fewer, and more burned out. Technology fixes all clearly has limitations, especially in basic child development, basic education, and basic health care where progress remains about people investing in people.

Governments, foundations, and communities are always hoping to facilitate more efficient and effective services. The Robert Wood Johnson Foundation has asked again and again - How do we give kids the building blocks for physical, cognitive, social, and emotional health? Other foundations measure progress and the results do not look good.
It has taken far too long to understand that it takes more than prenatal care and clinical interventions to address infant mortality and maternal mortality. Many "experts" have had a field day blaming religious leaders, women's health terminations, or states such as Texas for infant, maternal, Medicaid, or other outcomes. The factors that influence these outcomes are more about social fabric than other areas and the United States overall has allowed the social fabric soil to deteriorate. 

This makes it difficult for any number of investments to work as well - until the soil is improved. The likely area most closely related to soil improvements is child well being. By any number of measures we are not doing well.
Health outcomes are shaped by behaviors, environments, situations, and social determinants. 
Quality is in the matrix of relationships (Deming) 
Outcomes orientation should teach the value of these relationships. Instead we have quality efforts that focus on measures, technologies, and other areas that actually compromise the ability of education and health care teams to address their important societal tasks. Measures and technologies and their advocates take on a life of their own while infrastructures fall further behind.
The Status of Physical, Spiritual, and Human Infrastructure

Physical Infrastructure in the United States is also not doing well. For decades the United States worked at all levels to help make transportation, utilities, and other areas more efficient and effective. Now such investments are avoided as are the maintenance costs. Paying more later because of tragic neglect is far too common and should continue for some time.

The Spiritual Infrastructure in the United States seems to be at an all time low. It its difficult to get the American people regarding what the nation should do in many important areas. Congress is a reflection of this impasse. Spiritual infrastructure can have impact far beyond religion but also can be far less. Nationalism can also be a double-edged sword to unify or to divide US.

The Human Infrastructure in the United States most impacts education and health care. Nurses, teachers, public servants, public health, and other humans serve people directly in important health, education, public security, and other areas.

Few would argue that these representatives of human infrastructure are facing greater challenges from more directions, more regulations and standards, increasingly complex interactions, greater scrutiny, and increased burnout as more is required with same or less support.

With decent Spiritual Infrastructure, Physical Infrastructure, and investments in improving the social fabric/soil of living, the human infrastructure tasks are more reasonable, more efficient, and more effective. For example some states can invest far less in education for same or better outcomes. Some places can spend multiple times as much for worse outcomes.

Exceptional Circumstances and Exceptional Challenges

When a nurse, police officer, or teacher is working with a person who believes in future for themselves or others, there is some hope of needed behavioral or other changes. When there is not such belief, the outcomes of encounters become more unpredictable - and often dangerous for all involved. Mistakes are going to be made when people are unable or unwilling to invest the time and effort in addressing each other's needs.

Media Distractions

It is a great sadness of our time that our media and social media are about blame and shame rather than context, reflection, awareness, and problem solving.

Edward R. Murrow is a good source of reflection from past to present or from a time when the media worked to inform and educate as compared to media focused upon marketing, advertising revenue, and profits:

But during the daily peak viewing periods, television in the main insulates us from the realities of the world in which we live. If this state of affairs continues, we may alter an advertising slogan to read: LOOK NOW, AND PAY LATER.

Lip Service to People Factors But Not Investment in People to Impact Care

It is a great sadness of our time that our education and health care designers cannot see that outcomes are about people factors, behaviors, situations, environments, investments in each other, social fabric. If they had seen this they would have understood
  • The futility of measurement worship with numbers additional costs and compromise of the social fabric
  • The discrimination of Pay for Performance as schools, practices, and hospitals serving those with less resources and greater challenges get even less funding or are closed. 
  • The futility of health insurance expansion with payments too low to support basic services (cost of delivery higher than payments). Greater investments in the team members to deliver the care allows small hospitals and practices to address the needs of insured and uninsured patients - doing what the current insurance expansion cannot do. 
  • Other nations succeed in health and education where we fail because they invest far more in children age 0 - 6 (2% of their GDP) while we spend less than 0.5%. A move to 2% of our GDP invested in the earliest months and years of life could do much to reduce health spending from 17% to 12% or less. Nations such as the US and the UK have insufficient outcomes in health and education and both share bottom of the pack rankings for developed nations. (both from UNICEF)
The route to become a local teaching or health professional should begin, continue, and end locally. There is no longer a need to send children to distant colleges or professional schools when there are classrooms and practices without walls with great needs to address using local community resources - starting age 14 or sooner.

It is quite ridiculous to paying more and more to send a teacher or health professional to serve a population that will be difficult for them to relate to for two to three times the length of any loan repayment.

It is interesting that tele education and tele health are considered solutions for deficits of services when the internet can actually result in education and health care most specific to local needs and least distorted by those with other agendas. Murrow was right. The lights in the box distract, but fall short of the full potential.
Mutual Interdependency

The fact of the matter is that we are mutually interdependent. Physical, spiritual, and human infrastructure are also mutually interdependent. Compromises must be made so that we can move forward with needed investments specific to children, future generations, health care, education, and other areas.

We seem to forget the most important lessons all around - such as civil wars or our own civil war. These are of course places where the social fabric has been devastated with consequences for decades as we still see across Appalachia and parts of the South. New areas left behind are seeded by the old problems as yet unresolved.

Where we improve is about where we all invest. Outcomes are the result of preparing the soil to improve environments, situations, relationships, behaviors, social determinants, and outcomes in health, education, economics, and more.

The investments required rarely look efficient or effective when considering one outcome, but dozens of important outcomes can be shaped by these investments.

Some Can Learn the Most Important Lessons But Not Others

Sidney Kark went to South Africa to "fix trauma" care - to bring western triage and technology to bear. To his credit he did not leave or try to make claims of benefits in trauma care. He saw a greater need. What he discovered was that basic public health, sanitation, nutrition, and other people factors were more important and Community Oriented Primary Care was born. Eva Salber MD was a disciple and helped in the US in Boston, did early research exposing the harm of teen smoking, and facilitated lay nursing health care efforts in eastern North Carolina via black churches. There were other community health activities via her efforts and those of her husband. 

Community Health Centers can also vary in outcomes. Many are found in areas that have greatly improved in health and in health outcomes. One of the two original CHCs begun in 1965 was started in Bolivar County MS and there have been few changes in Bolivar County across 50 years. Investments in Appalachia have been many in type and amount, but the major improvements have been where superhighways, urban areas, and federal jobs impacted the area.

Working to Restore Social Fabric, Health, Education, Community

There is some element of Community Oriented Care rediscovered about every 20 or 30 years or when the usual clinical interventions are exposed as inappropriate, too costly, and lacking in the ability to change health outcomes, especially where people most need better outcomes.

This community idea does not need proving - it needs support and replication.

Essential is that people work together to address community needs as deemed necessary by the community aligning local assets.

What is tragic is that these lessons are lost or mistakes are made that should have been prevented by review of the previous works.

Social Fabric Experiences in Health Care

It is difficult to grasp the important concepts involving education, health, and societal outcomes. I consider it a great blessing to have family and job experiences that have taught me much about these areas. 

Solo rural practice learning from the people in Nowata OK was most important. Few understand just how much more important the first years of practice are for learning in many dimensions as compared to the short formal years of training. 

The State of Tennessee invested in me and in a rural FM fellowship development.  

HHS through HRSA invested in me in the rural minifellowship. The minifellows were as much teachers and mentors as learners. The right fabric can accomplish much. During the minifellowship activities it was great to meet Eva Salber and learn from her - one of the disciples of Kark.

At the time I did not realize it, but later I began to comprehend the value of my particular family medicine training at Waco. This training was the result of local community efforts to extend health access (a reason why the Mega CHC effort funded from above is so misguided). 

Asset based improvements have helped many communities. 

Gerald Doeksen was influential regarding the importance of economic activity to rural and small places spanning the 1980s and continuing to recent years. Studies that dismiss the consequences of losses of rural physicians, practices, and hospitals are quite appalling in their assertions.

Theresa Hilton was one of the most influential people I ever met and it was a great honor to send her students for her to mentor in Columbus NE as she constantly pushed health, public health, health access, and care where needed. It is indeed unfortunate that the National Health Service Corps would award programs that matched students to mentors in this program and through HPDP at Community Health Centers, and then take the funding away - or have it taken by a Congress that appears to understand less about people, outcomes, and future generations.

I give my thanks for all of the above and for supportive wife, her teaching experiences, and for children to illustrate much of what is essential in life.

Sowers, Seeds, and Outcomes

It only takes a few seeds to fall in fertile ground - but our nation suppresses the seeds and fails to prepare the groundwork. Half enough for primary care, public health, basic legal assistance, housing, nutrition, jobs, child development results in barren ground - making it harder for any seeds to survive, much less replicate.

That same day Jesus went out of the house and sat by the lake. Such large crowds gathered around him that he got into a boat and sat in it, while all the people stood on the shore. Then he told them many things in parables, saying: “A farmer went out to sow his seed. As he was scattering the seed, some fell along the path, and the birds came and ate it up. Some fell on rocky places, where it did not have much soil. It sprang up quickly, because the soil was shallow. But when the sun came up, the plants were scorched, and they withered because they had no root. Other seed fell among thorns, which grew up and choked the plants. Still other seed fell on good soil, where it produced a crop—a hundred, sixty or thirty times what was sown. Whoever has ears, let them hear.”

Cancer Gets a Moonshot and STDs Get No Shot at All

The Quality of Outpatient Care Delivered to Adults in the United States, 2002 to 2013

The Devaluation of The Doctor and Its Effect on The American People by Dr. Alaina George

Value Is Also Low Cost and Good Outcomes - Commentary by Alan Morgan: For a model of efficiency, quality care, look at performance of rural hospitals

Thursday, October 20, 2016

Cancer Gets a Moonshot and STDs Get No Shot at All

We are all responsible for this failure regarding the STD epidemic. After the smoke clears from all of the politicians and activists who are promoting their own reason for the STD epidemic, there are many reasons.

Those who promote their cause are delaying actions that would address the causes - and are helping to spread STDs.

This will be more of a listing than a blog, but people need to understand how we are all responsible for the STD failures of our nation. 

25 Reasons Why We Fail in STDs

1. We have not grasped that resistant organisms require steady changes in the treatments. 

2. Some drugs that could treat STDs more effectively are not available or are too costly. 

Drug companies have also required so much for some drugs that budgets are shot to deal with many areas - such as STDs. As demand goes up, prices also go up, fewer are treated, and demand goes up. This is a death spiral

4. Public health spending is half what it should be and austerity focus has long prevented more spending. Also organized medicine separated from public health a few decades back. 

5. Austerity focus at the county and state and national level has elected more political leaders, but has resulted in a number of direct and indirect contributors to the STD and other epidemics. Counties have been doing all that they can to minimize health care costs.

6. Traditional health care eats up 3 trillion dollars leaving very little for basic services, mental health, primary care, public health, STDs, etc.

7. Coordinate local efforts to break the sex, prostitution, drug, STD, drug and human trafficking connections

8. Yes it is true that political games have resulted in impairments of women's health, but where is the emphasis on men's health?

9. College health care is incapable of the many STD, mental health, and other challenges.

10. The nation continues to waste billions on fraud, abuse, ebola preparedness, etc.

11. Primary care in the nation is being destroyed by low payment and accelerating cost of regulation.

12. Drug companies create shortages of drugs and charge too much to allow much care.

13.  Lab companies charge too much for STD tests such that the tests are less available, 

14. Clinics that treat STDs some of the time are bare budget and lab results for STD tests are too slow

15. The technology tools to address the epidemic are held up by profiteering

16. The STD stream of resistant organisms coming from other nations is not being addressed (jobs, college, technical training). 

17. Care is increasingly inconvenient for the purpose of STD care.

18. Screening guidelines have been relaxed and fewer women are screened for much of anything.

19. People have sex - obvious, but important to understand

20. Sex tends to be private, controversial, and poorly discussed

21. Sexual body parts are private and poorly discussed

22. Teens don't talk much

23. Married people and families don't talk enough. Breakdowns of family and marriage and essential communication promote epidemics.

24. A decent program could have substantially reduced syphilis - but when levels are lower the attention is minimized along with dollars for screening and treatment, allowing a return.

25. And what do we do about intolerance and discrimination - which is why our nation fails to support public health, STD treatment, primary care, mental health, and more of the basics?

What should be done?

  • Double public health spending and primary care spending and take this spending design out of the hands of politicians and out of the hands of traditional government agencies that have marginalized these basics while sending dollars to highly specialized care.
  • Declare a public emergency and force drug and lab corporations to cooperate at a reasonable margin, cut deals for longer patents, and do whatever is necessary to lower costs for emergent treatment applications. 
  • Double mental health spending, especially with regard to drug abuse
  • Establish walk in STD treatment at urgent cares and primary care offices paid at higher rates to incent rapid, convenient services. Pharmacies could also participate in testing and treatment.
  • Consider studies of one time patient incentives paid when those who positive for STDs test negative at follow up.
  • Needle sharing programs
  • People could access testing online with deliveries of testing and followup and recommendations for treatment. 
  • Target STDs to eliminate where feasible with savings of hundreds of billions later for billions invested now efficiently and effectively - the STD Moonshot
  • Consider genetic testing and tracing of organisms but only in a way that facilitates treatment (not spending so much that it impairs treatment or the workforce to do treatment)

The Quality of Outpatient Care Delivered to Adults in the United States, 2002 to 2013

The Devaluation of The Doctor and Its Effect on The American People by Dr. Alaina George

Value Is Also Low Cost and Good Outcomes - Commentary by Alan Morgan: For a model of efficiency, quality care, look at performance of rural hospitals