An Interview with John Supplitt
John Supplitt is senior director of the Section for Small or Rural Hospitals of the American Hospital Association (AHA). Mr. Supplitt manages the Section’s member services, governance, and communications including its website, newsletters and technical advisories. He is the AHA’s liaison for rural health care strategy and public policy to the federal Office of Rural Health Policy, the American Academy of Family Physicians, Joint Commission, National Rural Health Association and state hospital associations. He has served on panels and advisory groups for development of national rural health policy, program development and demonstrations, and grant review and evaluation, and has spoken and written extensively on rural hospital advocacy and policy and the future of rural health care delivery to hospital CEOs and trustees across the country.
Supplitt came to AHA in 1981 as its swing-bed project director after having completed his Masters in Public Administration in Health Planning and Policy Analysis from New York University’s Wagner School of Public Administration.
Supplitt and his wife, Kathy, have four children. They live in Chicago. In his spare time, Supplitt enjoys fishing, “tolerates golf,” and is a former soccer player and coach.
What is the biggest challenge facing rural hospitals right now? Do challenges differ by region, or are they the same everywhere?
It is the same challenge that has plagued them for decades. That is, delivering the highest quality of care across vast regions of the United States while hampered by serious economic constraints. The secret to their success is that rural hospital CEOs, physicians, nurses, and all others that are part of the health care team, are value-driven professionals who will stop at nothing to assure their patients are provided the same breadth and quality of services as those who live in metropolitan communities.
Do rural and urban hospitals face similar challenges or are they completely different?
While superficially there appear to be significant differences, many similarities exist. For example, medical underservice is a challenge to both rural and urban populations. Expanding access and extending coverage to those who are disenfranchised is something they share in common. Filling the gaps in health care delivery for time, place and person is an ongoing problem for many urban and rural hospitals that must be resolved through public policy.
Is the issue of hospital workforce the same as it’s been, or is it getting worse?
Worse. If you look at data of physician distribution, things have improved in rural areas. But the shortage is pervasive and the demand is increasing. Whether you’re a critical access hospital (CAH) or a PPS hospital, in a frontier area or in a rural area adjacent to a metro, recruitment and retention of clinical professionals is a continuous effort. In my experience, almost all hospitals have identified this as a problem.
Where does workforce rank among the challenges confronting rural hospitals?
Without a doubt, workforce issues are the highest priority for all rural hospitals, second only to payment—and in many instances, workforce trumps payment. The focus is predominantly on physicians, but it also includes pharmacy, nurses, and other clinical providers. We’ve collectively looked at and experimented with numerous ways in which we can recruit and retain professional clinicians in our rural hospitals and communities—the “grow your own” and other models have worked, to a point. But the reality is that the maldistribution continues now, just as it has over the past three decades. The only way to address physician distribution is through Title VII of the Public Health Services Act, workforce incentives, or through bonuses and adjustments in health professional shortage areas and medically underserved areas. But it’s going to require congressional intervention in order for us to correct the maldistribution. As policy folks, we will continue our efforts to address the needs of rural communities.
How can CAHs maintain quality services in low-volume areas?
The advantage CAHs have over many hospitals is their proximity to the patient. While you can measure and report outcomes on critical indicators, there is no substitute for knowing the patient on a very personal basis. In rural communities, there is a much higher probability of that awareness of patients and their needs.
Continuity, access and availability are things that CAHs bring more readily than larger hospitals in bigger communities because they’re closer to the patient. Measuring performance and reporting outcomes on a list of process indicators is important but it’s not a substitute for knowing the patient as a neighbor and not a number.
What’s going on with HIT in rural hospitals?
The reality is that everyone is working toward meaningful use for electronic medical records. But achieving it in the timeframe that CMS and the Office of the National Coordinator for Health Information Technology (ONC) have laid out is unreasonable for rural hospitals. It has to do with the costs but also with things beyond their control—vendor certification, accessibility to vendors and the availability of vendors to meet their needs in a timely fashion. These are issues we’ve shared in the past with CMS and ONC that have not been adequately addressed, so the struggle will continue.
What is the timeline for rural hospitals to adopt HIT?
The timeline to achieve meaningful use is 2011 for CAHs and it continues through 2015 before penalties are imposed upon hospitals that have failed to achieve it. There are some 24 or more standards that have to be met; one of those requirements is computerized provider order entry (CPOE), for a minimum of 10 percent of all services rendered. So the standards are pretty aggressive. The thing that is beyond the control of providers is the ability to get their systems certified in a manner that meets ONC criteria. The vendors are going to work with their biggest customers first. Since many rural hospitals, particularly the freestanding and independent hospitals, are smaller accounts for these vendors, they are concerned that they won’t even have availability of vendors to address their needs, let alone get them addressed in a manner that meets CMS deadlines. Also, once you have all this infrastructure in place, you don’t get stimulus money [through the HITECH act, which was embedded in ARRA] for the software, just for the hardware. Then you have to train folks to operate it and experts to maintain it. The labor pool in most small communities is not sufficient to sustain these information systems continuously over time and the cost of outsourcing this function is prohibitive. [For more information, see the AHA HIT page.]
What about infrastructure issues? Is it difficult for dated facilities to access the capital they need for necessary rebuilding and improvements?
Most hospitals have access to capital but the price of capital is beyond the means of many freestanding and independent hospitals. That is, they can access capital through hospital bonds, but the interest rate makes it unaffordable. There are a number of hospitals that have replaced their facilities, which is terrific. However, for many more, much of the rebuilding is done incrementally—so you have wings added on to wings added on to wings. Then the hospital will reengineer its patient flow and its services to try to accommodate patients in the new environment, but it comes at the cost of efficiency in terms of the use of the building and use by staff.
How did you come to work at AHA, and in health policy, in the first place?
My interest has always been in health care. I saw it as a calling. I draw my inspiration as a rural hospital advocate the way one does who is endlessly chided by the competition as overmatched and undertrained. There is nothing that stokes the fire more than being told it can’t be done or you don’t have a chance. I see this fire burn in the bellies of my rural colleagues and draw from it like any of us who have cheered the underdog when faced with insurmountable odds. Failure is not an option for those who work in rural health care.
