Health Resources and Services Administration
Office of Rural Health Policy
Nebraska City, Nebraska
June 6-8, 2004
The 47th meeting of the National Advisory Committee on Rural Health and Human Services was held June 6-8, 2004, at the Lied Lodge in Nebraska City, Nebraska.
The meeting was convened by Dr. Marcia Brand, Director, Office of Rural Health Policy. Dr. Brand was substituting for the Committee Chairman, Governor David Beasley, who was unable to attend.
The members present were: Mr. David L. Berk; Mr. Evan S. Dillard, FACHE; Joellen Edwards, Ph.D.; Michael Enright, Ph.D.; Ms. Bessie Freeman-Watson; Mr. Joseph D. Gallegos; Lenard Kaye, D.S.W.; Arlene Jaine Jackson Montgomery, Ph.D.; Keith Mueller, Ph.D.; Ron L. Nelson, P.A.; Sister Janice Otis; The Honorable Larry Keith Otis; Glenn D. Steele, M.D., Ph.D.; Mr. Tim Size; Ms. Susan Birch, RN, BSN, MBA; Senator Raymond Rawson, D.D.S.; and Ms Heather Reed. The members unable to attend were Stephanie Bailey, M.D., Ms. Sally K. Richardson, and Mr. James R. Agras. Present from the Office of Rural Health Policy were: Marcia Brand, Ph.D.; Tom Morris, MPA; Michele Pray Gibson, MHS; Jennifer Riggle, J.D.; Mr. Craig Williams; and Ms Deanna Durett. Mr. Dennis Dudley attended representing the Administration on Aging, U.S. Department of Health and Human Services (DHHS), and Ms. Anne Barbagallo represented the Family Assistance Administration.
Dr. Brand welcomed the members and thanked Dr. Mueller for his work in hosting the meeting. She mentioned that DHHS Secretary Thompson will be leaving his position in January 2005 and that the Committee report for the current year will be the new Secretary's first introduction to the work of the Committee.
Governor Beasley addressed the Committee by phone, thanking the members for their work and stressing the importance of the work of the subcommittees. He briefly described the process that will be followed in preparing the annual report.
Dr. Mueller provided a brief overview of Nebraska, highlighting the State's diverse population and geography. The total population is 1.6 million. Most of the population is concentrated in the Eastern part of the State. Western Nebraska is mostly a frontier area. The State has a unicameral legislature where rural interests are strongly represented. The University of Nebraska is heavily involved with rural health professions training and has a system for tracking physicians and mid-level providers. Programs to recruit health professionals for rural practice sites have been in place for many years and are targeting high school students in rural areas. The State has two Area Health Education Centers. In recent years telecommunication applications to health care have been receiving more attention. The State is aiming to develop community-based services for behavioral and mental health, moving from institutional to community care. There is strong collaboration on health issues between the University and state government. The Center for Rural Health Research at the University is involved with health information programs, policy analyses, the Rural Health Works Project, and many other activities.
Dr. Mueller noted that there are 85 hospitals in Nebraska, including 60 Critical Access Hospitals and two regional centers. The hospitals are in the early stages of creating a telehealth/telemedicine network to link urban and rural hospitals across the State. The State has a very strong presence of Family Physicians, Physician Assistants, and Nurse Practitioners. Public health programs and community action agencies are present throughout the State.
Dr. Steele asked about economic trends in the State. Dr. Mueller replied that it is primarily an agricultural economy, but is becoming more diversified in the Eastern part of the State. There are important sectors in finance, insurance, meatpacking, etc.
Ms. Johnson described her organization's Medical Preceptor Program that provides a rural health experience to staff from the Center for Medicare and Medicaid Services (CMS). Staff from the Health Resources and Services Administration and the Office of Management and Budget is also involved. The program provides an opportunity for federal officials to visit rural hospitals where they follow physicians and administrators during their normal daily routines. Federal officials have been impressed by the close relationships they observed between rural physicians and hospitals. Several participants also commented on how impressed they were with rural physicians who are treating entire families.
Ms. Redoubtey said that Nebraska provides a favorable climate for physicians. There is a cap on malpractice awards and a state-run liability fund for exceptional cases. The fund covers liability in excess of certain thresholds and is funded by the physicians themselves. She reported that these protections were helping Nebraska recruit physicians from other states. They are also helping physicians to remain in practice and to perform OB services. She mentioned that about 25% of Family Physicians in Nebraska are providing obstetric care.
Ms. Redoutey reported that there are 85 hospitals in Nebraska, including 60 Critical Access hospitals (CAHs). The CAHs have forged the development of systems of hospital care in the State and the CAH program has been crucial to their success. Current issues faced by hospitals include: 1) limited access to capital; 2) shortages of behavioral health providers; 3) transportation shortages; and 4) availability of outpatient laboratory services.
Dr. Steele asked about malpractice insurance carriers in the State and the age of practicing physicians. Ms. Johnson replied that there are 5 insurance carriers and that rural communities are having success recruiting young physicians for their hospitals. State loan and loan repayment programs have contributed to this success.
Mr. Size asked about public reporting by hospitals on quality measures. Ms Redoutey responded that CAHs have begun reporting data on a voluntary basis.
Dr. Montgomery asked about utilization of Physician Assistants and Nurse Practitioners in the State. Ms. Johnson did not have the numbers, but said that both professions are being well utilized.
Ms. Bergman said that the Nebraska Department of Health and Human Services has offices throughout the state with close connections to their rural clients. Caseloads are small and there is less staff turnover than in urban areas. A recent study showed that rural clients in Nebraska are less dependent on welfare than in many other states. The Employment First program provides transitional support to families for up to two years. The keys to its success are job preparation and education. The program provides child care, transportation, life skills training, clothes and uniforms for work, etc. Close relationships are maintained with local employers. The State has received awards for this program and federal bonus payments for performance. It is among the most successful states in the nation based on program performance and putting people to work. Ms. Bergman stated that the program is based on federal waivers that have been codified by state law. The waivers are up for renewal and must be continued to sustain the program's success.
Dr. Rawson asked where clients find work. Ms. Bergman answered that many find work in non-agricultural employment including service industries and education.
Ms. Birch asked about collaboration with public health and programs on teen pregnancy. The speaker said that education on teen pregnancy is an important focus of the program.
Ms. Freeman-Watson inquired about administration of the program. Ms. Bergman responded that the program is administered through contractors who perform case-management services and other responsibilities. She mentioned that Goodwill Industries is one of the contractors.
Dr. Mueller stated that the program emphasizes the development of human capital, focusing on education the development of labor skill needed for successful employment. It differs from other programs where the primary emphasis is on job placements alone.
Dr. Shumard stated that all physicians in his practice were trained in obstetrics. The number of deliveries they perform is in decline and it has become difficult for them to maintain their skills. In-service training programs are important in this regard. He has seen significant changes in physicians coming out of medical school. Many residents are trained for urban settings where specialty care is readily available, and are not fully prepared to practice in a rural area. . He views the rising costs of medical malpractice insurance as a major emerging problem that threatens access to obstetrical care in rural areas. Rates are high and can be reduced if a physician does not elect to provide OB services. Fewer births and insurance rate increases my cause a majority of physicians to quit OB. He reported that his practice may have quit OB at some point in the future.
Dr. Luckey mentioned that anesthesia services are extremely short in rural Nebraska and that many women expect these services when they deliver. He reported several other challenges that will influence obstetric care in rural Nebraska: 1) Physician life-style expectations may cause them to exclude OB from their practices; 2) OB training for Family Physicians is often not up to standards; 3) There is a need for trained nurses and ancillary staff trained in OB; and 4) Facilities need to be pleasant and up-to-date. He said that malpractice insurance costs are keeping many of his colleagues from providing OB in rural Nebraska.
On the issue of obesity, Dr. Shumard believes that it is worse in rural areas where heart disease and diabetes are major threats. Dr Luckey added that the complications of obesity are severe and prevalent. He believes that the decline of family farms has contributed to the problem by eliminating a more active life-style. He also mentioned the availability of fast foods in schools and lack of exercise by students. Dr. Luckey also said that physicians need to provide obesity counseling, but there are no billing codes for this service. Dr. Shumard urged the development of federal programs to exercise, fitness, and wholesome diets.
Dr. Shumard stated that family practice residency programs must do a better job of preparing physicians for rural practice. Physicians should be better educated on realistic life-style expectations in rural communities. Dr. Luckey added that rural physicians must be more highly trained than urban physicians given the range of patients they will see and the lack of specialty support.
Dr. Steele noted the small number of deliveries (45) performed in Dr. Shumard's practice and asked if there were opportunities to partner with other practices where there are more deliveries. Dr. Shumard stated that rural hospitals and independent physicians could work together to promote OB and retain OB patients in the community.
Dr. Montgomery inquired about the availability of midwives in rural Nebraska. Dr. Luckey answered that there were no midwives practicing in rural parts of the State.
Dr. Rawson questioned the economic impact of the low number of deliveries performed by rural physicians. His question precipitated a discussion of whether malpractice insurance costs can exceed the revenue from deliveries and whether it might be cheaper to pick up rural patients with helicopters and fly them to urban areas for delivery. Dr. Luckey and Dr. Schumard agreed that it would not be feasible or desirable for all women to travel long distances for delivery. They suggested that regional birthing centers in rural areas might help to maintain access to OB and continuity of care.
Dr. Edwards asked about barriers to reduction of obesity. Dr. Luckey cited the availability of fast foods, irregular family meals, sedentary lifestyles, and the need to work with children and teens. Dr. Shumard added that rural physicians with typically large caseloads have little time to counsel patients on obesity.
At the close of the session, Dr. Luckey recommended that the Committee look into the issue of reimbursement mechanisms that would pay for services on the basis of quality rather than quantity, and to cover the costs of patient education on obesity and other health issues.
There were no public comments and the meeting was adjourned.
On Monday morning the Committee participated in site visits to obtain information and perspectives for the annual report. The subcommittees on Integrated Services and TANF visited Southwest Community College in Beatrice, NE. The Subcommittee on obesity visited Community Memorial Hospital in Syracuse, NE. The obstetrics group visited the practice of Keith W. Shuey, M.D., an independent family physician located in Tecumseh, NE.
At 11:30 a.m. the Committee arrived at the Crete Area Medical Center in Crete, NE. The Center staff conducted a tour of the facility, hosted the Committee for lunch and led a discussion about the hospital in particular and hospitals in Nebraska in general. After lunch, the Committee returned to Lied Lodge where the remainder of the day was devoted to separate work sessions for the subcommittees.
The meeting was adjourned at the close of subcommittee meetings.
Mr. Morris convened the meeting at 8:30 a.m. He asked Mr. Otis to talk about the meeting in September that will be held in Tupelo, Mississippi. Mr. Otis reported that the meeting would be held at the Executive Inn located in downtown Tupelo. There will be a reception on Saturday night and field trips are planned for the following Monday. The group on obesity will visit a town where significant weight loss has occurred. The obstetrics group will visit a hospital that has outstanding obstetrical care. The collaboration subcommittee will meet with a local foundation and several visits are being planned for the TANF subcommittee.
Mr. Morris asked for progress reports from each of the subcommittees.
The subcommittee will be looking at how service integration works at the local level. They will start the chapter with a statement of purpose and will discuss community development, population-based health issues, and quality of life. The report will then focus on federal programs at the Department of Health and Human Services and how local communities can make these programs work in a coordinated manner. They will examine the use of technology in program coordination and the role of leadership in the community. Strategies for cultivating community leadership will be discussed. The chapter will also examine broader issues of quality of life and their relationship to community development activities.
Mr. Size added that collaboration between private and governmental organizations would be addressed.
Mr. Morris announced that Dr. Mueller would continue to staff the report even though his term on the Committee has expired.
Mr. Nelson reported that the group was completing an outline of the chapter on obesity and had gathered data to document the extent of the problem. The group has identified unique rural issues on obesity related to poverty, decreasing exercise, transportation, and access to providers. The chapter will make policy recommendations to the Secretary in areas where the Department has authority. Recommendations may focus on such areas as: (1) The lack of a comprehensive national policy on the problem of obesity; (2) Payment policies to recognize obesity care as a reimbursable service; and (3) Education programs on obesity and greater involvement of schools.
Dr. Edwards added that staff would explore how to make obesity programs a priority in federal funding streams.
Dr. Steele reported that OB issues are representative of rural access problems with other specialties such as anesthesiology and behavioral health. The report will present data on access to OB services in rural areas, including the potential impact of rising malpractice insurance costs. Dr. Steele reported that some key data are not available including information on obstetrical outcomes in rural areas. The Subcommittee is hoping to find data to describe the status of OB services in rural hospitals. The report will address sociological issues related to physician lifestyles and lifestyle expectations. One issue is how to adopt the new career and lifestyle expectations of providers to the realities of practice in rural areas. The report will examine the possibilities for incentives that could lead to different practice styles for OB in rural areas. The report will also highlight provider supply issues, use of non-physician personnel in OB, and the need for data on the relationship between volume and quality of care in obstetrics.
Mr. Size and others suggested potential sources of data for the report.
Ms. Freeman-Watson reported on the site visit of the previous day and how the program is being handled in Nebraska. She provided an overview of the goals for the TANF program relating to family assistance, education, and employment. The report chapter will provide data on urban/rural differences related to TANF clients and programs, including wage differences, unemployment rates, transportation issues, child care, etc. Issues to be addressed include childcare, transportation, caseloads, providing technical assistance in rural areas, training of human service providers, policy development, and collaboration with other federal programs.
Dr. Kaye, Dr. Mueller, and others stressed the importance of collaboration between TANF and other federal programs.
Ms. Barbagallo talked about transportation programs in rural areas. She also described how states are emphasizing work over education in their administration of the TANF program. Nebraska is an exception to the work-first strategy that has been adopted by most states.
Mr. Morris reviewed the letter to the Secretary that will include a progress report, highlights of the site visits, and plans for the September meeting. The letter was approved.
Mr. Morris called for public comments. There were no comments and the meeting was adjourned.