Health Resources and Services Administration
Office of Rural Health Policy
September 10-12, 2000
The 36th meeting of the National Advisory Committee on Rural Health (NACRH) was held on September 10-12, 2000, at the University of Kentucky Center for Rural Health and at Hazard Community College. A reception was held for NACRH members on the evening of Saturday, September 9.
A brief orientation for new members (Dr. Stephanie Bailey, David L. Berk, Dr. Keith J. Mueller, and Sally K. Richardson) was conducted at the Hazard Hotel prior to the meeting's formal opening. In addition to the new members, the following participants attended the Hazard meeting: Nancy Kassebaum Baker, James F. Ahrens, H.D. Cannington, Shelly L. Crow, Dr. Steve Eckstat, Dana S. Fitzsimmons, Alison M. Hughes, John L. Martin, Dr. Mary Wakefield, Tom Morris, Sahi Rafiullah, Dr. Marcia Brand, and Dr. Wayne Myers. Rachel Gonzales-Hanson, Dr. Monnieque Singleton, and Dr. Thomas Nesbitt were unable to attend. A list of current NACRH members follows the meeting summary.
Chairwoman Kassebaum Baker convened the meeting at the University of Kentucky (UK) Center for Rural Health by first welcoming NACRH members and then announcing the retirement of Dr. Myers from his position as Director of the Office of Rural Health Policy. She thanked him for lending his leadership, guidance, and direction to the effectiveness of the rural health policy section of the Department of Health and Human Services (HHS). She then called on Dr. Myers to introduce several NACRH guests who were present at this opening session. They included the following:
Next, Bil Gorman, Mayor of Hazard and former head of the Appalachian Regional Healthcare (ARH) Center for 13 years, welcomed the Committee members to Hazard and thanked them for all the work they have done in the rural health care arena.
Senator Bailey provided NACRH members with a brief historical perspective of the central Appalachian region in eastern Kentucky and of the people who work and live in this area. He also discussed the impact of Medicare on the residents of Hazard and eastern Kentucky.
Senator Bailey began his overview of the area by explaining that the term Appalachia was first used around 1890 to describe an area of the country where "the people lived, worked, spoke, and behaved differently than other people of the United States." The Scotch-Irish, who were considered the best educated of all the groups that immigrated to the New World, first settled the region. Upon arrival, they immediately established schools in the area that were similar to the ones they had left behind in Ireland. These schools, which had to temporarily close because of the onset of the Civil War, later became the model on which the American system of education is based.
The Appalachian area has been scrutinized many times, both in literature and legislation. In 1960, during the War on Poverty, many young, misguided young people came to southern Appalachia from wealthy urban areas to offer their services to the local populace. They came without any type of guidance, supervision, or skills in social engineering, only to leave in failure. Around the same time, Senator Bailey, accompanied by 250 local college students and armed with the appropriate skills, was successful in his efforts in forming health care teams to improve the lives of the rural residents.
Next, Senator Bailey reported on the seriousness of the health care needs of the Appalachian people by presenting some dramatic statistics on health care in Kentucky. He stated that the average rate of hospitalization for children in the United States is 8 cases per 1,000 cases of children seeking treatment under age 15. In comparison, the State of Kentucky reports 12 cases per 1,000, while southeastern Kentucky reports 35 cases per 1,000. When the death rate was recently calculated per 1,000 people for a number of minority groups in which Appalachian Kentucky was included, it was determined that this region has the highest death rate. This minority group also included the largest number of uninsured.
Senator Bailey explained that Medicare and Medicaid are the two staples that have allowed for the development of health care programs in rural areas but that they have not yet reached their full potential, and in some instances, have actually stultified the growth of health care services in these areas. It is common knowledge that Medicaid pays physicians the same amount of money no matter where they live. This shortcoming has resulted in a shortage of primary care physicians in rural America. Therefore, the key to retaining these physicians in rural communities is to increase payment for service.
Senator Bailey then pointed out some specific problems he had encountered with Medicare and the Health Care Financing Administration (HCFA). In 1972, Knot County in eastern Kentucky asked for additional funds from several Federal Government programs to support the construction of a much-needed clinical facility in the region and was repeatedly turned down. County officials were told that their health care programs did not fit the Federal profile of what was considered best for rural America. The clinic was finally built with private funds. But surprisingly, even after the clinic was named the model program for the Horizon '76 Programs for the American Revolution Bicentennial, had received numerous awards for its health care programs, and had treated 400,000 patients, and even after the Robert Wood Johnson Foundation gave the University of North Carolina $12 million to duplicate the clinic's programs across rural America, clinic officials were told that they did not qualify for cost-based Medicare reimbursement because they had not shown a need for their programs.
According to Senator Bailey, HCFA refuses to consider any assistance to a rural health care program if "the program doesn't fit HCFA's preconceived notions." He believes that Medicare reimbursement of services in rural areas is much less than in urban areas, even though State law prohibits this inequity, and that this inequity is pervasive throughout rural America.
In summation, Senator Bailey spoke about the great strides that the people of rural eastern Kentucky have made during the past 15 years in building a model for rural health care. Today, because of the hard work of the UK Center for Rural Health, Hazard has a new well-equipped hospital with 122 doctors on staff and the only mental hospital in eastern Kentucky. Also thanks to Dr. Wilson, Mr. Goetz, and Dr. Main, the UK Center offers bachelor degree programs in medical technology and physical therapy, a master's degree program in nursing, and a family practice residency program. Furthermore, a number of foreign medical school graduates now practice in Hazard, allowing the UK Center access to practically "every foreign nation in the world." A future objective of the Center is to be known as an international center for rural health studies. The Center also is involved in health policy work and recently was instrumental in securing $500,000 from the Kentucky State legislature to establish a cardiac rehabilitation center at the Appalachian Regional Hospital.
Before Dr. Myers provided NACRH members with an update of the Office's activities, he too announced his departure from the Office of Rural Health Policy (ORHP) immediately after the November elections and the imminent succession of Dr. Brand from her position as Deputy Director to Acting Director. He also introduced Michelle Pray, an intern at ORHP from Johns Hopkins University School of Public Health and a native Appalachian from Hazard.
Dr. Myers briefly commented on ORHP's work with the Balanced Budget Refinement Act and with following the progress of congressional members in the enactment of their Medicare packages in their entirety before the end of this administration or in positioning their bills for review by the next Congress. The 22-member Office is concurrently determining its own budget for the next fiscal year and is contemplating what decisions need to be made during the protracted period from the November 7 election to the January 20 inauguration.
Dr. Myers then shifted to the issue of Medicare reform, the main topic of discussion for this meeting. He asked that the Committee members review the various proposals for Medicare reform that were analyzed by Dr. Mueller at the June meeting and outline for ORHP issues they believe are important, from a rural perspective, for consideration in any plan to reform Medicare. To help with this task, Dr. Myers requested that members prioritize these issues by using the following five categories:
NACRH responses to these areas of discussion are examined during Monday's session.
Dr. Myers suggested that a subcommittee composed of designated Committee members works closely with ORHP staff in drafting a document based on these responses. After a final review by all Committee members, together with input from the Rural Policy Research Institute (RUPRI), a final report incorporating this information on Medicare reform will be sent to the Secretary of HHS, most likely after the first of the year.
As a member of the Medicare Payment Advisory Commission, Dr. Wakefield reported that in June 2001 the Commission will produce a major document focusing entirely on rural health policy. She hopes that "the report will help publicize some of the really unfortunate structural hindrances that have been built into the Medicare Program to date. These are some, if not the same, of the problems that have been examined since 1964."
Dr. Mueller provided NACRH members with a brief summary on RUPRI's role in analyzing the topic of Medicare redesign. The task, which includes the development of three reports, has taken about a year to complete, with a couple of false starts. The first report, and the topic of discussion at the June NACRH meeting, reviewed the President's Medicare Reform Plan and the leading congressional reform proposal (S. 1895) put forth by Senators John Breaux (D-LA) and Bill Frist (R-TN).
The second report consists of two papers that focus on the issue of the wage index used to create a geographic adjustment in payment streams regarding inpatient hospitals. The first of these two papers is a short policy brief that lays out the elements of the wage index and how these elements vary between urban and rural locations. The final report, and the topic of Dr. Mueller's discussion at this meeting, looks at the global issues involving Medicare reform by "examining the desired state of being for health care delivery in rural areas." It incorporates input from the June meeting and is published by the RUPRI Center for Rural Health Policy Analysis.
Committee members each received a draft of the introduction and framework of the final report for review. Dr. Mueller hopes to have the final document ready for restricted circulation some time after Thanksgiving. Publication for the general public is scheduled for after the first of the year to allow time to review comments from NACRH members and RUPRI advisers and to try and coincide with the Committee's release of its own Medicare redesign report.
According to Dr. Mueller, this final RUPRI paper will differ from the others by presenting "a framework for what should be included in any discussion of Medicare policies." It is not a paper based on impending legislation. Dr. Mueller explained that one problem in writing a document of this nature is the selection of proper language that will convey the same meaning to all readers, for example, the use of the word or words "rural" or " rural health care delivery system." The definition of rural varies considerably from place to place, as does the health care delivery systems in rural areas. This report uses the term "rural" when referring "to dominant characteristics of rural areas, usually of delivery systems or of beneficiaries living in most of rural America, defined in geographic and not population terms."
Dr. Mueller then presented several slides that explained rural as a place, health care services in rural areas, and implications for Medicare policy.
Next, Dr. Mueller explained that policy makers have used two fundamental approaches when trying to redesign the Medicare program. The Government-based approach calls for Government intervention through a combination of regulation and financial actions (paying for new benefits or changing its payment reimbursement to providers and/or health plans). The private approach relies on actions of privately based health plans and providers to extend cost-effective services to beneficiaries. An "in between" approach, characterized as the managed competition approach, combines reliance on using new private initiatives with Government regulations that ensure a "level playing field."
These fundamental approaches to changing the Medicare program would have different impacts on health care for rural beneficiaries. They differ in
RUPRI's latest prescription drug document, which Committee members will soon receive, uses the same kind of thinking that went into the redesigning Medicare document. The prescription drug document, which is an assessment of the rural implications of prescription drug benefits and a precursor to RUPRI's Medicare document, relied on the S. 1895 bill and the President's proposal to demonstrate what prescription drug benefits should look like for rural environments.
Dr. Mueller pointed out that the analysis of the policy paper under discussion is structured around a set of principles that should guide any Medicare redesign effort. These principles are
Dr. Mueller explained that each principle was devised on behalf of all Medicare beneficiaries who live in rural areas. In the final paper, each principle will be compared to the current situation, and recommendations will be made for developing a Medicare program of greatest benefit to rural residents. Dr. Mueller does not see the current Medicare program as being optimal against any of these principles and views this program as unsatisfactory.
In the discussion that follows Dr. Mueller' presentation, several issues were raised:
Dr. Mueller also said that one has to either use the egalitarian principle that says everyone receives the same payment or use the economic principle, in which case one has to totally redefine service areas so that they make sense economically. RUPRI plans on doing something similar to the latter on service area definitions over the next year or so.
Ms. Crow offered that the "whole rural payment system is higher in rural areas than in urban areas" most likely because of the lack of resources. She has found that in her area phone bills and overhead costs at rural clinics are higher, leasing or purchasing patient equipment is more costly, and grants are not available to purchase new buildings.
Dr. Brand mentioned that she recently participated in the review of 35 States that applied for a State planning grant program. This program provides States with the resources necessary to conduct 1-year assessments of what it would take to provide access to affordable health insurance for all citizens in that State. Each State was asked to identify a range of health care options that would work in their State; ORHP has agreed to fund 11 applicants. Dr. Brand believes that the high interest in this program indicates that States are not "waiting around for Federal solutions to access the health insurance process."
Dr. Wakefield then explained that the issues this panel is struggling with parallel the issues that the next MedPAC meeting will discuss at length, that is, whether or not to define "access" and "quality" in terms of the Medicare program, and if so, what are the definitions as they relate to rural areas in particular. Any information that this panel "could provide to MedPAC on the subject could be critically important over the next 9 months."
Following the discussion, Chairwoman Kassebaum Baker asked the Committee members to come up with two or three Medicare redesign priorities they consider important when addressing such issues as equity, quality, cost, access, and workforce, and to be ready to discuss these priorities at tomorrow's session. She then asked for comments from the floor.
Chairwoman Kassebaum Baker opened the meeting by asking Ms. Hughes to report on her participation at the 9th International Congress of the World Federation of Public Health Associations (WFPHA), held in Beijing, China, on September 6, 2000. A draft report on the challenges for public health was adopted by the Congress in Beijing and is expected to be adopted by the World Federation within the next couple of months. Sixty countries were represented at the Congress, including the U.S. Public Health Association. These countries, which are trying to eradicate disease around the world, agreed at this time to promote three main points worldwide for both urban and rural areas. These points are advocacy, partnerships, and mobilization, which when put together will bring about positive social change. Other issues discussed at the Congress were the lack of potable drinking water and environmental pollution and its impact on health care.
Following Ms. Hughes's comments, the Committee discussed the structure of this morning's session and how best to shape the parameters of the Committee's Medicare redesign recommendations, which will be presented in a final report to the Secretary of HHS. The group was asked whether they should consider reshaping Medicare in specific terms or use a broader approach in their discussion of Medicare redesign. Suggestions on this subject include the following:
(1) Take a fresh look at the current Medicare situation and develop straightforward solutions to present to the Secretary.
(2) Think globally to determine clear rural-related objectives that should be included in any proposed Medicare change.
(3) Determine what this program should be doing for its beneficiaries.
(4) Determine what has or has not worked with certain elements of the program and decide whether or not they should be restructured, and if so how.
(5) Narrow the focus and use RUPRI as a guideline to address rural issues that are relative to anticipated changes in the Medicare program.
After a brief discussion, NACRH members decided to start with the development of recommendations for specific changes to the Medicare program as they relate to rural objectives and later develop more global recommendations about the structure of the program. Chairwoman Kassebaum Baker suggested beginning the discussion with the issue concerning access to health care from a rural perspective, which raised the following comments and questions:
Dr. Mueller views access in terms of "access to the continuum of care and the services that are within that continuum of care." Currently, Medicare pays for a professional medical service and is not concerned with a beneficiary's access to that service, which could require driving considerable distances for just a consultation. Because Dr. Mueller would like to see health care services made as convenient as possible for the beneficiary, he recommended that Medicare start funding telemedicine or telehealth hookups between rural and urban health facilities.
Ms. Hughes brought up the issue of consumer utilization in response to Mr. Berk's comments about the lack of utilization of rural health care systems. She noted that uninsured rural residents are less likely to seek medical care unless an emergency arises. These are the same people who will more than likely continue this practice after they become eligible for Medicare at age 65. Ms. Hughes asked whether some kind of consumer education exists that is responsible for educating people approaching Medicare age about the importance of attaining health care services. As an example of educating rural residents on a new type of health care technology so as to win their acceptance, Ms. Hughes cited the introduction of a telemedicine system to an Arizona Indian reservation. In this case, she introduced the new technology to the tribal leadership and community by asking the medicine man to bless the new telemedicine system. By doing this, cultural acceptance was secured and the new system was successfully implemented.
Ms. Hughes then briefly discussed the issue of asset management as it relates to Medicare. She pointed out that the panel is talking liberally about Medicare's shortcomings and not enough about the program's assets. She suggested that the Committee might want to discuss Medicare's positive features and then build on those.
As an example, she cited John McKnight's (Northwestern University) concept of asset mapping. This concept is used at the grassroots level in small communities to determine a community's assets. Once determined, a community can more easily establish policy because it is easier to build on positive attributes than build on negative ones.
Dr. Bailey would like to see Federal granting sources require States to conduct open dialog with their communities (e.g., via local health departments or rural health clinics) on local health care concerns. She questioned whether this same type of interaction could occur to better direct Medicare payments toward community needs.
Mr. Fitzsimmons believes that in addition to access to providers and services, beneficiaries should have access to different health plans. He reasoned that multiple plans lead to competition, which in turn leads to greater affordability for Medicare eligibles. He mentioned that Texas has seen a dramatic decrease in the number of plans available, in urban as well as in rural areas. In the Houston marketplace right now the number of Medicare HMOs has been reduced to one plan. In closing, Mr. Fitzsimmons said that the optimal health care situation does not exist anywhere right now but that possibly HMO-type plans or Medicare+Choice programs could be successful in rural areas.
Dr. Wakefield cited the definition of access from the Physician Payment Review Commission as being the ability to obtain needed medical care. This definition asks two questions: (1) What type of infrastructure should be in place? and (2) What are the payment mechanisms that need to be in place to ensure that Medicare beneficiaries in rural areas are able to obtain the needed health care? Dr. Wakefield also mentioned that a local web site or a network of essential services for Medicare beneficiaries should be available in rural areas. This network should provide the location of services that are close to where beneficiaries live.
Next, Chairwoman Kassebaum Baker steered the discussion toward the design and financing of a basic Medicare package. She favors a basic plan that would be offered to everyone, with adjustments and flexibility for the rural population. She asked the panel whether the State or Federal Government should be responsible for providing the extra resources for the additional continuum of care needed, that is, how can a program be adjusted and put together that meets the additional services over and above the basic package of benefits. Highlights of the groups' varying opinions follow:
In response to Chairwoman Kassebaum Baker's statement that the decision making for adjustments in financing and its flexibility should be in the hands of the State or local communities, Mr. Martin stated that he has no problem with the State picking up 5 or 10 percent of the access costs but that he wants assurance that the benefits will remain the same throughout all States. Mr. Cannington would like to see Medicare pick the access costs, which would ensure that rural beneficiaries are not paying these costs.
She also asserted that States should negotiate some type of formula in the establishment of adjustments to individual services because of State differentials in providing these core services. States should be closely monitored to make sure they give rural areas the same amount of money as they give urban areas.
In continuing the discussion on financing a basic set of benefits, Chairman Kassebaum Baker asked if the adjustment in the financing could be a "Federal and State mix" rather than just a Federal operation. Dr. Mueller noted that access and finance are mixed now and that everyone has the opportunity to access appropriate services. What he would like to see is Federal financing for a basic set of benefits that is the same across the board. Chairwoman Kassebaum Baker voiced concern that as the number of Medicare eligibles grow, financial problems will increase; therefore you must have either greater beneficiary support, possibly with a Part B benefit or a Part C benefit (i.e., a prescription drug program), or a mix of State, regional, or community support to help structure additional funding to ensure rural area access to services. These comments evoked discussion from the Committee.
Although these questions weren't answered directly, Ms. Richardson noted that many inequities will exist in infrastructure payments because the socioeconomic status of each State is different.
Chairwoman Kassebaum Baker added that Medicare should be responsible for some the basic overhead costs. The financial burden of overhead costs is a dominant problem in low-volume areas. Dr. Myers commented that Medicare should be structured so that the State and the community would have discretion in allocating those overhead funds.
In response to a comment that many people do not understand how Medicare works, Mr. Morris explained that money for Medicare comes from payroll taxes to provide health care services for individuals in their retirement. Medicare recipients are guaranteed the Part A benefit and pay an additional contribution for the Part B benefit.
The discussion then turned to addressing more conceptual and innovative ways to improve the Medicare package. Mr. Ahrens suggested that the Federal Government determine the price for a basic package by per population eligibility in a particular State and provide that State with a lump sum of money, or block grant, for a basic benefit package for each resident. Resources would not be used for services (e.g., burn units or kidney transplant operations) in a particular area if they were not in great need. Patients would always have the option to receive these specialized services at other locations.
Ms. Richardson proposed the need for some type of risk adjustment attached to these block grants to accommodate more populated areas and rural areas in which more resources are required. In response to this comment, Chairwoman Kassebaum Baker noted that block grants would allow for a certain amount of overhead, and the States would determine its use.
As another innovative option for the Medicare program, Ms. Hughes suggested to create rural health service districts or areas that are funded by local community taxes to address community needs. Although these service areas have worked well in Arizona, Mr. Martin admitted they have not worked well in Maine because of the politics involved.
Although she thought these innovative concepts were somewhat radical, Chairwoman Kassebaum Baker recommended that the group think about the issues for future debate.
Next, in response to several inquiries on the actual cost of health care delivery in rural areas, Dr. Myers claimed that the current spending is 29 percent less for a rural beneficiary than for an urban beneficiary. Mr. Morris mentioned that no one really knows what the true cost of health care delivery is in rural areas. He suggested that the Committee include in its final Medicare report costs for health care delivery in rural environments and a payment system designed around those costs. Cost figures currently used are pulled from a 1983 database that has not been updated. Mr. Morris noted that the health care system has changed dramatically since then and "yet we're still applying Band-Aids to the shortcomings of an antiquated system."
Chairwoman Kassebaum Baker then turned to the floor for comments.
Mr. Snyder asked rural health care professionals to closely monitor the number of physicians coming into rural areas and find ways to encourage them to remain in these areas. He also stressed that if the current system is going to improve, then nontraditional health interventions must be introduced. He encouraged the Committee to consider optimal collaboration among agencies that could have an impact on health care (e.g., social support systems, educational systems, the Public Health Service, and health care organizations from the nonprofit sector).
He also mentioned inconsistencies with graduate medical education reimbursement. Hospitals located in urban areas receive five to six times the graduate medical education reimbursement than rural areas receive, and the quality of education provided by both has been proven to be the same.
Mr. Goetz then discussed a number of problems, as he sees them, with health care access, human health care resources, and the lack of support systems in rural environments. Although the KY Center for Rural Health does not have solutions to many of these problems, it has taken a couple of steps in that direction. The Center works closely with a number of communities so as to solicit funds to supplement the Center's programs. In return, the Center encourages University of Kentucky faculty members to live in these communities. The Center also finds faculty members to relieve those who need some time off.
Chairwoman Kassebaum Baker, in following up on Dr. Myers' suggestion to form a subcommittee to help ORHP draft the report on Medicare redesign, called for volunteers to serve on the subcommittee. Mr. Cannington was designated as chairperson. Each Committee member will receive a copy of the draft for review.
Dr. Myers agreed to formulize all the points made at today's session for presentation tomorrow. Chairwoman Kassebaum Baker thanked NACRH guests for their contributions and then gave Committee members last-minute instructions for their afternoon site visits with staff from ARH Home Health Services and the Homeplace Project Lay Healthworker Project.
Mr. Rogers provided NACRH members with a brief history of the ARH Division of Home Health Care Services. This division was created in 1983 because the local hospital administration was largely ignoring the value of its on-site health care agencies and paid little attention to new developments across the continuum of care. Under the direction of a new hospital president, home health care became a highly visible autonomous unit with a $3 million budget, growing from 3 employees to 800 professionals over a short period of time.
Over the years ARH, with help from the University of Kentucky, has provided quality health care to the residents of Appalachia, offering a continuum of care such as occupational, physical, and speech therapy, nursing assistance, and AIDS services. The agency was fortunate to survive the impacts of the Balanced Budget Act of 1997 (BBA), even though its budget was reduced from $80 million to less than $40 million, and it lost a number of skilled nurses and other health care professionals. At present, ARH is trying to eliminate an additional 15 percent budget reduction that BBA is trying to impose on its services.
Mr. Rogers then introduced three coworkers from ARH: Russ McGuire, Floyd Davis, and Ellen Peets. In response to a question about the prospective payments system and the possibility of it causing ARH to lose some of its services, Mr. McGuire informed the panel that the agency is working hard at maintaining the highest quality of care for its patients throughout the service area despite issues surrounding the BBA and the PPS. The agency is also prepared to work closely with physicians in the community in establishing appropriate protocols and appropriate delivery of services. As new regulations are passed that affect home health care services, ARH's goal will remain the same-"to provide top-quality health care and to adjust the service delivery to the appropriateness of care."
Mr. Rogers noted that ARH finished out its fiscal year losing more than $2 million in home services by providing care for 27,000 patients and making less than 400,000 home visits. Approximately 30 to 40 percent of home health agencies in the nation that were operating in 1996 are no longer in existence. He expressed concern that hospitals are going to start having financial difficulties again because they are losing their ability to shift costs. (Two hospitals have already closed because of financial problems, although none have closed recently in eastern Kentucky.) In addition, soft money cannot be relied on anymore to keep the health care system solvent, and the reimbursement payment system has completely changed, causing problems for both providers and beneficiaries.
Mr. Rogers also is concerned about the cost of maintaining state-of-the-art knowledge within health care agencies, such as keeping abreast of new medications, new medical procedures, new equipment, and new approaches to inpatient care. He noted that as the baby boomers move into middle age, they will make up the largest single cadre of people in the United States. In about 15 years, this group will cause large drains on the medical system, and "there will not be enough money in the world to take care of them in an inpatient setting." One possible solution in alleviating this drain is to start putting funding in place now to develop the necessary clinical expertise so that a large portion of medical care can be done in the home.
Following Rogers' presentation on the ARH Home Health Care Services, Committee members offered respective comments.
Mr. Ahrens commented that if you lose hospitals, you lose home health care. He suggested soliciting help from senators and representatives at the Federal and State levels not only to help save hospitals financially but also to help put together a seamless health care system in which the system follows a patient throughout all stages of treatment and care, with the dollars following the patient accordingly. The challenge lies in "keeping the bucks with the patient."
Another challenge for health care workers in rural areas is increasing the health care knowledge of the populace. In many areas of eastern Kentucky, deeply ingrained traditional beliefs about health care exist, as well as a traditional bias toward certain vices. For example, it is difficult to convince those who live this area of the health risks of smoking, especially when the tobacco lobby is so strong in this part of the State. Furthermore, as young people move from rural to urban centers, rural populations become older and sparser, resulting in rural communities having more difficulty supporting a large range of medical services that are available in urban areas.
ARH realizes it must take the necessary steps to address these challenges and bring its organization into the 21st century. It has installed 83 laptops with state-of-the-art information systems in the hands of the center's nurses. An improved highway infrastructure and improved computer applications (e.g., telehealth) in rural health care have already helped negate some of these problems.
Ms. Hughes expressed appreciation to the family health advisors for conducting Monday's site visits and commended them for their devotion and hard work. On behalf of NACRH, Chairwoman Kassebaum Baker thanked Mr. Rogers and his coworkers for their insightful presentation on home health care activities and expressed gratitude to Mr. Rogers and his wife Audrey for generously hosting the Committee dinner Monday night. After presenting Dr. Myers with a departing gift from NACRH members, Chairwoman Kassebaum Baker discussed the Medicare reform priorities compiled by Drs. Myers and Calico from Monday's discussion. She asked the members to carefully review these priorities and pass any comments onto ORHP staff as soon as possible so that the comments may be incorporated into a final report to be put before the incoming HHS Secretary after the first of the year. The report will be discussed at the next NACRH meeting to be held in Washington, D.C., on February 4-6, 2001. The next on-site visit has been tentatively scheduled for the second week in June in Sacramento, California.