Health Resources and Services Administration
Office of Rural Health Policy
September 12-14, 2004
The 48th meeting of the National Advisory Committee on Rural Health and Human Services was held on September 12-14 at the Executive Inn in Tupelo, Mississippi.
Governor David Beasley, Chairman of the Committee, convened the meeting. Governor Beasley extended his thanks to the Honorable Larry Keith Otis, Mayor of Tupelo, for hosting the meeting. He then introduced the four new members of the Committee.
The new members are: Thomas C. Ricketts, Ph.D. from the University of North Carolina; Michael Meit, M.P.H. from the University of Pittsburgh, Bradford, Pa.; Patti J. Patterson, M.D. from the Texas Tech University Health Science Center; and Ms. Julia Hayes, Assistant Director of Minority Health, Office of Primary Care and Rural Health, Montgomery, Alabama.
Other members present were: Mr. James Agras; Ms. Susan Birch, RN, MBA; Mr. Evan S. Dillard, FACHE; Joellen Edwards, Ph.D.; Michael Enright, Ph.D.; Ms. Bessie Freeman-Watson; Mr. Joseph D. Gallegos; Leonard Kaye, D.S.W.; Arlene Jackson Montgomery, Ph.D.; Ron L. Nelson, P.A.; Sister Janice Otis; The Honorable Larry Keith Otis; Ms. Heather Reed; Glenn D. Steele, M.D., Ph.D.; and Mr. Tim Size. Senator Raymond Rawson, D.D.S. was unable to attend. Present from the Office of Rural Health Policy were: Tom Morris, MPA; Michele Pray Gibson, MHS; Jennifer Riggle, J.D.; and Ms. Deanna Durett. Mr. Dennis Dudley attended representing the Administration on Aging, U.S. Department of Health and Human Services, and Ms. Anne Barbagallo represent the Department's Administration on Children and Families.
Dr. Jones briefly described the status of the Medicaid program in Mississippi. The number of recipients is growing rapidly. Currently, about 25 percent of the population is eligible for Medicaid and costs are rising rapidly. The program now consumes over 20 percent of state dollars. The biggest growth areas are pharmaceuticals and care in nursing facilities. Dr. Jones emphasized the need for a new patient-centered approach to Medicaid that would provide a medical home for every client and reduce the demand for care in emergency rooms. He spoke about three new initiatives involving the establishment of a preferred drug formulary for Medicaid clients, coverage of physical examinations, and the transfer of eligibility determinations from the Department of Human Services in Mississippi to the Medicaid Division. He also spoke about the use of Medicare waivers to leverage coverage for disabled clients and other groups. Overall, he believes that Medicaid has a bright future in the State.
Mr. Dillard asked if there was regional collaboration among Medicaid Directors in neighboring states. Dr. Jones replied that state directors meet on a regular basis to share ideas.
Mr. Nelson asked about the impact of the drug formulary on providers. Dr. Jones said that physicians and other providers had bought into the formulary. The prevailing science on efficacy will govern the selection of drugs and then the issue of price will come into play.
Dr. Edwards asked about provider acceptance of the Medicaid home concept. Dr. Jones answered that the concept has uniform acceptance. There will be a study to determine whether the concept decreases costs.
Ms. Birch asked about nursing home issues in the state. Dr. Jones said that there is an adequate number of nursing homes, but that Medicaid has been criticized for spending so much of the budget on nursing home care. Part of the problem is that many small rural communities do not have the services needed to keep people out of nursing homes. They will be working on ways to improve the rural infrastructure.
Mr. Rumbarger talked about successful economic development programs in Tupelo and future economic development plans for the area. Economic development efforts have focused on training and education for the labor force, as well as enhancing community infrastructure in water, sewer, and other public services. The philosophy behind economic development in Tupelo has been that community development must precede economic development. There has been a solid growth of industry in Tupelo and a history of business involvement with economic and community development activities. The city has recently created a Workforce Creative Education Center to focus on working training. One of the biggest challenges it faces is the training of higher age workers who have been displaced by downsizing and other economic forces in the community.
Mr. Size asked how health care costs were affecting the competitiveness of local businesses. Mr. Rumbager answered that this issue is at the forefront of business concerns and that it is very much a competitive issue.
Mr. Gibbs spoke about the rural dimensions of welfare reform. The welfare reform legislation of 1996 had a dramatic effect in poor rural counties of the state. A conference sponsored by the Department of Agriculture highlighted some of the most pressing rural issues. Overall, studies presented at the conference showed that the rural and urban effects of the reform law were not that different. The studies showed positive effects in terms of smaller case loads and increased employment of single mothers. However, rural areas were shown to have higher poverty rates and lower earnings. They also have fewer services in such areas as childcare and transportation. These issues present special challenges in the implementation of welfare-to-work programs and are particularly acute in persistent poverty counties where large populations are at economic risk. He described rural challenges related to increasing the minimum wage, the lack of jobs with health insurance benefits, the need for more flexible hours of work, the lack of public transportation, and the shortage of opportunities for worker education.
Mr. Size asked about the definition of "informal work activities" under the law. Mr. Gibbs said that it means work not reported on a tax return.
Ms. Freeman-Watson asked about efforts to increase job opportunities and career ladders for single mothers. Mr. Gibbs answered that the law puts work first. There is a need for more emphasis on education programs to assist new workers, especially minorities.
Ms. Barbagallo added that new legislative proposals would place more emphasis on education to help working mothers acquire the training and education they need for advancement in the work force.
Governor Beasley called for public comments. There were no comments and the meeting was adjourned until Monday morning.
The meeting was convened at 8:30 a.m. for a discussion of the site visits that would take place during the day. At 9:00 a.m. the Subcommittees departed for site visits to the following locations:
The Commission on the Future of Northeast Mississippi, CREATE Foundation, Tupelo, MS.
West Point, Clay County, MS.
West Point, MS.
Project Lift, Inc., Monroe County Families First Resource Center, Aberdeen, MS.
At 12:30 p.m. the Full Committee met for lunch at the Northern Mississippi Medical Center in Tupelo. Arrangements had been made for speakers to address topics related to the annual report.
Dr. Agnes Hinton, Co-Director of the Center for Sustainable Health Outreach, University of Southern Mississippi
Dr. Hinton spoke about the national scope of the obesity problem and stated that Mississippi has the highest rate of obesity among the states. The problem is more widespread in rural areas. Mississippi leads in cardiovascular mortality as well, and the two issues are closely related. Half of the State is overweight or obese. A university survey of youth found that 26.9 percent of first graders are overweight. Almost 40 percent are obese by the 8th grade. The obesity problem is related to poor choices of food, lack of education on nutrition, resistance to lifestyle changes, lack of proper exercise, and other factors. She mentioned that the rural poor of Mississippi often do not have ready access to healthy foods, including fresh vegetables and fruits. Smaller grocery stores in many areas have higher prices and fewer choices. Mississippi has created a Council on Obesity Prevention and Management to address the problem. It will submit a report to the Governor and make recommendations. The Council represents state health agencies, health provider groups, academic centers, organizations that serve the elderly, food manufacturers, and other groups. The Center for Sustainable Health Outreach is also addressing the problem, working with many different groups concerned about the issue. The Center is promoting maternal and infant health programs aimed nutrition, and programs to promote exercise. She provided an excellent overview of state initiatives to combat the obesity problem.
Governor Beasley asked if the various organizations in the coalition are working on the issue of healthy foods in schools. Dr. Hinton said that many efforts are underway, but that much more needs to be done. Attempts to limit junk foods in schools are in place, with more emphasis on fruits and vegetables.
Mr. Gallegos asked if language barriers were a factor in nutrition education. Dr Hinton replied that language was a significant issue for the Latino population that has a high incidence of obesity.
The theme of Dr. Hill's presentation was "Innovative Ideas in Health Care." He said that Tupelo initiatives in health care offered a model of collaboration that could and should be emulated in other communities. Tupelo's success has rested on a common bond between health care providers and the business community. He talked about the need for comprehensive educational programs to address destructive behaviors (teenage pregnancies, obesity, smoking, drug use, lack of exercise, etc.) that have significant negative effects on health and place enormous burdens on scarce health care resources. The American Medical Association has become a major advocate for these kinds of programs. He mentioned that some people believe that funds for comprehensive programs to address behavioral issues will never be forthcoming. He presented ideas for better use of federal program funds and described a federal framework for funding that could be similar to the highway trust fund. Leadership and curriculum development must come from the local level, but programs could be developed within a general federal framework. Programs should be aimed at teaching good habits, beginning at the pre-kindergarten age and extending through all subsequent years of education. Mr. Size asked Dr. Hill to comment on community collaboration models to address destructive behaviors. Dr. Hill responded that the educational system must be at the heart of collaborative efforts. Somebody has to "drive the train" and education is the key.
Mr. Gallegos asked why we don't place a higher value on health insurance coverage and how can we get more people involved. Dr. Hill answered that those who have health insurance are often apathetic about the issue. Leadership must come from people rather than politicians.
Mr. Nelson asked Dr. Hill to talk about medical liability issues. Dr. Hill responded that the AMA does not believe that caps on economic damages will work. It favors a cap on non-economic damages. He said that it might come down to the creation of "Medical Courts" to eliminate frivolous litigation. This might be a long-term solution, but caps on non-economic damages are needed in the short-run.
Mr. David Lightwine, Director of the MS Office of Rural Health, and a guest at the meeting, asked for Dr. Hill's views on providing obstetrical care in rural areas. Dr. Hill spoke about the need for nurse-midwife training programs and home visitations. He said that team approaches using midwives should be much more common.
Dr. Mueller asked about linking health insurance coverage decisions with destructive behaviors. Dr. Hill responded that the two issues must be linked and that the medical community must become advocates for change.
Following Dr. Hill's presentation, Governor Beasley asked for public comments. There were no comments and the Committee returned to the Executive Inn for subcommittee meetings.
The respective Subcommittees met in separate sessions for the remainder of Monday afternoon. Their meetings were adjourned at 5:00 p.m.
Mr. Morris convened the meeting at 8:30 a.m. on Tuesday morning. Following a brief discussion of the letter to the Secretary, he called for reports from each of the subcommittee chairman.
Mr. Nelson reported that the site visit to West Point had focused on weight loss and exercise programs sponsored at the site. It is a combined effort involving the agricultural extension office, the medical and business communities, and other groups. The subcommittee heard about some barriers in federal funding for obesity prevention programs. One issue is that programs tend to focus on adults, with little emphasis on children. The subcommittee expects to focus on funding issues and policy barriers in its report. It will also examine interagency relationships and the extent to which agencies understand the unique rural issues on obesity.
Dr. Steele asked Mr. Nelson to expand on rural issues in obesity. Mr. Nelson said that it is one of the difficult problems the subcommittee has investigated. He mentioned increased poverty in rural areas and strong evidence that certain racial and ethnic groups in rural areas have a higher incidence of obesity. Lack of access to services is also a critical rural issue. He also noted that the smaller scale of rural obesity prevention programs might offer some advantages because more community groups can become involved. Mr. Size agreed that smaller scale is important, a point that is made in an upcoming report from the Institute of Medicine. Dr. Montgomery made the further points that smaller scale means better connectivity in the community, and those who complete a program can become mentors and educators for others. Dr. Mueller mentioned that communication about obesity programs is often difficult in outlying rural areas.
Dr. Steele reported that the subcommittee is continuing its search for data on the issue and that it has become apparent that obstetric services are representative of other specialty group problems in rural areas. Access to general surgery is one example. The subcommittee will pay particular attention to shortages of family practitioners that have obstetrics as a sub-specialty. The subcommittee's recommendations will deal with provider supply and distribution issues, revenue enhancements, the gender shift in obstetrics, malpractice insurance costs, provider lifestyle issues, and other factors. Dr. Steele reported that the site visit had been helpful. The subcommittee was interested in how arrangements for obstetric care at the Northern Mississippi Medical Center in West Point might be applicable to other areas. The Medical Center has maintained obstetric services by hiring obstetricians on its staff and is paying their malpractice costs. It is unlikely that many small rural hospitals can follow this strategy and the subcommittee is debating incentives that may help this to happen. The subcommittee will also comment on team strategies for obstetrical care and barriers to the use of midlevel health care providers. Mr. Lightwine commented that the use of Certified Midwives in Mississippi had declined dramatically in recent years. He also mentioned that Mississippi does not have a program for training family physicians in high-risk obstetrics. Dr. Ricketts stated that he would provide data to document trends in the age and gender of obstetric providers. Dr. Steele said that the subcommittee would make recommendations on how to identify and address the lack of obstetrical services in those rural areas that are most underserved. It will also discuss the "territoriality" issue that often impedes a team approach to obstetrical care.
Dr. Mueller reported on the site visit to the CREATE Foundation in Tupelo. The Foundation was created to foster collaboration among service delivery programs in the area. CREATE is an intriguing model that elevates collaboration as an end in itself. It makes use of interested parties in organizing collaborative activities among service agencies. The subcommittee's report will pick up on the theme of collaboration as an end in itself. The subcommittee also learned that there is a real need for leadership in the area of community collaborations and it will address this issue. The subcommittee chapter will have a broader focus that goes beyond federal programs. The report will have a wider audience that includes leaders at the community level. It will include a focus on community health and effective use of community-based resources. Another theme will be that communities must find ways to encourage and reward collaborative activities. The subcommittee will look at how rewards and incentives for collaboration can be incorporated into grant programs. Dr. Kaye added that the subcommittee would address the importance of regional planning in collaborative initiatives. Mr. Size noted that the group would draft a recommendation on federal programs that are working or not working in the area of collaboration. Dr. Edwards commented that in health professions education there is little opportunity to learn about collaboration and there may be ways to enhance these skills.
The subcommittee met with officials and clients of the LIFT project in Monroe County, MS. The project offers parenting classes and other programs. The three biggest rural challenges to service delivery are transportation, childcare, and educational technical assistance. The subcommittee will continue to study these issues. It will also look at issues related to the Head Start program. Conference calls will be scheduled. Mr. Agras noted that the House of Representatives is considering legislation to address the need for greater emphasis on training and education. He also noted that transportation would be a key factor in limiting access to any new programs. Ms. Birch said that staff at the LIFT project felt disconnected from health care providers and there is a need for making these connections. Dr. Ricketts stated that the subcommittee should consider Tupelo's experience in meeting the needs of outlying areas. This could help define what is meant by the new designation for "micropolitan" areas.
Mr. Morris announced that each subcommittee would schedule monthly conference calls through December. He also reminded the members to send their comments on the chapters to staff. A final draft of the annual report will be available in December.
The next meeting of the Committee will be on March 20-22, 2005 in Washington, D.C.
The Committee will discuss topic selections for the 2006 report at that time.
Mr. Morris called for public comments. There were no comments and the meeting was adjourned.