Health Resources and Services Administration
Office of Rural Health Policy
September 18-20, 2005
The 51st meeting of the National Advisory Committee on Rural Health and Human Services was held September 18-20, 2005, in Jackson, Wyoming.
Governor David Beasley, Chairman of the Committee, convened the meeting on Sunday afternoon. He extended a welcome to the Committee and expressed thanks to Dr. Enright for hosting the meeting.
Governor Beasley briefly described the role of the Committee in addressing rural health care and human services issues. He noted that Committee meetings, including meetings of the subcommittees, are open to the public.
The members present were: Susan Birch, RN, MBA; Evan Dillard, FACHE; Joellen Edwards, Ph.D.; Michael Enright, Ph.D.; Bessie Freeman-Watson; Julia Hayes; Lenard Kaye, D.S.W.; Michael Meit, M.P.H.; Arlene Jackson Montgomery, Ph.D.; Ron Nelson, P.A.; Sister Janice Otis; Larry Keith Otis; Patti J. Patterson, M.D.; Heather Reed; Thomas C. Ricketts, Ph.D.; and Tim Size; Members unable to attend were: Senator Raymond Rawson, D.D.S.; and Joseph Gallegos. Present from the Office of Rural Health Policy (ORHP) were: Tom Morris, MPA; Jennifer Riggle, J.D.; Karen Stewart, M.P.H.; Phuong Luu; Anjali Garg; and Michele Pray-Gibson. Dennis Dudley attended representing the Administration on Aging, U.S. Department of Health and Human Services (DHHS). Nikki Bratcher Bowman attended representing the Office of Intergovernmental Affairs, DHHS, and Delores Parron represented the Office of the Director, National Institutes of Health, DHHS.
Dr. Sherard provided an overview of geographic and demographic issues affecting health care delivery in Wyoming. Wyoming is the most frontier of all the states in the nation with a widely scattered population of 500,000 people. Most counties have a population density of less than 4.1 people per square mile. Severe winter weather and long distances between towns are major challenges for health care delivery. Patients are faced with isolation, lack of specialty care and limited access to in-patient care. Providers must deal with limited opportunities for consultations and continuing education, the high costs of malpractice insurance and limited access to state-of-the-art technologies. People over age 65 are the fastest growing of all age groups. There are high rates of chronic disease and infant mortality associated with poverty. Fourteen percent of the population is uninsured and 20% of all Wyoming employers offer no health insurance. A high percentage of citizens are dependent on Medicare and there is a great need for nursing homes and end-of-life services. Wyoming had 836 physicians in 2004, with 115 physician vacancies statewide. Shortages are more severe due to the maldistribution of physicians among the State's large counties. Wyoming had only 250 dentists in 2004. Seventy-five percent of them plan to retire in the next 10 years. There is also an acute shortage of nurses in the State. The average age of nurses is 46. Nurse salaries are low compared with other states and it is estimated that Wyoming will have about 2,000 fewer nurses than needed in 2010. Wyoming is also faced with a shortage of pharmacists and pharmacy technicians. At 52.1 pharmacists per 100,000 population, Wyoming is ranked 47th of the states, and with 160 pharmacy technicians, it is ranked last of all the states.
Dr. Kelley spoke about the education of health professionals in Wyoming. He said that shortages of physicians, nurses, dentists and pharmacists in Wyoming are accompanied by severe shortages in the numbers of mental health professionals and nursing aides. He provided a profile of rural practice in the State, including the challenges posed by high incidence of trauma, growing substance abuse, high rates of rural poverty and low hospital margins resulting from the shift to outpatient services. The challenge to Wyoming is to increase the numbers of health professionals in rural areas. There are 14 medical residents in the State each year. About 40-45% of medical residents remain in the State. The retention rate for pharmacists trained in the State is 20-25%. The rates are higher for nurses and social work graduates. Challenges to retention of graduates include compensation, working environment, family expectations and other factors. Patient mix is an enormous problem because physicians want to see a range of illnesses and problems, not just the routine medical issues commonly found in smaller towns. Dr. Kelley described the significant economic impact that physicians have in rural communities and the contract programs that support the training of medical students from Wyoming. The challenges to increased production of health care professionals in Wyoming are the lack of educational facilities; shortages of faculty; low support budgets; external accreditation standards; lack of clinical preceptor sites; and the need for new contract support programs in dentistry and other disciplines. Dr. Kelley concluded his remarks by reviewing a health care curriculum that will best meet the needs of heath professions students in the State.
Mr. Nelson asked about state support for the training of Physician Assistants and the status of Rural Health Clinics in Wyoming. Dr. Kelley responded that Physician Assistant training is supported by the state. Dr. Sherard added that Rural Health Clinics are doing well, and that physicians are comfortable working in these settings.
Mr. Size asked about health care that is leaving the state. Dr. Sherard answered that most care leaving the state is for specialty services. He also said that meeting the medical needs of the growing elderly population in Wyoming is a problem that must be addressed. In addition, the need for psychologists and psychiatrists is enormous.
Mr. Otis inquired about the extent of training for health care professionals at the community college level. Dr. Kelley responded that recruitment of faculty is a big issue in expanding the role of community colleges.
Ms. Morrow reviewed the demographics of the elderly population in Wyoming, noting that 12% of the population is age 65 and over and that the Census Bureau projects that Wyoming will rank second in the nation for the percent of people at age 65 and over by the year 2030. She said that 23% of Wyoming adults are currently providing assistance to an elderly parent or relative. Sixty-two percent of these caregivers say they need more help in caring for their elderly parents. Eighty-two percent of family caregivers are age 45 or older compared with 48% nationwide. In 2004 about 3,185 people received support from the National Family Caregiver Support Program overseen by the Department of Health. There are no Area Agencies on Aging in the state, so the Health Department contracts directly with local providers. The challenges noted by providers include an insufficient work force, travel distances for staff to provide services, increased fuel costs, inadequate salaries and benefits for staff and other issues. The Division on Aging has identified other challenges such as providers' lack of training and supervisory direction, high staff turnover, insufficient work forces in frontier areas and providers' lack of initiative on outreach and education. Ms. Morrow reviewed adult protective services in the state and some innovative approaches to care developed through partnerships between the Department of Health and other organizations throughout the state. She described programs to address guardianship issues, prevent child abuse, provide respite care and to identify unmet needs for legal services.
Dr. Kaye asked Ms. Morrow for her recommendations on changes that may be needed to improve the Family Caregivers Act. Ms. Morrow replied that assistance is required to help the state find more effective ways of working with small providers and to help them provide outreach to prospective clients. She also said that the state financial matching requirement of 25% is a big problem for Wyoming and too large a requirement for a vastly rural state.
Mr. Meit commented on the aging population and how the problems this creates might be affected by the loss of young people from the state. Ms. Morrow said there is a need to get young people more interested in health care occupations and to keep health care workers in the state. Compensation is a critical issue.
Dr. Homar began her presentation by emphasizing the frustrations and discouragements Americans are feeling regarding the high cost of medications. Many Americans do not take medications because they cannot afford them. Others skip doses to make their medications last longer, while others do not fill prescriptions because they do not understand their medical condition and do not know why particular medications can benefit them. The Wyoming Pharmacy Assistance Program was established with the primary goals of offering all citizens an avenue to investigate ways of controlling medication costs and to derive additional benefits from the proper use of medications. The program is unique because it offers face-to-face interactions with pharmacists and there are no age, insurance or income restrictions. Wyoming citizens can call a toll-free number to arrange for a one-on-one medication review with a state-licensed pharmacist. The Call Center is sponsored by the University of Wyoming School of Pharmacy. The Call Center Coordinator will mail the client a packet of information to complete and return. Upon receipt of the information, the client's needs are reviewed and a determination is made as to whether the client needs to be referred for a face-to-face medication review with a circuit pharmacist in his or her community. The program has currently contracted with 21 pharmacists who are especially trained to conduct consults with clients. Their job is to meet with clients, identify any problems or concerns regarding their current drug regimen and to present any appropriate cost-saving alternatives to the client such as generic substitutions, pill splitting and information on pharmaceutical manufacturer drug assistance programs. They also educate the client on the importance of maintaining an ongoing dialogue with their primary care provider. They provide a written summary of the client's current medications and costs. Client's pay $5.00 for the consultation and the Department of Health pays the pharmacist a $120 consultation fee. Dr. Homar said that the national pharmacist shortage is a challenge when trying to recruit pharmacists for the program. Most program pharmacists are employed full-time and conduct consultations during their time off. The average age of clients is 67 and more females are using the program than males. Clients using the program have reported monthly savings of $155 in drug costs. Dr. Homar reported that other states have been in contact with her to learn about the program.
Dr. Shatto said that in his experience most residents in the state have geographic access to medications. Many pharmacists in small areas will deliver to patients, and even the police will sometimes deliver medications. However, extreme weather conditions and long travel distances do create some significant access problems. Financial access to pharmaceuticals is a much more significant problem. In his pharmacy, 57% of customers pay cash. All other payments are from Medicaid, Medicare and private insurance. He highlighted several problems for small pharmacy owners including: (1) Cash-flow issues that arise when drugs must be paid for when ordered by the pharmacists and then there is a long-waiting time for third-party reimbursements after the drugs are dispensed; (2) Pharmacists have no control over dispensing fees because they are largely determined by third parties; (3) Some expensive drugs have a long shelf life, creating additional cash-flow problems for the pharmacy; and (4) Pharmacy owners in smaller communities are often unable to find time for vacations and have difficulty recruiting staff.
Mr. Nelson asked for Dr. Shatto's perspective on rising drug costs. Dr. Shatto commented that prices seem to have risen as third-party payments have grown and large numbers of patients are no longer involved with payments. Dr. Homar added that multiple prices for the same drug depends on the type of consumers using the drugs and that price controls have been vigorously opposed by manufacturers. She also expressed concern that information on pricing is protected by government.
Mr. Dillard inquired as to whether there is a central data source for information on state-run pharmacy assistant programs. Dr. Homar said that she was not aware of a central information source on such programs.
Mr. Otis asked about the spread of mail-order houses for drugs. Dr. Shatto expressed the concern that his pharmacy cannot purchase drugs at mail-order prices even though he can offer face-to-face interaction with patients. Dr. Homar added that a big weakness of mail-order programs is that they often handle only routine medications. Local pharmacists often pick up the slack when specific drugs are not available or when drugs are not delivered to patients on time.
Dr. Edwards asked about drug assistance programs for the uninsured population in Wyoming. Dr. Homar replied that some assistance is available as indicated in her presentation. The state program she described helps low-income patients identify drug assistance programs available from manufacturers.
Mr. Size commented on the general issue of drug pricing and urged that state partnerships be explored as a purchasing strategy.
Mr. Stelmach reviewed the efforts of the Wyoming Electronic Health Records Study in relation to the strategic goals of the Office of the National Coordinator of Health Information Technology (ONCHIT). The goals of ONCHIT are to inform clinicians about HIT, interconnect clinicians, develop personalized health records, and improve population health. Mr. Stelmach's company was hired to conduct a study of HIT resources in Wyoming. Following this study, The Wyoming Regional Health Information Organization was formed comprised of major stakeholders with roles in public health and quality improvement. Mr. Stelmach discussed the structure and role of the organization and presented a conceptual view of an electronic health network in Wyoming that would link hospitals, physicians and other health care providers through broadband and internet access. He described the goals of the network and the services it would provide for both patients and providers. He then reviewed a series of recommendations for management of the network and further development of the Wyoming Health Information Organization.
Mr. Urbanek represented the Medicare Quality Improvement Organization in Wyoming. He spoke about the goals of the organization to foster the adoption of HIT in Wyoming and improve the process for clinical care. The goals of his organization are to facilitate the adoption of electronic health records (EHRs) in the state, ensure that clinical practices are using EHRs to fullest capability to improve office efficiency and to use clinical data reports for improved practice performance and patient outcomes. He described specific performance requirements that are employed by his organization to measure progress in adoption of HIT throughout the state. He also spoke about the benefits of HIT for Wyoming physicians and the impact on Wyoming citizens. The benefits for providers and citizens include promoting continuity of care, reducing adverse health outcomes, increased patient safety, potential cost savings, and improved efficiencies in the delivery system. Currently, 15% of Wyoming primary care practices use EHRs, while 45% are considering them. Mr. Urbanek outlined the next steps for EHR adoption and the barriers that stand in the way.
Mr. Nelson raised the issue of standards for HIT and over-promising by vendors. He noted the problems of providers in finding the right vendor. Mr. Ubanek said that 80 vendors have been identified who are able to interface with Medicare, but that qualifications stop there.
Mr. Otis asked about the role of the private sector in setting standards for HIT. Mr. Stelmach said that the private sector is playing a waiting game when it comes to national standards for HIT. They are paying lip service to such standards while still seeking a competitive advantage with customers. Customized systems are still the norm. That has to change, particularly as smaller providers become engaged.
Dr. Patterson said that it is absurd that we do not have electronic medical records in the age of ATM cards and that perhaps we are making it too difficult and need to take smaller steps such as developing electronic immunization records.
Ms. Reed asked if Rural Health Clinics and Community Health Centers are eligible to participate in the initiatives discussed by Mr. Uranek. He responded that they are not able to participate at this time.
Dr. Ricketts said that the two presentations offer some hope for the advancement of HIT and asserted that if it cannot be done in a small state like Wyoming, we may not be able to do it anywhere. He asked the two speakers if they planned to share information about their projects. They replied that the results of their work will be distributed by the state and they are willing to share with any interested parties.
Ms Penny Hunt, Executive Director, Wyoming Health Resources Network, Inc. welcomed the Committee to Wyoming and spoke about the shortage of mental health workers in the state.
Ms. Deanne Olsen representing the American Society of Health Systems Pharmacists commented on access to pharmacy services in hospitals. She described the issues that arise when pharmacists are not readily available in hospitals, including drug security issues, patent safety issues, lack of medication reviews, etc. She stressed that smaller hospitals should have the same pharmacy capabilities as larger facilities, noting that pharmacists are expensive and that smaller hospitals will go without them unless they are required to provide their services. She said there is a need for comparable standards that are applied to both urban and rural hospitals.
Following public comments, the meeting was adjourned until Monday morning.
Governor Beasley convened the meeting at 8:30 a.m. for a brief orientation to the day's site visits. The rest of the morning was devoted to site visits arranged for the Committee.
The Family Caregiver Committee conducted a site visit at the Star Valley Senior Citizens Center in Afton, Wyoming.
The HIT and Pharmacy Committee's departed for site visits at St. John's Medical Center, Jackson, Wyoming
On Monday afternoon the Committee returned to the Spring Creek meeting center and spent most of the afternoon in Subcommittee meetings. The focus of these meetings was to develop final drafts and recommendations for the annual report to the Secretary due early in 2006.
The Full Committee was convened at 4:30 p.m. for general announcements and public comment.
There were no public comments and the meeting was adjourned.
The meeting was convened by Mr. Morris at 8:45 a.m. There were general announcements and Dr. Kaye commented briefly on the meeting in Maine that is scheduled for June, 2006.
Mr. Morris provided an update of Federal activities in rural health. He talked about efforts to help with the aftermath of Hurricane Katrina and its effect on several Community Health Centers in the region.
Dr. Ricketts presented a report from the Pharmacy Subcommittee. During it's meeting the previous day the Subcommittee focused on the structure of its chapter in the annual report and the recommendations it will present. He reviewed the recommendations relating to Federal programs and policies. They will address issues involving the pharmacy workforce, the 340b program, Medicare and other matters. He said that the Subcommittee has foreseen the need for further work on Medicare following implementation of the new prescription drug benefit.
Mr. Meit reported for the Subcommittee on HIT. He said that the site visit on Monday had been successful and informative. He reviewed the content and structure of the annual report for the Subcommittee. It will contain recommendations on the infrastructure to support HIT, a rural research agenda for HIT, Federal support for HIT activities, the need for rural representation at HIT forums and other matters.
Dr. Kaye reported for the Caregiver Subcommittee. He said that the site visit had provided insights on the challenges caregivers face in isolated rural communities. The annual report will focus on these challenges and how they can be addressed. It will be a data rich report and will have recommendations related to Federal support, best practice models, encouragement of consumer-driven approaches, strengthening Federal legislation and increased collaboration with medical service providers.
Mr. Morris reviewed the schedule for completing the annual report, including conference calls and circulation of final drafts for comments by the Committee.
Mr. Morris asked for suggestions on future topics to be addressed by the Committee. The members put forth ideas related to the health care workforce, mental health and drug abuse, rural disaster preparedness, the Medicare Advantage Program, the problems associated with widespread methdon abuse and rural border health issues.
Mr. Morris asked for comments and suggestion on the letter to the Secretary that will be sent following the meeting.
Mr. Size suggested that the letter thank the Secretary for acknowledging the group's concerns about the reporting of hospital quality performance data.
Ms. Birch suggested that the letter speak to the potential impact of Katrina on funding for Federal rural health programs.
The Committee approved these suggestions and a draft letter will be circulated in a few weeks.
There were no public comments and the meeting was adjourned.