Note: The bulk of the recommendations in the compendium focus solely on health care issues. Beginning in 2003, the Committee expanded its focus to also include human services. Recommendations on human services are only available from 2004 forward.
The Intersection of Rural Poverty and Federal Human Services Programs - Policy Brief January 2014
Rural Implications of the Affordable Care Act Outreach, Education, and Enrollment:
The Committee recommends that the Secretary evaluate the geographic efforts of year one enrollment and use that information to drive subsequent outreach, education, and enrollment efforts.
The Committee recommends that the Secretary work with the Internal Revenue Service to finalize the Community Health Needs Assessment Community Benefit reporting rules and promote the use of outreach, education, and enrollment as a way for non-profit hospitals to meet their Community Benefit requirement.
The Committee recommends that the Secretary direct the Centers for Medicare and Medicaid Services Advisory Panel on Outreach and Education to consider the unique needs of rural communities in the future.
The Committee recommends that the Secretary continue to work with rural human service providers such as Community Action Agencies to engage their client base in outreach, education, and enrollment.
Rural Implications of Changes to the Medicare Hospice Benefit:
The Committee recommends that the Secretary work with the Congress to allow physician assistants and nurse practitioners at rural health clinics to furnish and bill for hospice services.
The Committee recommends that the Secretary examine allowing telehealth consultations to count as face-to-face encounters and allowing nurse practitioners and physician assistants to certify the need for hospice care through face-to-face visits in rural areas.
The Committee recommends that the Secretary examine allowing hospices serving rural areas greater flexibility in fulfilling covered service requirements that takes into account potentially higher costs in rural areas such as for durable medical equipment and pharmaceuticals.
The Committee recommends that the Secretary provide greater flexibility to Critical Access Hospitals (CAHs) in cost-reporting carve outs related to the provision of hospice services so as not to lower the CAHs’ cost-based reimbursement.
The Committee recommends that the Secretary consider allowing cost-based reimbursement for hospice services in the upcoming Frontier Community Health Integration Program Demonstration.
The Committee recommends that the Secretary request that the Institute of Medicine evaluate the current status of terminal prognoses and make recommendations concerning both documentation and medical review of such.
The Committee recommends that the Secretary solicit feedback from rural hospices about specific instances of inconsistency among Medicare Administrative Contractors in evaluating patient eligibility for the Medicare Hospice Benefit and work with these parties to improve consistency.
The Committee recommends that the Secretary reexamine disparities in costs incurred in travel (i.e., windshield time) between urban and rural hospice providers given changes in utilization patterns over the past decade.
Rural Implications of the Center for Medicare and Medicaid Innovation:
The Committee recommends that the Secretary direct CMMI to offer preliminary advice to rural facilities on the suitability of project ideas and offer ongoing technical assistance to them during the preparation of applications.
The Committee recommends that the Secretary direct CMMI to extend the FQHC Advanced Primary Care Practice demonstration to include RHCs in order to broaden the impact of the program on rural areas.
The Committee recommends that the Secretary direct CMMI to establish a group of rural advisors within the Innovation Advisors program to help assure the direction of the Center includes a rural voice, and to help establish measurement systems that are relevant to rural health care.
The Committee recommends that the Secretary direct CMS to develop specific evaluation and measurement incentives to encourage collaboration across urban and rural lines, including an urban-rural collaboration preference during grant scoring.
The Committee recommends that the Secretary direct CMS to develop specific evaluation and measurement incentives to encourage collaboration across urban and rural lines, including an urban-rural collaboration preference during grant scoring.
The Committee recommends that the Secretary direct CMS to review and implement the Committee’s 2011 recommendation that CMS fund quality and cost incentive payments for rural hospitals from actuarially projected savings resulting from increased efficiency.
Options for Rural Health Care System Reform and Redesign:
The Committee recommends that the Secretary continue to promote the benefits of the ACA and broader health care reform and raise awareness among rural providers about provisions and models that account for the unique nature of rural health care demands and delivery.
The Committee recommends that the Secretary ensure that rural providers are engaged in ongoing discussions about health care reform and that these conversations recognize the necessary level of flexibility, stability, and support the current configuration of Medicare payment designations provides the rural health care system in a rapidly changing health care environment.
The Committee recommends that the Secretary work with the Congress to continue the FESC demonstration project beyond the program’s scheduled expiration in April 2013 or seek to continue a form of the FESC demonstration under the authority of CMMI. This will help ensure a strong evaluation of the demonstration project given the low patient volumes that FESCs have encountered.
The Committee recommends that the Secretary encourage CMS to consider the full range of costs and savings, including those from private payers, avoided transfers, and prevented hospitalizations, when evaluating the FESC and F-CHIP demonstration projects.
The Need to Integrate Work Programs for Low-Income Rural Residents:
The Committee recommends that the Secretary request that the Center for Medicare and Medicaid Innovations identify any of its programs that focus on entry-level workforce jobs that offer career pathways into the field of health care to see if these include any successful, rural focused models that could be replicated.
The Committee recommends that the Secretary encourage the White House Rural Council to examine ways for HHS, Labor and the United states’ Department of Education to work together to focus on rural integration of workforce and training programs.
Implications of Proposed Changes to Rural Hospital Payment Designations - Policy Brief December 2012
Challenges to Head Start and Early Childhood Development Programs in Rural Communities:
The Committee recommends that the Secretary work with Congress to increase collaboration between rural Head Start grantees and other federal programs on transportation
The Committee recommends that the Secretary work with Congress to pursue a temporary compliance waiver for grantees in good standing who meet a specified definition for rural and are located in a dental or mental health HPSA when their communities lose access to a sole dental health or mental health provider.
Rural Childhood Obesity:
The Secretary should create an interagency working group that will focus on rural childhood obesity and develop action steps to eliminate the higher rates of childhood obesity in rural communities.
The Secretary should ask departmental agencies to create a report card to demonstrate the current HHS investment and related results in addressing childhood obesity in rural communities.
The Secretary should ensure that at least 5 percent of funding from the Prevention and Public Health Fund goes directly to rural health specific grant competitions, specifically to rural counties that fall under the national poverty level.
Place Based Initiatives for Rural Early Childhood Development:
The Secretary should work with Congress to authorize and fund non-categorical, community-based outreach and coordination grants to support the development of place-based initiatives in rural communities.
The Secretary should require all Early Childhood grant guidance, both block and community-based, to require collaboration with other HHS funded program activities and designated funds for rural child care.
The Secretary should develop a data strategy that allows HHS programs to share client-level data to improve coordination and efficiency of services.
Rural Implications of Accountable Care Organizations and Payment Building:
The Secretary should use the authority granted to the Center for Medicare and Medicaid Innovation (CMMI) to determine whether HHS can support payment bundling demonstrations focused on those conditions for which care is contained in rural areas.
The Secretary should ensure that rural providers, particularly CAHs, RHCs, and rural FQHCs, are eligible to participate in the Accountable Care Organization demonstrations.
The Secretary should work with Congress to revise the Small Rural Hospital Improvement Program (SHIP) as authorized in statute 1820(g)(3) of the Social Security Act so that the funding can be targeted toward groups of providers that need support in forming an Accountable Care Organization.
The Secretary should report to Congress, particularly the Senate Rural Health Caucus and the House Rural Health Coalition, within one year of implementation of Accountable Care Organization and payment bundling demonstrations about the impact of these mechanisms on rural health care providers.
Rural Challenges for HHS in Implementing the Community-Based Care Transitions Program (CCTP):
The Committee recommends that in preparing guidance for the grant reviewers that CMS give strong consideration to whether the project gives evidence of good working relationships among the following partners: rural health clinics, principal rural or urban referral center(s), PPS hospitals, critical access hospitals, Aging and Disability Resource Centers, Area Agencies on Aging, home health agencies, skilled nursing facilities.
The Committee recommends that project proposals, especially those in rural areas, address at least three of the five interventions.
The Committee also recommends that attention be given to proposals that offer a comprehensive transitions approach that is more likely to be sustainable upon the conclusion of demonstration funding.
The Committee recommends that CMS include grant reviewers who have rural health experience in order to ensure a fair and unbiased review.
The Committee recommends that the CCTP (or future CMMI projects) give increased weight to applications that serve the dually eligible population.
Rural Policy Implications for Health Insurance Exchanges:
The Committee recommends that the Secretary use the maximum regulatory authority available to encourage early participation in the planning and establishment process.
The Committee recommends that States be encouraged and incented to adopt successful models emerging from this process that have demonstrated the ability to provide enrollees with varied choices, while maintaining an easily navigable marketplace.
The Committee recommends that the regulations account for differences in broadband access, especially in the individual market.
The Committee recommends that the Secretary adopt standards with respect to provider networks that require insurers to enroll Critical Access Hospitals and other key rural health safety net providers within a reasonable distance of the individuals they insure such as Sole Community Hospitals, Medicare Dependent Hospitals, Rural Health Clinics and Federally Qualified Health Centers.
The Committee recommends that current Medicare payment levels serve as a floor for payments by non-public insurers who are required under the ACA to contract with essential community providers but not if those providers do not accept the plan’s “generally applicable payment rates.”
Rural Policy Implications for Maternal, Infant and Early Childhood Home Visitation Program:
The Secretary should provide technical assistance, as documented in the SIR, specifically addressing the issue of small sample size in rural areas.
The Secretary should provide technical assistance for evaluation of promising approaches to States who are implementing them in high-need rural communities.
The Secretary should require States to collect rural-urban community data so as to allow for meaningful rural-urban evaluation of program impact.
The Rural Implications of Key Primary Care Provisions In the Affordable Care Act:
The Committee recommends that the Secretary examine the feasibility of allowing NHSC participants to be placed in a geographic area of their choosing consistent with allocating resources to the areas of greatest need.
The Committee recommends that the Secretary allow part-time nursing students enrolled in advanced-practice training programs to be eligible for the NYHSC Scholarship program
The Committee recommends that the Secretary track the re-allocation of Graduate Medical Education Physician Residency positions to determine how many of the residents chose to practice in primary care and the proportion that elected to practice in a rural community
The Committee recommends that the Secretary require any programs funded under the Nursing Graduate Medical Education Demonstration Program include significant training and allocation of training dollars for community-based ambulatory training sites and that preferences by given to applicants that include rural community-based training sites.
The Committee recommends that the Secretary, under Section 301 of the Public Service Act, conduct a demonstration project to identify the most effective ways to expand the number of accredited community-based primary care residency programs.
Affordable Care Act Provisions Affecting the Rural Elderly:
The Secretary should require training for ADRCs on key aspects of the rural health care delivery system through the HHS Office of Rural Health Policy to better understand the unique challenges faced by rural seniors.
The Secretary should promote regional applications that include rural providers for the Community-Based Care Transitions grant program.
The Secretary should ensure that any evaluation of Section 3026 includes an analysis of the number of rural beneficiaries served and the number of awards that include rural providers.
The Secretary should allow CAHs to report hospice-related costs at the skilled nursing service rate on the Medicare cost report in order to ensure that the payment of these services is consistent with the overall cost-based reimbursement methodology as outlined in Section 1820 of the Social Security Act.
Physician Value-Based Payment Modifier Program:
The Committee recommends that the Secretary make additional efforts to inform rural physicians about the upcoming implementation of the VBM program and establish a system to create dialogue among rural practitioners facing implementation challenges.
The Committee recommends that the Secretary require, for a trial period of 1-2 years, that rural physicians report 3-5 common measurements and receive timely reports about their performance. After the reporting system has been established and proficiency has been gained, additional measures could then be added.
The Committee recommends that the Secretary make additional assistance available to rural practitioners for the implementation of EHR systems, especially upfront acquisition support and support to secure staff needed to fulfill VBM requirements.
The Committee recommends that the Secretary ease the burden of implementation by allowing flexibility in program requirements that place a disproportionate burden on rural practitioners.
The Committee recommends that the Secretary account for differences in patient populations in the peer-grouping for physicians in the VBM program.
The Committee recommends that the Secretary assure that costs unrelated to the medical decisions of the primary physician be excluded from the cost comparisons made in the VBM program.
The Committee recommends that the Secretary use authority granted in Sec. 3007 to exclude rural physicians from the VBM during calendar year 2015 and 2016 to determine the costs, impacts and specific problems of implementing the VBM program in rural areas.
The Committee recommends that the Secretary adjust the VBM to recognize the increased cost and decreased administrative support available while providing care in rural areas.
Reducing Health Disparities in Rural America: Key Provisions in the Affordable Care Act:
The Committee recommends that the Secretary instruct the CDC to conduct an assessment of the CTG program after one year to determine if rural communities received at least 20 percent of the available funds in the first funding cycle.
The Committee recommends that the Secretary requires any local or state government CTG applicant to formally partner with that state’s respective State Office of Rural Health to administer and distribute funds.
The Committee recommends that the Secretary compiles an index of evidence-based strategies implemented under the CTG program to be distributed nationally to other health care professionals.
The Committee recommends that the Secretary implements comprehensive data collection efforts in rural communities, as outlined in Section 4302, and integrate key determinant variables associated with rural populations into all health services work that is funded by HHS.
The Committee recommends that the Secretary directs the relevant agencies to increase the sample size of data collected on rural populations, or, if needed, aggregate data across regions (e.g. “Delta region”) with similar demographic characteristics.
The Committee recommends the Secretary evaluate the distribution of grants under the Public Health and Prevention Fund and implement data collection efforts similar to those in Section 4302.
Home and Community Care for Rural Based Seniors:
The Secretary should evaluate whether rural seniors who are dually eligible for Medicare and Medicaid are able to take part in programs such as Money Follows the Person, Cash and Counseling, Home and Community-Based Services (HCBS), the Program of All-Inclusive Care for the Elderly, and Medicare Advantage Special Needs Plans to the same extent as urban seniors.
The Secretary should support an evaluation of current law prohibitions against payment to family members for care otherwise covered under Medicare or Medicaid, with a view toward determining whether they should be eliminated in light of current economic conditions.
The Secretary should instruct the Centers for Medicare and Medicaid Services (CMS) to develop a uniform assessment tool that works across post-acute care settings and Health and Human Services programs, as required under current law.
The Secretary should work with the Congress to change the requirements for coverage of the “Welcome to Medicare” physical to include provision of information about available home-based options for seniors. This information should also be a discharge planning function with a “handoff” to the Community Living Programs, Eldercare Locator Service, and Aging and Disability Resource Centers (ADRCs).
The Secretary should instruct CMS to find a method for claiming and reporting hospice payments for general inpatient services on a Critical Access Hospital (CAH) cost report in a manner that permits the CAH to claim the full cost of caring for the hospice patient.
The Secretary should develop a report in coordination with the Secretary of Transportation to identify all available legal authorities that provide transportation for those in need of health and human services and to determine their effectiveness in serving the elderly population, with particular emphasis on the availability and effectiveness of programs for the isolated rural elderly.
Rural Primary Care Workforce:
The Secretary should work with the Congress to re-authorize Title VII and VIII of the Public Health Service Act to include the authority for allocating funding to better meet emerging workforce needs in the health professions based on the most current data and projections available.
The Secretary should work with the Congress to ensure that any reauthorization of Title VII of the Public Health Service Act includes demonstration authority.
The Secretary should expand the Critical Shortage Facility list used for Nursing Scholarship and Nursing Loan Repayment programs to include Critical Access Hospitals.
The Secretary should work with the Congress to revise the legislation that defines “primary care” used by the National Health Service Corps Scholarship and Loan Repayment programs to create an exclusion for awardees employed by rural hospitals with less than 50 beds, so that time spent seeing patients in the emergency room, a nursing home, or hospital outpatient clinic will count toward the 32 hours of required weekly clinical time.
The Secretary should revise regulations to define an “integrated rural training track” as:
The Secretary should revise the regulations for “Community Preceptors” to allow preceptors to volunteer their time in serving as preceptors to residents.
The Secretary should redefine the definition of “all or substantially all” to allow the cost of GME residency training to be shared between hospital and non-hospital based providers.
The Secretary should work with the Congress to increase the Medicare cap for RHCs and rural FQHCs to match the rate for urban FQHCs.
The Secretary should ensure that when regulations for shortage areas are updated the process should only update the Medically Underserved Areas and Medically Underserved Population process and maintain the basic methodology for the Health Professional Shortage Areas regulations.
The Secretary should ensure that when the shortage area regulations are revised, protections are put in place to reduce the “yo-yo” effect of removing resources from a community when it loses its Health Professional Shortage Area designation due to the addition of less than five primary care providers in the rational service area or county.
The Secretary should work with the Congress to revise the regulations for the Health Professional Shortage Area Medicare bonus payment to Advanced Practice Nurses and Physician Assistants.
The Secretary should remove the HPSA score requirement from the HHS J-1 Visa Waiver regulations and expand the list of potential practice sites to include Critical Access Hospitals, Sole Community Hospitals, Medicare Dependent Hospitals, and any Section 1886(d) hospital with less than 50 beds.
Rural Health Care Provider Integration:
The Secretary should work with the Inspector General to develop regulations so that rural practitioners can be compensated for driving time at a fair market value.
The Secretary and the Inspector General should work together to assess the impact of the inurement rules on the ability of rural hospitals to hire practitioners in Health Professional Shortage Areas.
The Secretary should ensure that future demonstrations on quality improvement and care coordination, such as Accountable Care Organizations, payment bundling, and Medical Homes, incent the cooperation of the full range of rural providers.
The Secretary should place a moratorium on approval of any new specialty hospitals in order to determine the impact on access to care for Medicare beneficiaries, with particular emphasis on access to specialty services for rural beneficiaries.
The Secretary should revise current regulations so the sole emergency medical service providers (EMS) owned and operated by Critical Access Hospitals must be only a minimum of 25 miles (15 miles in mountainous terrain) from the nearest EMS provider in order to qualify for cost-based reimbursement rather than the requirement of 35 miles.
The Secretary should work with Congress to reauthorize and support funding for the Healthy Communities Access Program with revisions to support projects that focus on development and implementation of Medical Home components, e.g., incorporation of HIT and EHRs, chronic care management, and medication management.
The Secretary should work with Congress to authorize and support the development of a Critical Access Hospital Health Information Technology Grant Program under the Medicare Flexiblity program.
The Secretary should encourage the use of existing authorities and funding from the National Library of Medicine at the National Institutes of Health to make competitive grants and contracts to support the adoption of HIT by rural health care providers, given their current low level of HIT adoption.
The Secretary should develop data tracking systems for the health and human services workforce. Workforce data should be periodically collected and analyzed so that rural areas can identify their current and projected workforce needs. The workforce data and analysis should be disseminated in a timely manner to employers, Workforce Development Boards, training centers, and educational institutions so that they may better predict workforce oversupplies and shortages. Based on this data, the Secretary should target resources and develop training programs for appropriate health and human services professions in “high-need” geographic areas.
The Secretary should work with Congress to secure additional funding for the allied health training programs within Title VII of the Public Health Service Act and expand competitive opportunities for two-year educational and training programs for health and human services professions that are identified to have high vacancy rates, high demand, and high education and training costs associated with higher faculty salaries, laboratory fees, and clinical space.
The Secretary should work with Congress to amend the Title VII authority to allow greater discretion over how to allocate funding for different health professional needs over multi-year periods. The Committee believes that the flexibility will allow specific targeting of resources to reflect current and future projected needs.
The Secretary should work with Congress to secure additional funding for the Nursing Loan and Nursing Scholarship programs under Title VIII of the Public Health Service Act, so that these existing nursing programs can better meet current workforce shortages.
The Secretary should use Section 301 authority under the Public Health Service Act to support demonstration grants for creative, community-based workforce training programs that address local geographical and financial constraints and are targeted towards rural communities through Critical Access Hospitals, Rural Health Clinics, and Federally Qualified Health Centers. These demonstration projects should be evaluated to determine effectiveness and return on investment.
Recommendations related to the CMS Medicare Medical Home Demonstration Project:
The Committee recommends that the Secretary ensure that an appropriate number of rural practices, in each of the participating States, are selected for the Medicare Medical Home Demonstration for comparison with one another and with urban practices. The Committee recommends that these sites be located in varying regions of the country, to account for regional differences.
CMS should include physician assistants and advanced practice nurses as primary care providers, for reimbursement purposes, in the Medicare Medical Home Demonstration project and in any future medical home implementation projects.
CMS should ensure that the criteria and measures used for the Medicare Medical Home Demonstration are appropriate and relevant for rural practices. The Secretary should work with NCQA to bring their guidelines into the same framework.
CMS should work with the American Medical Association to develop Current Procedural Terminology (CPT) codes that describe the case management and coordination required for medical homes. The CPT codes should be priced so that Medicare and other payers can support implementation. CMS should also revise the RVRBS values to reflect billing under a medical home model.
The Secretary should clearly identify for the States which CMS Medicaid waiver authorities are available to support medical home demonstrations at the State level.
The Secretary should use Medicaid Transformation grants and Healthier U.S. grants to promote medical home implementation in rural areas.
The Secretary should work with Congress to reauthorize and support funding for the Healthy Communities Access Program with revisions to support projects that focus on development and implementation of medical home components, e.g., incorporation of HIT and EHRs, chronic care management, medication management, etc.
The Secretary should use existing Rural Health Care Services Outreach and Rural Health Network Development program grants to promote the medical home model in rural communities and use funding from these demonstrations to inform policymakers in developing medical home standards and regulations that take into account rural practice considerations.
The Secretary should examine and evaluate if low-population density in rural communities results in lack of adequate funding to implement and maintain prevention and intervention services for young children who are at-risk for maltreatment and adverse experiences, and their families.
The Secretary should work with Congress to secure additional funding for Subpart 2, Promoting Safe and Stable Families, of Title IV-B of the SSA, administered through ACF. This will help to support prevention services for at-risk children.
The Secretary should work with Congress to secure additional funding for ACF’s Child Care and Development Fund (CCDF). The additional funding should increase the required CCDF funding targeted to improve the quality of child care from 4 percent to a required minimum of 10 percent of the total funding received by States, and allow for additional services to parents. The Secretary should recommend that part of these funds be set aside specifically for training child care providers in evidence-based early childhood development services and for the mental health development of young children.
The Secretary should work to improve mental health services for children, from birth to five years, through the following actions:
The Secretary should support a HHS demonstration project that would allow maximum flexibility of use of HHS funds with other Departmental programs, such as those administered by ED, to enhance prevention and intervention projects for children and families in rural communities with limited resources.
The Secretary should conduct a demonstration to determine the feasibility of developing a pilot model for the screening tools and an appropriate referral system for children at-risk for physical or emotional abuse or neglect with the disease collaborative model that is used by many community health centers.
The Committee recommends that the Secretary of HHS create an Inter-Departmental Rural Working Group to determine how to improve collaboration among programs that serve rural communities. The Rural Working Group should include all pertinent agencies or operating divisions with programs that serve significant rural populations, such as: HHS, USDA, the U.S. Department of Veterans Affairs, the Treasury, Commerce, DOL, and DOT. The Rural Working Group should consult closely with States to identify elements in regulation implementation that may complicate coordination (e.g., opposing definitions, different reporting time frames). The Rural Working Group should produce an annual report to the Administration with recommendations to promote efficiency, coordinated service delivery, and integration and collaboration across programs that serve rural communities, emphasizing the reduction of administrative barriers, common reporting elements, and combined funding streams. This report should serve as a basis for regulatory changes that improve coordination.
The Committee recommends that the Secretary use existing demonstration authority to support two rural-focused demonstrations.
This demonstration should foster the integration of health and human services for the elderly. This demonstration should draw on the funding and programmatic intent of the following existing programs: the Outreach and Network Grant Programs, Meals on Wheels, Elderly Family Caregiver Support, and the United We Ride initiative. Integrating programs can help to simplify and coordinate navigation of services. By creating a single funding stream, the demonstration would promote ease of access, care management, better coordinated services for the elderly, and allow for advertising and outreach activities.
The Committee recommends that the Secretary work with the Administration to commission an independent study that would examine the statutory and regulatory provisions of the various Federally-funded health and human services programs now administered in rural areas. This study should identify provisions that act as barriers to coordination and integration at the local level. This analysis should be shared with the Rural Working Group, which should consider inconsistencies identified in the independent report and work with the Administration to develop recommendations to address the inconsistencies.
The Committee recommends that the Secretary require that all HHS programs collect data that delineate the rural versus urban geographic location of each recipient of Federal funds through direct grants, transfer payments, and block grants.
The Committee recommends that the Secretary require the following human services programs within HHS to evaluate their impacts in rural areas each year: Head Start, TANF, Family Caregiver Support, and the Alzheimer’s Disease Demonstration Grants to States. Performance measures that focus on how fully and effectively HHS programs serve rural communities could provide the tools necessary for Federal program administrators and policy makers to identify and account for the specific needs of rural communities. In addition, data and performance evaluation will help policy makers measure the success of improvements.
The Committee recommends that HHS use this rural-specific data to produce an annual report that quantifies the annual investment of HHS programs in rural communities. This initiative is most important for the Department’s human services programs, which historically have not supplied this information or evaluated their rural investment.
The Committee recommends that the Secretary work with Congress to extend the intent of Section 1102B of the Social Security Act, so that HHS would prepare a rural impact statement on all major regulatory policy decisions that may have a significant economic impact on rural communities. Currently, Section 1102B requires HHS to prepare an impact statement for public comment on any regulation under Title XVIII (Medicare) or Title IX (Medicaid) that may have a significant effect on the operations of a substantial number of small rural hospitals. The Committee believes that similar provisions in the authorization laws for all HHS programs would help ensure that program changes and new program designs take into account the needs of rural communities.
Nationwide beneficiaries have voiced frustrations at the complexity and difficulty in understanding MA plans. Navigating the variations in plan coverage, co-payments, out-of-network and in-network stipulations, and other factors has been challenging for many beneficiaries. CMS does provide some information to the beneficiaries, but the educational literature is often long and complex. The Committee recommends that CMS focus on presenting concise, easy-to-understand information that would allow beneficiaries to compare and contrast plans in a manner similar to that provided to beneficiaries comparing prescription drug plans.
In the past, CMS granted its regional offices considerable authority in answering questions and making determinations on certain policy issues. With the advent of Medicare Advantage, several Committee members noted that it appears that Medicare information and policy decision determinations are increasingly being centralized. These Committee members believe that location-specific decisions that were previously made in the CMS Regional Offices, such as those related to network adequacy and community standards of care, are increasingly being made in the CMS Central Office or in a single Regional Office. Rural providers can no longer travel reasonable distances to their local Regional Office to meet with CMS staff to ask questions or discuss concerns related to these decisions. The significant changes to Medicare through the MA program and the prescription drug benefit leave many rural providers with questions and a need for information. The Committee is concerned that any potential movement towards information centralization has the potential to leave many rural providers feeling removed from the changes and overwhelmed at the lack of direct assistance. The Committee believes CMS should consider strengthening the role of its Regional Offices to make some determinations on issues related to network adequacy and community standards of care as it relates to Medicare Advantage. Such a change will allow providers to better understand the market they operate in and respond to important coverage issues that relate to the Medicare Advantage beneficiaries they serve.
The Secretary should mandate that CMS solicit input from rural health care experts in determining and enforcing adequate rural community access standards.
CMS has emphasized that rural community access standards are a priority for the agency. While the Committee is encouraged by that stance, it is concerned that the present rural community access standards applicable to MA plans are not sufficient to meet the health care needs of rural beneficiaries. Thus, the Committee would like CMS to solicit input from rural health care experts in determining the rural community access standards and how best to enforce those standards for MA plans.
In researching this chapter, the Committee has been extremely frustrated by the delays in the expected release of county-level enrollment data for MA-only plans (i.e., those MA plans that do not include a Part D benefit). Typically, CMS reports the quarterly enrollment data within a few weeks after the end of the quarter. However, 2006 data was not released until September 2006 and was released in a format that prohibits rural-specific analysis. Further county-level data was not released until December. Since health plans are required to report enrollment data on a monthly basis, it is unclear why CMS has been so late in releasing the data to the public. The lack of data hampers efforts by the Committee and others to determine MA's full impact on rural communities.
The Committee has observed that there is a lack of transparency in how MA plans are approved. The Committee is especially concerned about the composition of plan provider networks and requirements for rural network adequacy. Thus, the Committee recommends that applications for MA plans be made accessible to the public via the CMS web site, allowing for more transparency and opportunities for rural advocates to comment on the plans.
Many rural providers have found it difficult to verify beneficiaries' plan enrollment. At times beneficiaries are unsure about their coverage and providers cannot easily access that information. Currently, there are two commercial services (MediFax and Passport Health Communications, Inc.) where Medicare enrollment can be verified. However, there are certain health insurers such as Blue Cross, Humana and United that do not participate in the sites. Though many providers have access to CMS' Common Working File, providers have discovered that information about a beneficiary's status in an MA plan is often not current. The Committee understands that CMS is working to ease access to beneficiaries' MA enrollment status via a secure web portal, and the Committee encourages this. The Committee urges CMS to ensure that the portal is easy to access for providers and provides real-time enrollment data. This web site would allow all providers ease of access and would ensure more efficient reimbursement transactions and less administrative work for the providers.
§1853(a) of the MMA requires that CMS adjust payments for local and regional MA plans to account for variations in "local payment rates" within each region the plan serves. This provision allows health plans to segregate rural providers within their region and offer them a substantially lower payment rate. The Committee is concerned that rural beneficiaries, plans and providers will continue to be disadvantaged as the proposed benchmarks for the health plans are significantly affected by some States' historically lower utilization rates. Historically, M+C was criticized for making extra benefits available in regions of the country that had high Medicare utilization, which could not be made available in regions with lower utilization. The Committee would like to prevent similar incidents from happening with the MA program.
Fiscal Intermediaries, at a minimum, should be allowed to release interim rate information directly to PFFS plans without requiring a Freedom of Information request from the plan. Plans should be required to pay the interim rate effective for the dates services were rendered. This is especially crucial for rural providers because PFFS plans are the most prevalent type of MA plan in rural areas. Additionally, plans should be required to pay for bad debt associated with services to their members and documented by the provider within a reasonable timeframe as uncollectible.
CMS has asserted that MA plans have the capacity to improve the quality of health care for Medicare beneficiaries. Additionally, one of the primary Congressional justifications for expanding M+C into Medicare Advantage was to provide more of the benefits of plan choice and the resultant services to rural beneficiaries. This would be a great improvement for rural health care; however, the Committee would like research to corroborate CMS' assertion and Congress' intentions. Thus, the Committee would recommend that the Secretary work with Congress to ask AHRQ to research the preventative services provided by non-HMO MA plans and to determine whether these services are beyond the level currently provided by traditional Medicare or local HMOs.
Many rural communities have not historically adapted to the managed care model. Thus, since the MA program will transform rural health care by increasing the prevalence of private plans, rural communities must be educated and informed on how to best collaborate in order to evaluate the rural contract reviews of the MA plans. Rural providers and other existing rural health care leaders need to ensure MA plans provide adequate community access for rural beneficiaries and fairness in payment to rural providers.
With the transition to the prescription drug benefit (Part D), the aging network, including the local area agencies on aging, were instrumental in educating the elderly in regards to the Part D changes. The same effort needs to be utilized for MA plans due to their complexity. The Committee would like to see an increase in funding to organizations such as the local area agencies on aging, so that they can effectively inform and educate the elderly about MA plans.
State insurance commissioners' offices are often knowledgeable about rural concerns, health issues facing their State and the managed care climate in their State. The Committee recommends that the Secretary actively encourage State insurance commissioners' offices to act as ombudsmen for rural beneficiaries. The Secretary should ensure these offices have the regulatory authority necessary to access information on MA plans and report violations of Medicare regulations.
States currently receive a grant from CMS to provide advice and counsel to citizens on a number of subjects, including Medicare managed care. Rural beneficiaries have less experience with managed care products, and information about MA is often difficult to obtain and confusing to beneficiaries. The Secretary should work with Congress to increase funding for SHIPs and specifically charge them with helping beneficiaries in rural areas make appropriate choices with regard to MA.
The Committee believes that small rural programs should not lose their grants when a small decline in the number of eligible children pushes them below the minimum enrollment standard. It recommends pursuing research into the effects of additional flexibility to enroll children from higher income families to avoid the loss of such programs. The Committee believes that this flexibility could be used with discretion to maintain programs in rural communities where there are few or no childhood education alternatives.
As noted in the text of this chapter, both the House and Senate reauthorization bills for Head Start call for an increase in the percentage of Head Start teachers holding a bachelor's degree. In recognition of the disadvantages that rural communities face in recruiting Head Start educators (lower salaries, fewer educational opportunities, travel distance to educational institutions, etc.) the Committee urges the Secretary to support the longest possible transition period for this requirement. The Committee also believes that work experience in the Head Start program should count towards credit for continuing education requirements.
Transportation waivers that release rural grantees from some of the most difficult to meet and costly Federal requirements could help solve some of the most pressing concerns regarding transportation for Head Start in rural communities. The Committee believes that rural sites should be as informed about the waivers as possible, so as to provide more transportation options for Head Start children in rural areas.
During the past year the Committee learned about collaborative programs involving rural Head Start grantees, public schools, dental schools and other health care providers. The Committee believes that collaborative arrangements are especially important in the areas of oral health and general health care. The Department has begun cross-collaborative discussions to identify areas where they build partnerships. The Committee urges the continuation of these discussions, and requests that the Secretary work to identify best practices among rural Head Start programs and to disseminate that information.
The Committee found strong support for the Head Start performance standards among the many program officials who spoke with us during the year. However, some concerns were raised about portions of the National Reporting System that may not be appropriate for rural Head Start children. The Committee believes that all assessments should be administered in a culturally and geographically sensitive manner and requests that the Secretary examine this issue, consulting with rural Head Start grantees.
Recognizing its limited understanding of the formula by which funding decisions are made through the SAPT Block Grant, the Committee would like to see research conducted that examines the equity of the formula. The typical "rural/urban" split of data is not as helpful to smaller communities and frontier areas because funding decision-making usually emphasizes population size, rather than the incidence of the problem. To provide answers to the problems of substance abuse in these communities more weight should be given to the prevalence of the substance abuse problem in a given geographic area. The cost to provide any type of health or human service is greater in rural areas because of the geographic distances and low volumes of clients. These factors do not minimize the need for services. Ideally, the Secretary could commission a comprehensive look at program authorities and regulations that deal with substance abuse programs to examine whether services are limited by the formula's guidelines.
The Committee specifically supports the following research priorities outlined in NIDA Research Monograph 168, Rural Substance Abuse: State of Knowledge and Issues:
The Committee believes this registry is an important tool for States, communities and practitioners to identify and replicate best practices in substance abuse prevention and treatment. It commends SAMHSA and HHS for its creation. The Committee also believes that collecting some information on rural-specific interventions and projects would provide even greater assistance to rural communities who struggle with unique funding, volume, resource and workforce challenges due to their isolation and distance from the standard substance abuse treatment and prevention infrastructure available in urban and suburban communities.
Such an initiative represents a unique partnership of Federal agencies and provides a necessary focus on preventing drug addiction among children and adolescents. In 2004 the Committee toured a Safe Schools/Healthy Students grantee site in Nebraska and was impressed by the scope of this collaborative initiative. The rural-focused projects funded by this grant program are numerous, and its mechanisms have been proven to work well for rural communities.
The Committee notes that mental health providers have achieved some level of success using telehealth technology to deliver needed services in rural communities. In the course of its work over the past year, the Committee believes that this technology may also hold great potential for providing substance abuse treatment. In addition, the use of this technology may also help decrease the stigmatization of substance abuse treatment in small rural communities since it may afford greater anonymity.
HHS and SAMHSA spend considerable time and money conducting needed research on substance abuse and treatment. This research has provided an important base of information through which to inform policy and program decisions. However, due to sample-size limitations, there are often problems conducting sub-State and/or sub-regional analysis. This limits the ability of States and communities to use this important data in targeting scarce resources. Further, nationally representative survey samples are often not generalizable to rural communities when population data are collected proportionally. By increasing overall sample sizes and including an over-sample of rural residents, HHS can greatly increase the utility of this data to draw conclusions on rural populations and for specific rural communities.
The Committee has identified several grant programs in the Department that could be used effectively to promote and support accessto pharmaceuticals and pharmacy services in rural areas. These include the Quentin Burdick Interdisciplinary Grants authorized under Title VII of the Public Health Service Act, the Rural Health Network Development Grants authorized under Title II, Section 330A of the Public Health Service Act, the Rural Health Outreach Grants authorized under Title II, Section 330A(f) of the Public Health Service Act, grants to support schools of pharmacy authorized by Title VII of the Public Health Service Act, and the 340B Medication Discount Program. The Secretary should identify other programs as well. Programs with appropriate authorizations should encourage applications from qualified organizations that can present innovative ideas for improving or sustaining access to pharmaceuticals and pharmacy services in rural areas, and for integrating pharmacy services with other components of rural health care delivery systems.
The National Health Service Corps recently completed a demonstration program that placed a small number of pharmacists in underserved areas of the country. The Committee believes that the mission of the Corps should now be expanded to include pharmacists among the other health professionals eligible for loan repayments, scholarships and placements through the Corps. Moreover, the Committee is aware of the potential difficulties posed by the lack of criteria for designating pharmacist shortage areas in rural parts of the country. The Committee believes, however, that the existing criteria for designating Health Professionals Shortage Areas are a reasonable proxy for shortages of pharmacists and could be used by the Corps until such time as more specific criteria could be developed.
The AHEC program has been, and continues to be, an effective source of support for educational programs and other efforts to help rural communities and rural health care providers develop more integrated systems of care. The critical role of pharmacy providers in rural areas and the need for them to become a more integral part of local health care delivery systems should be recognized and supported through the AHEC program.
In presenting this chapter, the Committee was able to use some limited information from a major study of the nation's pharmacy workforce conducted by HRSA in 2000. That study (and others like it) did not provide data on urban and rural differences in the pharmacy workforce. The Committee believes that any future studies should attempt to identify and present workforce data that allows comparisons between urban and rural areas. Further, the Committee recommends that the Secretary require HRSA to do an analysis of the urban/rural distribution of pharmacists in 2006. This study is critical given the projected disparity in the nation's supply and demand for pharmacists.
The Committee has found that more research needs to be conducted as to the potential factors that might place a rural community at risk of losing their local pharmacy. In identifying those issues, the Committee believes it will be easier to develop programs to target those risks.
Under the 340B program, rural health clinics should qualify if they operate on a sliding fee scale and Critical Access Hospitals should qualify if they show that they have a Disproportionate Share Percentage greater than 11.75 percent if paid under the Medicare Inpatient Prospective Payment System. Rural Health Clinics and Critical Access Hospitals that meet these criteria must be considered a vital part of the health care safety net in rural areas and should be recognized as such under the 340B program.
The Committee also recommends that the Secretary provide additional resources to the HRSA Office of Pharmacy Affairs that administers the 340B program. Throughout the year, the Committee received testimony that many entities eligible for the program are not aware of its benefits or have been unable to seek participation because of staffing limitations and other factors. Further, these entities often need technical assistance related to administration of the program at the local level. Presently, the Office of Pharmacy Affairs lacks sufficient resources to provide effective outreach to eligible entities and the technical assistance they require.
Moreover, the Committee recommends that the Office of Pharmacy Affairs should conduct a study to determine the extent of urban and rural differences in participation in the program and take steps to provide appropriate assistance to eligible rural entities.
In this chapter, the Committee has discussed some concerns about the potential impact of the new Medicare Modernization Act on rural seniors and pharmacy services providers. The validity of these concerns will not be known until the new benefit has been implemented and tested. However, the Committee believes that rural areas pose unique challenges for the program and there is the potential for problems to surface over the next few years. The Committee believes that the Secretary should support studies and monitoring systems to determine how well the program is serving rural beneficiaries and pharmacy providers so that problems can be identified and resolved at the earliest possible time. There may be opportunities to integrate such studies with other efforts that are already planned.
The Committee recommends that the Secretary conduct a demonstration program to examine the use of Medicare payments to provide medication therapy management services to seniors who are taking multiple medications and are at greatest risk for negative drug interactions. Medication therapy management services can have a significant impact on the health of seniors who are at high risk for negative drug interactions and other complications stemming from dependence on multiple medications. Demonstration programs should be conducted to identify those seniors most at risk in both the Medicare fee-for-service and Medicare Advantage settings. Such programs would also help to identify positive outcomes of medication therapy management services, as well as their impact on the cost of the Medicare program.
The Committee believes that telepharmacy has potential to increase access to pharmaceuticals and pharmacy services, particularly in communities that are unable to establish and sustain pharmacy services due to low population density, unfavorable economic circumstances, geographic isolation or other factors. However, the Committee is concerned that telepharmacy applications must improve access without compromising the quality of services that are available. The Committee believes that more information is needed on how well telepharmacy applications are balancing the issues of access and quality in rural areas. The evaluations should include studies on best practices and outcomes.
During its work on this chapter, the Committee received testimony describing several recently developed software programs designed to help low-income groups identify pharmaceutical assistance programs available to them and streamline the application process. The Committee also learned that many safety-net providers have been unable to aid their patients in applying for pharmaceutical assistance programs due to staffing limitations. Thus, these software programs would be able to mitigate that issue. The Committee believes that the Department can play an important role in identifying successful software programs, disseminating information about them and assisting providers in their implementation.
The 50-State Study reveals that differences in program availability, design and benefit exist within states individually and across the nation. The Department should take the lead in efforts at standardization and uniformity of caregiver programs and services. Such an undertaking will require inter- and intra-state agreement about mission and philosophy, eligibility criteria, funding priorities, program design, and administration of services.
The Committee recommends that all survey instruments within HHS be required to collect and evaluate data in a way which identifies rural characteristics. The NAPIS database, specifically, should begin to capture data on rural caregivers. The Committee is aware that no Department-wide definition of "rural" exists. As long as this situation persists, researchers, program administrators and policy-makers will be unable to truly determine and report the extent of rural need because the key federal organizations do not evaluate programs with a uniform rural geographic standard.
The health-related components of HHS are slowly changing their data structures to illuminate urban/rural differences. The Committee would encourage the Secretary to require that all survey instruments within the Department collect, evaluate and report data in a geographically-specific way which identifies rural characteristics. Such standardization of efforts could be based on previous successes such as those realized in the Health Resources and Services Administration's Maternal and Child Health Bureau.
The Committee commends the work of the NFCSP and recognizes its success, however, the Committee realizes that the program is in great need of enhanced funding. Since it was authorized, the range and scope of NFCSP services have expanded but program funding, though increased annually, has not kept pace. Gaps in service and variation of availability of caregiver services in rural areas across states remain problematic due to inadequate funding.
In recognition of the growing contingent of younger caregivers, the Department should work to lower the eligibility age from 60 to 50 and older.
The NFCS programs should specifically identify and promote rural best practices. In addition, rural best practice models for state home-based family caregiver waiver programs should also be widely distributed. The Florida legislature is considering a bill (S.B. 88 & H.B. 49) to promote best practices among informal caregivers. The legislation under consideration promotes caregiving as a non-licensed paraprofessional activity and encourages the use of caregiving best practices. The bill would also create the Florida Caregiver Institute, an independent not-for-profit corporation which would develop policy recommendations to improve the skills and availability of direct care workers. The Secretary should establish a working group to consider piloting this work in other States.
In addition, the Secretary could use the Alzheimer's Disease Demonstration Grant program a successful model which encourages the development of best practices models that can be replicated in underserved areas, particularly minority and rural communities, in all 50 states.
Caregiver assessment was identified in the 50-State Study as one of the top five needed technical assistance and training areas. Screening of caregivers should be done in the primary care setting as it has been shown that early assessment of caregivers needs helps prevent institutionalization of the care receiver upon crisis.
The Department's Administration on Aging should oversee a social marketing campaign to educate rural Americans about the difficult role of caregivers and the family caregiver support programs available to them. This campaign must use plain, easily understood language.
The need for more providers and limited access to services in rural areas were cited as two of the top five needs listed in the 50-State Study.
The Committee observed during its site visits that the centralized structure of the AoA administrative functions is problematic, especially in large rural states. The Committee discovered that uneven information distribution with in the State caused poor collaboration among local and state service providers. Committee members saw first hand, some of the short comings of centralization, for example, local program directors being unaware of the other state and local services that are available to their clients. The Committee concludes that the AAAs must be locally situated to be most effective. A single State office in the absence of local AAAs is too far removed from local issues, especially in geographically large rural states.
The impact of providing long-term home care to loved ones is immensely debilitating to the caregiver. Isolation, resentment, guilt, anger, financial difficulties in addition to missed work, all plague the caregiver. One out of three caregivers reports their own health to be fair or poor. Research shows that informal caregivers suffer from high levels of stress, burnout, and insomnia and are more likely to use psychotropic drugs. However, this research does not identify differences between the stresses of rural caregivers as compared to their urban counterparts.
The Federal Office of Rural Health Policy (ORHP) should build this recommendation into it cooperative agreement with the Rural Assistance Center (RAC). A special page should be built that is devoted to describing successful rural-based collaborations and that can be accessed in one step from the home page of the RAC Web site. The funding to RAC should support a reporting function to collect and present information regarding those collaborations.
The Federal Office of Rural Health Policy should dedicate a portion of its research budget to further specify opportunities for and barriers to collaboration, funding activity either through its research centers or its solicitation of independent research proposals. Researchers should develop models that explain reasons collaborations are successful, with success being defined, in part, as long-term sustainability. Research findings should identify barriers to successful collaborations as well as community, Tribal, State and Federal actions that facilitate successful collaborations.
The Secretary should instruct all agencies with programs support local service delivery to include funds for leadership development in their grant-making portfolios. The Federal Office of Rural Health Policy program for rural leaders should be continued. The Secretary should consider supporting regional leadership academies by combining current programs from separate entities in HHS. The Secretary should encourage private foundations to expand their efforts to train future leaders. The Nebraska Community Foundation is one example of the important and crucial role a foundation can play in fostering leadership development in rural areas.
The Secretary should require that all grant applications in program supporting service delivery in rural areas include an analysis of how the program will relate to broad-based efforts in community development. CREATE, in Mississippi, is measuring its success based on community indicators, such as the economy, education, public safety, social environment, health, housing and infrastructure.
An increased supply of rural physicians trained in obstetrics is essential to sustaining these services in hundreds of small rural communities. The Secretary should increase or reallocate funds under Title VII of the Public Health Service Act to target medical schools that train obstetricians and family physicians for rural practice, especially those that provide residents in family medicine with training in high-risk obstetrics. Family physicians are more likely to practice in rural areas than obstetricians, and programs that prepare them for high-risk obstetrics must be supported. Support for the training of CNMs and nurse practitioners who are interested in obstetrics also should be increased.
The Committee believes that the National Health Service Corps must focus more attention on rural areas that lack adequate obstetrics services. Recruitment efforts should focus on physicians who are trained in obstetrics and who are willing to deliver babies in the communities they serve. Additional incentives for new physicians are also needed and should be explored. One approach would be to pay the malpractice insurance costs of new Corps physicians who are fulfilling their obligation in areas with measurable and pronounced shortages of obstetrics care providers.
There are several existing grant programs in the Department (Healthy Community Access, Rural Network Development, Rural Hospital Flexibility Grants) that should be used to promote the development of hospital and physician networks in obstetrics care. The Committee believes that obstetrics services in many small rural hospitals and physician practices will be unsustainable over time, given the issues discussed in this report. Providers need encouragement and incentives to find more sustainable and efficient strategies for maintaining access to obstetrics care. Existing grant programs should be more aggressive in encouraging and funding grant applications that address the problem.
The Secretary should use this demonstration authority to develop a model program that supports regional approaches to improving access to obstetrics care in rural communities through networking and an emphasis on using interdisciplinary teams in several rural areas as a pilot project.
The Committee understands that Medicaid payments for services are determined by the States; however, the Secretary does have authority over State Medicaid waivers that affect the scope of services that Medicaid provides and populations served. The Secretary should explore ways in which the waiver approval process could be sued to provide incentives for the States to increase payments and improve access to obstetrics services in rural areas.
The malpractice insurance program for Federally Qualified Health Centers and Free Clinics should be extended to cover rural hospitals and physicians providing obstetrics services in underserved rural areas. The Committee believes that the current system for designating Health Professional Shortage Areas (HPSAs) may not be able to identify the rural areas most underserved by obstetrics services. Data are available to identify rural areas that have the lowest ratios of obstetrics providers to women of childbearing age, which may be a more effective access measure. Another approach would be to give greater weight to obstetrics services as a variable used in the HPSA designation process. The method used must be limited to those rural areas where access to obstetrics care is mot severely limited by provider shortages.
The Department should take the lead in working with the States to classify obesity as an illness and cover procedures related to treatment of obesity. This change is even more critical in Medicaid than it is in Medicare since it will allow health care providers to aggressively treat those with obesity and it will potentially help patients avoid more serious obesity-related health complications in the future.
The Committee commends the Secretary for launching the Steps to a HealthierUS community grant program, especially since it includes rural participation. However, the Committee is also hopeful that refinements will be made to assure that the concerns identified with respect to rural representation are addressed. Additional opportunities for direct granting to rural communities would be helpful, as many States did not include rural communities within their grants.
The Committee commends the efforts the CDC has made to conduct studies that include rural areas. These studies have consistently shown that rural areas have higher rates of obesity and are, in general, less healthy than urban or suburban areas. The Committee would encourage the publication of a new CDC Chartbook to provide current, more rural-specific items compared to the previous 2001 publication, and to continue the inclusion of rural areas in its other studies. In addition, the Committee encourages NIH and the CDC to include studies of rural-specific prevention and intervention.
The Committee commends the efforts CDC has made to conduct studies that include rural areas. These studies have consistently shown that rural areas have higher rates of obesity and are, in general, less healthy than urban or suburban areas. The Committee would encourage the publication of a new Rural-Urban Chartbook by no later than 2006 t provide current, more rural specific items compared to the previous 2001 publication, and to continue the inclusion of rural areas in its other studies. In addition, the Committee encourages the NIH and the CDC to include studies of rural-specific prevention and intervention.
The Secretary should work with the Administration for Children and Families (ACF) to provide targeted technical assistance that would encourage States to address the transportation, child care, and employment and training needs of rural TANF recipients.
The Secretary should emphasize collaboration and encourage States to utilize best practices, including those identified by ACF, particularly in efforts to serve rural clients.
The Secretary should strengthen the Department's leadership among Federal partnerships and collaborations.
The Secretary should propose legislation to the Congress that would establish a Medicare inpatient payment floor for rural hospitals with less than 50 acute care beds and for Sole Community Hospitals (SCHs). The payment floor would be based on an individual hospital's current cost experience. The legislation would be effective for hospital cost reporting periods beginning on or after October 1, 1989, and end at such time that special Medicare payment provisions for essential access facilities are implemented. For the purposes of this legislation, acute care beds include swing beds, but exclude licensed beds for long- term care and newborn bassinets.
The Secretary should work with the Congress to amend Section 1861(s) (2) of the Social Security Act to authorize State-licensed marriage and family therapists, licensed professional counselors and other behavioral health providers to provide behavioral health services as qualified mental health care service providers. The Secretary should also work with Congress to authorize Medicare payments for those services by amending Section 1833(a)(1) of the Social Security Act, as needed, to ensure that payment.
The Secretary should seek to broaden the definition of originating sites for telehealth services to include private physician offices under Title XVIII of the Social Security Act and ensure that all Medicare-eligible providers can offer mental health services via telehealth consultation.
The Secretary, under the auspices of Title XVIII and Title IX of the Social Security Act, should work to identify States with model licensure laws and scope of practice acts for non-physician behavioral health providers. The Secretary should share them with other States and policymakers in order to facilitate similar practices in rural areas of the country. The Secretary should also work with States and behavioral health professional associations to increase flexibility in State requirements for supervision of limited license behavioral health providers that would allow more rural training, either in person or through supervision delivered via telehealth technologies.
The Secretary should support increased funding for the Quentin N. Burdick Program for Rural Interdisciplinary Training. The program is authorized under Title VII, Section 754 of the Public Health Service Act. Grants awarded through the program can support innovative models and demonstrations of interdisciplinary care in rural areas. The program is uniquely suited to the support of programs that foster the development of integrated primary care and behavioral health care delivery systems.
The Secretary should support increased funding for the Graduate Psychology Education Program authorized under Title VII, Section 755(b)(1)(J), of the Public Health Service Act. This program supports grants to schools accredited by the American Psychological Association to help them plan and operate programs that foster an integrated approach to health care service and that train psychologists to work in underserved areas. The program was not included in the President's budget for 2005.
The Secretary should provide increased support of scholarships and loan repayment for behavioral health care providers under Section 331 of the Public Health Service Act.
The Secretary should work with the Congress to amend Title XVIII and Title XIX of the Social Security Act to require parity in payments and the resulting co-payments for mental health care services under Medicare and Medicaid.
The Secretary should work with the Centers for Medicare and Medicaid Services in administration of Section 1834(g) of the Social Security Act to clarify that Critical Access Hospitals can and should have the flexibility to provide mental health services as dictated by community need within the normal protections for patients.
The Secretary, under Title XIX of the Social Security Act, should authorize a five to ten percent increase in Federal matching funds for oral health services. This increased match would encourage States to expand dental coverage and provide dental reimbursements at a level sufficient to attract additional providers to the Medicaid program.
The Secretary should work with the Office of Management and Budget (OMB) and Congress to seek increased funding for the Quentin N. Burdick Program for Rural Interdisciplinary Training, authorized by Title VII, Section 754 of the Public Health Service Act. Priority should be given to Quentin N. Burdick applicants whose programs include dentists or dental hygienists. The Secretary should also attempt to obtain more funding for the Health Careers Opportunity Program (HCOP) and Centers for Excellence (COE) Program, authorized by Title VII, Sections 739 and 736, respectively. The additional funds should be used to increase the number of dental schools receiving HCOP and COE grants. This would provide more support for dental schools that seek to recruit additional minority and disadvantaged individuals and to expose students to practice opportunities in underserved communities.
The Secretary should ensure adequate funding for the National Health Service Corps under Section 331 of the Public Health Service Act and should encourage it to pursue innovative strategies that will attract more dentists and dental hygienists to take part in the program.
The Secretary should work with the Office of Management and Budget to seek additional funding for the recruitment and loan repayment of Indian Health Service dentists and hygienists and to ensure the Indian Health Service dental facilities and equipment are adequate to meet the demand for services.
The Secretary should work with the Office of Management and Budget and the Congress to explore the establishment of a new categorical grant program that would provide funding to States for the fluoridation of small community water supplies and provide ongoing technical assistance and maintenance for such systems.
The Secretary should work with Congress and the Office of Management and Budget to establish a Federal-State partnership that is modeled after the State Offices of Rural Health Grant Program. This partnership would support the establishment of State Dental Offices with full-time directors in all 50 States and U.S. territories. Since the majority of oral health policy issues are under State jurisdiction, it is important to ensure that States have an adequate infrastructure to address pressing oral health issues and coordinate Statewide oral health initiatives.
The Secretary should direct the National Institute for Dental and Craniofacial Research and the Agency for Healthcare Research and Quality to conduct a series of studies on rural oral health disparities. These studies will provide additional information on the oral health status of rural residents and will provide critical information that will be used to guide evidence-based policymaking.
The Secretary should develop a demonstration project through Section 301 of the Public Health Service Act that would explore innovative approaches to providing transportation to rural elderly and would examine current Federal and State regulations and opportunities to use existing systems operated through Area Agency on Aging programs, Head Start and State and local transportation systems such as school buses.
The Secretary should support research that examines how rural seniors access key services provided under the Older Americans Act to determine if there are any service gaps particular to rural communities.
The Secretary should work with the Agency on Aging to track expenditures in the National Family Caregivers Support Program to determine how much of the funding goes to rural communities.
The Secretary should work with CMS to promote demonstrations that examine how reimbursement might be used to promote quality improvement in the rural setting.
The Secretary should increase funding for state survey and certification activities. The survey and certification agencies are consistently under funded and this has a disproportionate effect on rural providers given their heavier reliance on using the survey and certification program and less reliance on accreditation compared to their urban counterparts.
The Secretary should amend the Seventh Scope of Work for the Quality Improvement Program to make this program more relevant for rural communities. This would include creating a stand-alone task focusing on rural health. It would also include a new evaluation methodology for reviewing the work of the Quality Improvement Organizations that includes more localized measures of areas with populations that suffer health disparities. The sole reliance on measures of state-wide improvement acts as a disincentive for working with harder-to-reach populations.
The Secretary should work with the Office of Management and Budget to increase funding for the Quality Improvement Organizations to encourage Quality Improvement Organizations to reach out more meaningfully to rural communities to rural communities and to help providers prepare for public reporting in hospital, home health and individual ambulatory provider settings.
The Secretary should solicit (via Federal Register notice) input from rural health care entities in identifying which measures shall be used for public reporting for all healthcare providers and include not only outcome measures but also process measures. This activity should promote appropriate benchmarking that compares organizations with similar characteristics such as geography, size, and volume. This is very important as outcome measures require statistical significance frequently not available in a typical rural facility due to lower volumes or that may not be appropriate for rural facilities.
The Secretary should work with AHRQ and NIH to ensure that each Agency's efforts to translate research to practice include a focus on rural health care quality issues as well as translation of findings to rural practice, dissemination and adoption of recommendations. AHRQ and NIH should also identify and examine "models that work" in rural areas.
The Secretary should work with the Congress to fund the new Small Health Care Provider Quality Improvement Program authorized in Public Law 107-251.
The Secretary should support re-authorization of the Medicare Rural Hospital Flexibility Grant program in a manner that strengthens the program's orientation to promoting quality in Critical Access Hospitals.
The Secretary should work with Congress to require the use of a uniform Medicare Disproportionate Share Hospital adjustment policy that treats all hospitals the same regardless of their urban or rural location.
The Secretary should work with Congress to raise the cap on Medicare Disproportionate Share Hospital payments for rural hospitals to an appropriate level that provides equity for rural hospitals.
The Secretary should work with States to expand options for using Medicaid Disproportionate Share Hospital Payments for eligible rural hospitals, including the ability to upgrade the financial stability of rural hospitals or to assist rural hospitals to develop physician or clinic networks.
The Secretary should work with Congress to ensure re-authorization and continued funding of the Medicare Rural Hospital Flexibility Grant Program, which is up for re-authorization in FY 2002.
The Secretary should work with Congress to eliminate any financial challenges to FQHC's providing care to the uninsured by eliminating the Medicare per-visit payment cap.
The Secretary should work with Congress to increase access to capital and to expand eligible uses of grant funds to include construction, renovation, and modernization of health center facilities.
The Secretary should encourage the development of criteria that will increase the number of FQHC sites in rural and frontier areas.
The Secretary should work with Congress to increase the RHC payment limit under section 1833 (f) of the Act to more closely correspond with the increase in payments for primary care services resulting from the full transition to the physician fee schedule.
The Secretary should amend the reimbursement methodology for Rural Health Clinics (RHCs) payment so that RHCs that 1) are non-profit, 2) see all patients regardless of ability to pay, and 3) elect to use a sliding fee scale do not have to count uninsured patients in determining the aggregate number of patients seen for calculation of the per-visit payment rate.
The Secretary should work with Congress to conduct strong, ongoing oversight of the implementation of the Medicaid PPS to ensure that States comply with requirements in the Federal PPS statute and that access to FQHC and RHC services are protected.
The Secretary should work with Congress to evaluate the Medicaid PPS to ensure that FQHCs and RHCs are being adequately reimbursed to protect access to care, including access to care for the uninsured. This includes examining whether the Medicare Economic Index (the current measure of inflation used in PPS) is sufficient to protect Medicaid reimbursement for these critical safety next providers.
The Secretary should issue an advisory letter that spells out the legality and specific requirements of income-related sliding fee scales and disseminate it widely.
The Secretary should continue to support and enhance the 340B Discount Drug Program and support Medicare reforms that include access to prescription drugs.
The Secretary should propose an increase in funding for the National Health Service Corps at levels sufficient to support the multi-year plan to expand health centers and to meet the pressing needs of other rural areas for health professionals.
The Secretary should create a focal point within the Department to coordinate the J-1 Visa Waivers issued by all Federal agencies and the communities in which they are placed to ensure that the visa waivers are used to meet patient care needs.
The Secretary should consider allowing HHS to issue J-1 Visa Waivers for primary care physicians if the USDA declines to continue issuing those waivers. If USDA continues to offer J-1 Visa Waivers, the Secretary should work with the Congress to re-authorize and expand the scope of the Conrad State 20 program to more adequately meet the primary care needs of rural communities.
The Secretary should work with the Congress to increase the amount of the Medicare Incentive Payment to 20 percent.
The Secretary should work with the Congress to allow nurse practitioners and physician assistants to qualify for the Medicare Incentive Payments.
The Secretary should work with Congress to eliminate Medicare Incentive Payments to urban specialists.
The Secretary should change the current auditing procedures used by the Medicare Contractors to ensure that providers who claim the Medicare Incentive Payment will not have any greater likelihood of being audited than providers who do not claim the extra payment.
The Secretary should evaluate the need for a low-volume adjustment within all of the Medicare prospective payment systems.
The Secretary should promote research into determining the true cost of providing care to Medicare beneficiaries in rural areas that take into account factors related to access, geographic isolation and volume. The results of this research should be used in redesigning the Medicare program to ensure equity of benefits for rural beneficiaries.
The Secretary should continue collecting data on occupational mix and implement an adjustment to the wage index as soon as possible.
The Secretary should collect wage data for both the skilled nursing and home health service areas and evaluate the impact of constructing an occupational mix adjustment within the wage index for both of these payment systems.
The Secretary should continue to refine the methodology for the disproportionate share adjustment for hospitals to treat all hospitals equally.
The Secretary should develop a standard benefit package that includes access to a reasonable prescription drug benefit under Medicare fee for service.
The Secretary should provide demonstration waivers to rural communities for innovative models that improve access to care and that focus on chronic care, case management, and preventive care.
The Secretary should examine the impact of the new prospective payment systems for home health, skilled nursing, and outpatient services to determine what impact these changes have had on access to care for rural Medicare beneficiaries.
The Secretary should monitor the closures of skilled nursing facilities and the impact of moving swing beds under skilled nursing facilities prospective payment to determine the impact on access to care for rural Medicare beneficiaries.
The Secretary should ensure that the core services (primary, preventive and chronic care management) and the full continuum of care are appropriately available for all Medicare beneficiaries.
The Secretary should amend the Medicare Conditions of Participation. Also, the Secretary should provide resources through entities such as the Peer Review Organizations to develop quality improvement tools to fit the rural environment with appropriate flexibility and an emphasis on outcome standards.
The Secretary should encourage the development of appropriate measures that take into account a rural environment that features low volume of primary care and ambulatory services.
In recognizing the link between quality health care and the workforce, the Committee recommends that the Secretary encourage more training of health professionals for rural communities to ensure access to high-quality care for Medicare beneficiaries.
The Secretary should support research that looks into issues related to volume and outcome in the rural context based on primary and ambulatory care.
The Secretary should support changes to Medicare policy to provide exceptions to the residency cap for rural training programs and provide direct and indirect GME funding for these programs.
The Secretary should support changes to Medicare policy that promote more community-based training of residents.
The Secretary should support changes to Medicare policy so that residency programs receiving GME funding would be required to provide training in rural settings.
The Secretary should support Rural GME demonstration projects that address workforce shortages in rural areas.
The Secretary should expand the scope and focus Title VII and Title VIII training grants to promote more rural training.
The Secretary should increase funding for the National Health Service Corps to promote more placements of Corps clinicians in underserved rural areas to serve Medicare and Medicaid beneficiaries.
The Secretary should protect and strengthen the Medicare Fee-For-Service delivery option under any redesign or reform of the Medicare program. This should include an acknowledgment that Medicare + Choice in its present form is not a viable option for bringing managed care and equity of benefits to rural beneficiaries. Consequently, the Secretary should recognize that fee-for-service delivery will continue to be the dominant service delivery mechanism for rural Medicare beneficiaries.
The Secretary should ensure protections for key rural service providers (critical access hospitals, sole community hospitals, Medicare-dependent hospitals, rural referral centers, rural health clinics and federally qualified health centers), in any redesign of the Medicare program to ensure access to care for rural beneficiaries.
The Secretary should explore the development of new service delivery models for rural beneficiaries that recognize the special circumstances of providing care in sparsely populated rural areas. Options such as coordinated care, primary care case-management and other forms of partial risk or capitation that emphasize local control and flexibility should be explored.
The Secretary should seek an Executive Order for the creation of a Federal Interagency Public Health Coordination Committee comprised of senior representatives from the various public health agencies and federal departments. The committee would study current efforts by each of the Federal Agencies involved in public health activities overall while evaluating ways to integrate funding stream to benefit rural communities in the areas of leadership development, workforce development, viability of the safety net, impact of managed care, and telecommunications. The newly formed committee would produce an annual report based on their studies. This committee would include appointed representatives from the Department of Health and Human Services, the Department of Agriculture, the Environmental Protection Agency, the Department of Commerce, the Department of Veteran Affairs, the Department of Labor, the Department of Education, the Department of Housing and Urban Development, the Department of Transportation, the Department of Defense and any other relevant Federal agencies.
The Secretary should support the development of a dedicated funding stream for public health infrastructure activities with assurances that funding is equitably distributed among rural and urban health departments at the local level.
The Committee recommends that the Secretary incorporate an occupational mix adjustment into the calculation of the Medicare Hospital Wage Index. This will require the Department to begin gathering data on wage and hours by occupational category in the Medicare cost reports or by obtaining it from the Bureau of Labor Statistics.
The Committee recommends that the Secretary develop separate wage indexes for the prospective payment systems for skilled nursing facilities and home health agencies within three years after these payment systems are in place.
The Committee recommends that the Secretary remove teaching physician costs from the hospital wage index since these costs are recognized elsewhere in the Medicare system through Graduate Medical Education payments.
The Committee recommends that the Secretary begin collecting hospital specific wage index market data during the next three years and develop and implement a New Medicare wage index based on hospital-specific labor market areas by FY 2003. The new wage index calculation would base wage-related costs on the costs incurred by neighboring hospitals.
The Committee recommends that the Secretary include a low-volume adjustment in the final rule for the Medicare outpatient prospective payment system to compensate rural providers who may be at a disadvantage under the new payment system if they serve low numbers of patients.
The Committee recommends that the Secretary include a low-volume adjustment in the final rule for the Medicare home health prospective payment system to compensate rural providers who may be at a disadvantage under the new payment system if they serve low numbers of patients.
The Committee recommends that the Secretary include a low-volume adjustment in the Medicare skilled nursing facility payment system to compensate rural providers who may be at a disadvantage under the new payment system if they serve low numbers of patients.
The Committee recommends that the Secretary include a low-volume adjustment in the final rule for the Medicare ambulance fee schedule to compensate rural providers who may be at a disadvantage under the new payment system if they serve low numbers of patients
The Committee recommends that the Secretary revise the formula by which rural hospitals receive disproportionate share payments under the Medicare program to more adequately compensate those rural providers that shoulder a large burden of indigent care.
The Committee recommends that the Secretary to support the creation of a loan program for physical capital needs in licensed acute care rural hospitals that encourages consolidation and coordination of services at the local level.
The Committee recommends that the Secretary give a preference in the reviewing of grant proposals to projects that include a Critical Access Hospitals as a part of the applicant consortia or network under Federal health grants administered by the Department of Health and Human Services.
The Committee recommends that the Secretary encourage national and state accrediting bodies to examine rural-specific quality issues and work with the Department to develop relevant standards appropriate to the size, setting, and services provided by rural hospitals, health systems, rural provider practices and health plans serving rural areas. The Secretary should also support recognition of these issues by Congressional members and staff.
The Secretary recommends that the Secretary support the development of two sets of standards for the delineation of metropolitan and nonmetropolitan areas. This would include:
The Committee urges the Secretary to seek an Executive Order for the creation of a Federal Interagency Public Health Coordination Committee comprised of senior representatives from the various public health agencies and federal departments. The committee would produce an annual report (the first of which would be produced within 12 months of the establishment of the Committee). The Committee would study current efforts by each of the Federal Agencies involved in public health activities overall while evaluating ways to integrate funding streams to benefit rural communities in the areas of leadership development, workforce development, viability of the safety net, impact of managed care, and telecommunications.
The Committee urges the Secretary to support the development of a dedicated funding stream for public health infrastructure activities with assurances that funding is equitably distributed among rural and urban health departments at the local level.
The Committee recommends that the Secretary ensure that the new regulations for telehealth reimbursement allow a referring practitioner, usually located in a rural area, to bill for a primary care visit on the same day as a video consultation if the primary care visit is the basis of the consultation or was for a medical problem unrelated to the consultation.
The Committee recommends that the Secretary ensure that the new regulations for telehealth reimbursement interpret "rural health professional shortage" area as being all rural health professional shortage areas, including partial county, whole county and multiple county as well as governor-designated HPSAs. The original legislation did not specify which HPSAs were eligible.
The Committee recommends that the Secretary ensure that the new regulations for telehealth reimbursement require that the fee schedule be based on the location of the consultant rather than the referring clinician. The original legislation did not specify whether the payment should be based on the patients location in the rural area or the specialists location, which is usually in an urban area. The urban payment tends to be higher.
The Committee Recommends that the Secretary ensure that for the purpose of telemedicine payment, interactive consultation should be interpreted in as broad a manner as is possible. A video interaction between two practitioners where enhanced information is provided by the referring practitioner involving tele-imaging and appropriate medical history, physical findings, and diagnostic/management concerns for use in the consultation should count as an interactive consultation, even if the patient is not present.
The Committee Recommends that the Secretary ensure that the referring provider should be permitted to bill for a primary care visit on the same day as a video consultation if the primary care visit is the basis of the consultation, or was for a medical problem unrelated to the consultation.
The Committee Recommends that the Secretary ensure that the unbundling of the fee between the two providers should be left to the discretion of the two providers (institutions or practitioners) involved and should not be specified in regulation. In the event that it is determined that this is not permissible because of the provisions of other legislation, then the unbundling should be designed to ensure that there are incentives for both the referring and consulting physician to participate in telemedicine consultations.
The Committee Recommends that the Secretary should support a technical amendment that defines an interactive consultation. For the purpose of telemedicine payment interactive consultation should be interpreted in as broad a manner as is possible to include video interactions between two practitioners in which enhanced information is provided by tele-imaging and appropriate medical history, physical findings and diagnostic/management concerns are provided by the referring practitioner for use in the consultation, even if the patient is not present.
The Committee Recommends that the Secretary support a clarification of the statute that would allow a nurse, under the supervision of a practitioner who is not physically present in the room, to present a patient for a teleconsultation.
The Committee recommends that the Secretary support a $25 million appropriation to implement the Rural Hospital Flexibility Program and ensure that it is administered by the Office of Rural Health Policy in the Health Resources and Services Administration.
The Committee recommends that the Secretary support legislation to make technical changes on a series of GME provision from the Balanced Budget Act. Specifically, the legislation should:
The Committee recommends to the Secretary that the Health Care Financing Administration consider not only where a residency program is located but where its graduating physicians practice in their definition of programs servicing rural or rural underserved.
The Secretary should assure access to care for rural Medicaid eligible individuals served by managed behavioral health care systems. Toward that end, the Secretary should
The Secretary should require States, as part of defining the requirement for the State Request for Proposals, to commission a study of the rural impact of changing Medicaid provision of behavioral care services to delivery by a managed care organization. This commission should:
The Secretary should disseminate best practice guidelines for managed behavioral care organizations which recommend that managed care organizations recognize, utilize, and reimburse properly trained primary care providers as essential components of the behavioral health systems, especially in rural areas. These guidelines should ensure that:
Clinical records and reports must exist to demonstrate the accomplishment of effective coordination of physical and behavioral components of health care of individuals
The Committee urged the Secretary to support changes to the way Medicare pays for managed care services. Medicare pays a set amount for each beneficiary under the Average Adjusted Per Capita Cost (AAPCC) rate. Specifically, the Committee urged a new formula that would allow greater equity of payment between rural and urban areas.
The Committee urged the Secretary to impose a cap or per-visit limit on provider-based rural health clinics.
The Committee recommends that the Secretary create a national limited service hospital program based on the EACH (Essential Access Community Hospital)/RPCH (Rural Primary Care Hospital) program.
The Committee recommends that the Secretary base the wage index, which is used to calculate Medicare hospital payments, on relative labor costs adjusted to a standard occupational mix. To accomplish this, the Secretary should establish a data base for making a labor market specific occupational mix adjustment.
The Committee supports the goal of providing incentives for physicians to provide primary care, as contained in the Health Security Act, and urges the Secretary to continue to support such provisions in the absence of national health reform.
The Committee recommends that the Secretary consider alternatives to the use of historical costs as the basis for setting fee schedules, premium caps, or any other cost containment mechanisms introduced as part of health care reforms.
The Committee recommends that the Secretary initiate a change in the federal regulations for AFDC (aid to Families with Dependent Children) regarding self-employment income for farmers. AFDC regulations at 45-CFR 233.209(a)(6)(V)(B) require that states include the depreciation of business investments when calculating earned income from self-employment. The Committee recommends that depreciation of farm investments not be included in farmers' incomes when calculating their eligibility for AFDC because AFDC guidelines generally drive a family's eligibility for Medicaid.
The Committee recommends that all governing and advisory boards that are established to implement any future health reform be specifically required to have rural representatives among their members. In particular, any alliance (or similar body) that includes a rural population should be required to have substantial rural representation on its governing board and professional advisory board. In addition, any requirements for these boards to consult with outside interest should include a requirement to consult with individuals and organizations representing rural interests.
The Committee recommends that the Secretary develop technical assistance programs to strengthen rural health care delivery systems and prepare rural areas for health care reforms.
The Committee recommends that the Secretary, in conjunction with the Department of Justice and the Federal Trade Commission, use the federal Office of Rural Health Policy (or any other appropriate office) and the State Offices of Rural Health to educate rural providers and health professionals about antitrust aspects of developing alternative health delivery systems.
The Committee endorses the Secretary's current efforts to evaluate and test payment methodologies for telemedicine. The Committee recommends that additional pilot projects be established within the next fiscal year to test payment methodologies and collect data on costs, utilization, outcomes, provider and patient satisfaction, etc. The pilot projects should be non-proprietary, open architecture systems using a variety of telemedicine technologies and configurations. These projects should be evaluated on an ongoing basis with annual reports to the Secretary. After two years, each annual report should include information that will assist the Secretary in developing appropriate payment policies.
The Secretary should increase the rural samples and take other steps to improve the rural analytic capability of two key national health surveys -- the National Medical Expenditure Survey and the National Health Interview Survey. This improved capability is critical to assessing differences in access to health care for citizens living in communities that vary by degree of rurality, for example, by population density and distance to an urban area. In addition, the Secretary should direct the National Center for Health Statistics to explore augmenting the rural sample of the Health and Nutrition Examination Survey.
The Committee recommends that explicit attention be paid to rural concerns as risk adjustment methodologies are developed in conjunction with health insurance reforms. Such concerns include the lack of good cost data on rural minority populations and occupational illness and injury. The Committee urges the Secretary to consult rural experts, including the Committee, in developing data bases and methodologies for risk adjusters that include rural populations.
The Committee recommends that the Secretary take steps to ensure that grant and contract program announcements issued by the Department do not ignore rural realities and disadvantage rural applicants. The Committee also recommends that the Secretary find additional methods for announcing program opportunities in rural areas, rather that relying exclusively on the Commerce Business Daily and Federal Register.
Recommendation: Medicare under Health Care Reform
The Committee reiterates recommendation 93-15 from the Sixth Annual Report on Rural Health asking the Secretary to assimilate Medicare beneficiaries into the health alliances of the reformed health care system as quickly as possible.
Recommendation: Medicare Dependent Hospitals
The Committee recommends that the Secretary establish a short-term task force to study the need to continue the Medicare Dependent Hospital program under health care reform.
Recommendation: Migrant Workers
The Committee recommends that the Secretary consider development of separate health alliances for migrant workers in each of the migrant streams.
The Committee recommends that the Secretary support legislation to authorize the Health Care Financing Administration (HCFA) to conduct demonstrations of alternative rural health care delivery systems that require waivers of the Medicare conditions of participation for hospitals.
The Committee reiterates the recommendations it made in its Sixth Annual Report on Rural Health addressing health professions education (93-5 to 93-14).
The Committee recommends that the Secretary support legislation to provide tax incentives to primary health care practitioners who locate their practices in rural Health Professions Shortage Areas (HPSAs) and Medically Underserved Areas (MUAs). Such incentives should be offered both to new and existing rural practitioners.
The Committee recommends that the Secretary support enhanced mental health and substance abuse services.
The Secretary should expand the personnel qualifications for physician-performed microscopy procedures to include other primary care practitioners, i.e., nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (Pas), and certified nurse-midwives (CNMs).
The Secretary should extend the grandfathering clause for general supervisor of a high complexity laboratory to all individuals who were qualified, as of February 28, 1992, to serve as the general supervisor of a hospital laboratory under the clinical laboratory requirements published March 14, 1990.
The Secretary should support legislation authorizing the Secretary to designate Rural Primary Care Hospitals (RPCHs), as defined by law, in communities where hospitals have been closed for more than one year.
The Secretary should appoint a rural representative to the Clinical Laboratory Improvement Advisory Committee (CLIAC).
The Secretary should develop a national health professions workforce plan that specifies goals for the types, specialties, and geographic distribution of health professionals necessary to meet the health care needs of the nation.
The Secretary should support legislation to restructure federal funding of education programs for health professionals so the funding decisions are based on the success with which the training programs contribute toward achieving the goals of the health professions workforce plan.
The Secretary should support legislation requiring all health care payers to participate in funding health professions education.
The Secretary should support legislation to make health professional education funding available to health professional and residency programs in varied settings, not just those owned or operated by a hospital.
The Secretary should support the development of rural practice sites as training sites for both undergraduate and graduate health professional training.
The Secretary should encourage the development of interdisciplinary training programs
The Secretary should develop initiatives to broaden access and innovation in health care delivery by supporting local programs that utilize indigenous community workers and paraprofessionals as essential members of community health care delivery teams.
The Secretary should support legislation to modify the Medicare payment provisions for graduate medical education to provide funding for undergraduate and graduate training of physicians and other health care professionals.
The Secretary should support legislation to provide Medicare funding for training in varied settings, not just those owned or operated by a hospital.
The Secretary should support, both through policy development and legislation, a restructuring of the Medicare physician payment system so it contributes toward achieving the goals of the health professions workforce plan.
The Secretary should support legislation to assimilate Medicare beneficiaries into the health alliances of the reformed health care system as quickly as possible.
The Secretary should consider the special needs of rural areas in the further development of mental health and substance abuse benefits under health care reform, and the need to improve access to these services in rural areas. The Committee recommends several general principles to be considered in meeting the needs of rural areas.
The Secretary should direct the Bureau of Health Professions to develop and implement (in collaboration with the National Association of State Mental Health Program Directors, the Center for Mental Health Services, and the Office of Rural Health Policy) a national plan to respond to the severe shortage of mental health professionals in rural areas.
The Secretary should support the Center for Mental Health Services, the Center for Substance Abuse Treatment, and the Center for Substance Abuse Prevention in developing the capabilities required to effectively carry out their respective missions as stated in P.L. 102-321 (the SAMHSA Reauthorization Act) in ways that are responsive to the needs and concerns of rural areas and populations. In responding to this recommendation, each Center should:
The Secretary should direct the Substance Abuse and Mental Health Services Administration to develop technical assistance programs to integrate mental health and substance abuse service with "generic" rural service delivery systems (i.e., primary health care, education, aging, developmental disabilities, criminal justice, etc.) and increase the capacity of these systems to meet the needs of their clients with mental health and substance abuse problems.
The Secretary should support the development of new ways to ensure that rural areas and populations have equal access to federal funding and support in mental health and substance abuse. Specifically, the Secretary should:
The Secretary should establish a demonstration grant program to rural communities to provide early parenting education and support to first-time parents. the demonstration program should include a three-pronged strategy that would involve the development of local family resource centers, community-based assessment and home visitation services, and the development of networks and referral agreements between related programs and services.
The Secretary should support legislation to continue the Rural Hospital Transition Grant Program.
The Secretary should convene a meeting of the key participants in the EACH/RPCH program to resolve problems and to develop legislative and regulatory strategies that will facilitate implementation of the program.
a) The proposed guideline for hospitals seeking a higher wage index should require wage payments that are 100 percent instead of 108 percent of the average hourly wages of the area in which they are physically located.
b) The Secretary should seek a legislative or administrative change that would permit reclassification decisions to be made for periods of three years rather than one year.
The Secretary should support a legislation change that would allow for different adjustments in fees paid to rural and urban providers if volume of services rendered by urban providers rises faster than for rural physicians.
The Secretary should propose legislation that provides additional financial incentives for physicians to practice in rural areas. The incentives should be greatest for physicians practicing in rural Medically Underserved Areas (MUAs) and rural Health Professional Shortage Areas (HPSAs).
The Secretary should reconcile the regulatory requirements for clinical laboratories and the regulatory requirements for RHCs to make it possible for RHCs to comply with the requirements of both programs as "certificate of waiver" laboratories.
When reviewing health care reform proposals, the Secretary should use the principles developed by the Committee as a guide for evaluating the appropriateness of the reform proposal for rural areas.
The Secretary should support legislation that will establish a set of minimum, portable, uniform benefits for all Americans. The program should not exclude individuals from eligibility for health insurance and access to health care due to employment status or lack of permanent residence. The benefits should provide a continuum of services ranging from preventive care to rehabilitative and long-term care.
The Secretary should develop demonstration programs that allow and encourage collaboration of all major health care providers to make health care available in rural communities.
The Secretary should support health care reform legislation that will assure that rural residents have adequate access to health care. Specifically, support should be given for the following areas:
The Secretary should support health care reform legislation that encourages the integration of health and education services for all segments of society.
The Secretary should support health care reform legislation that provides for rapid resolution of payment disputes.
The Secretary should direct the Office of Rural Health Policy to establish a coordinating forum on agricultural health and safety for the purpose of sharing information and coordinating agricultural health and safety activities across federal departments or agencies.
The Secretary should seek an increased appropriation for the State Offices of Rural Health Program (SORHs) to enable each State Office to take a leadership role in, and provide a forum for, addressing rural occupational health and safety issues (including farming, logging, fishing, and mining) within their respective state and local health communities.
The Secretary should seek an appropriation for the Bureau of Health Professions (BHPr) of the Health Resources and Services Administration to support the development of continuing education programs in agricultural health and safety, including prevention, diagnosis, and treatment.
The Secretary of Health and Human Services should ask the U.S. Department of Agriculture to request that the Cooperative Extension Service begin a child farm safety course for farm children and the parents of children who help on the farm. The course should include a manual of information, similar to the Hunter Safety Course now offered by the National Rifle Association. This manual could be all inclusive, from equipment to pesticides, to hypothermia, to first aid, and so forth.
The Secretary of Health and Human Services should work with the Secretary of Agriculture to develop cooperative programs and incentive funding to attract rural young people to health careers. This should be accomplished in cooperation with the Youth-at-Risk Initiative of the Extension Service's 4-H Development Program. Special attention should be paid to providing opportunities to young people from ethnic and cultural minorities. Whenever possible, this initiative should involve the State Offices of Rural Health, and should be developed with participation from AHECs, the Office of Minority Health, and local health departments.
The Secretary should work with the Secretaries of the Department of Labor, Commerce, and Agriculture to seek legislation for the mandatory inclusion of Rollover Protective Structures (ROPS) and seat belts on all new tractors, and a five-year incentive program to retrofit ROPS and seat belts on tractors currently in use. The cost of the tractor retrofits could be shared by state and federal governments, equipment manufacturers, and tractor owners. Tractor-like devices used in logging should be included under the provisions of this recommendation.
In anticipation of the North American Free Trade Agreement (NAFTA), the Secretary of Health and Human Services should work with federal, state, local, and private agencies and businesses on both sides of the U.S./Mexico border to identify and create effective working models that address the health care challenges faced by populations living along the border. The models should address housing, sanitation, water quality, infectious disease, pesticide and other environmental hazards, and occupational health and safety. In addition, the models, should, as much as possible, reflect a community organization approach that empowers local residents.
In cooperation with the Mexican Ministry of Health, Pan American Health Organization (PAHI), and/or private foundations, the Secretary of Health and Human Services is urged to support six to eight binational U.S./Mexico Rural Border Area projects to demonstrate improved, comprehensive, primary health care services. This would include sanitation and preventive care focusing on maternal, infant, and adolescent health.
The Secretary should urge the newly-created Center for Mental Health Services in the Substance Abuse and Mental Health Services Administration (SAMHSA) to address the severe shortages of mental health professionals in rural areas as one of its first priorities.
The Secretary should direct the Administration for Native Americans to develop and disseminate a technical assistance document that reviews current roles and responsibilities of federal, state, local and tribal governments for rural Native Americans' and Alaska Natives' health. It should provide examples of rural models for collaboration among these governmental entities.
The Secretary should direct the Indian Health Service to develop strategies for improving health services to Native Americans through the expansion of specialized women's clinics, school-based clinics, enhanced support of substance abuse and fetal alcohol syndrome prevention initiatives, and increased training and use of physician assistants and nurse practitioners.
The Secretary should provide technical assistance regarding FQHC and RHC programs by: 1) offering a technical assistance hotline so that questions about program elements, distinctions of the two programs, and requirements can be answered; and 2) offering regional workshops, marketed to a broad spectrum of practitioners and facilities, to assist attendees in understanding the similarities and differences in the programs.
The Secretary should direct the Bureau of Primary Health Care to set aside dollars appropriated to the National Health Service Corps (NHSC) for more travel and on-site consultation with states to promote a greater understanding of the goals and the policies of the NHSC program.
At least one of the annual policy objectives or program priorities of the Secretary, the Assistant Secretary for Health, and the Administrator of the Health Care Financing Administration should address improving access to health care for America's rural citizens.
Concurrent with the annual submission of the President's budget, the Secretary should prepare an analysis of the budget's impact on programs that provide access to health care in rural areas.
Any adjustments for budget neutrality in the transition rules for phasing in the new fee schedule should incorporate only those adjustments which can be shared equally by all physicians, not just those whose fees are, by design, significantly increased under the new fee schedule.
The Secretary should direct the Health Care Financing Administration (HCFA) to examine the expected volume response to the new system by specific specialty groups and for specific procedures. Based on this examination, HCFA should develop methods to penalize only those providers whose volume of services increases inappropriately, rather than all physicians.
The Secretary should seek legislative change which would eliminate all geographic payment adjustments under the new fee schedule for physicians.
The Secretary should direct HCFA to refine its malpractice adjustment in the Medicare physician fee schedule formula to recognize the actual services provided by rural primary care physicians.
The Secretary should establish a minimum level of financial protection of all hospitals under the new Medicare prospective capital payment system. Specifically, a "payment floor" of 80 percent should be established so that under the new system, no hospital would receive less than 80 percent of its actual capital costs.
The Secretary should direct HCFA to include leasing costs in the definition of "old capital" under the new system.
Essential Access Community Hospitals and Rural Primary Care Hospitals should receive special financial protection under the prospective payment system for capital.
The Secretary should direct the General Counsel of the Health Care Financing Administration (HCFA) to review the Administration's (HCFA's) original interpretation of OBRA-87 -- Section 4073 relating to the coverage of nurse-midwife services under Medicare.
If, upon review of the original interpretation, a decision is made to cover gynecological and family planning services provided by CNMs under Medicare, HCFA should issue revised manual instructions to the carriers in an expeditious manner and issue regulations pertaining to the statute no later than March 1, 1992.
If, upon review, the General Counsel concludes that the original interpretation of the statute is the best (in light of the legislative language), the Secretary should propose that Congress amend the statute to provide for coverage of CNM services outside of the maternity cycle.
Any cost-based payment system for FQHCs should reflect their actual cost experience, without imposition of arbitrary limits. The FQHC payment system should not incorporate arbitrary distinctions between urban and rural areas.
The Secretary should require annual reports from FQHC look-alikes and develop a recertification process for them that occurs at least every three years.
The Secretary should direct the Agency for Health Care Policy and Research (AHCPR) to establish obstetrical access and liability as a research priority within its legal-medicine program in 1992. As a component of this priority, the Agency should evaluate state health care malpractice and liability initiatives that address obstetrical access.
The Secretary should continue to work closely with the Department of Justice to support legislation that would provide relief to community and migrant health centers from excessive malpractice insurance costs. This relief could be provided by amending the Federal Tort Claim Act to extend coverage to community and migrant health centers (C/MHCs) and to health professionals who are employees or contractors of C/MHCs, or through some alternative mechanism.
The Secretary should allow dollars currently being utilized by health centers for malpractice premiums to remain in the health centers. The dollars should be directed to risk management and quality improvement activities, as well as activities to expand or enhance patient care. The Secretary, through the Bureau of Health Care Delivery and Assistance, should continue to support rigorous risk management and quality improvement activities in C/MHCs.
The User Liaison Program of the Agency for Health Care Policy and Research (AHCPR) should include a rural focus in programs developed to educate state legislators and executive staff about medical malpractice and liability issues.
The Committee further recommends that AHCPR include the 1987 DHHS Report of the Task Force on Medical Liability and Malpractice in its program materials. Last, it recommends that AHCPR provide the technical assistance needed to help implement the model Health Care Provider Liability Reform Act or a comparable comprehensive reform model act.
The Agency for Health Care Policy and Research should assure that rural representation is included in all phases of the guideline development process, including rural representation among peer review consultants and among the facilities in which clinical guidelines are pilot-tested. It should further seek to include rural representation, including rural consumers, on the guideline advisory panels. The AHCPR should work with the Office of Rural Health Policy to identify rural consultants for the peer review process and rural facilities for the pilot-testing of the standards.
The Secretary should instruct HCFA to amend the Medicare reimbursement formula for home health services to cover additional costs of delivering health care in rural areas that result from such factors as increased travel distances.
The Secretary should instruct HCFA to issue specific regulations or instructions to implement the "social factors" provision contained in OBRA '87. This provision directs Peer Review Organizations (PROs) to approve, under specific circumstances, inpatient hospitalization for treatment that would otherwise be on an outpatient basis. Specific circumstances that justify inpatient hospitalization include special problems associated with delivering care in remote rural areas, the availability of service alternatives to inpatient hospitalization, and other factors that could adversely affect the safety or effectiveness of treatment provided on an outpatient basis (Public Law 100-203, sec. 4094(a)).
The Secretary should direct the Office of Disease Prevention and Health Promotion and the Administration on Aging to develop, in cooperation with the Office of Rural Health Policy, a health promotion initiative that focuses on rural communities. This effort should also involve the USDA Cooperative Extension Service, and any foundations that are investing in this issue.
A. The Administration on Aging (AoA/DHHS) should work with the Urban Mass Transportation Administration (UMTA/DOT) to:
B. The Secretary should request that DOT fund demonstration projects from UMTA funds that will improve access to health services for the rural elderly.
The Secretary should work with States to develop a quality assurance strategy for certified home health services and services provided at extended care facilities in rural areas.
The National Institute on Aging should direct its Exploratory Centers on Aging and Health in Rural America to work with the ORHP-funded Rural Health Research Centers, as appropriate to:
Based on these findings, NIA, in consultation with ORHP, should determine whether it is desirable and feasible to conduct a pilot project implementing some of the best approaches.
The Secretary should improve the availability of information regarding the rural elderly through support of activities such as the Rural Information Center/Health Services (RICHS) at the National Agricultural Library, the National Resource Center for Rural Elderly at the University of Missouri-Kansas City, and the Rural Outreach Program of the National Library of Medicine (NLM).
The Secretary should seek increased appropriations for Title VII and Title VIII health professions programs, targeting funds to programs which train health professionals for practice in rural and other underserved areas.
The Secretary should support legislation to amend Title VII to include the Rural Interdisciplinary Program, and should seek an increased appropriation for this program
The Secretary should support legislation to amend Title VII of the U.S. PHS Act to include the Rural Medical Education Demonstration Program. The program's authorization should be amended to expand the program to ambulatory settings and authorize start-up grant funds.
The Secretary should establish the following funding factors (preference and priorities) for the Title VII and VIII health professions programs:
The Secretary should direct the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) to revise the ADMS block grant drug apportionment formula used to allocate drug monies between states. The formula's preferential weighting for urban populations should be adjusted downward to more accurately reflect the actual differences in urban and rural drug abuse rates. The Secretary should then propose legislation that incorporates the revised funding formula.
The Secretary should propose legislation to eliminate the mandated set-aside for drug abuse services within the ADMS block grant's intra-state substance abuse funding component. This should be eliminated to allow the intrastate allocation of funds to more accurately reflect the actual rates of alcohol and drug abuse in rural areas.
Until legislation can be enacted to ensure a more equitable distribution of substance abuse monies within states, ADAMHA should expedite the granting of waivers to states for the intravenous drug abuse set-aside.
The Secretary should require that each state describe in its ADMS block grant plans how it will address the specific service delivery needs of its rural populations.
The Department should identify ten model communities where the provision of alcohol, drug abuse and mental health services are currently integrated into the delivery of other primary care services. Their successful strategies should be described and promulgated to other rural communities across the nation. Any legislative, regulatory or administrative barriers that impede such integration should be identified and targeted for elimination.
The Office of Rural Health Policy should work closely with the "Primary Care - Substance Abuse Linkage Initiative" of the Office of Treatment Improvement, ADAMHA, to coordinate activities and strengthen its rural focus.
The Secretary should seek legislation to expand the authority of the Office of Rural Health Policy to include policy issues on rural mental health and substance abuse and should seek an increased appropriation to support such activities.
The Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) should develop research strategies to establish the epidemiology of substance abuse and mental health problems in rural areas, identify the full range of professionals providing mental health services to these populations, and measure the current level of service availability.
The Secretary should direct the National Institute of Mental Health to conduct research to define the scope of primary mental health services needed in rural areas.
When this research has been completed, the Secretary should:
The Secretary should implement targeted educational initiatives, including continuing education, to increase the number of health and human service professionals providing rural mental health, substance abuse prevention and treatment services.
The Secretary should direct the National Health Service Corps (NHSC) to: 1) establish a second priority within its scholarship and loan repayment programs for individuals in the five core mental health professions, and 2) seek an increased appropriation to support this second priority.
The Committee requests that the Health Resources and Services Administration analyze the impact on frontier areas of the new criteria for allocating National Health Service Corps (NHSC) personnel to "HPSAs of greatest need." If the new criteria appear to be detrimental to the placement of personnel in frontier areas, the Bureau of Health Care Delivery and Assistance should work with the Office of Rural Health Policy to revise them for the 1993 placement cycle.
By October 1, 1991, the Secretary should draft legislation to establish direct payment of mid-level providers practicing in rural areas according to the following criteria:
a. Definition of Mid-level Providers: Mid-level providers are primary care physician assistants and advanced practice nurses (nurse practitioners and clinical nurse specialists) who meet state licensure requirements.
b. Services and Settings: Payment should be made for primary care services covered by Medicare physician payment policies. The existing Medicare definition of primary care services include: office and clinic visits, hospital visits, nursing home visits, emergency care, and home visits.
c. Geographic Areas: Payments for such services should be limited to mid-level providers practicing in rural Health Manpower Shortage Areas (HMSAs), rural Medically Underserved Areas (MUAs) designated by the U.S. Public Health Service, or non-metropolitan counties with a primary care physician-to-population ratio less than the national rural average for the same ratio. Primary care physicians are defined as physician providers in the fields of Family Practice, General Practice, General Internal Medicine, General Pediatrics and Obstetrics/Gynecology, excluding medical residents and fellows.
d. Collaboration with Physicians: Formal collaboration and referral arrangements between mid-level providers and primary care physicians should be an essential condition of participation in the Medicare program. Consultations provided by primary care physicians should be reimbursed appropriately under a relative value scale, except as already provided through other payment programs such as the Rural Health Clinics Act.
e. Payment Policy: The payment level for mid-level providers should be set at a level of 100% of primary care physician payment for the same services.
f. Assignment Policy: The assignment policy for mid-level providers should be the same as the assignment policy for primary care physicians.
The Secretary should delay implementation of CLIA '88 until its impact on access to care in rural areas can be adequately assessed.
The Secretary should propose legislation to modify the EACH Program. The legislation would be amended to give States and rural hospitals more flexibility in designing rural health care networks. The recommended changes would: 1) Provide for a waiver of the 72 hour limit on inpatient stays within a Rural Primary Care Hospital (RPCH) for states that submit acceptable proposals to establish a set of services which may be appropriately provided within the RPCH or for other alternative approaches to defining a RPCH; (2) Provide for waivers that would allow states to propose alternative definitions for the EACH; (3) Clarify that hospitals designated as a RPCH are allowed to participate in the swing bed program; 4) Stipulate that states may propose to include hospitals in adjacent states in a rural health network.
The Secretary should create a set-aside fund under the Rural Hospital Transition Grant program specifically earmarked for rural hospitals that propose a transition from a full service acute care facility to an institution which offers less intensive but essential services to its community. The fund would also support experimental efforts toward the development of the "primary care hospital" concept.
To ensure a rural focus in the Department's efforts to improve the health status of African Americans, Hispanics, Native Americans and Asian/Pacific Islanders, the Secretary should direct the Office of Minority Health, in cooperation with the Office of Rural Health Policy, to:
1) Sponsor and conduct a national conference on improving minority health in rural areas; and
2) By September 1, 1991, subject a report which outlines recommendations for departmental initiatives to reduce the health disparity of minorities living in rural areas.
The Secretary should establish a task force to develop strategies that promote coordination of Bureau of Health Professions (BHPr) and Bureau of Health Care Delivery and Assistance (BHCDA) programs to better link training and service in Federal programs. More specifically, the task force should develop strategies that foster utilization of rural community and migrant health centers (C/MHCs) as sites for conducting career awareness and clinical training activities. As a component of this initiative, a demonstration program should be developed to provide funding to rural C/MHCs to engage in career awareness activities and clinical training.
The Secretary should direct the Health Resources and Services Administration to make the following changes in its programs to promote awareness of health career opportunities and promote career development among rural minority populations:
The Secretary should direct that all Departmental surveys of health professionals be designed so as to permit analyses by urban/rural and racial/ethnic classifications. Departmental surveys should be designed to permit evaluation of personnel information on minority health professionals by urban and rural location of practice. Data collection systems should also be devised which permit the further categorization of rural data into"frontier" and "non-frontier" rural areas.
The Secretary should sponsor an invitational workshop for the purpose of developing a standardized format for the collection of rural/urban and racial/ethnic health professional data. The workshop should include representation from national health professional associations, health education associations, and training programs.
The Secretary should direct the Bureau of Health Professions (BHPr) and the National Institutes of Health (NIH) to require a health personnel training programs funded by them to routinely collect program monitoring data that use both urban/rural and racial/ethnic identifiers, consistent with the Privacy Act and confidentiality constraints. In addition, the programs should be required to track participants as to where they practice upon completion of their training. These data should be collated and analyzed by the various funding agencies, and reported to the Office of Rural Health Policy and Office of Minority Health.
The Department of Health and Human Services should collect accurate, comprehensive information about the extent, characteristics, and impact on HIV disease in rural areas. The Agency for Health Care Policy and Research, the Centers for Disease Control, the Alcohol, Drug Abuse, and Mental Health Administration, and other Federal agencies or programs, as appropriate, should fund studies to improve understanding of the epidemiology, demographics, impact, and trends of HIV disease in rural areas.
Federal block grants to states for HIV disease prevention and treatment services should be contingent upon the existence of a statewide plan which effectively addresses rural HIV/AIDS needs and the designation of a single state agency responsible for coordinating the state's response to HIV disease.
The Centers for Disease Control and the Health Resources and Services Administration should develop and support a coordinated program of technical assistance for community-based organizations doing HIV prevention and providing services to HIV-infected persons in rural areas.
The community-based organizations play a critical role in preventing the spread of HIV and providing services to HIV-infected persons. These programs need technical assistance with organizational development and programming. Currently technical assistance is provided by a number of agencies and programs. These are not well coordinated, and there is no assurance that all important areas of training are addressed. Training and technical assistance should address at least:
The appropriate Federal agencies, in particular the Centers for Disease Control and the Health Resources and Services Administration, should support programs to promote and foster local leadership to orchestrate the HIV response in rural areas.
The AIDS Education and Training Centers should establish or expand telephone hot line services and other programs to assure that rural primary care providers have easy, rapid access to HIV/AIDS treatment information, drug trials and referrals. Further, the AIDS Education and Training Centers should expand networks linking rural health care providers with major medical centers, to ensure access and quality care to persons with HIV disease.
State Medicaid Offices should establish 800 numbers to provide information on Medicaid eligibility for and coverage of HIV-disease to HIV-infected persons, providers, patient advocates, and the state's local social service offices.
The Secretary should provide guidance to states in their use of the Ryan White Act HIV/AIDS funds to assure attention to the needs of the increasing number of HIV-infected persons in rural areas.
The Secretary should accept the recommendations of the third report of the National Commission on AIDS, especially their recommendations to develop comprehensive community-based primary health care systems and to expand AIDS education and outreach services to rural communities. (National Commission on Aids, Report No. 3, Recommendations One and Two.)
The Secretary should direct the Health Resourcesand Services Administration to develop a compendium of state initiatives that have been undertaken or are currently underway to address obstetrical malpractice. In addition, the compendium should describe state initiatives to train and place practitioners of all levels (physicians and mid-level practitioners) in rural areas to more effectively meet these areas need for obstetrical practitioners. The compendium should include copies of legislation (proposed and enacted) and should be disseminated to the National Governors Association, National Conference State Legislatures, Council of State Governments, the National Association of Counties, state offices of rural health, and other appropriate entities.
The Health Resources and Services Administration should work with the Agency for Health Care Policy and Research (AHCPR) to track or monitor ongoing state initiatives that address obstetrical malpractice issues and evaluate their effects.
The Secretary should establish a special commission to examine the barriers to effective and efficient utilization of all obstetrical providers (both physicians and mid-level practitioners) who provide care in rural areas. The commission should be charged with proposing policy and strategies for implementation at Federal, state and local levels. Strategies should include the development of incentives to promote more effective utilization of all health professionals who provide obstetrical services. To facilitate the development and acceptance of policies and strategies, the commission should include representatives from the National Governors' Association, the National Conference of State Legislatures, the Council of State Governments, and the National Association of Counties.
The Bureau of Health Professions should establish a funding priority for health professions education/training programs which prepare health professionals for rural primary care practice and which have a strong obstetrical practice component.
The Secretary should propose legislation to the Congress that would establish a Medicare inpatient payment floor for rural hospitals with less than 50 acute care beds and for Sole Community Hospitals (SCHs). The payment floor would be based on an individual hospital's current cost experience. The legislation would be effective for hospital cost reporting periods beginning on or after October 1, 1989, and end at such time that special Medicare payment provisions for essential access facilities are implemented. For the purposes of this legislation, acute care beds include swing beds, but exclude licensed beds for long-term care and newborn bassinets.
The Secretary should propose legislation that would establish a single national standardized payment amount to replace the separate urban and rural Medicare standardized amounts. The single payment rate system should incorporate more sensitive adjustments for differences in case-mix, severity, area wage levels, and other non-labor price adjustors. The current urban-rural differential should be phased out over a 3-year period such that a single national standardized amount would be implemented for cost reporting periods beginning no later than October 1, 1992.
By the beginning of FY 1991, the Secretary should implement a refined area wage adjustment to better reflect differences in hospital wages. Prior to implementing this adjustment, the Secretary should develop and test the appropriateness of an area wage adjustment that assumes a single national labor market for professional personnel.
By the beginning of FY 1992, the Secretary should have in place a mechanism of annually updating the area wage index used in the Medicare PPS. The data collected should reflect the true labor costs of hospitals for professional and non-professional occupational categories of employees.
Given the congressional mandate for the Secretary to develop a legislative proposal on prospective payment for hospital outpatient services, the Secretary should evaluate carefully the impact of such proposals on rural hospitals.
The Secretary should continue the Department's support for the Medical Assistance Facility Demonstration Project in Montana. Additional research and demonstrations should be supported to encourage communities to test various transition strategies to ensure continued access to health services in their communities.
By April 1, 1992, the Secretary should submit to Congress legislative proposals for implementation, by October 1, 1992, of a coordinated strategy to protect the financial viability of essential access facilities (EAFs). The strategy should include uniform guidelines for identifying EAFs, a process for designating such facilities, and the design of appropriate Federal program protections. Incentives and specialized grant programs should be developed to encourage adoption of the EAF concept and enhance the quality and scope of services available in these facilities. The Office of Rural Health Policy should be charged with the responsibility for defining and developing the strategy because EAFs play a major role in ensuring access to health care in rural communities.
The Secretary should work with the Department of Housing and Urban Development (HUD) and the U.S. Department of Agriculture to improve access to capital for rural facilities through increased availability of Farmers Home Administration direct and guaranteed loans (non-farm), HUD 242 and 232 loan guarantees, and PHS Section 1610(a) and (b) grants for construction and modernization. Such funding would be limited to those facilities determined to be critical for access to health care in the community.
The Secretary should support the rural Hospital Transition Grant Program through FY 1990. Beginning in FY 1991, legislation should be proposed to the Congress that would make non-hospital health organizations, community organizations, agencies, or political subdivisions eligible as grantees. The program's title should be changed to "Rural Health Services Transition Grant Program" and be broadened in scope to include a community needs assessment which encompasses comprehensive health care, health promotion, alcoholism, substance abuse, mental health, and emergency medical services.
By October 1, 1992, the Secretary should develop a series of programs that would facilitate integration and coordination of services in or among rural communities. The programs should include new demonstrations and increased emphasis in current programs on improving both horizontal and vertical linkages, integration, and cooperation between community and migrant health centers, local primary care providers, hospitals, medical group practices, and public health departments. These programs should be the result of a careful analysis by the Office of Rural Health Policy of existing demonstrations and should reflect a thorough review of existing Federal and state barriers, both legislative and regulatory, that impede integration.
The Secretary should propose legislation to the Congress establishing a demonstration program (10 rural sites) that would consolidate all categorical funds and programs for health into a single "one-stop" office, particularly in very poor or small communities.
The Committee recommends that any policy positions adopted by the Department that relate to a restructured reimbursement system for physicians should adhere to the following principles:
1) Medicare payments to all physicians practicing in rural areas should be increased to eliminate existing urban-rural differentials.
2) Payment increases for rural primary care physicians should be accelerated. During the transition period to any new reimbursement system, the payment floor for primary care services should be increased from 50 percent to 80 percent of national average prevailing charges to be effective January 1, 1990. The increased payment schedule should be restricted to physician specialists in family practice, general practice, general internal medicine, obstetrics and gynecology, and general pediatrics who practice in designated rural (i.e., non-metropolitan statistical) areas of the Nations.
3) Provisions for updating any physician fee schedule should allow for differential updates according to geographic locations, category of service, or other pertinent variables explicitly related to addressing access problems of the underserved.
4) Attempts to define, by legislation, a geographic practice cost index should be deferred until 1991 to allow sufficient time for the Physician Payment Review Commission to complete proposed studies and subsequent evaluations related to alleged variations in the geographic costs of practice.
5) In the event a restructured payment system is not adopted by Congress, the Secretary should recommend an increase in the payment floor as noted above in Principle 2.
The Secretary should propose legislation to amend the Internal Revenue Code of 1986 to provide refundable income tax credits to primary care providers who work in federally-designated rural health manpower shortage areas (HMSAs). Primary care providers should be defined as doctors of medicine or osteopathy, physician assistants, nurse specialists who provide direct patient care and practice principally in one of the four following primary care specialties: general or family practice, general internal medicine, general pediatrics, and obstetrics and gynecology.
The Secretary also should support legislation to extend the Medicare incentive payment bonus for physicians practicing in Class 1 and Class 2 designated HMSAs to primary care physicians practicing in all designated rural HMSAs, and increase the bonus such that these physicians receive not less than a 10 percent payment bonus.
The Secretary should seek appropriations from Congress in FY 1990 and subsequent years to provide scholarships to entering medical and osteopathic, nurse practitioner, nurse-midwifery, clinical nurse specialist and physician assistant students. In addition, the Secretary should make or, where necessary, seek the authority to make, the following programmatic changes to revitalize the scholarship program:
Priority for scholarships should be limited initially to medical, osteopathic, nurse practitioner, physician assistant, nurse midwifery and clinical nurse specialist students who intend to specialize in family practice, general internal medicine, general pediatrics, or obstetrics/gynecology.
The Secretary should support states in their efforts to establish effective loan repayment programs by providing adequate funding to states. The Secretary should also continue to seek to develop an effective Federal loan repayment program. As such, the Secretary should seek increased appropriations for the loan repayment program and support legislation that eliminates the tax liability of the Federal loan repayment programs. Among techniques the Secretary should consider to attract larger numbers of qualified individuals into the Federal loan repayment program are: (1) increasing publicity about the program; (2) increasing the loan amount the Government can repay; and (3) covering undergraduate loans.
The Secretary should recommend that funding for the health professions programs administered by the Department of Health and Human Services be maintained to preserve the capacity and continuity of education/training programs that ensure a supply of competent health care providers for rural areas and other underserved groups. Special priority should be given to programs that prepare individuals for primary care, rural practice, or practice with other underserved groups.
The Secretary should establish a special short-term task force to develop specific recommendations addressing barriers in health professions accreditation and licensure standards that impede the development of rural clinical experiences, internships, preceptorships and residencies.
The Secretary should seek an appropriation of $5 million for the "Health Care for Rural Areas" program, authorized in 1988 (P.L. 100-607). The program would provide grants to develop innovative, interdisciplinary training programs that would educate health professionals for rural practice.
The Secretary should propose legislation to expand the "Rural Medical Education Demonstration Projects" program to an additional 12 demonstrations, half of which utilize rural hospitals as a teaching site and half of which would utilize a rural ambulatory practice setting. The expanded program should incorporate flexible geographic criteria for awarding demonstrations that would result in a reasonable representation of provider sites across the Nation.
The Secretary should propose an increase for the C/MHC programs in the Department's FY 1991 budget. At least 50 percent of the increase should be earmarked for projects in rural and frontier areas.
The Secretary should ensure that the current process for designating HMSAs and MUAs is maintained until a full evaluation is conducted on the implications that any change would have on the myriad of programs that utilize the designations.
The Secretary should disseminate information to promote an increase in the number of RHCs. Technical assistance should be provided to assist potential providers in qualifying for RHC designation.
The Secretary should direct the Office of Rural Health Policy to convene and staff a Federal Rural Health Work Group composed of all Federal agencies that have programs/activities with a rural health-related mission (e.g., Departments of Agriculture, Transportation, and Veteran's Affairs). Further, the Secretary should recommend establishment of a Presidential Rural Health Council to mobilize the public and private sectors to better address rural health problems.
The Secretary should establish a focal point within the Department for the planning and coordination of emergency medical services (EMS) activities. The Secretary should propose legislation to improve the availability of EMS in rural areas through matching grants to states.
The Secretary should issue a policy directive to states that implementation of all block grants address the unique service needs of rural areas.
The Secretary should ensure that current departmental efforts to address education and treatment in the "war on drugs" include a focus on rural communities.
The Secretary should propose legislation to the Congress that would establish a national occupational/environmental health program to address major health hazards through an interdisciplinary educational program in conjunction with high schools, colleges, academic health centers and Cooperative Extension Services.
In addition, the Secretary should propose legislation to the Congress that would establish a national network of 10 rural occupational/environmental health services centers in conjunction with academic health centers or major medical centers. These would provide screening, diagnosis, treatment, research, and educational services using an interdisciplinary team approach.
The Secretary should propose legislation to the Congress that would establish a national demonstration program (five rural community sites), in cooperation with states and the private sector, to establish different types of adolescent health programs. Such demonstrations would include implementation of a comprehensive K through 12 health education curriculum in combination with on-site counseling, preventive and social/health services within a school district. These services would be provided by a health professional.
The Secretary should support continuation of the HCFA "10 percent set-aside" of research and development funds for rural health research. The Office of Rural Health Policy should encourage the rural health research centers to sponsor a national conference.
The Secretary should direct the Office of Rural Health Policy to identify and catalog models of rural-focused health professions education and training programs, including those programs which address leadership, management and governance. A compendium of these models should be developed and disseminated.
The Secretary should ensure that all Federal health personnel data collection efforts permit analysis by urban and rural classifications. Further, the Secretary should work with public and private organizations that are involved in rural health personnel research and data collection efforts to promote the uniform gathering and analysis of data using urban and rural categories.
The Secretary should seek adequate funding to enable the National Library of Medicine (NLM) to implement its outreach program. The Committee believes priority should initially be given to the following areas: