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Department of Health and Human Services
The National Advisory Committee on Rural Health and Human Services
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February 22-24, 2004, Washington, D.C.

Health Resources and Services Administration
Office of Rural Health Policy

Washington, D.C.
February 22-24, 2004


Meeting Summary

The 46th meeting of the National Advisory Committee on Rural Health and Human Services was held on February 22-24, 2004, at the Grand Hyatt Hotel in Washington, D.C.

Sunday, February 22

Governor David Beasley, Chairman of the Committee, convened the meeting. Governor Beasley welcomed the members and introduced two members who were attending the meeting for the first time. These members were Senator Raymond Rawson, D.D.S. from Nevada, and Ms. Heather Reed, Rural Health Administrator, Ohio Department of Health.

Other members present were: Mr. James R. Agras; Mr. David L. Berk; Mr. Evan S. Dillard, FACHE; Joellen Edwards, Ph.D., NP; Michael Enright, Ph.D.; Ms Bessie Freeman-Watson; Mr. Joseph D. Gallegos; Lenard Kaye, D.S.W.; Arlene Jaine Jackson Montgomery, Ph.D.; Keith Mueller, Ph.D.; Ron L. Nelson, P.A.; Sister Janice Otis; The Honorable Larry Keith Otis; Ms. Sally K. Richardson; Glenn D. Steele, M.D., Ph.D.; and Mr. Tim Size. The two members unable to attend were Stephanie Bailey, M.D., MSHSA, and Susan Birch, RN, BSN, MBA. Present from the Office of Rural Health Policy were: Marcia Brand, Ph.D.; Tom Morris, MPA; Ms. Michele Pray Gibson, MHS; and Jennifer Riggle, J.D. Present from the Administration on Aging was Mr. Dennis Dudley. Present from the Administration for Children and Families was Ms. Rachel Owen.

Governor Beasley asked if there were any changes to the minutes of the previous meeting. There were none and the minutes were approved. He then asked for comments on the annual report to the Secretary. Ms. Sally Richardson praised the report and asked that West Virginia be cited as one of the states providing mental health training to primary care physicians. Staff will make this change. Senator Rawson asked for clarification of some oral health data in the report. Mr. Morris will review the data and make any changes that are necessary. The Committee voted to adopt the report.

Staff Updates

Ms. Jennifer Riggle, Office of Rural Health Policy (ORHP)
Mr. Dennis Dudley, Administration on Aging (AoA)
Ms. Rachel Owen, Administration for Children and Families (ACF)

Ms. Riggle provided updates on the Secretary's Rural Initiative and the Medicare Modernization Act. She described the President's Community Health Center initiative and the Department's assumption of new responsibilities for the J-1 Visa Program. She also mentioned a new grant program at the Agency for Health Quality and Research. The Medicare Modernization Act provides over $20 billion for rural programs over the next 10 years. Ms. Riggle reviewed the FY 2004 appropriation for the ORHP and the Health Resources and Services Administration that includes $158 million for rural health programs. Finally, she reviewed several projects underway at the ORHP, including the Rural Assistance Center and the Emergency Medical Services Assistance Center.

Mr. Dudley presented a review and update of programs at the Administration on Aging. He described the AoA partnerships with State Units on Aging and the designated Area Agencies on Aging located throughout the country. AoA programs are closely coordinated through these agencies. He briefly described programs authorized by the Older Americans Act of 1965. They encompass transportation, services for low-income minority elders, health promotion, caregiver support, and others. Mr. Dudley highlighted the Assistant Secretary's priorities in health and the National Eldercare Locator system that helps seniors find services in their communities. He spoke about programs to help older people to remain at home and provided information on the National Family Caregiver Support Program.

Ms. Owen distributed an organization chart for the ACF and spoke about focus groups that have been conducted with rural grantees. A report on the focus groups will be available in a few months. Ms. Owen stated that the Assistant Secretary for ACF would be speaking later in the day and would provide more details on ACF activities.

Cross Sector Policy: A Rural Opportunity

Mr. Chuck Fluharty, Director, Rural Health Policy Research Institute

Mr. Fluharty gave a thought provoking presentation on framing public policy for rural health and human services. His major theme was the need to move beyond generalized approaches to rural health policy toward polices that are "place-based" and "cross-sectional." He stated that that there is a growing understanding of the rural landscape in the public policy sector as evidenced by the increasing importance of regional commissions and policies that recognize rural diversity. He described a "perfect storm" of issues, opportunities and challenges including: (1) The challenges of distance and space in operating programs; (2) Political trends and influences in the states; (3) Unique linkages between federal, state, and local government organizations; (4) Greater international focus on rural economic development; (5) The need for greater regional collaboration and a re-evaluation of jurisdictional alignments; (6) Greater involvement by the private sector; (7) The need for rural entrepreneurship, and (8) Opportunities presented by state agricultural officials who are beginning to think about rural economics in new ways. He discussed some hopeful trends in public policy related to greater collaboration among governmental and private organizations, a growing understanding of cultural diversity in rural America, and hopeful international trends. He used examples where local community colleges are working with rural hospitals and businesses on economic development issues. He also mentioned that rural health is now a priority for the National Association of Counties and other agencies that are strategically placed to address rural issues.

Mr. Fluharty spoke about the unique mission of the Advisory Committee and how it is well placed to be a voice on rural health and human services issues. The Committee's work establishes linkage between rural health and human services with emphasis on community-based and cross-sectional approaches.

Committee Discussion

Governor Beasley led a discussion on the selection of issues that the Committee will examine during the coming year.
Mr. Size commented on the difficulty of differentiating and coordinating health and human services issues. He spoke about bureaucratic impediments to collaboration.

Mr. Otis used the example of teenage pregnancy as a crosscutting issue and commented that community development must precede economic development in rural areas.

Ms. Richardson commented that separate funding streams for health and human service programs make coordination and collaboration very difficult.

Mr. Gallegos talked about building and maintaining infrastructure in rural communities.

Dr. Mueller stated the need to address structural problems in rural health programs and suggested the possibility of community impact statements tied to Federal funds. He called for more flexibility in programs.

Dr. Brand mentioned the greater flexibility now available in Federal block grants to the states.

Mr. Otis talked about the reluctance of health care leaders to engage in community development activities.

Ms. Freeman-Watson stated that Federal guidelines for rural programs need to be reviewed with the aim of affording greater flexibility.

Mr. Size expressed hope that the Committee would choose a children/family issue to pursue this year.

Monday, February 23

2005 Report Planning

Governor Beasley opened the meeting by emphasizing that the 2005 report topics must be realistic and lead to achievable results. He expressed the hope that some of the work would focus on the needs of children and families.
Mr. Size suggested that the Committee focus on the new Medicare Modernization Act. Mr. Morris responded that the bill includes hundreds of provisions and there are many issues that could be addressed.

Dr. Edwards and Dr. Glenn suggested that the Committee include health care quality issues in its agenda.

Dr. Mueller and others advocated issues regarding the availability and use of health information technologies in rural areas.

Mr. Otis, Dr. Kaye, Ms. Freeman-Watson and others talked about community development and collaboration issues.

Rural Human Services Priorities of the Department

Wade Horn, Ph.D., Assistant Secretary for Children and Families, Department of Health and Human Services.

Assistant Secretary Horn described his agency as having 1400 employees nationwide and a total budget of $47 billion. The programs he directs include Head Start, Family Assistance, Foster Care, Child Support Enforcement and many others. He identified several unique challenges of rural service delivery relating to transportation, information dissemination and governmental structural problems. In response to Secretary Thompson's rural initiative, the Agency has begun a series of new initiatives involving its major organizational components. He cited several examples involving the Head Start Program and new demonstration projects in rural transportation. He also mentioned the Compassion Capital Fund that supports intermediary organizations in their work with faith-based programs to expand faith-based activities. He closed the presentation by saying that the Agency will work on better ways to communicate with rural communities, particularly the development of messages for at-risk children in these communities. The Agency is also working to strengthen family assistance programs in rural areas and to provide technical assistance to states in administering these programs.

Mr. Dillard described a transportation program for children in Alabama that involved the private sector. Governor Beasley had seen the system first-hand and attested to its success.

Mr. Nelson described contract issues that prohibit for-profit organizations from working with non-for-profit groups in rural communities. He further stated that schools were the most likely places to reach rural children. Dr. Horn acknowledged the importance of this issue, but also mentioned that in the human services area non-profit groups are not always active in rural places. He agreed on the need to connect children with human services agencies and mentioned an Agency program that mentors young people to work with Head Start children.

Mr. Agras described programs in Pennsylvania to help young people develop employment skills and cited examples of governmental regulations that get in the way of such programs.

Dr Horn closed by thanking the Committee for its work and emphasizing the need for a holistic approach to health and human services in rural areas.

Rural Health Service Priorities of the Department

Dr. Betty James Duke, Administrator, Health Resources and Services Administration (HRSA)

Dr. Duke expressed her thanks to the Committee and her appreciation for its work. She commented on the special challenges faced by rural health care providers and reasserted the Secretary's strong interest and commitment to improving access to health care in rural areas. Dr. Duke discussed the Medicare Modernization Act and HRSA's participation in the Departmental Steering Committee charged with implementation of the Act. She described recent HRSA initiatives in rural health including establishment of the Rural Assistance Center and the Rural Hospital Improvement Project. HRSA is also helping rural hospitals find new sources of capital. Other programs are underway involving: 1) Grants to help hospitals with HIPPA implementation and to strengthen emergency services; 2) The five-year program to expand Community Health Centers; 3) Expansion of the National Health Service Corps; and 4) The Department's new role in the J-1 Visa Program.

Dr. Enright asked if the expansion of the National Health Service Corp would involve increases in mental health provides. Dr. Duke responded that there would be an increase and promised to furnish additional information to the Committee.

Mr. Nelson asked if there were any studies on retention of J-1 Visa providers. Dr. Duke said that no studies have been conducted to date, but that HRSA's involvement with the program was just underway and studies of retention might be appropriate in the future.

Mr. Dillard voiced concern about the disruption that occurs when J-1 Visa providers and National Health Service Corp provides leave a community. Dr. Duke replied that Corp retention is over 55% and that the methodology to derive that data may be applicable to the J-1 Visa retention issue.

Mr. Otis asked about the effects of Community Health Center expansion in communities. Dr. Duke said that expansion has fostered community needs assessments, encouraged networking among health care providers, and strengthened community participation in health care.

Dr. Montgomery asked about HRSA's role in the J-1 Visa Program. Dr, Duke explained that HRSA matches providers with communities that need them.

Mr. Size asked about the potential for collaboration between Community Health Centers and hospitals given issues related to the composition of their respective boards. Dr. Duke spoke about a study now underway to examine this issue. It will examine ways to improve access to primary care in underserved communities with a Critical Access Hospital. It will identify and promote models that improve collaboration between two of HRSA's major safety-net programs, Critical Access Hospitals and the Federally Qualified Health Centers. Five sites in five different states will be studied. The study should be completed by the end of the summer.

Overview of the Medicare Prescription Drug Bill

Ms. Jennifer Bell, Senate Finance Committee Majority Staff

Ms. Bell thanked the Committee for its influence on Medicare issues and extended greetings from Senator Grassley. She stated that the Medicare bill is a work in progress with many issues that remain unresolved. She spoke about how rural health became prominent in the bill and was the "glue" that solidified political support for the measure. She gave examples of how rural legislators were persuaded to support the bill. The bill is the largest rural package ever passed into law. It provides $25 billion for rural providers, protections for rural pharmacies and protections for rural hospitals that participate in networks. It is hoped that State Health Insurance programs will disseminate information about the bill. Proposals to ensure equal drug benefits for rural seniors were left out of the bill.

Dr. Steele mentioned the challenge of building an infrastructure for information technology in rural areas. He said that the biggest barrier was not money, but the lack of technical assistance for providers. Ms. Bell suggested that broad band could be a useful tool in areas where it is available.

Mr. Nelson said that the cap on payments to Rural Health Clinics remains an important issue. The speaker agreed that it must be addressed.

Dr. Kaye offered that information dissemination is a big issue in rural areas. Ms. Bell agreed that this would be a challenge and that providers may be a source of information.

Mr. Dillard asked if there would be attempts to dismantle the bill or reduce its impact. Ms. Bell replied that legislation to change the bill has already been introduced, but the current focus is on implementation.

Emerging Health Care Issues

Dr. Marcia Brand, Director, Office of Rural Health Policy

Dr. Brand reviewed past rural health topics and said that the 2005 report is to include at least two health topics and one human service topic. The topics should be important, national in scope and present opportunities for the Department. Potential topics include the uninsured, medical malpractice, workforce issues, access to technology, program integration and coordination, prevention and case management and emergency medical services.

Committee Discussion

Mr. Size asked if the Committee could select four topics for the report. Mr. Morris responded that this was a possibility.

Dr. Steele reiterated his support for the topic of information technology.

Governor Beasley suggested that the widespread and growing problem of obesity would be a timely and important topic.

Dr. Mueller stated that malpractice expenses might create a crisis for OG/GYN services throughout the country. Mr. Morris added that the issue has major implications for access to care in rural areas and data is available.

Several members talked about workforce issues and managed care.

Dr. Mueller and Dr. Rawson spoke to the issue of uninsured populations.

Mr. Size talked about the need for leadership development in rural communities.

Panel Discussion: Emerging Issues

Mr. Gary Cyphers, Director of Member Services, American Public Human Services Association
Mr. Alan Morgan, Vice President, National Rural Health Association
Ms. Sandy Markwood, Executive Director, National Association of Area Agencies on Aging

Mr. Cyphers described the membership of his association. He stated that welfare reform is their biggest endeavor at the present time. Rural areas face tough times because service delivery agencies are lacking in low-density population areas and there are fewer job opportunities for those making the transition from welfare to work. Emerging issues are the need to build organizational and leadership capacity for human service organizations in rural areas and workforce shortages faced by human services programs.

Mr. Morgan also mentioned workforce shortages as a major issue. Malpractice insurance is also a big issue and is closely linked with workforce shortages. He also cited problems of the uninsured and the need for rural providers to gain greater access to information technologies.

Ms. Markwood spoke about the need for home and community-based services in rural areas and the problems faced by caregivers in the home. Problems related to stress, hypertension and burnout are significant human services issues for caregivers in rural areas. The need for health promotion and prevention programs is a major issue for rural communities. Ms. Markwood also raised the issue of physicians who are not trained in geriatrics.

2005 Workplan: Committee Discussion

The Committee members proposed a wide range of topics for the 2005 report. After lengthy discussion, the Committee voted to select the following four topics: (1) Options for improving health and human service program collaboration in rural communities; (2) Rural technical assistance to needy families (TANF); (3) Obesity in rural communities: impact on families; and (4) Access to obstetrical care in rural communities.

Governor Beasley appointed chairpersons and members of the four subcommittees that will handle these issues. He reiterated that all members would have opportunities to be involved with each issue.
Governor Beasley called for public comments. There were no comments and the meeting was adjourned for the day.

Tuesday, February 24

Governor Beasley convened the meeting and requested comments on the letter to the Secretary. The letter will summarize the meeting and thank the Secretary for the presentations by Departmental officials. There were no comments on the letter.

The Governor distributed information on subcommittee assignments and restated the process for preparing the 2005 report.

Mr. Morris announces that staff would gather information for the subcommittees and schedule conference calls. The goal is to have a working document for the June meeting and a rough draft for the meeting in September.

Governor Beasley asked Dr. Mueller about the June meeting in Nebraska City. Dr. Mueller will arrange site visits for the Committee that will inform its work on the four new topics. The meeting will be held at the Arbor Lodge and members should plan to arrive Saturday night.

The four subcommittees met separately to discuss their respective topics for the 2005 report.

There were no public comments and the meeting was adjourned.