The National Advisory Committee
on Rural Health and Human Services
U.S. Department of Health and Human Services
Compendium of Recommendations by the National Advisory Committee on Rural Health
Note: Many of the items included on this page reflect the Committee’s past charge to focus specifically on rural health. Beginning in March of 2003, the Committee will expand its focus to human service issues.
Recommendation 89-1: Create a Medicare Payment Floor for Rural Hospitals With Less than 50 Beds and for Sole Community Hospitals
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.
Recommendation 89-2: Establish a single National Standardized Payment Amount by Fiscal Year 1993
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.
Recommendation 89-3: Develop and Test a Refined Area Wage Adjustment
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.
Recommendation 89-4: Update the Area Wage Index Annually
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.
Recommendation 89-5: Evaluate the Impact of Prospective Payment Systems on Rural Hospital Outpatient Care Under Medicare
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.
Recommendation 89-7: Define and Identify Essential Access Facilities
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.
Recommendation 91-7: Medicare Capital Payment Floor
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.
Recommendation 91-8: Old Capital
The Secretary should direct HCFA to include leasing costs in the definition of "old capital" under the new system.
Recommendation 91-9: Capital Payment Policy for Essential Access Community Hospitals and Rural Primary Care Hospitals
Essential Access Community Hospitals and Rural Primary Care Hospitals should receive special financial protection under the prospective payment system for capital.
Recommendation 92-3: Geographic Reclassification of Hospitals for Purposes of the Wage Index
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.
c) Reclassification decisions should be based on the most current data that hospitals can supply.
Recommendation 94-13: Adjust for Occupational Mix in the Medicare Wage Index
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.
Recommendation 96-1: Expand the EACH/RPCH Program Nationwide
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.
Recommendation 98-4: Support Full Funding of the Rural Hospital Flexibility Program
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.
Recommendation 99-1: Incorporate an occupational mix adjustment into the Wage Index
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.
Recommendation 99-2: Develop Separate Wage Indexes for Sub-Acute Care PPS
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.
Recommendation 99-3: Remove Teaching Physician Costs from the Wage Index
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.
Recommendation 99-4: Collect and Evaluate Hospital-Specific Labor Data for the Wage Index
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.
Recommendation 99-5: Low-volume adjustment for the Medicare Outpatient Prospective Payment System for Rural 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.
Recommendation 99-6: Low-volume adjustment for the Medicare Home Health Prospective Payment System for Rural Providers
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.
Recommendation 99-7: Low-volume adjustment for the Medicare Skilled Nursing Facility Prospective Payment System for Rural Providers
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.
Recommendation 99-8: Low-volume adjustment for the Medicare Ambulance Fee Schedule for Rural Providers
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
Recommendation 99-9: Revision of the Medicare Disproportionate Share Payment Adjustment for Rural Hospitals
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.
Recommendation 99-10: Creation of a Rural Hospital Capital Need Loan Program
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.
Recommendation 99-11: Critical Access Hospital Grant Incentives
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.
2. PHYSICIAN AND MID-LEVEL PAYMENTS
Recommendation 89-12: Medicare Physician Payment Policies
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.
Recommendation 90-1: Medicare Payment for Mid-level Primary Care Services (Part e. repeated in 1992)
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.
Recommendation 91-3: Adjustments for Budget Neutrality in Transition Rules for Medicare Physician Payment System
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.
Recommendation 91-4: Targeted Adjustments for Volume Increases in Medicare Physician Payment System
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.
Recommendation 91-5: Elimination of Geographic Payment Adjustments Under the Medicare Physician Payment Fee Schedule
The Secretary should seek legislative change which would eliminate all geographic payment adjustments under the new fee schedule for physicians.
Recommendation 91-6: Malpractice Adjustment
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.
Recommendation 92-4: Targeted Adjustments for Volume Increases Under the Medicare Physician Payment System
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.
Recommendation 92-5: Incentives 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).
Recommendation 93-14: Align Payment Incentives with Educational Incentives
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.
Recommendation 94-03: Payments for Physician Services
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.
Recommendation 94-05: Historical Costs
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.
3. REGULATORY REFORMS
Recommendation 90-2: Delay Implementation of the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88)
The Secretary should delay implementation of CLIA '88 until its impact on access to care in rural areas can be adequately assessed.
Recommendation 91-10: Coverage of Certified Nurse-Midwife Gynecological and Family Planning Services Under Medicare (repeated in 1992)
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.
Recommendation 91-17: Medicare Payment Formula for Home Health Services
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.
Recommendation 91-18: Implement the "Social Factors" Medicare Payment Provision of the Peer Review Norms Amendments in OBRA '87
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)).
Recommendation 92-6: The Clinical Laboratory Improvement Amendments of 1988 (CLIA) and Rural Health Clinics (RHCs) (repeated in 1993)
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.
Recommendation 93-1: Personnel Qualifications for Physician-performed Microscopy
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).
Recommendation 93-2: Requirements for General Supervisors of High Complexity Laboratories
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.
Recommendation 93-4: Rural Representation on the Clinical Laboratory Improvement Advisory Committee
The Secretary should appoint a rural representative to the Clinical Laboratory Improvement Advisory Committee (CLIAC).
Recommendation 94-14: Medicaid Eligibility for Farm Families
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.
Recommendation 97-1: Adjustment to the Medicare AAPCC Rate for Managed Care
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.
Recommendation 97-2: Imposition of a Cap on Provider-Based RHCs
The Committee urged the Secretary to impose a cap or per-visit limit on provider-based rural health clinics.
Recommendation 98-1: Allow Referring Practitioner to Bill For Telehealth Consultations
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.
Recommendation 98-2: Reimburse for Telehealth Services in All HPSAs
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.
Recommendation 98-3: Base Telehealth Payment on Consultant Setting
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.
Recommendation 98-4: Medicare Adopt a Broad Telehealth Consultation Definition
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.
Recommendation 98-5: Allow Same-Day Office and Telehealth Consult Billing
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.
Recommendation 98-6: Allow Unbundling of Telehealth Consultation Fee by Participating Providers
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.
Recommendation 98-7: Adopt a Broad Definition of Interactive 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.
Recommendation 98-8: Allow Nurse Presenters in Medicare Telehealth Consultations
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.
Recommendation 99-5: Encourage Development of Rural-Specific Quality Standards
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.
Recommendation 99-6: Development of Two Sets of Definitions for Rural Areas
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:
- A county-based set of standards as OMBs official standards, for statistical reporting purposes and as one option for federal funding programs.
- A Census tract-based system, to be available as an alternative option for federal funding programs and experimental use for reporting federal statistics.
4. PROGRAM DEVELOPMENT AND HEALTH CARE REFORM
Recommendation 89-8: Improve Access to Capital for Rural Facilities
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.
Recommendation 89-9: Support the Rural Hospital Transition Grant Program and Broaden Its Scope to Include Community Needs Assessment
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.
Recommendation 89-10: Implement Federal Grant Programs to Promote the Integration and Coordination of Services in Rural Areas
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.
Recommendation 89-11: Establish a "One-Stop Shopping" Demonstration Program
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.
Recommendation 89-18: Fund the "Health Care for Rural Areas" Program
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.
Recommendation 89-20: Support Increased Funds for Community and Migrant Health (C/MHC) Programs
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.
Recommendation 89-21: Maintain the Current Process for Designating Heath Manpower Shortage Areas and Medically Underserved Areas (HMSAs and MUAs)
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.
Recommendation 89-22: Improve the Administration of the Rural Health Clinics (RHC) Act Program
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.
Recommendation 89-23: Convene a Federal Interagency Rural Health Work Group and a Presidential Rural Health Council
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.
Recommendation 89-24: Expand Federal Activities to Improve the Availability of Emergency Medical Services
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.
Recommendation 89-25: Ensure that Federal Block Grants Address Rural Health Problems
The Secretary should issue a policy directive to states that implementation of all block grants address the unique service needs of rural areas.
Recommendation 89-26: Ensure a Rural Focus in the "War on Drugs"
The Secretary should ensure that current departmental efforts to address education and treatment in the "war on drugs" include a focus on rural communities.
Recommendation 89-27: Establish a National Occupational/Environmental Health Program and a National Network of Rural Occupational/Environmental Health Services Centers
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.
Recommendation 89-28: Establish a National Adolescent Health Demonstration Program
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.
Recommendation 89-30: Develop a Compendium of Model Rural-Focused Health Professions Education and Training Programs
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.
Recommendation 89-32: Provide Adequate Funding for the National Library of Medicine's Rural Outreach Activities
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:
- Increasing the marketing of Grateful Med and other NLM services to rural and other underserved health care individuals and agencies, and provide opportunities for individuals to learn how to access the Grateful Med system.
- Expanding the capabilities of entities that enable rural professionals to access information in rural communities (e.g., regional medical libraries and health facility libraries). Existing networks such as Area Health Education Centers and community colleges and universities should be utilized whenever feasible.
- Augmenting the biomedical database to include pharmacy, social work, nursing and other allied health listings and increase listings relevant to rural health.
Recommendation 90-4: Modification of the Rural Hospital Transition
Grant Program
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.
Recommendation 90-5: Provide a Rural Focus in the Department's Efforts to Improve the Health Status of Minority Populations
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.
Recommendation 90-11: Improve Federal Data Collection on HIV Disease in Rural Areas
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.
Recommendation 90-12: Require States to Have a Statewide Plan which Designates a Single State Agency as Responsible for Coordinating State Response to HIV/AIDS and which Addresses Rural HIV/AIDS Needs as a Condition of Receiving Federal AIDS Block Grants
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.
Recommendation 90-13: Provide Federal Support for Technical Assistance to Community-Based Organizations which Address the Needs of HIV Infected Persons in Rural Areas
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:
- Targeted prevention programs;
- Service programs;
- Organizational development;
- Program evaluations; and
- Fund Raising.
Recommendation 90-14: Provide Federal Support to Foster Local Leadership
to Respond to the HIV/AIDS Challenge in Rural Areas
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.
Recommendation 90-15: Expand the AIDS Education and Training Center Activities to More Effectively Reach Rural Primary Care Providers
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.
Recommendation 90-16: Establish State 800 Numbers to Provide Information on Medicaid Eligibility and Coverage of Services for HIV Infected Persons
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.
Recommendation 90-17: Provide Federal Guidance to States on Implementation of Ryan White Act
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.
Recommendation 90-18: Accept the Recommendations of the National Commission on AIDS
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.)
Recommendation 90-19: Develop a Compendium of State Initiatives Undertaken to Address Obstetrical Malpractice
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.
Recommendation 90-20: Monitor State Initiatives which Address Obstetrical Malpractice
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.
Recommendation 91-1: DHHS Program Priority: Improving Health Care Access for Rural Citizens
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.
Recommendation 91-2: Impact on President's Budget on Health Care Access in Rural Areas
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.
Recommendation 91-11: FQHC Payments Based on Actual Cost Experience Without Arbitrary Urban and Rural Distinctions
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.
Recommendation 91-12: FQHC Reporting Requirements for Look-Alikes
The Secretary should require annual reports from FQHC look-alikes and develop a recertification process for them that occurs at least every three years.
Recommendation 91-14: Community and Migrant Health Centers - Federal Tort Claim Coverage and Risk Management
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.
Recommendation 91-15: AHCPR User Liaison Program: Rural Focus on Medical Malpractice and Liability
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.
Recommendation 91-16: Rural Representation in the AHCPR Guideline Development Process
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.
Recommendation 91-19: Rural Initiative for Prevention, Health Promotion and Wellness with Older Persons
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.
Recommendation 91-20: Improve Transportation Services for Older and Disabled Persons Living in Rural Areas
A. The Administration on Aging
(AoA/DHHS) should work with the Urban Mass Transportation Administration
(UMTA/DOT) to:
- Conduct a study on the current status and problems that rural transportation pose to obtaining health care.
- Identify and remove Federal barriers to transportation service coordination in rural areas.
- Develop and implement programs to improve the coordination of Federal, State and local transportation services to older persons and others with special needs in rural areas.
- Identify "best practices" in transportation services for older and disabled people living in rural areas, disseminate information on these models to rural communities, and provide technical assistance to state and local agencies to help them apply this information to their own transportation programs.
B. The Secretary should request that DOT fund demonstration projects from
UMTA funds that will improve access to health services for the rural elderly.
Recommendation 91-21: Develop a Quality Assurance Strategy for In-Home Services and Extended Care Facilities
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.
Recommendation 91-23: Improve Information Dissemination on the Rural Elderly
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).
Recommendation 92-1: Rural Hospital Transition Grant Program
The Secretary should support legislation to continue the Rural Hospital Transition Grant Program.
Recommendation 92-7: Utilizing Health Care Reform Principles
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.
Recommendation 92-8: Basic Health Care Benefits for All Americans
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.
Recommendation 92-10: Assuring Adequate Access to Health Care
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:
- programs to increase the numbers of primary care providers -- physicians and mid-level practitioners;
- programs and payment levels that encourage primary care providers and other health care professionals to locate in underserved areas;
- transportation, emergency, and technological systems so rural residents of all ages can receive, and providers can render, health care;
- targeted programs that address the special needs of farm families, rural minorities, migrants, and Native Americans.
- policies and regulations that assure flexibility for communities and/or states to respond to local health care needs.
Recommendation 92-11: Integration of Health and Education Services
The Secretary should support health care reform legislation that encourages the integration of health and education services for all segments of society.
Recommendation 92-12: Rapid Resolution of Payment Disputes
The Secretary should support health care reform legislation that provides for rapid resolution of payment disputes.
Recommendation 92-14: Increased Support for State Offices of Rural Health
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.
Recommendation 92-17: Health Career Opportunities Initiative
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.
Recommendation 92-19: North American Free Trade Agreement
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.
Recommendation 92-22: Models for Intergovernmental Collaboration
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.
Recommendation 92-23: Expansion of Initiatives to Address Native American Health Problems
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.
Recommendation 92-24: Technical Assistance: Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHC)
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.
Recommendation 93-6: Outcomes-based Funding of Health Professions Education Programs
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.
Recommendation 93-15: Assimilate Medicare Beneficiaries into the Health Alliances (repeated in April 1994)
The Secretary should support legislation to assimilate Medicare beneficiaries into the health alliances of the reformed health care system as quickly as possible.
Recommendation 94-01: Rural Representation
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.
Recommendation 94-06: Technical Assistance Programs
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.
Recommendation 94-08: Antitrust
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.
Recommendation 94-10: Telemedicine Pilot Projects
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.
Recommendation 94-11: Increasing the Rural Sample of Leading National Health Surveys
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.
Recommendation 94-12: Risk Adjustments
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.
Recommendation 94-15: Fair Competition for Rural Grants and Contracts Applicants
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.
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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. |
5. RESEARCH AND DEMONSTRATIONS
Recommendation 89-6: Continue and Increase Support for Research and Demonstrations on Innovative and Alternative Delivery Systems
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.
Recommendation 89-19: Expand the "Rural Medical Education Demonstration Projects" Program
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.
Recommendation 89-29: Increase the Quantity and Quality of Rural Research
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.
Recommendation 90-3: Modification of the Essential Access Community Hospital (EACH) Program
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.
Recommendation 91-13: Obstetrical Access and Medical Malpractice
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.
Recommendation 91-22: Expand Research on In-Home and Community-Based Health Care Services for the Chronically Ill Rural Elderly
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:
- conduct a study on the availability of and barriers to in-home services for chronically ill rural elders, including the costs of providing access to such services in rural areas, and
- conduct a thorough review and synthesis of the literature on rural programs that enable rural elders with functional disabilities to prevent or delay institutionalization for long-term care by providing in-home and community-based services. The synthesis should assess the effectiveness, including quality of care, and the potential for replication of the various programs, and discuss the policy implications of the findings.
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.
Recommendation 92-2: Essential Access Community Hospital/Rural Primary Care Hospital (EACH/RPCH) 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.
Recommendation 92-9: Demonstration Programs to Encourage Collaboration Among Providers
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.
Recommendation 92-20: U.S./Mexico Rural Border Area Projects
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.
Recommendation 93-3: Designation of Rural Primary Care Hospitals
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.
Recommendation 93-21: Rural Parent Education and Support Program
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.
Recommendation 94-09: Alternative Rural Health Care Delivery Systems
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.
Recommendation 99-11: Improved Coordination of Federal Public Health Activities
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.
Recommendation 99-12: Creation of a Dedicated Funding Stream for Public Health Activities
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.
6. WORKFORCE DEVELOPMENT
Recommendation 89-13: Stabilize Current Levels of Primary Care Providers in Rural Areas through Tax Credits and Incentive Pay
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.
Recommendation 89-14: Revitalize the National Health Service Corps (NHSC) Scholarship Program
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.
- Priority for scholarships should be given to qualified applicants from HMSAs, MUAs and rural areas, to qualified minority applicants, and to qualified applicants with exceptional financial need.
- Participation should be targeted to those educational institutions that graduate a significant proportion of professionals (as identified in the first bullet) who enter primary care practice in rural or other underserved areas.
- Adequate personnel and dollars should be made available to the NHSC program to enable it to provide support services for scholarship and loan recipients necessary for their continued commitment to the program while in training, and necessary for their retention in HMSAs once placed.
Recommendation 89-15: Support MHSC Loan Repayment Programs
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.
Recommendation 89-16: Maintain and Target Funding for the Health Professions Programs Administered by the Department of Health and Human Services
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.
Recommendation 89-17: Establish a Task Force to Assess Policies of Health Professions Accreditation Bodies and State Approval Entities
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.
Recommendation 89-31: Promote Uniform Data Collection on Rural Health Personnel
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.
Recommendation 90-6: Establish a Task Force on Improving Coordination of Departmental Service Programs and Training Programs
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.
Recommendation 90-7: Modify Departmental Health Career Awareness Programs to Promote Career Development Among Rural Minority Populations
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:
- Modify the regulations governing the Bureau of Health Professions' (HPr) Health Career Opportunity Program (HCOP) to allow for career awareness, counseling, and academic enrichment activities in grades 7-12 in rural schools. (Career awareness activities should be developed for both students and counselors in these rural school systems.) Additional funds should be appropriated for the HCOP program to allow it to fund this specific activity.
- Develop a funding priority in the Area Health Education Center (AHEC) and the Health Education Training Center (HETC) programs for proposals that address the career awareness needs of rural, minority youth. Also, develop a funding preference in these programs for minority health professions proposals that utilize rural training sites (e.g., C/MHCs).
- Develop evaluation criteria within BHPr programs that recognize the time-intensive nature of working with disadvantaged students who require enhancement/remedial activities such that programs are not penalized for low faculty/student ratios.
- Revise the reporting requirements of the Bureau of Health Care Delivery and Assistance and the productivity formula for C/MHCs to reflect the impact on productivity of teaching. The productivity formula should, at a minimum, ensure that C/MHCs are not penalized for engaging in training activities, and should ultimately be revised to provide incentives for C/MHCs to engage in training activities.
Recommendation 90-8: Incorporate Urban/Rural and Racial/Ethnic Identifiers
in All Departmental Surveys of Health Professionals
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.
Recommendation 90-9: Sponsor an Invitational Workshop on Rural Minority Data Collection on Health Professionals
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.
Recommendation 90-10: Improve Data Collection in Departmental Health Professions 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.
Recommendation 90-21: Establish a Commission on Obstetrical Access
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.
Recommendation 90-22: Establish a Funding Priority in the Bureau of Health Professions Training Programs for Rural Primary Care Practice Programs that Include a Strong Obstetrical Practice Component
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.
Recommendation 91-24: Increase and Target Funding for Titles VII and VIII Health Professions Programs (U.S. Public Health Service Act)
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.
Recommendation 91-25: Rural Interdisciplinary Training Grant Program
The Secretary should support legislation to amend Title VII to include the Rural Interdisciplinary Program, and should seek an increased appropriation for this program
Recommendation 91-26: Rural Medical Education Demonstration 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.
Recommendation 91-27: Funding Factors for Health Professions Programs
The Secretary should establish the following funding factors (preference and priorities) for the Title VII and VIII health professions programs:
- A funding preference for programs that provide clinical experiences in rural and other underserved areas.
- A funding preference for medical schools that have a department of family medicine.
- A funding priority for programs that link rural clinicians and the faculty of teaching institutions.
- A funding priority for programs whose curricula address the health needs of rural and other underserved individuals and the health systems serving them.
- A funding priority for programs that weight admission criteria to favor rural, underserved and/or disadvantaged/minority applicants.
Recommendation 91-36: National health Service Corps Mental Health Professionals
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.
Recommendation 91-37: Evaluation of the Health Personnel Shortage Areas (HPSAs) "Greatest Need Criteria" on Frontier Areas
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.
Recommendation 92-25: Recruitment and Retention of Health Personnel
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.
Recommendation 93-5: National Health Professions Workforce Plan
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.
Recommendation 93-7: All Payers Contribute to Health Professions Education
The Secretary should support legislation requiring all health care payers to participate in funding health professions education.
Recommendation 93-8: Training in a Variety of Settings
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.
Recommendation 93-9: Rural Training Sites
The Secretary should support the development of rural practice sites as training sites for both undergraduate and graduate health professional training.
Recommendation 93-10: Interdisciplinary Training Programs
The Secretary should encourage the development of interdisciplinary training programs
Recommendation 93-11: Train Local Health Care Workers
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.
Recommendation 93-12: Broaden use of Medicare Graduate Medical Education Dollars
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.
Recommendation 93-13: Medicare Payment for Non-hospital Based Training
The Secretary should support legislation to provide Medicare funding for training in varied settings, not just those owned or operated by a hospital.
Recommendation 94-02: Health Professions Education
The Committee reiterates the recommendations it made in its Sixth Annual Report on Rural Health addressing health professions education (93-5 to 93-14).
Recommendation 94-04: Tax Incentives for Practitioners in Rural HPSAs and MUAs
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.
Recommendation 98-10: Support a legislative change to 1997 GME Legislation
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:
- strike the phrase "in the hospital" from Section 4621 of the Balanced Budget Act of 1997. This section of the BBA establishes a cap on FTEs based on the number of residents who were being trained in the hospital on or shortly before December 31, 1996.
- allow an increase in a hospitals FTE count if residents are moved from another teaching hospital at the discretion of the hospital accredited to sponsor the residency.
- permit the expansion of primary care residencies when they are the only program sponsored by the institution.
- Change the cutoff date to September 1999 to allow recently accredited primary care programs to become established.
Recommendation 98-10: Include Residency Programs Producing Rural
Physicians in the Definition of Serving Rural Areas
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.
7. MENTAL HEALTH
Recommendation 91-28: Modification of the ADMS Block Grant Apportionment Formula
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.
Recommendation 91-29: Modification of Substance Abuse Set-Aside Requirements
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.
Recommendation 91-30: ADMS State Block Grant Plans
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.
Recommendation 91-31: Integration of Alcohol, Drug Abuse and Mental Health Services with Other Primary Care Services in Rural Communities
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.
Recommendation 91-32: The Office of Rural Health Policy's Role in Mental Health and Substance Abuse Policy
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.
Recommendation 91-33: Improve Data Collection on Alcohol, Drug Abuse and Mental Health Needs, Services and Personnel in Rural Areas
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.
Recommendation 91-34: Defining the Scope of Rural Primary Mental Health Services and Educating Professionals to Provide These Services
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:
- seek funding to support educational programs that prepare individuals for rural primary mental health practice;
- develop mechanisms concurrently to finance the services provided by these individuals; and
- identify any additional barriers to the utilization of appropriately qualified mental health professionals and initiate Federal actions to eliminate them.
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 seek an increased appropriation for preventive and clinical training in mental health, and should direct NIMH to establish a rural priority in its clinical training grants (e.g., individual faculty scholar program).
- NIMH and HRSA should develop an innovative, joint clinical training grant program that utilizes the training resources of each agency.
- Federal programs which fund mental health training programs should encourage the use of Federally-funded clinics in underserved areas as clinical training sites through incentives such as funding priorities.
- A specific AHEC initiative should be funded to enhance the skills of rural primary care providers in mental illness and substance abuse diagnosis, treatment, referral and prevention.
- ADAMHA should review the educational initiatives it currently funds, including its public education programs, to determine their sensitivity to rural needs. Such initiatives include the DART program (Depression, Awareness, Recognition and Treatment). In conjunction with the Office of Rural Health Policy, ADAMHA should then develop mechanisms to better target its programs to rural needs.
Recommendation 92-21: Shortage of Mental Health Professionals in Rural
Areas
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.
Recommendation 93-16: Consider Rural Needs in Developing Mental Health and Substance Abuse Benefits under Health Care Reform
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.
Recommendation 93-17: National Plan for Mental Health Professionals in 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.
Recommendation 93-18: Substance Abuse and Mental Health Services Administration (SAMHSA) Reauthorization Act
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:
- establish a least one full-time position devoted to ensuring that rural interests are taken into account in national mental health and substance abuse public policy;
- create a coordinated and focused rural technical assistance capacity; and
- ensure that their statistical and analytic reports describe, in comparative fashion, the full range of variation by setting (metropolitan, suburban, rural, small town, frontier) and region in the delivery of mental health and substance abuse services.
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.
Recommendation 93-20: Equal Access to Federal Funding for Mental Health and Substance Abuse Services
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:
- should increased mental health and substance abuse block grant funding with a mandate that at least 25% of these funds be expended in rural areas in service to rural populations, and
- create a task force of Public Health Service officials and rural service providers to study and recommend new ways that federal support can be make available to rural and frontier areas.
Recommendation 94-07: Mental Health and Substance Abuse Services
The Committee recommends that the Secretary support enhanced mental health and substance abuse services.
Recommendation 98-9: Assure Access to Mental Health Care in Medicaid Managed Care
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
- Actively monitor and evaluate the design and implementation of State Medicaid managed health plans
- Require that the Health Care Financing Administration, the Substance Abuse and Mental Health Services Administration and the Office of Rural Health Policy work together to address issues related to Medicaid managed behavioral care in rural areas.
- Increase the supply of training programs and technical assistance materials for States on the design, implementation and oversight of Medicaid managed behavioral health care in rural areas
- Recommend that States' savings realized through Medicaid behavioral health be reinvested in rural areas with a shortage of behavioral health care.
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:
- Define adequate rural access
- Establish a stratified rate structure that takes into account the increased expense of service provision in rural areas.
- Establish a patient-level database and a process for monitoring the rural impact of providing Medicaid behavioral health care through a managed care organization, and provide for cessation of rural managed care service provision during the implementation period in the event that minimum performance standards are not achieved.
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:
- Managed care organizations recognize and adopt means which improve and integrate behavioral health services such as networking and telehealth technologies.
- Managed care plans provide access for rural Medicaid eligible individuals and their rural providers to urban specialists
- Managed care plans provide access for rural Medicaid eligible individuals to appropriate psychopharmacologic agents and monitoring for therapeutic outcomes and side effects
- Managed care plans coordinate physical and behavioral components of health care
- Clinical records and reports must exist to demonstrate the accomplishment of effective coordination of physical and behavioral components of health care of individuals
8. AGRICULTURAL HEALTH AND SAFETY
Recommendation 92-13: Establish a Coordinating Forum on Agricultural Health and Safety
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.
Recommendation 92-15: Development of Continuing Education Programs in Agricultural Health and Safety
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.
Recommendation 92-16: Safety Training for Farm Children
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.
Recommendation 92-18: Mandatory Rollover Protective Structures and Seat Belts
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.