The National Advisory Committee
on Rural Health and Human Services
U.S. Department of Health and Human Services
Office of Rural Health Policy
National Advisory Committee on Rural Health
and Human Services
Washington, D.C. Meeting Summary The 55th meeting of the National Advisory Committee on Rural Health and
Human Services was held on February 28-March 2 in Washington, D.C. Wednesday, February 28, 2007 Governor David Beasley, Chairman, convened the meeting at 9:00 on Wednesday
and introduced the new members of the Committee. The new members are Tom
Hoyer from Rehoboth Beach, DE; Paul Craig from Anchorage AK; Clint MacKinney
from St. Joseph, MN; Dave Hewett from Sioux Falls, SD; Sharon Hansen from
Kildeer, ND, and Karen Perdue from Fairbanks AK. For the benefit of new
members, Governor Beasley briefly described the role of the Committee
and its mode of operations. The members present were: Susan Birch, RN, MBA; Paul L. Craig, Ph.D.,
A.B.P.P.; Bessie Freeman-Watson; Joseph Gallegos; Sharon A. Hansen; Julia
Hayes; David Hewett; Thomas E. Hoyer, Jr., M.B.A.; Clinton MacKinney,
M.D., M.S.; Michael Meit, M.P.H.; Sister Janice Otis; Larry K. Otis; Patti
J. Patterson, M.D.; Karen Perdue; Heather Reed; Thomas C. Ricketts, Ph.D.,
and Tim Size, M.B.A. Members unable to attend were: Lenard Kaye, D.S.W.;
Ron L. Nelson, P.A., and Arlene Jaine Jackson Montgomery, Ph.D. Present
from the Office of Rural Health Policy were: Marcia Brand, Ph.D.; Tom
Morris, M.P.A.; Caroline Cochran, M.P.A.; Thomas Pack; Michele Pray-Gibson;
Erica Moliner; Jennifer Chang; and Andrea Halverson. RURAL AMERICA: THEN, NOW AND IN THE FUTURE Dr. Cromartie spoke about population trends in rural America, including
population loss, increasing ethnic diversity, and the aging of the population.
He reviewed the different definitions of rural America that have been
developed by federal agencies. He noted that many Americans are living
in rural areas of metropolitan counties and are dealing with the same
rural issues as less populated areas. He presented data on rural population
changes since 1970, out-migration from rural areas, growth of the rural
Hispanic population, and growth of the rural population 65 years of age
and older. Mr. Gibbs presented on economic trends in rural areas. While there is
an upward trend in job growth, rural areas have lagged behind metropolitan
areas on this important indicator. Service industry employment is the
fastest growing sector, while manufacturing jobs have declined. Rural
unemployment is not the major issue it was 20 years ago, but the unemployment
rate is still higher than for urban areas. Real earnings fell in rural
areas during the 1990s and most of the impact was on non-college graduates.
Wage declines are due in part to the loss of higher paying manufacturing
jobs. There remains a gap between rural and urban poverty rates, with
rural rates about 2% higher than urban rates. Per capita government transfer
payments are growing more rapidly in rural areas than in urban sites.
Despite the overall decline of manufacturing in rural areas, it is a critical
component of rural economies. Mr. Gibbs concluded by discussing his data
on farm dependence in rural areas, recreation and retirement counties,
and other economic parameters. Mr. Hoyer noted that rural and urban areas have many similarities that
could have implications for economic policies. Mr. Cromartie agreed that
some economic policies might well be formulated for both areas, but that
some policies do not work as well for rural areas. Dr. Ricketts commented on persistent poverty data and asked whether data
from the last 20 years shows trends that will project forward. Mr. Gibbs
responded that the track record for such prognostications is not good. Mr. Gallegos commented on the growth of the Hispanic population and the
implications for health and human services. HEALTH PANEL Dr. Slifkin’s presentation centered on the status of rural health
care providers over the past 20 years and current provider issues. She
explained that the historical data on providers is difficult to interpret
because federal definitions of rural areas have changed and provider data
sources have also changed over time. With these qualifications, she provided
data on the growth of federally designated Rural Health Clinics, Federally
Qualified Health Centers, Home Health Agencies, Nursing Facilities, Skilled
Nursing Care, and short-term general hospitals. She also charted the growth
of Rural Critical Access hospitals and changes to hospital financial margins.
Looking back, she noted that increasing numbers of rural providers are
reimbursed outside traditional payment systems and speculated how payments
might change when and if rural providers were paid like everyone else.
With regard to current provider issues, she highlighted the struggles
of rural community pharmacies, Medicare contracting issues, and increasing
burdens of the uninsured. Looking forward, she stated that rural providers
need special payment systems that recognize the challenges of small markets,
but the system is moving towards privatization without low volume protections Dr. Ricketts was asked to present for Dr Hart who was unable to attend
the meeting. He spoke about the rural health workforce and major workforce
issues related to practitioner shortages, ability of rural populations
to pay for care, the role of foreign medical graduates in rural areas,
and related issues. He noted the shortages of general surgeons, dental
hygienists and dentists, specialty physicians, and other providers. He
said that homeland security issues could affect the future availability
of foreign medical graduates in rural areas, a group that now represents
about one-fourth of the physician supply. He provided extensive data on
trends in the national supply of physicians and other health care professionals.
He presented a list of questions and policy issues that will have to be
addressed to assure an adequate supply of health professionals in the
future. Future challenges include adequacy of the workforce, the distribution
of generalists and specialists, population diversity, technology changes,
pay for performance, and state and federal health care funding mechanisms.
Dr. Coburn talked about rural health insurance trends and their policy
implications. He provided an overview of current rural insurance trends,
noting that 21% of the rural population is uninsured compared with 19%
of the urban population. Rural employers are facing unsustainable increases
in health insurance premiums, while rural residents are faced with increased
cost sharing. The impact on rural providers is significant as they deal
with a growing pool of the uninsured and underinsured. Large plans and
employers expanding the use of tiered providers networks could be problematic
for rural providers and residents. Residents may face higher costs if
they choose to use lower tier local providers. The Deficit Reduction Act
of 2005 gives states freedom to re-design their Medicaid Programs for
cost savings and these changes could reduce access to care in rural areas.
More positively, and in the absence of comprehensive federal reform, states
have renewed interest in expanding insurance coverage. Dr. Coburn discussed
some rural issues related to state reforms and commented on where we seem
to be headed on national reforms of the health care system. Larry Otis commented that he would like to see expenditures on health
workforce training by the states. Karen Perdue emphasized a need to look at behavioral health provider
issues as closely as those for physical health. Dr. Ricketts said that we need to better understand the cadre of lower
paid health care workers in this country and the quality of care they
provide. He also said that we also do not know enough about recent changes
in the private insurance market, such as the shift to high deductible
plans, and their potential impact on the rural infrastructure. Mr. Meit commented on the workforce implications of turf battles among
health provider trade associations. SECOND HEALTH PANEL Dr. Schoenman presented on health status indicators in rural and urban
areas based on evidence from the past 20 years. Rural residents show a
consistent pattern in ranking themselves lower than urban residents on
self-reported health status. Rural residents also experience a higher
presence of chronic conditions and greater health related activity limitations.
Mortality rates are relatively alike for urban and rural areas. In rural
areas mortality increases as population density declines. In terms of
overall health status, chronic conditions, mortality, and activity limitations,
where a person lives does make a difference. However, there does not appear
to have been significant improvement over the past 20 years. Ms. Casey spoke about the rural issues and challenges of quality measurement,
public reporting and pay for performance. Rural PPS hospitals must submit
data on quality measures to Medicare or have their Medicare annual payment
update reduced. Critical Access Hospitals may voluntarily submit data
and about 52% comply. There are important issues on the relevance of quality
measures for small rural hospitals. Some hospitals may not have a sufficient
volume of patients to reliably measure their performance. For example,
small rural hospitals have high transfer rates for heart patients, and
some cardiac procedures are rarely performed. The recommended care for
hospital inpatients with heart attacks and heart failure may not be relevant
to these hospitals. She stated that important quality measures for rural
hospitals are missing in such areas as emergency care, patient transfers,
and outpatient care. Her data shows that for many existing measures, less
than half of Critical Access Hospitals had data for more than 25 patients
in 2005. Small hospitals also have higher fixed costs for reporting quality
data. Ms. Casey said that there are dozens of pay-for-performance initiatives
throughout the country, but very little research on their impacts on rural
hospitals. She talked about uncertainties about the ranking of small rural
hospitals based on Medicare reporting and raised significant rural issues
related to payment incentives. She concluded with recommendations on how
pay-for-performance programs and policies could recognize the unique circumstances
of small rural hospitals. Dr. Mueller presented policy issues related to Medicare, particularly
the new emphasis on private delivery systems and their impact in rural
areas. He spoke about private insurance and cost pressures, climbing uninsured
rates, pressures on rural safety net providers, and new pressures on providers
to be more accountable for performance. In the current policy climate,
states have become laboratories for health care reforms, with mixed results
for rural areas. The federal government has facilitated state activities
for both good and ill. The dark cloud of budget deficits hangs over all
efforts at reform. However, he believes there is an emerging consensus
for change among politicians and business leaders. Dr. Mueller asked whether
we might have reached a tipping point for systems change. He discussed
the work and recommendations for leading health care commissions and organization
that are speaking about the need for change. He closed by mentioning the
work of the Hagel Health Care Commission led by Senator Hagel from Nebraska.
Dr. Ricketts asked Dr. Shoenman about rural mortality data and whether
it can be misleading when presented in the aggregate. She agreed that
the rates can vary dramatically from rural place to place, and will look
more deeply into the issues. Dr. Ricketts also commented that the drive for provider accountability
could be a bad thing when we fail to have good measures. Dr. Mueller agreed,
saying that results should focus on value to patients, and not process
measures. Mr. Hoyer recounted his personal experience with developing outcome measure
and commented that we are not very far along. He also commented on the
relationship between performance and payment systems. HUMAN SERVICES PANEL Mr. Dabson discussed rural poverty and its impact on future health and
human service delivery. He reported that rural poverty rates have fallen
dramatically over past decades but remain persistently above urban rates.
Rural female-headed families are disproportionately poor and one-third
live in poverty. Poverty rates are more severe as in the more remote rural
areas. Persistent poverty counties are often characterized by large minority
populations, fewer residents with a high school education and above, high
unemployment, and low mean per capita income. He spoke about issues that
are addressed by the Rural Poverty Research Center and the organization
of the center. He talked about the need for a national framework that
will bring poverty programs and agencies together to coordinate activities
on a regional basis. Regional diversity has to be embraced and people
need integrated solutions if poverty is to be alleviated. Mr. Weber spoke about the impact of changes in the social safety net
on rural people and places. In his overview, he noted the increasing importance
of local context in policies to reduce poverty. Policy options include
cash assistance, in-kind assistance, earnings supplements, as well as
job search and training programs. Over the past 20 years there has been
an expansion of the earned income tax credit, welfare reform, increased
medical subsidies, and increases of the minimum wage in some states. The
most important change has been welfare reform. Mr. Weber emphasized the
importance of local context in combating poverty and how it has been enhanced
by welfare reform. Success in a work-oriented approach depends on the
local economy, state and local decisions, and non-governmental organization.
Mr. Weber described barriers to work in rural areas such as the lack of
childcare and transportation services. He talked about job growth in rural
areas and how jobs and work effort are less effective in moving people
out of poverty in rural areas. He reviewed federal and state policies
on the social safety net, education and job training, childcare, and transportation.
Rural areas face greater challenges in each of these areas. He said that
we have learned that improved labor market conditions reduce poverty,
but less so in rural areas. The same can be said for education, subsidized
childcare, and transportation subsidies. Sister Otis commented that lack of education about existing human services
is a key problem in rural areas. Governor Beasley said the Governor’s
Office is a powerful locus for coordinating public education on human
services programs. Ms. Hansen said that the local infrastructure is also critical to promote
education. Mr. Size asked how we deal with individual accountability in addressing
poverty. Mr. Dabson said that it ties in with community responsibility
and that individuals and their communities are inseparable in this area.
Mr. Dabson said that block grants with local direction on use of funds
are a good approach and that rural areas do not have the equivalent of
urban block grants. Mr.. Meit discussed the potential role of community colleges in human
services delivery and education. There was a general discussion on the links between community development,
leadership development, and human services programs. PUBLIC COMMENTS There were no public comments and the meeting was adjourned. Governor Beasley convened the meeting and initiated a discussion of Committee
reactions to the presentations on Wednesday. There was a discussion of
the need for integration of health and human services in rural areas and
general agreement that this should be a major emphasis of the Committee
in 2007. It could be the unifying theme for the report to the Secretary
later this year. Several members expressed concern about the potential
loss of special payment benefits for rural health care providers under
a more national system of health care. Other issues raised by the members
related to the health and human services workforce in rural areas, leadership
development, influencing health and human services demonstration projects,
revitalization of the Rural Health Task Force in the Department of Health
and Human Services, service issues related to immigration, and others.
Governor Beasley polled the Committee for its ideas on subcommittees for
the coming year. RURAL POLICY MOVING FORWARD Dr. O’Grady began his presentation by talking about some of the
pressures on health and human services programs. These include the zero-sum
budget environment; rapid spending growth in health care due to demographics
and new technologies; the passage of Medicare Part D and its effect on
taking national health insurance off the table; and growth of the Medicaid
Program. Good news included the proposed expansion of the State Child
Health Insurance Program. Rural health and human services programs have
some advantages in the U.S. Senate where important Committee Chairmen
have strong rural interests. Strong lobbying efforts are needed from people
who have expertise and credibility. There is always the danger of backlash
from the Hill if people overreach on rural advocacy. Dr. O’Grady
spoke about current leadership in the Department of Health and Human Services
(DHHS) and how policies are developed. He mentioned the importance of
demonstration projects and Advisory Panels to the Department. He concluded
by saying that some traditional coalitions with rural interests are breaking
down, using the example of broken links between rural pharmacists and
their clients. Karen Perdue asked about the influence of DHHS Regional Administrators
in the Department. The speaker replied that their influence is often a
function of how they are used by agency directors in the Department. Policy
development is more likely to be centered in Washington. Dr. Ricketts asked for an opinion on the grantee performance assessment
reviews conducted by the Department. Dr. O’Grady responded that
these are accountability tools and there is a tension between doing them
well and using them to justify programs. Dr. Ricketts then said that some
programs are difficult to measure and there seem to be problems in approaching
the Office of Management and Budget on measurement issues. Dr. O’Grady
acknowledged this problem, adding that some agencies do not have staff
to work with OMB and make lack sophistication on performance assessment
measures. David Hewitt inquired about the influence of Governors on the Department.
The speaker replied that the influence of the National Governors’
Association has increased, but Governors’ have burnt some bridges
in raiding federal dollars for the Medicaid Program. Larry Otis asked about emerging issues on integrated services delivery.
The speaker talked about the silo effect for programs and how policy makers
can be caught in the vice of competing agency interests. He advised the
Committee to think about how integrated programs can work on the ground.
COMMONWEALTH FUND ACTIVITY Dr. Wakefield spoke about the work of the Commonwealth Fund’s Commission
on a High Performance Health System. She presented objectives for the
system that have been articulated by the Commission. These are: high quality,
safe care; access to care for all people; efficient, high value care;
and systems capacity to improve. She described the requirements for achieving
such a system and the scorecard that has been developed for measuring
system performance. She presented a series of slides showing international
mortality data, state variations in the quality of care, medical errors,
health care costs, and the distribution of uninsured populations. She
also showed how the U.S. ranks against other countries on mortality, health
care spending, and other factors. In this country the discourse has changed
to recognize that we spend more on health care than any other country
and need to get more value for what we are spending. She reviewed the
goals for a high performance health care system and the specific keys
to development of the system. She talked about the most important health
care issues for Presidential and Congressional action, including health
insurance expansion, the cost of prescription drugs, improved quality
of car and malpractice reform. The importance of primary care was discussed
and the concern that the U.S. is moving in the wrong direction on this
issue. Other issues that Dr. Wakefield covered were the expanded use of
information technologies, development of the primary care workforce, encouraging
leadership and collaboration among public and private stakeholders, and
what states and individuals can do to promote a high performance health
care system. She concluded with the remark that what we all must stop
doing is protecting our turf. Dr. MacKinney asked whether the work of the Commission was getting traction
with the 2008 presidential campaign. Dr. Wakefield replied that the concept
is getting attention from the Congress where testimony has been given,
the health trade press, and other venues. Mr. Size commented that economic development and its relationship to
the health care system seems to be missing from the report. Dr Wakefield
said that moving beyond the key objectives for the system as identified
by the Commission would be too much to tackle at the present time. PRESENTATION BY HRSA ADMINISTRATOR Dr. Duke presented recent issues and events of interest to the Committee.
She talked about the recent budget hearings for HRSA and gave an overview
of the current budget situation. HRSA has completed an expansion of the
Community Health Center Program and has targeted expansions to high poverty
areas. She explained how the Centers are selected and how the White House
became supportive of the expansions. She also reported on her testimony
at the appropriation hearings on the issues of oral health care in rural
areas. She told the Committee that it is a difficult battle. She talked
about funding for the National Health Service Corp that has been flat
for several years. HRSA is trying to recruit more dentists for the Corp.
She spoke about HRSA successes in using electronic technologies to improve
program administration. Mr. Size expressed appreciation for HRSA’s dental initiatives and
said that dental care is a major workforce issue. Dr. Duke replied that
HRSA has some programs for dental education and is trying to recruit dentists
for he National Health Service Corp. HRSA is encouraging grantees to make
arrangements with dental schools for the delivery of dental services in
HRSA clinic sites. Dr. Craig asked for thoughts on mental health services. Dr. Duke spoke
about the challenges of providing these services in primary care setting
in the face of provider issues and financing challenges. HRSA is working
with Medicare on mental health payments and supporting telehealth services.
SUBCOMMITTEE MEETINGS Governor Beasley and Mr. Morris discussed the framework and rationale
for subcommittee designations. The three subcommittees established for
2007 are: (1) Health; (2) Human Services; and (3) Integration. Each member
expressed a preference and was assigned to work with one of the subcommittees.
After a general discussion of the approaches each subcommittee would take,
the subcommittees met in separate session until adjournment at the end
of the day. Friday, March 2, 2007 Mr. Morris convened the meeting. He announced that the meeting in Washington,
D.C. in 2008 is scheduled for February 20-22 at the Sofitel Hotel. He
then asked for reports from the Subcommittee Chairmen. Subcommittee on Health: Mr. Hoyer reported that the substance of the
subcommittee report for 2007 is yet to be decided in detail. In general,
the report will talk about access and connectivity, fragmented government
programs, provider viability, health education in rural areas, linkages
with human services, and other issues. Some specific topics could include
Critical Access Hospitals, quality of care issues, and post-acute care
services in rural areas. Subcommittee On Human Services: Andrea Halverson (reporting for the Chairman)
said that the subcommittee would focus on public education, early childhood
development, coordination of service resources, and role of community
colleges. Electronic human services records, and the impact of changing
rural demographics will also be studied.. Subcommittee on Integration: Dr. Ricketts reported that the group was
working on defining its tasks and developing a definition of what is meant
by integration. The parameters of integration could be identified along
a continuum within both health and human services, and between them. The
group discussed a problem-oriented approach for its report and ORHP staff
was asked to identify existing programs that have requirements for integration
and collaboration. Staff will also review the Committee’s prior
recommendations related to integration of services and report on how they
may have influenced program officials. LETTER TO THE SECRETRY Mr. Morris asked for comments and suggestions on the letter to the Secretary
that is prepared after each meeting of the Committee. Mr. Hewett said that there is pressure to move dollars for emergency
preparedness from rural to urban areas and wanted to alert the Secretary
to this concern. Mr. Morris and staff will work on language for the letter
and coordinate with Mr. Hewett. Jennifer Chang on the ORHP staff spoke about plans for the June meeting
that will be held in Fort Collins, Colorado on June 10-12. PUBLIC COMMENT There were no public comments and the meeting was adjourned.
February 28-March 2, 2007
John Cromartie, Ph.D., Economic Research Service, U.S. Department of Agriculture
Robert Gibbs, Economic Research Service, U.S. Department of Agriculture
Rebecca Slifkin, Ph.D., University of North Carolina
Gary Hart, Ph.D., University of Washington
Andrew Coburn, Ph.D., University of Southern Maine
Julie A. Schoenman, Ph.D., University of Chicago
Michelle Casey, M.A., University of Minnesota
Keith Mueller, Ph.D., Rural Policy Research Institute
Mr. Brian Dabson, Associate Director, Rural Policy Research Institute
(RUPRI)
Mr. Bruce Weber, Professor of Agriculture and Resource Economics, Oregon
State University and Co-Director of the RUPRI Poverty Research Center.
Thursday, March 1, 2007
Michael J. O’Grady, Ph.D.; Senior Fellow at the National Opinion
Research Center, University of Chicago
He also said that some State experiences are not relevant to the national
scene.
Mary Wakefield, Ph.D., Director, Center for Rural Health, University of
North Dakota
Elizabeth Duke, Ph.D., Administrator, Health Resources and Services Administration