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The National Advisory =
Committee on Rural Health and Human Services=20 U.S. Department of Health and Human=20 Services |
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NATIONAL=20 ADVISORY COMMITTEE ON RURAL HEALTH AND HUMAN = SERVICES RECOMMENDATIONS BY YEAR: Recommendation 06-01:
The Committee has identified several grant programs in the = Department=20 that could be used effectively to promote and support accessto=20 pharmaceuticals and pharmacy services in rural areas. These = include the=20 Quentin Burdick Interdisciplinary Grants authorized under Title = VII of the=20 Public Health Service Act, the Rural Health Network Development = Grants=20 authorized under Title II, Section 330A of the Public Health = Service Act,=20 the Rural Health Outreach Grants authorized under Title II, = Section=20 330A(f) of the Public Health Service Act, grants to support = schools of=20 pharmacy authorized by Title VII of the Public Health Service Act, = and the=20 340B Medication Discount Program. The Secretary should identify = other=20 programs as well. Programs with appropriate authorizations should=20 encourage applications from qualified organizations that can = present=20 innovative ideas for improving or sustaining access to = pharmaceuticals and=20 pharmacy services in rural areas, and for integrating pharmacy = services=20 with other components of rural health care delivery systems. Recommendation 06-02:
The National Health Service Corps recently completed a = demonstration=20 program that placed a small number of pharmacists in underserved = areas of=20 the country. The Committee believes that the mission of the Corps = should=20 now be expanded to include pharmacists among the other health=20 professionals eligible for loan repayments, scholarships and = placements=20 through the Corps. Moreover, the Committee is aware of the = potential=20 difficulties posed by the lack of criteria for designating = pharmacist=20 shortage areas in rural parts of the country. The Committee = believes,=20 however, that the existing criteria for designating Health = Professionals=20 Shortage Areas are a reasonable proxy for shortages of pharmacists = and=20 could be used by the Corps until such time as more specific = criteria could=20 be developed. Recommendation 06-03:
The AHEC program has been, and continues to be, an effective = source of=20 support for educational programs and other efforts to help rural=20 communities and rural health care providers develop more = integrated=20 systems of care. The critical role of pharmacy providers in rural = areas=20 and the need for them to become a more integral part of local = health care=20 delivery systems should be recognized and supported through the = AHEC=20 program. Recommendation 06-04:
In presenting this chapter, the Committee was able to use some = limited=20 information from a major study of the nation's pharmacy workforce=20 conducted by HRSA in 2000. That study (and others like it) did not = provide=20 data on urban and rural differences in the pharmacy workforce. The = Committee believes that any future studies should attempt to = identify and=20 present workforce data that allows comparisons between urban and = rural=20 areas. Further, the Committee recommends that the Secretary = require HRSA=20 to do an analysis of the urban/rural distribution of pharmacists = in 2006.=20 This study is critical given the projected disparity in the = nation's=20 supply and demand for pharmacists. Recommendation 06-05:
The Committee has found that more research needs to be = conducted as to=20 the potential factors that might place a rural community at risk = of losing=20 their local pharmacy. In identifying those issues, the Committee = believes=20 it will be easier to develop programs to target those risks. Recommendation 06-06:
Under the 340B program, rural health clinics should qualify if = they=20 operate on a sliding fee scale and Critical Access Hospitals = should=20 qualify if they show that they have a Disproportionate Share = Percentage=20 greater than 11.75 percent if paid under the Medicare Inpatient=20 Prospective Payment System. Rural Health Clinics and Critical = Access=20 Hospitals that meet these criteria must be considered a vital part = of the=20 health care safety net in rural areas and should be recognized as = such=20 under the 340B program. The Committee also recommends that the Secretary provide = additional=20 resources to the HRSA Office of Pharmacy Affairs that administers = the 340B=20 program. Throughout the year, the Committee received testimony = that many=20 entities eligible for the program are not aware of its benefits or = have=20 been unable to seek participation because of staffing limitations = and=20 other factors. Further, these entities often need technical = assistance=20 related to administration of the program at the local level. = Presently,=20 the Office of Pharmacy Affairs lacks sufficient resources to = provide=20 effective outreach to eligible entities and the technical = assistance they=20 require. Moreover, the Committee recommends that the Office of Pharmacy = Affairs=20 should conduct a study to determine the extent of urban and rural=20 differences in participation in the program and take steps to = provide=20 appropriate assistance to eligible rural entities. Recommendation 06-07:
In this chapter, the Committee has discussed some concerns = about the=20 potential impact of the new Medicare Modernization Act on rural = seniors=20 and pharmacy services providers. The validity of these concerns = will not=20 be known until the new benefit has been implemented and tested. = However,=20 the Committee believes that rural areas pose unique challenges for = the=20 program and there is the potential for problems to surface over = the next=20 few years. The Committee believes that the Secretary should = support=20 studies and monitoring systems to determine how well the program = is=20 serving rural beneficiaries and pharmacy providers so that = problems can be=20 identified and resolved at the earliest possible time. There may = be=20 opportunities to integrate such studies with other efforts that = are=20 already planned. Recommendation 06-08:
The Committee recommends that the Secretary conduct a = demonstration=20 program to examine the use of Medicare payments to provide = medication=20 therapy management services to seniors who are taking multiple = medications=20 and are at greatest risk for negative drug interactions. = Medication=20 therapy management services can have a significant impact on the = health of=20 seniors who are at high risk for negative drug interactions and = other=20 complications stemming from dependence on multiple medications.=20 Demonstration programs should be conducted to identify those = seniors most=20 at risk in both the Medicare fee-for-service and Medicare = Advantage=20 settings. Such programs would also help to identify positive = outcomes of=20 medication therapy management services, as well as their impact on = the=20 cost of the Medicare program. Recommendation 06-09:
The Committee believes that telepharmacy has potential to = increase=20 access to pharmaceuticals and pharmacy services, particularly in=20 communities that are unable to establish and sustain pharmacy = services due=20 to low population density, unfavorable economic circumstances, = geographic=20 isolation or other factors. However, the Committee is concerned = that=20 telepharmacy applications must improve access without compromising = the=20 quality of services that are available. The Committee believes = that more=20 information is needed on how well telepharmacy applications are = balancing=20 the issues of access and quality in rural areas. The evaluations = should=20 include studies on best practices and outcomes. Recommendation 06-10:
During its work on this chapter, the Committee received = testimony=20 describing several recently developed software programs designed = to help=20 low-income groups identify pharmaceutical assistance programs = available to=20 them and streamline the application process. The Committee also = learned=20 that many safety-net providers have been unable to aid their = patients in=20 applying for pharmaceutical assistance programs due to staffing=20 limitations. Thus, these software programs would be able to = mitigate that=20 issue. The Committee believes that the Department can play an = important=20 role in identifying successful software programs, disseminating=20 information about them and assisting providers in their = implementation.=20 Recommendation 06-11:
Recommendation 06-12:
Recommendation 06-13:
Recommendation 06-14:
Recommendation 06-15:
Recommendation 06-16:
Recommendation 06-17:
Recommendation 06-18:
The 50-State Study reveals that differences in program = availability,=20 design and benefit exist within states individually and across the = nation.=20 The Department should take the lead in efforts at standardization = and=20 uniformity of caregiver programs and services. Such an undertaking = will=20 require inter- and intra-state agreement about mission and = philosophy,=20 eligibility criteria, funding priorities, program design, and=20 administration of services. Recommendation 06-19:
The Committee recommends that all survey instruments within HHS = be=20 required to collect and evaluate data in a way which identifies = rural=20 characteristics. The NAPIS database, specifically, should begin to = capture=20 data on rural caregivers. The Committee is aware that no = Department-wide=20 definition of "rural" exists. As long as this situation persists,=20 researchers, program administrators and policy-makers will be = unable to=20 truly determine and report the extent of rural need because the = key=20 federal organizations do not evaluate programs with a uniform = rural=20 geographic standard. The health-related components of HHS are slowly changing their = data=20 structures to illuminate urban/rural differences. The Committee = would=20 encourage the Secretary to require that all survey instruments = within the=20 Department collect, evaluate and report data in a = geographically-specific=20 way which identifies rural characteristics. Such standardization = of=20 efforts could be based on previous successes such as those = realized in the=20 Health Resources and Services Administration's Maternal and Child = Health=20 Bureau. Recommendation 06-20:
The Committee commends the work of the NFCSP and recognizes its = success, however, the Committee realizes that the program is in = great need=20 of enhanced funding. Since it was authorized, the range and scope = of NFCSP=20 services have expanded but program funding, though increased = annually, has=20 not kept pace. Gaps in service and variation of availability of = caregiver=20 services in rural areas across states remain problematic due to = inadequate=20 funding. Recommendation 06-21:
In recognition of the growing contingent of younger caregivers, = the=20 Department should work to lower the eligibility age from 60 to 50 = and=20 older. Recommendation 06-22:
The NFCS programs should specifically identify and promote = rural best=20 practices. In addition, rural best practice models for state = home-based=20 family caregiver waiver programs should also be widely = distributed. The=20 Florida legislature is considering a bill (S.B. 88 & H.B. 49) = to=20 promote best practices among informal caregivers. The legislation = under=20 consideration promotes caregiving as a non-licensed = paraprofessional=20 activity and encourages the use of caregiving best practices. The = bill=20 would also create the Florida Caregiver Institute, an independent=20 not-for-profit corporation which would develop policy = recommendations to=20 improve the skills and availability of direct care workers. The = Secretary=20 should establish a working group to consider piloting this work in = other=20 States. In addition, the Secretary could use the Alzheimer's Disease=20
Demonstration Grant program a successful model which encourages =
the=20
development of best practices models that can be replicated in =
underserved=20
areas, particularly minority and rural communities, in all 50=20
states. Recommendation 06-23:
Caregiver assessment was identified in the 50-State Study as = one of the=20 top five needed technical assistance and training areas. Screening = of=20 caregivers should be done in the primary care setting as it has = been shown=20 that early assessment of caregivers needs helps prevent=20 institutionalization of the care receiver upon crisis. Recommendation 06-24:
The Department's Administration on Aging should oversee a = social=20 marketing campaign to educate rural Americans about the difficult = role of=20 caregivers and the family caregiver support programs available to = them.=20 This campaign must use plain, easily understood language. Recommendation 06-25:
The need for more providers and limited access to services in = rural=20 areas were cited as two of the top five needs listed in the = 50-State=20 Study. Recommendation 06-26:
Recommendation 06-27:
Recommendation 06-28:
The Committee observed during its site visits that the = centralized=20 structure of the AoA administrative functions is problematic, = especially=20 in large rural states. The Committee discovered that uneven = information=20 distribution with in the State caused poor collaboration among = local and=20 state service providers. Committee members saw first hand, some of = the=20 short comings of centralization, for example, local program = directors=20 being unaware of the other state and local services that are = available to=20 their clients. The Committee concludes that the AAAs must be = locally=20 situated to be most effective. A single State office in the = absence of=20 local AAAs is too far removed from local issues, especially in=20 geographically large rural states. Recommendation 06-29:
The impact of providing long-term home care to loved ones is = immensely=20 debilitating to the caregiver. Isolation, resentment, guilt, = anger,=20 financial difficulties in addition to missed work, all plague the=20 caregiver. One out of three caregivers reports their own health to = be fair=20 or poor. Research shows that informal caregivers suffer from high = levels=20 of stress, burnout, and insomnia and are more likely to use = psychotropic=20 drugs. However, this research does not identify differences = between the=20 stresses of rural caregivers as compared to their urban = counterparts. Recommendation = 05-1:=20 Create a Web Resource Page for "Models that Work" for = Collaborations=20 The Federal Office = of Rural=20 Health Policy (ORHP) should build this recommendation into it = cooperative=20 agreement with the Rural Assistance Center (RAC). A special page = should be=20 built that is devoted to describing successful rural-based = collaborations=20 and that can be accessed in one step from the home page of the RAC = Web=20 site. The funding to RAC should support a reporting function to = collect=20 and present information regarding those collaborations. = Recommendation = 05-2:=20 Support Research that Specify Opportunities and Barriers to=20 Collaboration The Federal Office = of Rural=20 Health Policy should dedicate a portion of its research budget to = further=20 specify opportunities for and barriers to collaboration, funding = activity=20 either through its research centers or its solicitation of = independent=20 research proposals. Researchers should develop models that explain = reasons=20 collaborations are successful, with success being defined, in = part, as=20 long-term sustainability. Research findings should identify = barriers to=20 successful collaborations as well as community, Tribal, State and = Federal=20 actions that facilitate successful collaborations. Recommendation = 05-3:=20 Support Leadership Development in Rural Communities The Secretary = should=20 instruct all agencies with programs support local service delivery = to=20 include funds for leadership development in their grant-making = portfolios.=20 The Federal Office of Rural Health Policy program for rural = leaders should=20 be continued. The Secretary should consider supporting regional = leadership=20 academies by combining current programs from separate entities in = HHS. The=20 Secretary should encourage private foundations to expand their = efforts to=20 train future leaders. The Nebraska Community Foundation is one = example of=20 the important and crucial role a foundation can play in fostering=20 leadership development in rural areas. Recommendation = 05-4:=20 Require Grant Recipients Engaged in Direct Delivery of Services to = Demonstrate an Effect on Community Development The Secretary = should require=20 that all grant applications in program supporting service delivery = in=20 rural areas include an analysis of how the program will relate to=20 broad-based efforts in community development. CREATE, in = Mississippi, is=20 measuring its success based on community indicators, such as the = economy,=20 education, public safety, social environment, health, housing and=20 infrastructure. Recommendation = 05-5:=20 Increase Support for Medical Schools that Have Distinct Program = and a=20 Proven Track Record for Training Physicians to Practice Obstetrics = in=20 Rural Areas An increased = supply of rural=20 physicians trained in obstetrics is essential to sustaining these = services=20 in hundreds of small rural communities. The Secretary should = increase or=20 reallocate funds under Title VII of the Public Health Service Act = to=20 target medical schools that train obstetricians and family = physicians for=20 rural practice, especially those that provide residents in family = medicine=20 with training in high-risk obstetrics. Family physicians are more = likely=20 to practice in rural areas than obstetricians, and programs that = prepare=20 them for high-risk obstetrics must be supported. Support for the = training=20 of CNMs and nurse practitioners who are interested in obstetrics = also=20 should be increased. Recommendation = 05-6: Make=20 the Recruitment and Placement of Physicians Trained in Obstetrics = a Major=20 Goal for the National Health Service Corps The Committee = believes that=20 the National Health Service Corps must focus more attention on = rural areas=20 that lack adequate obstetrics services. Recruitment efforts should = focus=20 on physicians who are trained in obstetrics and who are willing to = deliver=20 babies in the communities they serve. Additional incentives for = new=20 physicians are also needed and should be explored. One approach = would be=20 to pay the malpractice insurance costs of new Corps physicians who = are=20 fulfilling their obligation in areas with measurable and = pronounced=20 shortages of obstetrics care providers. Recommendation = 05-7:=20 Support Program to Create Hospital and Physician Networks that = will=20 Sustain and Improve Access to Obstetric Services in Rural=20 Areas There are several = existing=20 grant programs in the Department (Healthy Community Access, Rural = Network=20 Development, Rural Hospital Flexibility Grants) that should be = used to=20 promote the development of hospital and physician networks in = obstetrics=20 care. The Committee believes that obstetrics services in many = small rural=20 hospitals and physician practices will be unsustainable over time, = given=20 the issues discussed in this report. Providers need encouragement = and=20 incentives to find more sustainable and efficient strategies for=20 maintaining access to obstetrics care. Existing grant programs = should be=20 more aggressive in encouraging and funding grant applications that = address=20 the problem. Recommendation = 05-8:=20 Promote the Development of Team Approaches to Obstetrics Care = Involving=20 Physicians, Nurse Practitioners, Certified Nurse Midwives and = Other=20 Non-Physician Providers The Secretary = should use=20 this demonstration authority to develop a model program that = supports=20 regional approaches to improving access to obstetrics care in = rural=20 communities through networking and an emphasis on using = interdisciplinary=20 teams in several rural areas as a pilot project. Recommendation = 05-9:=20 Increase Medicaid Payments for Obstetrics Services The Committee = understands=20 that Medicaid payments for services are determined by the States; = however,=20 the Secretary does have authority over State Medicaid waivers that = affect=20 the scope of services that Medicaid provides and populations = served. The=20 Secretary should explore ways in which the waiver approval process = could=20 be sued to provide incentives for the States to increase payments = and=20 improve access to obstetrics services in rural areas. Recommendation = 05-10:=20 Address the Malpractice Insurance Issue by Supporting Legislation = that=20 will Extend the Federal Tort Claims Act to Rural Obstetrics = Providers in=20 Federally Designated Shortage Areas The malpractice = insurance=20 program for Federally Qualified Health Centers and Free Clinics = should be=20 extended to cover rural hospitals and physicians providing = obstetrics=20 services in underserved rural areas. The Committee believes that = the=20 current system for designating Health Professional Shortage Areas = (HPSAs)=20 may not be able to identify the rural areas most underserved by = obstetrics=20 services. Data are available to identify rural areas that have the = lowest=20 ratios of obstetrics providers to women of childbearing age, which = may be=20 a more effective access measure. Another approach would be to give = greater=20 weight to obstetrics services as a variable used in the HPSA = designation=20 process. The method used must be limited to those rural areas = where access=20 to obstetrics care is mot severely limited by provider shortages.=20 Recommendation = 05-11:=20 Encourage the State to Revise Their Medicaid Policy to Remove Any=20 References of Obesity Not Being an Illness The Department = should take=20 the lead in working with the States to classify obesity as an = illness and=20 cover procedures related to treatment of obesity. This change is = even more=20 critical in Medicaid than it is in Medicare since it will allow = health=20 care providers to aggressively treat those with obesity and it = will=20 potentially help patients avoid more serious obesity-related = health=20 complications in the future. Recommendation = 05-12:=20 Make Refinements to the HealthierUS Community Grant Program so = that Rural=20 Concerns can be more Thoroughly Represented The Committee = commends the=20 Secretary for launching the Steps to a HealthierUS community grant = program, especially since it includes rural participation. = However, the=20 Committee is also hopeful that refinements will be made to assure = that the=20 concerns identified with respect to rural representation are = addressed.=20 Additional opportunities for direct granting to rural communities = would be=20 helpful, as many States did not include rural communities within = their=20 grants. Recommendation = 05-13:=20 Ensure that the Next Publication of the CDC Chartbook includes = more=20 Rural-Specific Data and that Other, Future Publications Include = References=20 to Rural The Committee = commends the=20 efforts the CDC has made to conduct studies that include rural = areas.=20 These studies have consistently shown that rural areas have higher = rates=20 of obesity and are, in general, less healthy than urban or = suburban areas.=20 The Committee would encourage the publication of a new CDC = Chartbook to=20 provide current, more rural-specific items compared to the = previous 2001=20 publication, and to continue the inclusion of rural areas in its = other=20 studies. In addition, the Committee encourages NIH and the CDC to = include=20 studies of rural-specific prevention and intervention. Recommendation = 05-14:=20 Ensure that Rural Residents are Seen as a Separate and Unique = Segment of=20 the Population in Funding, Research and Data = Collection The Committee = commends the=20 efforts CDC has made to conduct studies that include rural areas. = These=20 studies have consistently shown that rural areas have higher rates = of=20 obesity and are, in general, less healthy than urban or suburban = areas.=20 The Committee would encourage the publication of a new Rural-Urban = Chartbook by no later than 2006 t provide current, more rural = specific=20 items compared to the previous 2001 publication, and to continue = the=20 inclusion of rural areas in its other studies. In addition, the = Committee=20 encourages the NIH and the CDC to include studies of = rural-specific=20 prevention and intervention. Recommendation = 05-15:=20 Provide targeted technical assistance to States to Examine to How = to=20 Address the Transportation, Child Care, and Employment Needs of = Rural TANF=20 recipients The Secretary = should work=20 with the Administration for Children and Families (ACF) to provide = targeted technical assistance that would encourage States to = address the=20 transportation, child care, and employment and training needs of = rural=20 TANF recipients. Recommendation = 05-16:=20 Emphasize Collaboration and Encourage States to Utilize Best = Practices in=20 Efforts to Service Rural TANF Clients The Secretary = should=20 emphasize collaboration and encourage States to utilize best = practices,=20 including those identified by ACF, particularly in efforts to = serve rural=20 clients. Recommendation = 05-17:=20 Strengthen Department's Leadership and Work with Federal Partners=20 The Secretary = should=20 strengthen the Department's leadership among Federal partnerships = and=20 collaborations. The Secretary = should propose=20 legislation to the Congress that would establish a Medicare = inpatient=20 payment floor for rural hospitals with less than 50 acute care = beds and=20 for Sole Community Hospitals (SCHs). The payment floor would be = based on=20 an individual hospital's current cost experience. The legislation = would be=20 effective for hospital cost reporting periods beginning on or = after=20 October 1, 1989, and end at such time that special Medicare = payment=20 provisions for essential access facilities are implemented. For = the=20 purposes of this legislation, acute care beds include swing beds, = but=20 exclude licensed beds for long- term care and newborn=20 bassinets. Recommendation = 04-1:=20 Allow Behavioral Health Providers to Provide Behavioral Health = Services as=20 Qualified Mental Health Care Service Providers The Secretary = should work=20 with the Congress to amend Section 1861(s) (2) of the Social = Security Act=20 to authorize State-licensed marriage and family therapists, = licensed=20 professional counselors and other behavioral health providers to = provide=20 behavioral health services as qualified mental health care service = providers. The Secretary should also work with Congress to = authorize=20 Medicare payments for those services by amending Section = 1833(a)(1) of the=20 Social Security Act, as needed, to ensure that payment. = Recommendation = 04-2:=20 Broaden the Definition of Originating Sites for Telehealth = Services=20 The Secretary = should seek to=20 broaden the definition of originating sites for telehealth = services to=20 include private physician offices under Title XVIII of the Social = Security=20 Act and ensure that all Medicare-eligible providers can offer = mental=20 health services via telehealth consultation. Recommendation = 04-3:=20 Identify States with Model Licensure Laws and Scope of Practice = Acts for=20 Non-Physician Behavioral Health Providers The Secretary, = under the=20 auspices of Title XVIII and Title IX of the Social Security Act, = should=20 work to identify States with model licensure laws and scope of = practice=20 acts for non-physician behavioral health providers. The Secretary = should=20 share them with other States and policymakers in order to = facilitate=20 similar practices in rural areas of the country. The Secretary = should also=20 work with States and behavioral health professional associations = to=20 increase flexibility in State requirements for supervision of = limited=20 license behavioral health providers that would allow more rural = training,=20 either in person or through supervision delivered via telehealth=20 technologies. Recommendation = 04-4:=20 Increase Funding for the Quentin N. Burdick Program for Rural=20 Interdisciplinary Training The Secretary = should support=20 increased funding for the Quentin N. Burdick Program for Rural=20 Interdisciplinary Training. The program is authorized under Title = VII,=20 Section 754 of the Public Health Service Act. Grants awarded = through the=20 program can support innovative models and demonstrations of=20 interdisciplinary care in rural areas. The program is uniquely = suited to=20 the support of programs that foster the development of integrated = primary=20 care and behavioral health care delivery systems. Recommendation = 04-5:=20 Increase Funding for the Graduate Psychology Education=20 Program The Secretary = should support=20 increased funding for the Graduate Psychology Education Program = authorized=20 under Title VII, Section 755(b)(1)(J), of the Public Health = Service Act.=20 This program supports grants to schools accredited by the American = Psychological Association to help them plan and operate programs = that=20 foster an integrated approach to health care service and that = train=20 psychologists to work in underserved areas. The program was not = included=20 in the President's budget for 2005. Recommendation = 04-6:=20 Increase Support for Scholarships and Loan Repayment for = Behavioral Health=20 Care Providers The Secretary = should provide=20 increased support of scholarships and loan repayment for = behavioral health=20 care providers under Section 331 of the Public Health Service Act. = Recommendation = 04-7:=20 Amend Title XVIII and Title XIX of the Social Security Act to = Require=20 Parity in Payments The Secretary = should work=20 with the Congress to amend Title XVIII and Title XIX of the Social = Security Act to require parity in payments and the resulting = co-payments=20 for mental health care services under Medicare and = Medicaid. Recommendation = 04-8:=20 Clarify that Critical Access Hospitals Can Provide Mental Health = Services=20 The Secretary = should work=20 with the Centers for Medicare and Medicaid Services in = administration of=20 Section 1834(g) of the Social Security Act to clarify that = Critical Access=20 Hospitals can and should have the flexibility to provide mental = health=20 services as dictated by community need within the normal = protections for=20 patients. Recommendation = 04-9:=20 Increase the Federal Matching Funds for Oral Health Services by = Five to=20 Ten Percent The Secretary, = under Title=20 XIX of the Social Security Act, should authorize a five to ten = percent=20 increase in Federal matching funds for oral health services. This=20 increased match would encourage States to expand dental coverage = and=20 provide dental reimbursements at a level sufficient to attract = additional=20 providers to the Medicaid program. Recommendation = 04-10:=20 Increase Funding for the Quentin N. Burdick Program for Rural=20 Interdisciplinary Training, Health Careers Opportunity Program and = Centers=20 for Excellence Program The Secretary = should work=20 with the Office of Management and Budget (OMB) and Congress to = seek=20 increased funding for the Quentin N. Burdick Program for Rural=20 Interdisciplinary Training, authorized by Title VII, Section 754 = of the=20 Public Health Service Act. Priority should be given to Quentin N. = Burdick=20 applicants whose programs include dentists or dental hygienists. = The=20 Secretary should also attempt to obtain more funding for the = Health=20 Careers Opportunity Program (HCOP) and Centers for Excellence = (COE)=20 Program, authorized by Title VII, Sections 739 and 736, = respectively. The=20 additional funds should be used to increase the number of dental = schools=20 receiving HCOP and COE grants. This would provide more support for = dental=20 schools that seek to recruit additional minority and disadvantaged = individuals and to expose students to practice opportunities in=20 underserved communities. Recommendation = 04-11:=20 Ensure Adequate Funding for the National Health Service Corps=20 The Secretary = should ensure=20 adequate funding for the National Health Service Corps under = Section 331=20 of the Public Health Service Act and should encourage it to pursue = innovative strategies that will attract more dentists and dental=20 hygienists to take part in the program. Recommendation = 04-12:=20 Seek Additional Funding for the Recruitment and Loan Repayment of = Indian=20 Health Service Dentists and Hygienists The Secretary = should work=20 with the Office of Management and Budget to seek additional = funding for=20 the recruitment and loan repayment of Indian Health Service = dentists and=20 hygienists and to ensure the Indian Health Service dental = facilities and=20 equipment are adequate to meet the demand for services. = Recommendation = 04-13:=20 Establish a Program that would Fund the Fluoridation of Small = Community=20 Water Supplies The Secretary = should work=20 with the Office of Management and Budget and the Congress to = explore the=20 establishment of a new categorical grant program that would = provide=20 funding to States for the fluoridation of small community water = supplies=20 and provide ongoing technical assistance and maintenance for such=20 systems. Recommendation = 04-14:=20 Establish State Dental Offices in All 50 States and U.S.=20 Territories The Secretary = should work=20 with Congress and the Office of Management and Budget to establish = a=20 Federal-State partnership that is modeled after the State Offices = of Rural=20 Health Grant Program. This partnership would support the = establishment of=20 State Dental Offices with full-time directors in all 50 States and = U.S.=20 territories. Since the majority of oral health policy issues are = under=20 State jurisdiction, it is important to ensure that States have an = adequate=20 infrastructure to address pressing oral health issues and = coordinate=20 Statewide oral health initiatives. Recommendation = 04-15:=20 Direct the National Institutes of Health and the Agency for = Healthcare=20 Research and Quality to Conduct Studies on Oral Health Disparities = The Secretary = should direct=20 the National Institute for Dental and Craniofacial Research and = the Agency=20 for Healthcare Research and Quality to conduct a series of studies = on=20 rural oral health disparities. These studies will provide = additional=20 information on the oral health status of rural residents and will = provide=20 critical information that will be used to guide evidence-based=20 policymaking. Recommendation = 04-16:=20 Develop a Demonstration Program to Explore Innovative Approaches = to=20 Providing Transportation to the Rural Elderly The Secretary = should develop=20 a demonstration project through Section 301 of the Public Health = Service=20 Act that would explore innovative approaches to providing = transportation=20 to rural elderly and would examine current Federal and State = regulations=20 and opportunities to use existing systems operated through Area = Agency on=20 Aging programs, Head Start and State and local transportation = systems such=20 as school buses. Recommendation = 04-17:=20 Support Research that Examines How Rural Seniors Access the = Services=20 Provided under the Older Americans Act The Secretary = should support=20 research that examines how rural seniors access key services = provided=20 under the Older Americans Act to determine if there are any = service gaps=20 particular to rural communities. Recommendation = 04-18:=20 Track Expenditures in the National Family Caregivers Support=20 Program The Secretary = should work=20 with the Agency on Aging to track expenditures in the National = Family=20 Caregivers Support Program to determine how much of the funding = goes to=20 rural communities. Recommendation = 03-1:=20 Promote Demonstrations through CMS that Examines How Reimbursement = can=20 Promote Quality Improvement The Secretary = should work=20 with CMS to promote demonstrations that examine how reimbursement = might be=20 used to promote quality improvement in the rural = setting. Recommendation = 03-2:=20 Increase Funding for State Survey and Certification=20 Activities The Secretary = should=20 increase funding for state survey and certification activities. = The survey=20 and certification agencies are consistently under funded and this = has a=20 disproportionate effect on rural providers given their heavier = reliance on=20 using the survey and certification program and less reliance on=20 accreditation compared to their urban counterparts. Recommendation = 03-3:=20 Amend the Seventh Scope of Work for the Quality Improvement=20 Program The Secretary = should amend=20 the Seventh Scope of Work for the Quality Improvement Program to = make this=20 program more relevant for rural communities. This would include = creating a=20 stand-alone task focusing on rural health. It would also include a = new=20 evaluation methodology for reviewing the work of the Quality = Improvement=20 Organizations that includes more localized measures of areas with=20 populations that suffer health disparities. The sole reliance on = measures=20 of state-wide improvement acts as a disincentive for working with=20 harder-to-reach populations. Recommendation = 03-4:=20 Increase Funding for the Quality Improvement Program = The Secretary = should work=20 with the Office of Management and Budget to increase funding for = the=20 Quality Improvement Organizations to encourage Quality Improvement = Organizations to reach out more meaningfully to rural communities = to rural=20 communities and to help providers prepare for public reporting in=20 hospital, home health and individual ambulatory provider settings. = Recommendation = 03-5:=20 Solicit Input from Rural Health Care Providers in Identifying = Measures for=20 Public Reporting The Secretary = should solicit=20 (via Federal Register notice) input from rural health care = entities in=20 identifying which measures shall be used for public reporting for = all=20 healthcare providers and include not only outcome measures but = also=20 process measures. This activity should promote appropriate = benchmarking=20 that compares organizations with similar characteristics such as=20 geography, size, and volume. This is very important as outcome = measures=20 require statistical significance frequently not available in a = typical=20 rural facility due to lower volumes or that may not be appropriate = for=20 rural facilities. Recommendation = 03-6:=20 Ensure that Research Translated into Practice Include a Focus on = Rural=20 Health Care The Secretary = should work=20 with AHRQ and NIH to ensure that each Agency's efforts to = translate=20 research to practice include a focus on rural health care quality = issues=20 as well as translation of findings to rural practice, = dissemination and=20 adoption of recommendations. AHRQ and NIH should also identify and = examine=20 "models that work" in rural areas. Recommendation = 03-7: Fund=20 the new Small Health Care Provider Quality Improvement=20 Program The Secretary = should work=20 with the Congress to fund the new Small Health Care Provider = Quality=20 Improvement Program authorized in Public Law 107-251. Recommendation = 03-8:=20 Support Re-Authorization of the Medicare Rural Hospital = Flexibility Grant=20 Program The Secretary = should support=20 re-authorization of the Medicare Rural Hospital Flexibility Grant = program=20 in a manner that strengthens the program's orientation to = promoting=20 quality in Critical Access Hospitals. Recommendation = 02-1:=20 Require a Uniform Medicare Disproportionate Share Hospital = Adjustment=20 Policy The Secretary = should work=20 with Congress to require the use of a uniform Medicare = Disproportionate=20 Share Hospital adjustment policy that treats all hospitals the = same=20 regardless of their urban or rural location. Recommendation = 02-2:=20 Raise the Cap on Medicare Disproportionate Hospital=20 Payments The Secretary = should work=20 with Congress to raise the cap on Medicare Disproportionate Share = Hospital=20 payments for rural hospitals to an appropriate level that provides = equity=20 for rural hospitals. Recommendation = 02-3:=20 Expand Options for Using Medicaid Disproportionate Share Hospital = Payments=20 for Eligible Rural Hospitals The Secretary = should work=20 with States to expand options for using Medicaid Disproportionate = Share=20 Hospital Payments for eligible rural hospitals, including the = ability to=20 upgrade the financial stability of rural hospitals or to assist = rural=20 hospitals to develop physician or clinic networks. Recommendation = 02-4:=20 Ensure Re-Authorization and Continued Funding of the Rural = Hospital=20 Flexibility Grant Program The Secretary = should work=20 with Congress to ensure re-authorization and continued funding of = the=20 Medicare Rural Hospital Flexibility Grant Program, which is up for = re-authorization in FY 2002. Recommendation = 02-5:=20 Eliminate the Medicare Per-Visit Payment Cap The Secretary = should work=20 with Congress to eliminate any financial challenges to FQHC's = providing=20 care to the uninsured by eliminating the Medicare per-visit = payment=20 cap. Recommendation = 02-6:=20 Increase Access to Capital and Expand Eligible Uses of Grant Funds = for=20 Rural Providers The Secretary = should work=20 with Congress to increase access to capital and to expand eligible = uses of=20 grant funds to include construction, renovation, and modernization = of=20 health center facilities. Recommendation = 02-7:=20 Increase Federally Qualified Health Centers in Rural and Frontier=20 Areas The Secretary = should=20 encourage the development of criteria that will increase the = number of=20 FQHC sites in rural and frontier areas. Recommendation = 02-8:=20 Increase Rural Health Clinics Payment Limit The Secretary = should work=20 with Congress to increase the RHC payment limit under section 1833 = (f) of=20 the Act to more closely correspond with the increase in payments = for=20 primary care services resulting from the full transition to the = physician=20 fee schedule. Recommendation = 02-9:=20 Amend Reimbursement Methodology for Rural Health Clinics = The Secretary = should amend=20 the reimbursement methodology for Rural Health Clinics (RHCs) = payment so=20 that RHCs that 1) are non-profit, 2) see all patients regardless = of=20 ability to pay, and 3) elect to use a sliding fee scale do not = have to=20 count uninsured patients in determining the aggregate number of = patients=20 seen for calculation of the per-visit payment rate. Recommendation = 02-10:=20 Work with Congress to Conduct Strong Oversight of the = Implementation of=20 the Medicaid PPS The Secretary = should work=20 with Congress to conduct strong, ongoing oversight of the = implementation=20 of the Medicaid PPS to ensure that States comply with requirements = in the=20 Federal PPS statute and that access to FQHC and RHC services are=20 protected. Recommendation = 02-11:=20 Work with Congress to Evaluate the Medicaid PPS to Ensure that = FQHCs and=20 RHCs are being Adequately Reimbursed The Secretary = should work=20 with Congress to evaluate the Medicaid PPS to ensure that FQHCs = and RHCs=20 are being adequately reimbursed to protect access to care, = including=20 access to care for the uninsured. This includes examining whether = the=20 Medicare Economic Index (the current measure of inflation used in = PPS) is=20 sufficient to protect Medicaid reimbursement for these critical = safety=20 next providers. Recommendation = 02-12:=20 Issue an Advisory Letter Disseminating the Legality and Specific=20 Requirements of the Income-Related Sliding Fee = Scales The Secretary = should issue=20 an advisory letter that spells out the legality and specific = requirements=20 of income-related sliding fee scales and disseminate it = widely. Recommendation = 02-13:=20 Support and Enhance the 340B Discount Drug Program The Secretary = should=20 continue to support and enhance the 340B Discount Drug Program and = support=20 Medicare reforms that include access to prescription = drugs. Recommendation = 02-14:=20 Propose an Increase in Funding for the National Health Service=20 Corps The Secretary = should propose=20 an increase in funding for the National Health Service Corps at = levels=20 sufficient to support the multi-year plan to expand health centers = and to=20 meet the pressing needs of other rural areas for health=20 professionals. Recommendation = 02-15:=20 Create a Focal Point within the Department to Coordinate the J-1 = Visa=20 Waivers The Secretary = should create=20 a focal point within the Department to coordinate the J-1 Visa = Waivers=20 issued by all Federal agencies and the communities in which they = are=20 placed to ensure that the visa waivers are used to meet patient = care=20 needs. Recommendation = 02-16:=20 Consider Allowing HHS to Issue J-1 Visa Waivers for Primary Care=20 Physicians if the USDA Declines to Continue Issuing Those=20 Waivers The Secretary = should=20 consider allowing HHS to issue J-1 Visa Waivers for primary care=20 physicians if the USDA declines to continue issuing those waivers. = If USDA=20 continues to offer J-1 Visa Waivers, the Secretary should work = with the=20 Congress to re-authorize and expand the scope of the Conrad State = 20=20 program to more adequately meet the primary care needs of rural=20 communities. Recommendation = 02-17:=20 Increase the Amount of Medicare Incentive Payment to 20=20 Percent The Secretary = should work=20 with the Congress to increase the amount of the Medicare Incentive = Payment=20 to 20 percent. Recommendation = 02-18:=20 Allow Nurse Practitioners and Physician Assistants to Qualify for = the=20 Medicare Incentive Payments The Secretary = should work=20 with the Congress to allow nurse practitioners and physician = assistants to=20 qualify for the Medicare Incentive Payments. Recommendation = 02-19:=20 Eliminate Medicare Payments to Urban Specialists The Secretary = should work=20 with Congress to eliminate Medicare Incentive Payments to urban=20 specialists. Recommendation = 02-20:=20 Change the Current Auditing Procedures Used the Medicare=20 Contractors The Secretary = should change=20 the current auditing procedures used by the Medicare Contractors = to ensure=20 that providers who claim the Medicare Incentive Payment will not = have any=20 greater likelihood of being audited than providers who do not = claim the=20 extra payment. Recommendation = 01-1:=20 Evaluate the Need for a Low-Volume Adjustment in = Medicare The Secretary = should=20 evaluate the need for a low-volume adjustment within all of the = Medicare=20 prospective payment systems. Recommendation = 01-2:=20 Research into the Cost of Providing Care to Medicare Beneficiaries = in=20 Rural Areas The Secretary = should promote=20 research into determining the true cost of providing care to = Medicare=20 beneficiaries in rural areas that take into account factors = related to=20 access, geographic isolation and volume. The results of this = research=20 should be used in redesigning the Medicare program to ensure = equity of=20 benefits for rural beneficiaries. Recommendation = 01-3:=20 Continue Collecting Data on Occupational Mix The Secretary = should=20 continue collecting data on occupational mix and implement an = adjustment=20 to the wage index as soon as possible. Recommendation = 01-4:=20 Collect Wage Data for the Skilled Nursing and Home Health Service=20 Areas The Secretary = should collect=20 wage data for both the skilled nursing and home health service = areas and=20 evaluate the impact of constructing an occupational mix adjustment = within=20 the wage index for both of these payment systems. Recommendation = 01-5:=20 Refine the Methodology for Determining the Disproportionate Share=20 Adjustment for Hospitals The Secretary = should=20 continue to refine the methodology for the disproportionate share=20 adjustment for hospitals to treat all hospitals = equally. Recommendation = 01-6:=20 Develop a Standard Benefit Package for Medicare Beneficiaries=20 The Secretary = should develop=20 a standard benefit package that includes access to a reasonable=20 prescription drug benefit under Medicare fee for service. = Recommendation = 01-7:=20 Provide Demonstration Waivers to Rural Communities for Innovative = Health=20 Care Models The Secretary = should provide=20 demonstration waivers to rural communities for innovative models = that=20 improve access to care and that focus on chronic care, case = management,=20 and preventive care. Recommendation = 01-8:=20 Examine Impact of Prospective Payment Systems in Home Health and = Skilled=20 Nursing for Medicare Beneficiaries The Secretary = should examine=20 the impact of the new prospective payment systems for home health, = skilled=20 nursing, and outpatient services to determine what impact these = changes=20 have had on access to care for rural Medicare beneficiaries. = Recommendation = 01-9:=20 Monitor the Closures of Skilled Nursing Facilities The Secretary = should monitor=20 the closures of skilled nursing facilities and the impact of = moving swing=20 beds under skilled nursing facilities prospective payment to = determine the=20 impact on access to care for rural Medicare beneficiaries. = Recommendation = 01-10:=20 Ensure Core Services are Available to all Medicare=20 beneficiaries The Secretary = should ensure=20 that the core services (primary, preventive and chronic care = management)=20 and the full continuum of care are appropriately available for all = Medicare beneficiaries. Recommendation = 01-11:=20 Amend the Medicare Conditions of Participation The Secretary = should amend=20 the Medicare Conditions of Participation. Also, the Secretary = should=20 provide resources through entities such as the Peer Review = Organizations=20 to develop quality improvement tools to fit the rural environment = with=20 appropriate flexibility and an emphasis on outcome = standards. Recommendation = 01-12:=20 Encourage Development of Appropriate Quality Measures for Rural=20 Areas The Secretary = should=20 encourage the development of appropriate measures that take into = account a=20 rural environment that features low volume of primary care and = ambulatory=20 services. Recommendation = 01-13:=20 Encourage More Training of Health Professionals for Rural=20 Communities In recognizing the = link=20 between quality health care and the workforce, the Committee = recommends=20 that the Secretary encourage more training of health professionals = for=20 rural communities to ensure access to high-quality care for = Medicare=20 beneficiaries. Recommendation = 01-14:=20 Support Research Related to Volume and Outcome for Primary and = Ambulatory=20 Care The Secretary = should support=20 research that looks into issues related to volume and outcome in = the rural=20 context based on primary and ambulatory care. Recommendation = 01-15:=20 Support Changes to Medicare Policy to Provide Exceptions for Rural = Training Programs The Secretary = should support=20 changes to Medicare policy to provide exceptions to the residency = cap for=20 rural training programs and provide direct and indirect GME = funding for=20 these programs. Recommendation = 01-16:=20 Promote More Community-Based Trainings The Secretary = should support=20 changes to Medicare policy that promote more community-based = training of=20 residents. Recommendation = 01-17:=20 Require Training Programs that Receive Graduate Medical Education = Funding=20 to Have Rural Training Sites The Secretary = should support=20 changes to Medicare policy so that residency programs receiving = GME=20 funding would be required to provide training in rural=20 settings. Recommendation = 01-18:=20 Support Rural Graduate Medical Education = Demonstrations The Secretary = should support=20 Rural GME demonstration projects that address workforce shortages = in rural=20 areas. Recommendation = 01-19:=20 Promote Rural Training in Title VII and Title VIII = Programs The Secretary = should expand=20 the scope and focus Title VII and Title VIII training grants to = promote=20 more rural training. Recommendation = 01-20:=20 Increase Funding for the National Health Service Corps to Promote = More=20 Clinicians Serving in Rural Areas The Secretary = should=20 increase funding for the National Health Service Corps to promote = more=20 placements of Corps clinicians in underserved rural areas to serve = Medicare and Medicaid beneficiaries. Recommendation = 01-21:=20 Protect and Strengthen the Medicare Fee-For-Service = Program The Secretary = should protect=20 and strengthen the Medicare Fee-For-Service delivery option under = any=20 redesign or reform of the Medicare program. This should include an = acknowledgment that Medicare + Choice in its present form is not a = viable=20 option for bringing managed care and equity of benefits to rural=20 beneficiaries. Consequently, the Secretary should recognize that=20 fee-for-service delivery will continue to be the dominant service = delivery=20 mechanism for rural Medicare beneficiaries. Recommendation = 01-22:=20 Ensure that Rural Health Care Providers are Kept in Mind during = any=20 Redesign of the Medicare Program The Secretary = should ensure=20 protections for key rural service providers (critical access = hospitals,=20 sole community hospitals, Medicare-dependent hospitals, rural = referral=20 centers, rural health clinics and federally qualified health = centers), in=20 any redesign of the Medicare program to ensure access to care for = rural=20 beneficiaries. Recommendation = 01-23:=20 Explore Potential New Service Delivery Models for Rural=20 Areas The Secretary = should explore=20 the development of new service delivery models for rural = beneficiaries=20 that recognize the special circumstances of providing care in = sparsely=20 populated rural areas. Options such as coordinated care, primary = care=20 case-management and other forms of partial risk or capitation that = emphasize local control and flexibility should be explored. = Recommendation = 00-1:=20 Improve Coordination of Federal Public Health = Activities The Secretary = should seek an=20 Executive Order for the creation of a Federal Interagency Public = Health=20 Coordination Committee comprised of senior representatives from = the=20 various public health agencies and federal departments. The = committee=20 would study current efforts by each of the Federal Agencies = involved in=20 public health activities overall while evaluating ways to = integrate=20 funding stream to benefit rural communities in the areas of = leadership=20 development, workforce development, viability of the safety net, = impact of=20 managed care, and telecommunications. The newly formed committee = would=20 produce an annual report based on their studies. This committee = would=20 include appointed representatives from the Department of Health = and Human=20 Services, the Department of Agriculture, the Environmental = Protection=20 Agency, the Department of Commerce, the Department of Veteran = Affairs, the=20 Department of Labor, the Department of Education, the Department = of=20 Housing and Urban Development, the Department of Transportation, = the=20 Department of Defense and any other relevant Federal = agencies.
The Secretary = should support=20 the development of a dedicated funding stream for public health=20 infrastructure activities with assurances that funding is = equitably=20 distributed among rural and urban health departments at the local=20 level. Recommendation = 99-1:=20 Incorporate an occupational mix adjustment into the Wage Index = The Committee = recommends=20 that the Secretary incorporate an occupational mix adjustment into = the=20 calculation of the Medicare Hospital Wage Index. This will require = the=20 Department to begin gathering data on wage and hours by = occupational=20 category in the Medicare cost reports or by obtaining it from the = Bureau=20 of Labor Statistics. Recommendation = 99-2:=20 Develop Separate Wage Indexes for Sub-Acute Care PPS The Committee = recommends=20 that the Secretary develop separate wage indexes for the = prospective=20 payment systems for skilled nursing facilities and home health = agencies=20 within three years after these payment systems are in place. = Recommendation = 99-3:=20 Remove Teaching Physician Costs from the Wage Index The Committee = recommends=20 that the Secretary remove teaching physician costs from the = hospital wage=20 index since these costs are recognized elsewhere in the Medicare = system=20 through Graduate Medical Education payments. Recommendation = 99-4:=20 Collect and Evaluate Hospital-Specific Labor Data for the Wage = Index=20 The Committee = recommends=20 that the Secretary begin collecting hospital specific wage index = market=20 data during the next three years and develop and implement a New = Medicare=20 wage index based on hospital-specific labor market areas by FY = 2003. The=20 new wage index calculation would base wage-related costs on the = costs=20 incurred by neighboring hospitals. Recommendation = 99-5:=20 Low-volume adjustment for the Medicare Outpatient Prospective = Payment=20 System for Rural hospitals The Committee = recommends=20 that the Secretary include a low-volume adjustment in the final = rule for=20 the Medicare outpatient prospective payment system to compensate = rural=20 providers who may be at a disadvantage under the new payment = system if=20 they serve low numbers of patients. Recommendation = 99-6:=20 Low-volume adjustment for the Medicare Home Health Prospective = Payment=20 System for Rural Providers The Committee = recommends=20 that the Secretary include a low-volume adjustment in the final = rule for=20 the Medicare home health prospective payment system to compensate = rural=20 providers who may be at a disadvantage under the new payment = system if=20 they serve low numbers of patients. Recommendation = 99-7:=20 Low-volume adjustment for the Medicare Skilled Nursing Facility=20 Prospective Payment System for Rural Providers The Committee = recommends=20 that the Secretary include a low-volume adjustment in the Medicare = skilled=20 nursing facility payment system to compensate rural providers who = may be=20 at a disadvantage under the new payment system if they serve low = numbers=20 of patients. Recommendation = 99-8:=20 Low-volume adjustment for the Medicare Ambulance Fee Schedule for = Rural=20 Providers The Committee = recommends=20 that the Secretary include a low-volume adjustment in the final = rule for=20 the Medicare ambulance fee schedule to compensate rural providers = who may=20 be at a disadvantage under the new payment system if they serve = low=20 numbers of patients Recommendation = 99-9:=20 Revision of the Medicare Disproportionate Share Payment Adjustment = for=20 Rural Hospitals The Committee = recommends=20 that the Secretary revise the formula by which rural hospitals = receive=20 disproportionate share payments under the Medicare program to more = adequately compensate those rural providers that shoulder a large = burden=20 of indigent care. Recommendation = 99-10:=20 Creation of a Rural Hospital Capital Need Loan Program The Committee = recommends=20 that the Secretary to support the creation of a loan program for = physical=20 capital needs in licensed acute care rural hospitals that = encourages=20 consolidation and coordination of services at the local level. = Recommendation = 99-11:=20 Critical Access Hospital Grant Incentives The Committee = recommends=20 that the Secretary give a preference in the reviewing of grant = proposals=20 to projects that include a Critical Access Hospitals as a part of = the=20 applicant consortia or network under Federal health grants = administered by=20 the Department of Health and Human Services.=20 Recommendation = 99-12:=20 Encourage Development of Rural-Specific Quality Standards = The Committee = recommends=20 that the Secretary encourage national and state accrediting bodies = to=20 examine rural-specific quality issues and work with the Department = to=20 develop relevant standards appropriate to the size, setting, and = services=20 provided by rural hospitals, health systems, rural provider = practices and=20 health plans serving rural areas. The Secretary should also = support=20 recognition of these issues by Congressional members and staff. = Recommendation = 99-13:=20 Development of Two Sets of Definitions for Rural Areas The Secretary = recommends=20 that the Secretary support the development of two sets of = standards for=20 the delineation of metropolitan and nonmetropolitan areas. This = would=20 include:
Recommendation = 99-14:=20 Improved Coordination of Federal Public Health Activities = The Committee = urges the=20 Secretary to seek an Executive Order for the creation of a Federal = Interagency Public Health Coordination Committee comprised of = senior=20 representatives from the various public health agencies and = federal=20 departments. The committee would produce an annual report (the = first of=20 which would be produced within 12 months of the establishment of = the=20 Committee). The Committee would study current efforts by each of = the=20 Federal Agencies involved in public health activities overall = while=20 evaluating ways to integrate funding streams to benefit rural = communities=20 in the areas of leadership development, workforce development, = viability=20 of the safety net, impact of managed care, and = telecommunications.=20 Recommendation = 99-15:=20 Creation of a Dedicated Funding Stream for Public Health = Activities=20 The Committee = urges the=20 Secretary to support the development of a dedicated funding stream = for=20 public health infrastructure activities with assurances that = funding is=20 equitably distributed among rural and urban health departments at = the=20 local level.=20 Recommendation = 98-1:=20 Allow Referring Practitioner to Bill For Telehealth = Consultations=20 The Committee = recommends=20 that the Secretary ensure that the new regulations for telehealth=20 reimbursement allow a referring practitioner, usually located in a = rural=20 area, to bill for a primary care visit on the same day as a video=20 consultation if the primary care visit is the basis of the = consultation or=20 was for a medical problem unrelated to the consultation. Recommendation = 98-2:=20 Reimburse for Telehealth Services in All HPSAs The Committee = recommends=20 that the Secretary ensure that the new regulations for telehealth=20 reimbursement interpret "rural health professional shortage" area = as being=20 all rural health professional shortage areas, including partial = county,=20 whole county and multiple county as well as governor-designated = HPSAs. The=20 original legislation did not specify which HPSAs were eligible. = Recommendation = 98-3: Base=20 Telehealth Payment on Consultant Setting The Committee = recommends=20 that the Secretary ensure that the new regulations for telehealth=20 reimbursement require that the fee schedule be based on the = location of=20 the consultant rather than the referring clinician. The original=20 legislation did not specify whether the payment should be based on = the=20 patient=92s location in the rural area or the specialist=92s = location, which=20 is usually in an urban area. The urban payment tends to be higher. = Recommendation = 98-4:=20 Medicare Adopt a Broad Telehealth Consultation Definition = The Committee = Recommends=20 that the Secretary ensure that for the purpose of telemedicine = payment,=20 interactive consultation should be interpreted in as broad a = manner as is=20 possible. A video interaction between two practitioners where = enhanced=20 information is provided by the referring practitioner involving=20 tele-imaging and appropriate medical history, physical findings, = and=20 diagnostic/management concerns for use in the consultation should = count as=20 an interactive consultation, even if the patient is not present. = Recommendation = 98-5:=20 Allow Same-Day Office and Telehealth Consult Billing The Committee = Recommends=20 that the Secretary ensure that the referring provider should be = permitted=20 to bill for a primary care visit on the same day as a video = consultation=20 if the primary care visit is the basis of the consultation, or was = for a=20 medical problem unrelated to the consultation. Recommendation = 98-6:=20 Allow Unbundling of Telehealth Consultation Fee by Participating=20 Providers The Committee = Recommends=20 that the Secretary ensure that the unbundling of the fee between = the two=20 providers should be left to the discretion of the two providers=20 (institutions or practitioners) involved and should not be = specified in=20 regulation. In the event that it is determined that this is not=20 permissible because of the provisions of other legislation, then = the=20 unbundling should be designed to ensure that there are incentives = for both=20 the referring and consulting physician to participate in = telemedicine=20 consultations. Recommendation = 98-7:=20 Adopt a Broad Definition of Interactive Consultations The Committee = Recommends=20 that the Secretary should support a technical amendment that = defines an=20 interactive consultation. For the purpose of telemedicine payment=20 interactive consultation should be interpreted in as broad a = manner as is=20 possible to include video interactions between two practitioners = in which=20 enhanced information is provided by tele-imaging and appropriate = medical=20 history, physical findings and diagnostic/management concerns are = provided=20 by the referring practitioner for use in the consultation, even if = the=20 patient is not present. Recommendation = 98-8:=20 Allow Nurse Presenters in Medicare Telehealth Consultations = The Committee = Recommends=20 that the Secretary support a clarification of the statute that = would allow=20 a nurse, under the supervision of a practitioner who is not = physically=20 present in the room, to present a patient for a teleconsultation. = Recommendation = 98-9:=20 Support Full Funding of the Rural Hospital Flexibility Program = The Committee = recommends=20 that the Secretary support a $25 million appropriation to = implement the=20 Rural Hospital Flexibility Program and ensure that it is = administered by=20 the Office of Rural Health Policy in the Health Resources and = Services=20 Administration.
Recommendation = 98-10:=20 Support a legislative change to 1997 GME Legislation The Committee = recommends=20 that the Secretary support legislation to make technical changes = on a=20 series of GME provision from the Balanced Budget Act. = Specifically, the=20 legislation should:=20
The Committee = recommends to=20 the Secretary that the Health Care Financing Administration = consider not=20 only where a residency program is located but where its graduating = physicians practice in their definition of programs servicing = rural or=20 rural underserved.=20 Recommendation = 98-12:=20 Assure Access to Mental Health Care in Medicaid Managed Care = The Secretary = should assure=20 access to care for rural Medicaid eligible individuals served by = managed=20 behavioral health care systems. Toward that end, the Secretary=20 should=20
Clinical records = and reports=20 must exist to demonstrate the accomplishment of effective = coordination of=20 physical and behavioral components of health care of = individuals=20 Recommendation = 97-1:=20 Adjustment to the Medicare AAPCC Rate for Managed Care The Committee = urged the=20 Secretary to support changes to the way Medicare pays for managed = care=20 services. Medicare pays a set amount for each beneficiary under = the=20 Average Adjusted Per Capita Cost (AAPCC) rate. Specifically, the = Committee=20 urged a new formula that would allow greater equity of payment = between=20 rural and urban areas. Recommendation = 97-2:=20 Imposition of a Cap on Provider-Based RHCs The Committee = urged the=20 Secretary to impose a cap or per-visit limit on provider-based = rural=20 health clinics.=20 Recommendation = 96-1:=20 Expand the EACH/RPCH Program Nationwide The Committee = recommends=20 that the Secretary create a national limited service hospital = program=20 based on the EACH (Essential Access Community Hospital)/RPCH = (Rural=20 Primary Care Hospital) program.=20 Recommendation = 94-01:=20 Adjust for Occupational Mix in the Medicare Wage Index The Committee = recommends=20 that the Secretary base the wage index, which is used to calculate = Medicare hospital payments, on relative labor costs adjusted to a = standard=20 occupational mix. To accomplish this, the Secretary should = establish a=20 data base for making a labor market specific occupational mix = adjustment.=20 Recommendation = 94-02:=20 Payments for Physician Services The Committee = supports the=20 goal of providing incentives for physicians to provide primary = care, as=20 contained in the Health Security Act, and urges the Secretary to = continue=20 to support such provisions in the absence of national health = reform.=20 Recommendation = 94-03:=20 Historical Costs The Committee = recommends=20 that the Secretary consider alternatives to the use of historical = costs as=20 the basis for setting fee schedules, premium caps, or any other = cost=20 containment mechanisms introduced as part of health care reforms. = Recommendation = 94-04:=20 Medicaid Eligibility for Farm Families The Committee = recommends=20 that the Secretary initiate a change in the federal regulations = for AFDC=20 (aid to Families with Dependent Children) regarding = self-employment income=20 for farmers. AFDC regulations at 45-CFR 233.209(a)(6)(V)(B) = require that=20 states include the depreciation of business investments when = calculating=20 earned income from self-employment. The Committee recommends that=20 depreciation of farm investments not be included in farmers' = incomes when=20 calculating their eligibility for AFDC because AFDC guidelines = generally=20 drive a family's eligibility for Medicaid. Recommendation = 94-05:=20 Rural Representation The Committee = recommends=20 that all governing and advisory boards that are established to = implement=20 any future health reform be specifically required to have rural=20 representatives among their members. In particular, any alliance = (or=20 similar body) that includes a rural population should be required = to have=20 substantial rural representation on its governing board and = professional=20 advisory board. In addition, any requirements for these boards to = consult=20 with outside interest should include a requirement to consult with = individuals and organizations representing rural interests. = Recommendation = 94-06:=20 Technical Assistance Programs The Committee = recommends=20 that the Secretary develop technical assistance programs to = strengthen=20 rural health care delivery systems and prepare rural areas for = health care=20 reforms.=20 Recommendation = 94-07:=20 Antitrust The Committee = recommends=20 that the Secretary, in conjunction with the Department of Justice = and the=20 Federal Trade Commission, use the federal Office of Rural Health = Policy=20 (or any other appropriate office) and the State Offices of Rural = Health to=20 educate rural providers and health professionals about antitrust = aspects=20 of developing alternative health delivery systems.=20 Recommendation = 94-08:=20 Telemedicine Pilot Projects The Committee = endorses the=20 Secretary's current efforts to evaluate and test payment = methodologies for=20 telemedicine. The Committee recommends that additional pilot = projects be=20 established within the next fiscal year to test payment = methodologies and=20 collect data on costs, utilization, outcomes, provider and patient = satisfaction, etc. The pilot projects should be non-proprietary, = open=20 architecture systems using a variety of telemedicine technologies = and=20 configurations. These projects should be evaluated on an ongoing = basis=20 with annual reports to the Secretary. After two years, each annual = report=20 should include information that will assist the Secretary in = developing=20 appropriate payment policies.=20 Recommendation = 94-09:=20 Increasing the Rural Sample of Leading National Health Surveys = The Secretary = should=20 increase the rural samples and take other steps to improve the = rural=20 analytic capability of two key national health surveys -- the = National=20 Medical Expenditure Survey and the National Health Interview = Survey. This=20 improved capability is critical to assessing differences in access = to=20 health care for citizens living in communities that vary by degree = of=20 rurality, for example, by population density and distance to an = urban=20 area. In addition, the Secretary should direct the National Center = for=20 Health Statistics to explore augmenting the rural sample of the = Health and=20 Nutrition Examination Survey.=20 Recommendation = 94-10:=20 Risk Adjustments The Committee = recommends=20 that explicit attention be paid to rural concerns as risk = adjustment=20 methodologies are developed in conjunction with health insurance = reforms.=20 Such concerns include the lack of good cost data on rural minority = populations and occupational illness and injury. The Committee = urges the=20 Secretary to consult rural experts, including the Committee, in = developing=20 data bases and methodologies for risk adjusters that include rural = populations.=20 Recommendation = 94-11:=20 Fair Competition for Rural Grants and Contracts Applicants = The Committee =
recommends=20
that the Secretary take steps to ensure that grant and contract =
program=20
announcements issued by the Department do not ignore rural =
realities and=20
disadvantage rural applicants. The Committee also recommends that =
the=20
Secretary find additional methods for announcing program =
opportunities in=20
rural areas, rather that relying exclusively on the Commerce =
Business=20
Daily and Federal Register. Recommendation:=20
Medicare under Health Care Reform
The =
Committee=20
reiterates recommendation 93-15 from the Sixth Annual Report =
on=20
Rural Health asking the Secretary to assimilate Medicare=20
beneficiaries into the health alliances of the reformed =
health care=20
system as quickly as possible.
Recommendation:=20
Medicare Dependent Hospitals
The =
Committee=20
recommends that the Secretary establish a short-term task =
force to=20
study the need to continue the Medicare Dependent Hospital =
program=20
under health care reform.
Recommendation:=20
Migrant Workers
The =
Committee=20
recommends that the Secretary consider development of =
separate=20
health alliances for migrant workers in each of the migrant=20
streams. Recommendation =
94-12:=20
Alternative Rural Health Care Delivery Systems
The Committee =
recommends=20
that the Secretary support legislation to authorize the Health =
Care=20
Financing Administration (HCFA) to conduct demonstrations of =
alternative=20
rural health care delivery systems that require waivers of the =
Medicare=20
conditions of participation for hospitals Recommendation =
94-13:=20
Health Professions Education
The Committee =
reiterates the=20
recommendations it made in its Sixth Annual Report on Rural =
Health=20
addressing health professions education (93-5 to 93-14).=20
Recommendation =
94-14: Tax=20
Incentives for Practitioners in Rural HPSAs and MUAs
The Committee =
recommends=20
that the Secretary support legislation to provide tax incentives =
to=20
primary health care practitioners who locate their practices in=20
rural Health Professions Shortage Areas (HPSAs) and =
Medically=20
Underserved Areas (MUAs). Such incentives should be offered both =
to new=20
and existing rural practitioners.=20
Recommendation =
94-07:=20
Mental Health and Substance Abuse Services
The Committee =
recommends=20
that the Secretary support enhanced mental health and substance =
abuse=20
services.=20
Recommendation =
93-1:=20
Personnel Qualifications for Physician-performed Microscopy =
The Secretary =
should expand=20
the personnel qualifications for physician-performed microscopy =
procedures=20
to include other primary care practitioners, i.e., nurse =
practitioners=20
(NPs), clinical nurse specialists (CNSs), physician assistants =
(Pas), and=20
certified nurse-midwives (CNMs).
Recommendation =
93-2:=20
Requirements for General Supervisors of High Complexity =
Laboratories=20
The Secretary =
should extend=20
the grandfathering clause for general supervisor of a high =
complexity=20
laboratory to all individuals who were qualified, as of =
February=20
28, 1992, to serve as the general supervisor of a hospital =
laboratory=20
under the clinical laboratory requirements published March 14, =
1990.=20
Recommendation =
93-3:=20
Designation of Rural Primary Care Hospitals
The Secretary =
should support=20
legislation authorizing the Secretary to designate Rural Primary =
Care=20
Hospitals (RPCHs), as defined by law, in communities where =
hospitals have=20
been closed for more than one year.=20
Recommendation =
93-4:=20
Rural Representation on the Clinical Laboratory Improvement =
Advisory=20
Committee
The Secretary =
should appoint=20
a rural representative to the Clinical Laboratory Improvement =
Advisory=20
Committee (CLIAC).
Recommendation =
93-5:=20
National Health Professions Workforce Plan
The Secretary =
should develop=20
a national health professions workforce plan that specifies goals =
for the=20
types, specialties, and geographic distribution of health =
professionals=20
necessary to meet the health care needs of the nation.=20
Recommendation =
93-6:=20
Outcomes-based Funding of Health Professions Education =
Programs=20
The Secretary =
should support=20
legislation to restructure federal funding of education programs =
for=20
health professionals so the funding decisions are based on the =
success=20
with which the training programs contribute toward achieving the =
goals of=20
the health professions workforce plan.=20
Recommendation =
93-7: All=20
Payers Contribute to Health Professions Education
The Secretary =
should support=20
legislation requiring all health care payers to participate in =
funding=20
health professions education.=20
Recommendation =
93-8:=20
Training in a Variety of Settings
The Secretary =
should support=20
legislation to make health professional education funding =
available to=20
health professional and residency programs in varied settings, not =
just=20
those owned or operated by a hospital.=20
Recommendation =
93-9:=20
Rural Training Sites
The Secretary =
should support=20
the development of rural practice sites as training sites for both =
undergraduate and graduate health professional training.=20
Recommendation =
93-10:=20
Interdisciplinary Training Programs
The Secretary =
should=20
encourage the development of interdisciplinary training =
programs=20
Recommendation =
93-11:=20
Train Local Health Care Workers
The Secretary =
should develop=20
initiatives to broaden access and innovation in health care =
delivery by=20
supporting local programs that utilize indigenous community =
workers and=20
paraprofessionals as essential members of community health care =
delivery=20
teams.=20
Recommendation =
93-12:=20
Broaden use of Medicare Graduate Medical Education Dollars =
The Secretary =
should support=20
legislation to modify the Medicare payment provisions for graduate =
medical=20
education to provide funding for undergraduate and graduate =
training of=20
physicians and other health care professionals.=20
Recommendation =
93-13:=20
Medicare Payment for Non-hospital Based Training
The Secretary =
should support=20
legislation to provide Medicare funding for training in varied =
settings,=20
not just those owned or operated by a hospital.=20
Recommendation =
93-14:=20
Align Payment Incentives with Educational Incentives
The Secretary =
should=20
support, both through policy development and legislation, a =
restructuring=20
of the Medicare physician payment system so it contributes toward=20
achieving the goals of the health professions workforce plan. =
Recommendation =
93-15:=20
Assimilate Medicare Beneficiaries into the Health Alliances =
(repeated in=20
April 1994)
The Secretary =
should support=20
legislation to assimilate Medicare beneficiaries into the health =
alliances=20
of the reformed health care system as quickly as possible.=20
Recommendation =
93-16:=20
Consider Rural Needs in Developing Mental Health and Substance =
Abuse=20
Benefits under Health Care Reform
The Secretary =
should=20
consider the special needs of rural areas in the further =
development of=20
mental health and substance abuse benefits under health care =
reform, and=20
the need to improve access to these services in rural areas. The =
Committee=20
recommends several general principles to be considered in meeting =
the=20
needs of rural areas.=20
Recommendation =
93-17:=20
National Plan for Mental Health Professionals in Rural Areas =
The Secretary =
should direct=20
the Bureau of Health Professions to develop and implement (in=20
collaboration with the National Association of State Mental Health =
Program=20
Directors, the Center for Mental Health Services, and the Office =
of Rural=20
Health Policy) a national plan to respond to the severe shortage =
of mental=20
health professionals in rural areas.=20
Recommendation =
93-18:=20
Substance Abuse and Mental Health Services Administration (SAMHSA) =
Reauthorization Act
The Secretary =
should support=20
the Center for Mental Health Services, the Center for Substance =
Abuse=20
Treatment, and the Center for Substance Abuse Prevention in =
developing the=20
capabilities required to effectively carry out their respective =
missions=20
as stated in P.L. 102-321 (the SAMHSA Reauthorization Act) in ways =
that=20
are responsive to the needs and concerns of rural areas and =
populations.=20
In responding to this recommendation, each Center should:=20
The Secretary =
should direct=20
the Substance Abuse and Mental Health Services Administration to =
develop=20
technical assistance programs to integrate mental health and =
substance=20
abuse service with "generic" rural service delivery systems (i.e., =
primary=20
health care, education, aging, developmental disabilities, =
criminal=20
justice, etc.) and increase the capacity of these systems to meet =
the=20
needs of their clients with mental health and substance abuse=20
problems.=20
Recommendation =
93-20:=20
Equal Access to Federal Funding for Mental Health and Substance =
Abuse=20
Services
The Secretary =
should support=20
the development of new ways to ensure that rural areas and =
populations=20
have equal access to federal funding and support in mental health =
and=20
substance abuse. Specifically, the Secretary should:=20
Recommendation =
93-21:=20
Rural Parent Education and Support Program
The Secretary =
should=20
establish a demonstration grant program to rural communities to =
provide=20
early parenting education and support to first-time parents. the=20
demonstration program should include a three-pronged strategy that =
would=20
involve the development of local family resource centers, =
community-based=20
assessment and home visitation services, and the development of =
networks=20
and referral agreements between related programs and =
services.=20
Recommendation =
92-1:=20
Rural Hospital Transition Grant Program
The Secretary =
should support=20
legislation to continue the Rural Hospital Transition Grant=20
Program.=20
Recommendation =
92-2:=20
Essential Access Community Hospital/Rural Primary Care Hospital=20
(EACH/RPCH) Program
The Secretary =
should convene=20
a meeting of the key participants in the EACH/RPCH program to =
resolve=20
problems and to develop legislative and regulatory strategies that =
will=20
facilitate implementation of the program.=20
Recommendation =
92-3:=20
Geographic Reclassification of Hospitals for Purposes of the Wage=20
Index
a) The proposed =
guideline=20
for hospitals seeking a higher wage index should require wage =
payments=20
that are 100 percent instead of 108 percent of the average hourly =
wages of=20
the area in which they are physically located.
b) The Secretary =
should seek=20
a legislative or administrative change that would permit =
reclassification=20
decisions to be made for periods of three years rather than one =
year.=20
Recommendation =
92-4:=20
Targeted Adjustments for Volume Increases Under the Medicare =
Physician=20
Payment System
The Secretary =
should support=20
a legislation change that would allow for different adjustments in =
fees=20
paid to rural and urban providers if volume of services rendered =
by urban=20
providers rises faster than for rural physicians.
Recommendation =
92-5:=20
Incentives for Rural Physicians
The Secretary =
should propose=20
legislation that provides additional financial incentives for =
physicians=20
to practice in rural areas. The incentives should be greatest for=20
physicians practicing in rural Medically Underserved Areas (MUAs) =
and=20
rural Health Professional Shortage Areas (HPSAs).
Recommendation =
92-6: The=20
Clinical Laboratory Improvement Amendments of 1988 (CLIA) and =
Rural Health=20
Clinics (RHCs) (repeated in 1993)
The Secretary =
should=20
reconcile the regulatory requirements for clinical laboratories =
and the=20
regulatory requirements for RHCs to make it possible for RHCs to =
comply=20
with the requirements of both programs as "certificate of waiver"=20
laboratories.
Recommendation =
92-7:=20
Utilizing Health Care Reform Principles
When reviewing =
health care=20
reform proposals, the Secretary should use the principles =
developed by the=20
Committee as a guide for evaluating the appropriateness of the =
reform=20
proposal for rural areas.=20
Recommendation =
92-8:=20
Basic Health Care Benefits for All Americans
The Secretary =
should support=20
legislation that will establish a set of minimum, portable, =
uniform=20
benefits for all Americans. The program should not exclude =
individuals=20
from eligibility for health insurance and access to health care =
due to=20
employment status or lack of permanent residence. The benefits =
should=20
provide a continuum of services ranging from preventive care to=20
rehabilitative and long-term care.=20
Recommendation =
92-9:=20
Demonstration Programs to Encourage Collaboration Among =
Providers=20
The Secretary =
should develop=20
demonstration programs that allow and encourage collaboration of =
all major=20
health care providers to make health care available in rural=20
communities.=20
Recommendation =
92-10:=20
Assuring Adequate Access to Health Care
The Secretary =
should support=20
health care reform legislation that will assure that rural =
residents have=20
adequate access to health care. Specifically, support should be =
given for=20
the following areas:=20
The Secretary =
should support=20
health care reform legislation that encourages the integration of =
health=20
and education services for all segments of society.=20
Recommendation =
92-12:=20
Rapid Resolution of Payment Disputes
The Secretary =
should support=20
health care reform legislation that provides for rapid resolution =
of=20
payment disputes.=20
Recommendation =
92-13:=20
Establish a Coordinating Forum on Agricultural Health and =
Safety=20
The Secretary =
should direct=20
the Office of Rural Health Policy to establish a coordinating =
forum on=20
agricultural health and safety for the purpose of sharing =
information and=20
coordinating agricultural health and safety activities across =
federal=20
departments or agencies.=20
Recommendation =
92-14:=20
Increased Support for State Offices of Rural Health
The Secretary =
should seek an=20
increased appropriation for the State Offices of Rural Health =
Program=20
(SORHs) to enable each State Office to take a leadership role in, =
and=20
provide a forum for, addressing rural occupational health and =
safety=20
issues (including farming, logging, fishing, and mining) within =
their=20
respective state and local health communities.=20
Recommendation =
92-15:=20
Development of Continuing Education Programs in Agricultural =
Health and=20
Safety
The Secretary =
should seek an=20
appropriation for the Bureau of Health Professions (BHPr) of the =
Health=20
Resources and Services Administration to support the development =
of=20
continuing education programs in agricultural health and safety, =
including=20
prevention, diagnosis, and treatment.=20
Recommendation =
92-16:=20
Safety Training for Farm Children
The Secretary of =
Health and=20
Human Services should ask the U.S. Department of Agriculture to =
request=20
that the Cooperative Extension Service begin a child farm safety =
course=20
for farm children and the parents of children who help on the =
farm. The=20
course should include a manual of information, similar to the =
Hunter=20
Safety Course now offered by the National Rifle Association. This =
manual=20
could be all inclusive, from equipment to pesticides, to =
hypothermia, to=20
first aid, and so forth.=20
Recommendation =
92-17:=20
Health Career Opportunities Initiative
The Secretary of =
Health and=20
Human Services should work with the Secretary of Agriculture to =
develop=20
cooperative programs and incentive funding to attract rural young =
people=20
to health careers. This should be accomplished in cooperation with =
the=20
Youth-at-Risk Initiative of the Extension Service's 4-H =
Development=20
Program. Special attention should be paid to providing =
opportunities to=20
young people from ethnic and cultural minorities. Whenever =
possible, this=20
initiative should involve the State Offices of Rural Health, and =
should be=20
developed with participation from AHECs, the Office of Minority =
Health,=20
and local health departments.=20
Recommendation =
92-18:=20
Mandatory Rollover Protective Structures and Seat Belts =
The Secretary =
should work=20
with the Secretaries of the Department of Labor, Commerce, and =
Agriculture=20
to seek legislation for the mandatory inclusion of Rollover =
Protective=20
Structures (ROPS) and seat belts on all new tractors, and a =
five-year=20
incentive program to retrofit ROPS and seat belts on tractors =
currently in=20
use. The cost of the tractor retrofits could be shared by state =
and=20
federal governments, equipment manufacturers, and tractor owners.=20
Tractor-like devices used in logging should be included under the=20
provisions of this recommendation.=20
Recommendation =
92-19:=20
North American Free Trade Agreement
In anticipation of =
the North=20
American Free Trade Agreement (NAFTA), the Secretary of Health and =
Human=20
Services should work with federal, state, local, and private =
agencies and=20
businesses on both sides of the U.S./Mexico border to identify and =
create=20
effective working models that address the health care challenges =
faced by=20
populations living along the border. The models should address =
housing,=20
sanitation, water quality, infectious disease, pesticide and other =
environmental hazards, and occupational health and safety. In =
addition,=20
the models, should, as much as possible, reflect a community =
organization=20
approach that empowers local residents.=20
Recommendation =
92-20:=20
U.S./Mexico Rural Border Area Projects
In cooperation =
with the=20
Mexican Ministry of Health, Pan American Health Organization =
(PAHI),=20
and/or private foundations, the Secretary of Health and Human =
Services is=20
urged to support six to eight binational U.S./Mexico Rural Border =
Area=20
projects to demonstrate improved, comprehensive, primary health =
care=20
services. This would include sanitation and preventive care =
focusing on=20
maternal, infant, and adolescent health.=20
Recommendation =
92-21:=20
Shortage of Mental Health Professionals in Rural Areas
The Secretary =
should urge=20
the newly-created Center for Mental Health Services in the =
Substance Abuse=20
and Mental Health Services Administration (SAMHSA) to address the =
severe=20
shortages of mental health professionals in rural areas as one of =
its=20
first priorities.=20
Recommendation =
92-22:=20
Models for Intergovernmental Collaboration
The Secretary =
should direct=20
the Administration for Native Americans to develop and disseminate =
a=20
technical assistance document that reviews current roles and=20
responsibilities of federal, state, local and tribal governments =
for rural=20
Native Americans' and Alaska Natives' health. It should provide =
examples=20
of rural models for collaboration among these governmental=20
entities.=20
Recommendation =
92-23:=20
Expansion of Initiatives to Address Native American Health =
Problems=20
The Secretary =
should direct=20
the Indian Health Service to develop strategies for improving =
health=20
services to Native Americans through the expansion of specialized =
women's=20
clinics, school-based clinics, enhanced support of substance abuse =
and=20
fetal alcohol syndrome prevention initiatives, and increased =
training and=20
use of physician assistants and nurse practitioners.=20
Recommendation =
92-24:=20
Technical Assistance: Federally Qualified Health Centers (FQHCs) =
and Rural=20
Health Clinics (RHC)
The Secretary =
should provide=20
technical assistance regarding FQHC and RHC programs by: 1) =
offering a=20
technical assistance hotline so that questions about program =
elements,=20
distinctions of the two programs, and requirements can be =
answered; and 2)=20
offering regional workshops, marketed to a broad spectrum of =
practitioners=20
and facilities, to assist attendees in understanding the =
similarities and=20
differences in the programs.=20
Recommendation =
92-25:=20
Recruitment and Retention of Health Personnel
The Secretary =
should direct=20
the Bureau of Primary Health Care to set aside dollars =
appropriated to the=20
National Health Service Corps (NHSC) for more travel and on-site=20
consultation with states to promote a greater understanding of the =
goals=20
and the policies of the NHSC program.=20
Recommendation =
91-1: DHHS=20
Program Priority: Improving Health Care Access for Rural =
Citizens=20
At least one of =
the annual=20
policy objectives or program priorities of the Secretary, the =
Assistant=20
Secretary for Health, and the Administrator of the Health Care =
Financing=20
Administration should address improving access to health care for=20
America's rural citizens.=20
Recommendation =
91-2:=20
Impact on President's Budget on Health Care Access in Rural =
Areas=20
Concurrent with =
the annual=20
submission of the President's budget, the Secretary should prepare =
an=20
analysis of the budget's impact on programs that provide access to =
health=20
care in rural areas.=20
Recommendation =
91-3:=20
Adjustments for Budget Neutrality in Transition Rules for Medicare =
Physician Payment System
Any adjustments =
for budget=20
neutrality in the transition rules for phasing in the new fee =
schedule=20
should incorporate only those adjustments which can be shared =
equally by=20
all physicians, not just those whose fees are, by design, =
significantly=20
increased under the new fee schedule.
Recommendation =
91-4:=20
Targeted Adjustments for Volume Increases in Medicare Physician =
Payment=20
System
The Secretary =
should direct=20
the Health Care Financing Administration (HCFA) to examine the =
expected=20
volume response to the new system by specific specialty groups and =
for=20
specific procedures. Based on this examination, HCFA should =
develop=20
methods to penalize only those providers whose volume of services=20
increases inappropriately, rather than all physicians.
Recommendation =
91-5:=20
Elimination of Geographic Payment Adjustments Under the Medicare =
Physician=20
Payment Fee Schedule
The Secretary =
should seek=20
legislative change which would eliminate all geographic payment=20
adjustments under the new fee schedule for physicians.
Recommendation =
91-6:=20
Malpractice Adjustment
The Secretary =
should direct=20
HCFA to refine its malpractice adjustment in the Medicare =
physician fee=20
schedule formula to recognize the actual services provided by =
rural=20
primary care physicians.
Recommendation =
91-7:=20
Medicare Capital Payment Floor
The Secretary =
should=20
establish a minimum level of financial protection of all hospitals =
under=20
the new Medicare prospective capital payment system. Specifically, =
a=20
"payment floor" of 80 percent should be established so that under =
the new=20
system, no hospital would receive less than 80 percent of its =
actual=20
capital costs.
Recommendation =
91-8: Old=20
Capital
The Secretary =
should direct=20
HCFA to include leasing costs in the definition of "old capital" =
under the=20
new system.
Recommendation =
91-9:=20
Capital Payment Policy for Essential Access Community Hospitals =
and Rural=20
Primary Care Hospitals
Essential Access =
Community=20
Hospitals and Rural Primary Care Hospitals should receive special=20
financial protection under the prospective payment system for =
capital.=20
Recommendation =
91-10:=20
Coverage of Certified Nurse-Midwife Gynecological and Family =
Planning=20
Services Under Medicare (repeated in 1992)
The Secretary =
should direct=20
the General Counsel of the Health Care Financing Administration =
(HCFA) to=20
review the Administration's (HCFA's) original interpretation of =
OBRA-87 --=20
Section 4073 relating to the coverage of nurse-midwife services =
under=20
Medicare.
If, upon review of =
the=20
original interpretation, a decision is made to cover gynecological =
and=20
family planning services provided by CNMs under Medicare, HCFA =
should=20
issue revised manual instructions to the carriers in an =
expeditious manner=20
and issue regulations pertaining to the statute no later than =
March 1,=20
1992.
If, upon review, =
the General=20
Counsel concludes that the original interpretation of the statute =
is the=20
best (in light of the legislative language), the Secretary should =
propose=20
that Congress amend the statute to provide for coverage of CNM =
services=20
outside of the maternity cycle.
Recommendation =
91-11:=20
FQHC Payments Based on Actual Cost Experience Without Arbitrary =
Urban and=20
Rural Distinctions
Any cost-based =
payment=20
system for FQHCs should reflect their actual cost experience, =
without=20
imposition of arbitrary limits. The FQHC payment system should not =
incorporate arbitrary distinctions between urban and rural =
areas.=20
Recommendation =
91-12:=20
FQHC Reporting Requirements for Look-Alikes
The Secretary =
should require=20
annual reports from FQHC look-alikes and develop a recertification =
process=20
for them that occurs at least every three years.=20
Recommendation =
91-13:=20
Obstetrical Access and Medical Malpractice
The Secretary =
should direct=20
the Agency for Health Care Policy and Research (AHCPR) to =
establish=20
obstetrical access and liability as a research priority within its =
legal-medicine program in 1992. As a component of this priority, =
the=20
Agency should evaluate state health care malpractice and liability =
initiatives that address obstetrical access.=20
Recommendation =
91-14:=20
Community and Migrant Health Centers - Federal Tort Claim Coverage =
and=20
Risk Management
The Secretary =
should=20
continue to work closely with the Department of Justice to support =
legislation that would provide relief to community and migrant =
health=20
centers from excessive malpractice insurance costs. This relief =
could be=20
provided by amending the Federal Tort Claim Act to extend coverage =
to=20
community and migrant health centers (C/MHCs) and to health =
professionals=20
who are employees or contractors of C/MHCs, or through some =
alternative=20
mechanism.=20
The Secretary =
should allow=20
dollars currently being utilized by health centers for malpractice =
premiums to remain in the health centers. The dollars should be =
directed=20
to risk management and quality improvement activities, as well as=20
activities to expand or enhance patient care. The Secretary, =
through the=20
Bureau of Health Care Delivery and Assistance, should continue to =
support=20
rigorous risk management and quality improvement activities in=20
C/MHCs.=20
Recommendation =
91-15:=20
AHCPR User Liaison Program: Rural Focus on Medical Malpractice and =
Liability
The User Liaison =
Program of=20
the Agency for Health Care Policy and Research (AHCPR) should =
include a=20
rural focus in programs developed to educate state legislators and =
executive staff about medical malpractice and liability =
issues.=20
The Committee =
further=20
recommends that AHCPR include the 1987 DHHS Report of the Task =
Force on=20
Medical Liability and Malpractice in its program materials. =
Last, it=20
recommends that AHCPR provide the technical assistance needed to =
help=20
implement the model Health Care Provider Liability Reform =
Act or a=20
comparable comprehensive reform model act.=20
Recommendation =
91-16:=20
Rural Representation in the AHCPR Guideline Development =
Process=20
The Agency for =
Health Care=20
Policy and Research should assure that rural representation is =
included in=20
all phases of the guideline development process, including rural=20
representation among peer review consultants and among the =
facilities in=20
which clinical guidelines are pilot-tested. It should further seek =
to=20
include rural representation, including rural consumers, on the =
guideline=20
advisory panels. The AHCPR should work with the Office of Rural =
Health=20
Policy to identify rural consultants for the peer review process =
and rural=20
facilities for the pilot-testing of the standards.=20
Recommendation =
91-17:=20
Medicare Payment Formula for Home Health Services
The Secretary =
should=20
instruct HCFA to amend the Medicare reimbursement formula for home =
health=20
services to cover additional costs of delivering health care in =
rural=20
areas that result from such factors as increased travel distances. =
Recommendation =
91-18:=20
Implement the "Social Factors" Medicare Payment Provision of the =
Peer=20
Review Norms Amendments in OBRA '87
The Secretary =
should=20
instruct HCFA to issue specific regulations or instructions to =
implement=20
the "social factors" provision contained in OBRA '87. This =
provision=20
directs Peer Review Organizations (PROs) to approve, under =
specific=20
circumstances, inpatient hospitalization for treatment that would=20
otherwise be on an outpatient basis. Specific circumstances that =
justify=20
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=20
adversely affect the safety or effectiveness of treatment provided =
on an=20
outpatient basis (Public Law 100-203, sec. 4094(a)).
Recommendation =
91-19:=20
Rural Initiative for Prevention, Health Promotion and Wellness =
with Older=20
Persons
The Secretary =
should direct=20
the Office of Disease Prevention and Health Promotion and the=20
Administration on Aging to develop, in cooperation with the Office =
of=20
Rural Health Policy, a health promotion initiative that focuses on =
rural=20
communities. This effort should also involve the USDA Cooperative=20
Extension Service, and any foundations that are investing in this=20
issue.=20
Recommendation =
91-20:=20
Improve Transportation Services for Older and Disabled Persons =
Living in=20
Rural Areas
A. The =
Administration on=20
Aging (AoA/DHHS) should work with the Urban Mass Transportation=20
Administration (UMTA/DOT) to: Recommendation =
91-21:=20
Develop a Quality Assurance Strategy for In-Home Services and =
Extended=20
Care Facilities
The Secretary =
should work=20
with States to develop a quality assurance strategy for certified =
home=20
health services and services provided at extended care facilities =
in rural=20
areas.=20
Recommendation =
91-22:=20
Expand Research on In-Home and Community-Based Health Care =
Services for=20
the Chronically Ill Rural Elderly
The National =
Institute on=20
Aging should direct its Exploratory Centers on Aging and Health in =
Rural=20
America to work with the ORHP-funded Rural Health Research =
Centers, as=20
appropriate to:=20
Recommendation =
91-23:=20
Improve Information Dissemination on the Rural Elderly
The Secretary =
should improve=20
the availability of information regarding the rural elderly =
through=20
support of activities such as the Rural Information Center/Health =
Services=20
(RICHS) at the National Agricultural Library, the National =
Resource Center=20
for Rural Elderly at the University of Missouri-Kansas City, and =
the Rural=20
Outreach Program of the National Library of Medicine (NLM). =
Recommendation =
91-24:=20
Increase and Target Funding for Titles VII and VIII Health =
Professions=20
Programs (U.S. Public Health Service Act)
The Secretary =
should seek=20
increased appropriations for Title VII and Title VIII health =
professions=20
programs, targeting funds to programs which train health =
professionals for=20
practice in rural and other underserved areas.=20
Recommendation =
91-25:=20
Rural Interdisciplinary Training Grant Program
The Secretary =
should support=20
legislation to amend Title VII to include the Rural =
Interdisciplinary=20
Program, and should seek an increased appropriation for this=20
program=20
Recommendation =
91-26:=20
Rural Medical Education Demonstration Program
The Secretary =
should support=20
legislation to amend Title VII of the U.S. PHS Act to include the =
Rural=20
Medical Education Demonstration Program. The program's =
authorization=20
should be amended to expand the program to ambulatory settings and =
authorize start-up grant funds.=20
Recommendation =
91-27:=20
Funding Factors for Health Professions Programs
The Secretary =
should=20
establish the following funding factors (preference and =
priorities) for=20
the Title VII and VIII health professions programs:=20
Recommendation =
91-28:=20
Modification of the ADMS Block Grant Apportionment Formula =
The Secretary =
should direct=20
the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) =
to=20
revise the ADMS block grant drug apportionment formula used to =
allocate=20
drug monies between states. The formula's preferential weighting =
for urban=20
populations should be adjusted downward to more accurately reflect =
the=20
actual differences in urban and rural drug abuse rates. The =
Secretary=20
should then propose legislation that incorporates the revised =
funding=20
formula.=20
Recommendation =
91-29:=20
Modification of Substance Abuse Set-Aside Requirements
The Secretary =
should propose=20
legislation to eliminate the mandated set-aside for drug abuse =
services=20
within the ADMS block grant's intra-state substance abuse funding=20
component. This should be eliminated to allow the intrastate =
allocation of=20
funds to more accurately reflect the actual rates of alcohol and =
drug=20
abuse in rural areas.=20
Until legislation =
can be=20
enacted to ensure a more equitable distribution of substance abuse =
monies=20
within states, ADAMHA should expedite the granting of waivers to =
states=20
for the intravenous drug abuse set-aside.=20
Recommendation =
91-30:=20
ADMS State Block Grant Plans
The Secretary =
should require=20
that each state describe in its ADMS block grant plans how it will =
address=20
the specific service delivery needs of its rural =
populations.=20
Recommendation =
91-31:=20
Integration of Alcohol, Drug Abuse and Mental Health Services with =
Other=20
Primary Care Services in Rural Communities
The Department =
should=20
identify ten model communities where the provision of alcohol, =
drug abuse=20
and mental health services are currently integrated into the =
delivery of=20
other primary care services. Their successful strategies should be =
described and promulgated to other rural communities across the =
nation.=20
Any legislative, regulatory or administrative barriers that impede =
such=20
integration should be identified and targeted for =
elimination.=20
The Office of =
Rural Health=20
Policy should work closely with the "Primary Care - Substance =
Abuse=20
Linkage Initiative" of the Office of Treatment Improvement, =
ADAMHA, to=20
coordinate activities and strengthen its rural focus.=20
Recommendation =
91-32: The=20
Office of Rural Health Policy's Role in Mental Health and =
Substance Abuse=20
Policy
The Secretary =
should seek=20
legislation to expand the authority of the Office of Rural Health =
Policy=20
to include policy issues on rural mental health and substance =
abuse and=20
should seek an increased appropriation to support such =
activities.=20
Recommendation =
91-33:=20
Improve Data Collection on Alcohol, Drug Abuse and Mental Health =
Needs,=20
Services and Personnel in Rural Areas
The Alcohol, Drug =
Abuse and=20
Mental Health Administration (ADAMHA) should develop research =
strategies=20
to establish the epidemiology of substance abuse and mental health =
problems in rural areas, identify the full range of professionals=20
providing mental health services to these populations, and measure =
the=20
current level of service availability.=20
Recommendation =
91-34:=20
Defining the Scope of Rural Primary Mental Health Services and =
Educating=20
Professionals to Provide These Services
The Secretary =
should direct=20
the National Institute of Mental Health to conduct research to =
define the=20
scope of primary mental health services needed in rural =
areas.=20
When this research =
has been=20
completed, the Secretary should: The Secretary =
should=20
implement targeted educational initiatives, including continuing=20
education, to increase the number of health and human service=20
professionals providing rural mental health, substance abuse =
prevention=20
and treatment services.=20
The Secretary =
should direct=20
the National Health Service Corps (NHSC) to: 1) establish a second =
priority within its scholarship and loan repayment programs for=20
individuals in the five core mental health professions, and 2) =
seek an=20
increased appropriation to support this second priority.=20
Recommendation =
91-37:=20
Evaluation of the Health Personnel Shortage Areas (HPSAs) =
"Greatest Need=20
Criteria" on Frontier Areas
The Committee =
requests that=20
the Health Resources and Services Administration analyze the =
impact on=20
frontier areas of the new criteria for allocating National Health =
Service=20
Corps (NHSC) personnel to "HPSAs of greatest need." If the new =
criteria=20
appear to be detrimental to the placement of personnel in frontier =
areas,=20
the Bureau of Health Care Delivery and Assistance should work with =
the=20
Office of Rural Health Policy to revise them for the 1993 =
placement=20
cycle.=20
Recommendation =
90-1:=20
Medicare Payment for Mid-level Primary Care Services (Part e. =
repeated in=20
1992)
By October 1, =
1991, the=20
Secretary should draft legislation to establish direct payment of=20
mid-level providers practicing in rural areas according to the =
following=20
criteria:
a. Definition =
of=20
Mid-level Providers: Mid-level providers are primary care =
physician=20
assistants and advanced practice nurses (nurse practitioners and =
clinical=20
nurse specialists) who meet state licensure requirements.
b. Services and =
Settings: Payment should be made for primary care services =
covered by=20
Medicare physician payment policies. The existing Medicare =
definition of=20
primary care services include: office and clinic visits, hospital =
visits,=20
nursing home visits, emergency care, and home visits.
c. Geographic =
Areas:=20
Payments for such services should be limited to mid-level =
providers=20
practicing in rural Health Manpower Shortage Areas (HMSAs), rural=20
Medically Underserved Areas (MUAs) designated by the U.S. Public =
Health=20
Service, or non-metropolitan counties with a primary care=20
physician-to-population ratio less than the national rural average =
for the=20
same ratio. Primary care physicians are defined as physician =
providers in=20
the fields of Family Practice, General Practice, General Internal=20
Medicine, General Pediatrics and Obstetrics/Gynecology, excluding =
medical=20
residents and fellows.
d. =
Collaboration with=20
Physicians: Formal collaboration and referral arrangements =
between=20
mid-level providers and primary care physicians should be an =
essential=20
condition of participation in the Medicare program. Consultations =
provided=20
by primary care physicians should be reimbursed appropriately =
under a=20
relative value scale, except as already provided through other =
payment=20
programs such as the Rural Health Clinics Act.
e. Payment =
Policy:=20
The payment level for mid-level providers should be set at a level =
of 100%=20
of primary care physician payment for the same services.
f. Assignment =
Policy:=20
The assignment policy for mid-level providers should be the same =
as the=20
assignment policy for primary care physicians.
Recommendation =
90-2:=20
Delay Implementation of the Clinical Laboratory Improvement =
Amendments of=20
1988 (CLIA '88)
The Secretary =
should delay=20
implementation of CLIA '88 until its impact on access to care in =
rural=20
areas can be adequately assessed.
Recommendation =
90-3:=20
Modification of the Essential Access Community Hospital (EACH) =
Program=20
The Secretary =
should propose=20
legislation to modify the EACH Program. The legislation would be =
amended=20
to give States and rural hospitals more flexibility in designing =
rural=20
health care networks. The recommended changes would: 1) Provide =
for a=20
waiver of the 72 hour limit on inpatient stays within a Rural =
Primary Care=20
Hospital (RPCH) for states that submit acceptable proposals to =
establish a=20
set of services which may be appropriately provided within the =
RPCH or for=20
other alternative approaches to defining a RPCH; (2) Provide for =
waivers=20
that would allow states to propose alternative definitions for the =
EACH;=20
(3) Clarify that hospitals designated as a RPCH are allowed to =
participate=20
in the swing bed program; 4) Stipulate that states may propose to =
include=20
hospitals in adjacent states in a rural health network.=20
Recommendation =
90-4:=20
Modification of the Rural Hospital Transition Grant Program =
The Secretary =
should create=20
a set-aside fund under the Rural Hospital Transition Grant program =
specifically earmarked for rural hospitals that propose a =
transition from=20
a full service acute care facility to an institution which offers =
less=20
intensive but essential services to its community. The fund would =
also=20
support experimental efforts toward the development of the =
"primary care=20
hospital" concept.=20
Recommendation =
90-5:=20
Provide a Rural Focus in the Department's Efforts to Improve the =
Health=20
Status of Minority Populations
To ensure a rural =
focus in=20
the Department's efforts to improve the health status of African=20
Americans, Hispanics, Native Americans and Asian/Pacific =
Islanders, the=20
Secretary should direct the Office of Minority Health, in =
cooperation with=20
the Office of Rural Health Policy, to:=20
1) Sponsor and =
conduct a=20
national conference on improving minority health in rural areas;=20
and=20
2) By September 1, =
1991,=20
subject a report which outlines recommendations for departmental=20
initiatives to reduce the health disparity of minorities living in =
rural=20
areas.=20
Recommendation =
90-6:=20
Establish a Task Force on Improving Coordination of Departmental =
Service=20
Programs and Training Programs
The Secretary =
should=20
establish a task force to develop strategies that promote =
coordination of=20
Bureau of Health Professions (BHPr) and Bureau of Health Care =
Delivery and=20
Assistance (BHCDA) programs to better link training and service in =
Federal=20
programs. More specifically, the task force should develop =
strategies that=20
foster utilization of rural community and migrant health centers =
(C/MHCs)=20
as sites for conducting career awareness and clinical training =
activities.=20
As a component of this initiative, a demonstration program should =
be=20
developed to provide funding to rural C/MHCs to engage in career =
awareness=20
activities and clinical training.=20
Recommendation =
90-7:=20
Modify Departmental Health Career Awareness Programs to Promote =
Career=20
Development Among Rural Minority Populations
The Secretary =
should direct=20
the Health Resources and Services Administration to make the =
following=20
changes in its programs to promote awareness of health career=20
opportunities and promote career development among rural minority=20
populations:=20
The Secretary =
should direct=20
that all Departmental surveys of health professionals be designed =
so as to=20
permit analyses by urban/rural and racial/ethnic classifications.=20
Departmental surveys should be designed to permit evaluation of =
personnel=20
information on minority health professionals by urban and rural =
location=20
of practice. Data collection systems should also be devised which =
permit=20
the further categorization of rural data into"frontier" and =
"non-frontier"=20
rural areas.=20
Recommendation =
90-9:=20
Sponsor an Invitational Workshop on Rural Minority Data Collection =
on=20
Health Professionals
The Secretary =
should sponsor=20
an invitational workshop for the purpose of developing a =
standardized=20
format for the collection of rural/urban and racial/ethnic health=20
professional data. The workshop should include representation from =
national health professional associations, health education =
associations,=20
and training programs.=20
Recommendation =
90-10:=20
Improve Data Collection in Departmental Health Professions =
Training=20
Programs
The Secretary =
should direct=20
the Bureau of Health Professions (BHPr) and the National =
Institutes of=20
Health (NIH) to require a health personnel training programs =
funded by=20
them to routinely collect program monitoring data that use both=20
urban/rural and racial/ethnic identifiers, consistent with the =
Privacy Act=20
and confidentiality constraints. In addition, the programs should =
be=20
required to track participants as to where they practice upon =
completion=20
of their training. These data should be collated and analyzed by =
the=20
various funding agencies, and reported to the Office of Rural =
Health=20
Policy and Office of Minority Health.=20
Recommendation =
90-11:=20
Improve Federal Data Collection on HIV Disease in Rural Areas =
The Department of =
Health and=20
Human Services should collect accurate, comprehensive information =
about=20
the extent, characteristics, and impact on HIV disease in rural =
areas. The=20
Agency for Health Care Policy and Research, the Centers for =
Disease=20
Control, the Alcohol, Drug Abuse, and Mental Health =
Administration, and=20
other Federal agencies or programs, as appropriate, should fund =
studies to=20
improve understanding of the epidemiology, demographics, impact, =
and=20
trends of HIV disease in rural areas.=20
Recommendation =
90-12:=20
Require States to Have a Statewide Plan which Designates a Single =
State=20
Agency as Responsible for Coordinating State Response to HIV/AIDS =
and=20
which Addresses Rural HIV/AIDS Needs as a Condition of Receiving =
Federal=20
AIDS Block Grants
Federal block =
grants to=20
states for HIV disease prevention and treatment services should be =
contingent upon the existence of a statewide plan which =
effectively=20
addresses rural HIV/AIDS needs and the designation of a single =
state=20
agency responsible for coordinating the state's response to HIV=20
disease.=20
Recommendation =
90-13:=20
Provide Federal Support for Technical Assistance to =
Community-Based=20
Organizations which Address the Needs of HIV Infected Persons in =
Rural=20
Areas
The Centers for =
Disease=20
Control and the Health Resources and Services Administration =
should=20
develop and support a coordinated program of technical assistance =
for=20
community-based organizations doing HIV prevention and providing =
services=20
to HIV-infected persons in rural areas.=20
The =
community-based=20
organizations play a critical role in preventing the spread of HIV =
and=20
providing services to HIV-infected persons. These programs need =
technical=20
assistance with organizational development and programming. =
Currently=20
technical assistance is provided by a number of agencies and =
programs.=20
These are not well coordinated, and there is no assurance that all =
important areas of training are addressed. Training and technical=20
assistance should address at least:=20
The appropriate =
Federal=20
agencies, in particular the Centers for Disease Control and the =
Health=20
Resources and Services Administration, should support programs to =
promote=20
and foster local leadership to orchestrate the HIV response in =
rural=20
areas.=20
Recommendation =
90-15:=20
Expand the AIDS Education and Training Center Activities to More=20
Effectively Reach Rural Primary Care Providers
The AIDS Education =
and=20
Training Centers should establish or expand telephone hot line =
services=20
and other programs to assure that rural primary care providers =
have easy,=20
rapid access to HIV/AIDS treatment information, drug trials and =
referrals.=20
Further, the AIDS Education and Training Centers should expand =
networks=20
linking rural health care providers with major medical centers, to =
ensure=20
access and quality care to persons with HIV disease.=20
Recommendation =
90-16:=20
Establish State 800 Numbers to Provide Information on Medicaid =
Eligibility=20
and Coverage of Services for HIV Infected Persons
State Medicaid =
Offices=20
should establish 800 numbers to provide information on Medicaid=20
eligibility for and coverage of HIV-disease to HIV-infected =
persons,=20
providers, patient advocates, and the state's local social service =
offices.=20
Recommendation =
90-17:=20
Provide Federal Guidance to States on Implementation of Ryan White =
Act=20
The Secretary =
should provide=20
guidance to states in their use of the Ryan White Act HIV/AIDS =
funds to=20
assure attention to the needs of the increasing number of =
HIV-infected=20
persons in rural areas.=20
Recommendation =
90-18:=20
Accept the Recommendations of the National Commission on AIDS =
The Secretary =
should accept=20
the recommendations of the third report of the National Commission =
on=20
AIDS, especially their recommendations to develop comprehensive=20
community-based primary health care systems and to expand AIDS =
education=20
and outreach services to rural communities. (National Commission =
on Aids,=20
Report No. 3, Recommendations One and Two.)=20
Recommendation =
90-19:=20
Develop a Compendium of State Initiatives Undertaken to Address=20
Obstetrical Malpractice
The Secretary =
should direct=20
the Health Resourcesand Services Administration to develop a =
compendium of=20
state initiatives that have been undertaken or are currently =
underway to=20
address obstetrical malpractice. In addition, the compendium =
should=20
describe state initiatives to train and place practitioners of all =
levels=20
(physicians and mid-level practitioners) in rural areas to more=20
effectively meet these areas need for obstetrical practitioners. =
The=20
compendium should include copies of legislation (proposed and =
enacted) and=20
should be disseminated to the National Governors Association, =
National=20
Conference State Legislatures, Council of State Governments, the =
National=20
Association of Counties, state offices of rural health, and other=20
appropriate entities.=20
Recommendation =
90-20:=20
Monitor State Initiatives which Address Obstetrical =
Malpractice=20
The Health =
Resources and=20
Services Administration should work with the Agency for Health =
Care Policy=20
and Research (AHCPR) to track or monitor ongoing state initiatives =
that=20
address obstetrical malpractice issues and evaluate their =
effects.=20
Recommendation =
90-21:=20
Establish a Commission on Obstetrical Access
The Secretary =
should=20
establish a special commission to examine the barriers to =
effective and=20
efficient utilization of all obstetrical providers (both =
physicians and=20
mid-level practitioners) who provide care in rural areas. The =
commission=20
should be charged with proposing policy and strategies for =
implementation=20
at Federal, state and local levels. Strategies should include the=20
development of incentives to promote more effective utilization of =
all=20
health professionals who provide obstetrical services. To =
facilitate the=20
development and acceptance of policies and strategies, the =
commission=20
should include representatives from the National Governors' =
Association,=20
the National Conference of State Legislatures, the Council of =
State=20
Governments, and the National Association of Counties.=20
Recommendation =
90-22:=20
Establish a Funding Priority in the Bureau of Health Professions =
Training=20
Programs for Rural Primary Care Practice Programs that Include a =
Strong=20
Obstetrical Practice Component
The Bureau of =
Health=20
Professions should establish a funding priority for health =
professions=20
education/training programs which prepare health professionals for =
rural=20
primary care practice and which have a strong obstetrical practice =
component.=20
Recommendation =
89-1:=20
Create a Medicare Payment Floor for Rural Hospitals With Less than =
50 Beds=20
and for Sole Community Hospitals The Secretary =
should propose=20
legislation to the Congress that would establish a Medicare =
inpatient=20
payment floor for rural hospitals with less than 50 acute care =
beds and=20
for Sole Community Hospitals (SCHs). The payment floor would be =
based on=20
an individual hospital's current cost experience. The legislation =
would be=20
effective for hospital cost reporting periods beginning on or =
after=20
October 1, 1989, and end at such time that special Medicare =
payment=20
provisions for essential access facilities are implemented. For =
the=20
purposes of this legislation, acute care beds include swing beds, =
but=20
exclude licensed beds for long-term care and newborn bassinets. =
Recommendation =
89-2:=20
Establish a single National Standardized Payment Amount by Fiscal =
Year=20
1993
The Secretary =
should propose=20
legislation that would establish a single national standardized =
payment=20
amount to replace the separate urban and rural Medicare =
standardized=20
amounts. The single payment rate system should incorporate more =
sensitive=20
adjustments for differences in case-mix, severity, area wage =
levels, and=20
other non-labor price adjustors. The current urban-rural =
differential=20
should be phased out over a 3-year period such that a single =
national=20
standardized amount would be implemented for cost reporting =
periods=20
beginning no later than October 1, 1992.
Recommendation =
89-3:=20
Develop and Test a Refined Area Wage Adjustment
By the beginning =
of FY 1991,=20
the Secretary should implement a refined area wage adjustment to =
better=20
reflect differences in hospital wages. Prior to implementing this=20
adjustment, the Secretary should develop and test the =
appropriateness of=20
an area wage adjustment that assumes a single national labor =
market for=20
professional personnel.
Recommendation =
89-4:=20
Update the Area Wage Index Annually
By the beginning =
of FY 1992,=20
the Secretary should have in place a mechanism of annually =
updating the=20
area wage index used in the Medicare PPS. The data collected =
should=20
reflect the true labor costs of hospitals for professional and=20
non-professional occupational categories of employees.
Recommendation =
89-5:=20
Evaluate the Impact of Prospective Payment Systems on Rural =
Hospital=20
Outpatient Care Under Medicare
Given the =
congressional=20
mandate for the Secretary to develop a legislative proposal on =
prospective=20
payment for hospital outpatient services, the Secretary should =
evaluate=20
carefully the impact of such proposals on rural hospitals.
Recommendation =
89-6:=20
Continue and Increase Support for Research and Demonstrations on=20
Innovative and Alternative Delivery Systems
The Secretary =
should=20
continue the Department's support for the Medical Assistance =
Facility=20
Demonstration Project in Montana. Additional research and =
demonstrations=20
should be supported to encourage communities to test various =
transition=20
strategies to ensure continued access to health services in their=20
communities.=20
Recommendation =
89-7:=20
Define and Identify Essential Access Facilities
By April 1, 1992, =
the=20
Secretary should submit to Congress legislative proposals for=20
implementation, by October 1, 1992, of a coordinated strategy to =
protect=20
the financial viability of essential access facilities (EAFs). The =
strategy should include uniform guidelines for identifying EAFs, a =
process=20
for designating such facilities, and the design of appropriate =
Federal=20
program protections. Incentives and specialized grant programs =
should be=20
developed to encourage adoption of the EAF concept and enhance the =
quality=20
and scope of services available in these facilities. The Office of =
Rural=20
Health Policy should be charged with the responsibility for =
defining and=20
developing the strategy because EAFs play a major role in ensuring =
access=20
to health care in rural communities.
Recommendation =
89-8:=20
Improve Access to Capital for Rural Facilities
The Secretary =
should work=20
with the Department of Housing and Urban Development (HUD) and the =
U.S.=20
Department of Agriculture to improve access to capital for rural=20
facilities through increased availability of Farmers Home =
Administration=20
direct and guaranteed loans (non-farm), HUD 242 and 232 loan =
guarantees,=20
and PHS Section 1610(a) and (b) grants for construction and =
modernization.=20
Such funding would be limited to those facilities determined to be =
critical for access to health care in the community.=20
Recommendation =
89-9:=20
Support the Rural Hospital Transition Grant Program and Broaden =
Its Scope=20
to Include Community Needs Assessment
The Secretary =
should support=20
the rural Hospital Transition Grant Program through FY 1990. =
Beginning in=20
FY 1991, legislation should be proposed to the Congress that would =
make=20
non-hospital health organizations, community organizations, =
agencies, or=20
political subdivisions eligible as grantees. The program's title =
should be=20
changed to "Rural Health Services Transition Grant Program" and be =
broadened in scope to include a community needs assessment which=20
encompasses comprehensive health care, health promotion, =
alcoholism,=20
substance abuse, mental health, and emergency medical =
services.=20
Recommendation =
89-10:=20
Implement Federal Grant Programs to Promote the Integration and=20
Coordination of Services in Rural Areas
By October 1, =
1992, the=20
Secretary should develop a series of programs that would =
facilitate=20
integration and coordination of services in or among rural =
communities.=20
The programs should include new demonstrations and increased =
emphasis in=20
current programs on improving both horizontal and vertical =
linkages,=20
integration, and cooperation between community and migrant health =
centers,=20
local primary care providers, hospitals, medical group practices, =
and=20
public health departments. These programs should be the result of =
a=20
careful analysis by the Office of Rural Health Policy of existing=20
demonstrations and should reflect a thorough review of existing =
Federal=20
and state barriers, both legislative and regulatory, that impede=20
integration.=20
Recommendation =
89-11:=20
Establish a "One-Stop Shopping" Demonstration Program
The Secretary =
should propose=20
legislation to the Congress establishing a demonstration program =
(10 rural=20
sites) that would consolidate all categorical funds and programs =
for=20
health into a single "one-stop" office, particularly in very poor =
or small=20
communities.=20
Recommendation =
89-12:=20
Medicare Physician Payment Policies
The Committee =
recommends=20
that any policy positions adopted by the Department that relate to =
a=20
restructured reimbursement system for physicians should adhere to =
the=20
following principles:
1) Medicare =
payments to all=20
physicians practicing in rural areas should be increased to =
eliminate=20
existing urban-rural differentials.
2) Payment =
increases for=20
rural primary care physicians should be accelerated. During the =
transition=20
period to any new reimbursement system, the payment floor for =
primary care=20
services should be increased from 50 percent to 80 percent of =
national=20
average prevailing charges to be effective January 1, 1990. The =
increased=20
payment schedule should be restricted to physician specialists in =
family=20
practice, general practice, general internal medicine, obstetrics =
and=20
gynecology, and general pediatrics who practice in designated =
rural (i.e.,=20
non-metropolitan statistical) areas of the Nations.
3) Provisions for =
updating=20
any physician fee schedule should allow for differential updates =
according=20
to geographic locations, category of service, or other pertinent =
variables=20
explicitly related to addressing access problems of the =
underserved.=20
4) Attempts to =
define, by=20
legislation, a geographic practice cost index should be deferred =
until=20
1991 to allow sufficient time for the Physician Payment Review =
Commission=20
to complete proposed studies and subsequent evaluations related to =
alleged=20
variations in the geographic costs of practice.
5) In the event a=20
restructured payment system is not adopted by Congress, the =
Secretary=20
should recommend an increase in the payment floor as noted above =
in=20
Principle 2.
Recommendation =
89-13:=20
Stabilize Current Levels of Primary Care Providers in Rural Areas =
through=20
Tax Credits and Incentive Pay
The Secretary =
should propose=20
legislation to amend the Internal Revenue Code of 1986 to provide=20
refundable income tax credits to primary care providers who work =
in=20
federally-designated rural health manpower shortage areas (HMSAs). =
Primary=20
care providers should be defined as doctors of medicine or =
osteopathy,=20
physician assistants, nurse specialists who provide direct patient =
care=20
and practice principally in one of the four following primary care =
specialties: general or family practice, general internal =
medicine,=20
general pediatrics, and obstetrics and gynecology.=20
The Secretary also =
should=20
support legislation to extend the Medicare incentive payment bonus =
for=20
physicians practicing in Class 1 and Class 2 designated HMSAs to =
primary=20
care physicians practicing in all designated rural HMSAs, and =
increase the=20
bonus such that these physicians receive not less than a 10 =
percent=20
payment bonus.=20
Recommendation =
89-14:=20
Revitalize the National Health Service Corps (NHSC) Scholarship=20
Program
The Secretary =
should seek=20
appropriations from Congress in FY 1990 and subsequent years to =
provide=20
scholarships to entering medical and osteopathic, nurse =
practitioner,=20
nurse-midwifery, clinical nurse specialist and physician assistant =
students. In addition, the Secretary should make or, where =
necessary, seek=20
the authority to make, the following programmatic changes to =
revitalize=20
the scholarship program:=20
Priority for =
scholarships=20
should be limited initially to medical, osteopathic, nurse =
practitioner,=20
physician assistant, nurse midwifery and clinical nurse specialist =
students who intend to specialize in family practice, general =
internal=20
medicine, general pediatrics, or obstetrics/gynecology.=20
The Secretary =
should support=20
states in their efforts to establish effective loan repayment =
programs by=20
providing adequate funding to states. The Secretary should also =
continue=20
to seek to develop an effective Federal loan repayment program. As =
such,=20
the Secretary should seek increased appropriations for the loan =
repayment=20
program and support legislation that eliminates the tax liability =
of the=20
Federal loan repayment programs. Among techniques the Secretary =
should=20
consider to attract larger numbers of qualified individuals into =
the=20
Federal loan repayment program are: (1) increasing publicity about =
the=20
program; (2) increasing the loan amount the Government can repay; =
and (3)=20
covering undergraduate loans.=20
Recommendation =
89-16:=20
Maintain and Target Funding for the Health Professions Programs=20
Administered by the Department of Health and Human Services =
The Secretary =
should=20
recommend that funding for the health professions programs =
administered by=20
the Department of Health and Human Services be maintained to =
preserve the=20
capacity and continuity of education/training programs that ensure =
a=20
supply of competent health care providers for rural areas and =
other=20
underserved groups. Special priority should be given to programs =
that=20
prepare individuals for primary care, rural practice, or practice =
with=20
other underserved groups.=20
Recommendation =
89-17:=20
Establish a Task Force to Assess Policies of Health Professions=20
Accreditation Bodies and State Approval Entities
The Secretary =
should=20
establish a special short-term task force to develop specific=20
recommendations addressing barriers in health professions =
accreditation=20
and licensure standards that impede the development of rural =
clinical=20
experiences, internships, preceptorships and residencies.=20
Recommendation =
89-18:=20
Fund the "Health Care for Rural Areas" Program
The Secretary =
should seek an=20
appropriation of $5 million for the "Health Care for Rural Areas" =
program,=20
authorized in 1988 (P.L. 100-607). The program would provide =
grants to=20
develop innovative, interdisciplinary training programs that would =
educate=20
health professionals for rural practice.=20
Recommendation =
89-19:=20
Expand the "Rural Medical Education Demonstration Projects" =
Program=20
The Secretary =
should propose=20
legislation to expand the "Rural Medical Education Demonstration =
Projects"=20
program to an additional 12 demonstrations, half of which utilize =
rural=20
hospitals as a teaching site and half of which would utilize a =
rural=20
ambulatory practice setting. The expanded program should =
incorporate=20
flexible geographic criteria for awarding demonstrations that =
would result=20
in a reasonable representation of provider sites across the =
Nation.=20
Recommendation =
89-20:=20
Support Increased Funds for Community and Migrant Health (C/MHC)=20
Programs
The Secretary =
should propose=20
an increase for the C/MHC programs in the Department's FY 1991 =
budget. At=20
least 50 percent of the increase should be earmarked for projects =
in rural=20
and frontier areas.=20
Recommendation =
89-21:=20
Maintain the Current Process for Designating Heath Manpower =
Shortage Areas=20
and Medically Underserved Areas (HMSAs and MUAs)
The Secretary =
should ensure=20
that the current process for designating HMSAs and MUAs is =
maintained=20
until a full evaluation is conducted on the implications that any =
change=20
would have on the myriad of programs that utilize the =
designations.=20
Recommendation =
89-22:=20
Improve the Administration of the Rural Health Clinics (RHC) Act=20
Program
The Secretary =
should=20
disseminate information to promote an increase in the number of =
RHCs.=20
Technical assistance should be provided to assist potential =
providers in=20
qualifying for RHC designation.=20
Recommendation =
89-23:=20
Convene a Federal Interagency Rural Health Work Group and a =
Presidential=20
Rural Health Council
The Secretary =
should direct=20
the Office of Rural Health Policy to convene and staff a Federal =
Rural=20
Health Work Group composed of all Federal agencies that have=20
programs/activities with a rural health-related mission (e.g., =
Departments=20
of Agriculture, Transportation, and Veteran's Affairs). Further, =
the=20
Secretary should recommend establishment of a Presidential Rural =
Health=20
Council to mobilize the public and private sectors to better =
address rural=20
health problems.=20
Recommendation =
89-24:=20
Expand Federal Activities to Improve the Availability of Emergency =
Medical=20
Services
The Secretary =
should=20
establish a focal point within the Department for the planning and =
coordination of emergency medical services (EMS) activities. The =
Secretary=20
should propose legislation to improve the availability of EMS in =
rural=20
areas through matching grants to states.=20
Recommendation =
89-25:=20
Ensure that Federal Block Grants Address Rural Health Problems =
The Secretary =
should issue a=20
policy directive to states that implementation of all block grants =
address=20
the unique service needs of rural areas.=20
Recommendation =
89-26:=20
Ensure a Rural Focus in the "War on Drugs"
The Secretary =
should ensure=20
that current departmental efforts to address education and =
treatment in=20
the "war on drugs" include a focus on rural communities.=20
Recommendation =
89-27:=20
Establish a National Occupational/Environmental Health Program and =
a=20
National Network of Rural Occupational/Environmental Health =
Services=20
Centers
The Secretary =
should propose=20
legislation to the Congress that would establish a national=20
occupational/environmental health program to address major health =
hazards=20
through an interdisciplinary educational program in conjunction =
with high=20
schools, colleges, academic health centers and Cooperative =
Extension=20
Services.=20
In addition, the =
Secretary=20
should propose legislation to the Congress that would establish a =
national=20
network of 10 rural occupational/environmental health services =
centers in=20
conjunction with academic health centers or major medical centers. =
These=20
would provide screening, diagnosis, treatment, research, and =
educational=20
services using an interdisciplinary team approach.=20
Recommendation =
89-28:=20
Establish a National Adolescent Health Demonstration Program =
The Secretary =
should propose=20
legislation to the Congress that would establish a national =
demonstration=20
program (five rural community sites), in cooperation with states =
and the=20
private sector, to establish different types of adolescent health=20
programs. Such demonstrations would include implementation of a=20
comprehensive K through 12 health education curriculum in =
combination with=20
on-site counseling, preventive and social/health services within a =
school=20
district. These services would be provided by a health=20
professional.=20
Recommendation =
89-29:=20
Increase the Quantity and Quality of Rural Research
The Secretary =
should support=20
continuation of the HCFA "10 percent set-aside" of research and=20
development funds for rural health research. The Office of Rural =
Health=20
Policy should encourage the rural health research centers to =
sponsor a=20
national conference.=20
Recommendation =
89-30:=20
Develop a Compendium of Model Rural-Focused Health Professions =
Education=20
and Training Programs
The Secretary =
should direct=20
the Office of Rural Health Policy to identify and catalog models =
of=20
rural-focused health professions education and training programs,=20
including those programs which address leadership, management and=20
governance. A compendium of these models should be developed and=20
disseminated.=20
Recommendation =
89-31:=20
Promote Uniform Data Collection on Rural Health Personnel =
The Secretary =
should ensure=20
that all Federal health personnel data collection efforts permit =
analysis=20
by urban and rural classifications. Further, the Secretary should =
work=20
with public and private organizations that are involved in rural =
health=20
personnel research and data collection efforts to promote the =
uniform=20
gathering and analysis of data using urban and rural =
categories.=20
Recommendation =
89-32:=20
Provide Adequate Funding for the National Library of Medicine's =
Rural=20
Outreach Activities
The Secretary =
should seek=20
adequate funding to enable the National Library of Medicine (NLM) =
to=20
implement its outreach program. The Committee believes priority =
should=20
initially be given to the following areas:=20
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