The National Advisory Committee
on Rural Health and Human Services
U.S. Department of Health and Human Services
Compendium
of Recommendations by the National Advisory Committee on Rural Health
Note: The bulk of the recommendations in the compendium focus solely on health care issues. Beginning in 2003, the Committee expanded its focus to also include human services. Recommendations on human services are only available from 2004 forward.
2. PHYSICIAN AND MID-LEVEL PAYMENTS
4. PROGRAM DEVELOPMENT AND HEALTH CARE REFORM
5. RESEARCH AND DEMONSTRATIONS
8. AGRICULTURAL HEALTH AND SAFETY
Recommendation 89-1: Create a Medicare Payment Floor for Rural Hospitals With Less than 50 Beds and for Sole Community Hospitals
The Secretary should propose legislation to the Congress that would establish a Medicare inpatient payment floor for rural hospitals with less than 50 acute care beds and for Sole Community Hospitals (SCHs). The payment floor would be based on an individual hospital's current cost experience. The legislation would be effective for hospital cost reporting periods beginning on or after October 1, 1989, and end at such time that special Medicare payment provisions for essential access facilities are implemented. For the purposes of this legislation, acute care beds include swing beds, but exclude licensed beds for long-term care and newborn bassinets.
Recommendation 89-2: Establish a single National Standardized Payment Amount by Fiscal Year 1993
The Secretary should propose legislation that would establish a single national standardized payment amount to replace the separate urban and rural Medicare standardized amounts. The single payment rate system should incorporate more sensitive adjustments for differences in case-mix, severity, area wage levels, and other non-labor price adjustors. The current urban-rural differential should be phased out over a 3-year period such that a single national standardized amount would be implemented for cost reporting periods beginning no later than October 1, 1992.
Recommendation 89-3: Develop and Test a Refined Area Wage Adjustment
By the beginning of FY 1991, the Secretary should implement a refined area wage adjustment to better reflect differences in hospital wages. Prior to implementing this adjustment, the Secretary should develop and test the appropriateness of an area wage adjustment that assumes a single national labor market for professional personnel.
Recommendation 89-4: Update the Area Wage Index Annually
By the beginning of FY 1992, the Secretary should have in place a mechanism of annually updating the area wage index used in the Medicare PPS. The data collected should reflect the true labor costs of hospitals for professional and non-professional occupational categories of employees.
Recommendation 89-5: Evaluate the Impact of Prospective Payment Systems on Rural Hospital Outpatient Care Under Medicare
Given the congressional mandate for the Secretary to develop a legislative proposal on prospective payment for hospital outpatient services, the Secretary should evaluate carefully the impact of such proposals on rural hospitals.
Recommendation 89-7: Define and Identify Essential Access Facilities
By April 1, 1992, the Secretary should submit to Congress legislative proposals for implementation, by October 1, 1992, of a coordinated strategy to protect the financial viability of essential access facilities (EAFs). The strategy should include uniform guidelines for identifying EAFs, a process for designating such facilities, and the design of appropriate Federal program protections. Incentives and specialized grant programs should be developed to encourage adoption of the EAF concept and enhance the quality and scope of services available in these facilities. The Office of Rural Health Policy should be charged with the responsibility for defining and developing the strategy because EAFs play a major role in ensuring access to health care in rural communities.
Recommendation 91-7: Medicare Capital Payment Floor
The Secretary should establish a minimum level of financial protection of all hospitals under the new Medicare prospective capital payment system. Specifically, a "payment floor" of 80 percent should be established so that under the new system, no hospital would receive less than 80 percent of its actual capital costs.
Recommendation 91-8: Old Capital
The Secretary should direct HCFA to include leasing costs in the definition of "old capital" under the new system.
Recommendation 91-9: Capital Payment Policy for Essential Access Community Hospitals and Rural Primary Care Hospitals
Essential Access Community Hospitals and Rural Primary Care Hospitals should receive special financial protection under the prospective payment system for capital.
Recommendation 92-3: Geographic Reclassification of Hospitals for Purposes of the Wage Index
a) The proposed guideline for hospitals seeking a higher wage index should require wage payments that are 100 percent instead of 108 percent of the average hourly wages of the area in which they are physically located.
b) The Secretary should seek a legislative or administrative change that would permit reclassification decisions to be made for periods of three years rather than one year.
c) Reclassification decisions should be based on the most current data that hospitals can supply.
Recommendation 94-13: Adjust for Occupational Mix in the Medicare Wage Index
The Committee recommends that the Secretary base the wage index, which is used to calculate Medicare hospital payments, on relative labor costs adjusted to a standard occupational mix. To accomplish this, the Secretary should establish a data base for making a labor market specific occupational mix adjustment.
Recommendation 96-1: Expand the EACH/RPCH Program Nationwide
The Committee recommends that the Secretary create a national limited service hospital program based on the EACH (Essential Access Community Hospital)/RPCH (Rural Primary Care Hospital) program.
Recommendation 98-4: Support Full Funding of the Rural Hospital Flexibility Program
The Committee recommends that the Secretary support a $25 million appropriation to implement the Rural Hospital Flexibility Program and ensure that it is administered by the Office of Rural Health Policy in the Health Resources and Services Administration.
Recommendation 99-1: Incorporate an occupational mix adjustment into the Wage Index
The Committee recommends that the Secretary incorporate an occupational mix adjustment into the calculation of the Medicare Hospital Wage Index. This will require the Department to begin gathering data on wage and hours by occupational category in the Medicare cost reports or by obtaining it from the Bureau of Labor Statistics.
Recommendation 99-2: Develop Separate Wage Indexes for Sub-Acute Care PPS
The Committee recommends that the Secretary develop separate wage indexes for the prospective payment systems for skilled nursing facilities and home health agencies within three years after these payment systems are in place.
Recommendation 99-3: Remove Teaching Physician Costs from the Wage Index
The Committee recommends that the Secretary remove teaching physician costs from the hospital wage index since these costs are recognized elsewhere in the Medicare system through Graduate Medical Education payments.
Recommendation 99-4: Collect and Evaluate Hospital-Specific Labor Data for the Wage Index
The Committee recommends that the Secretary begin collecting hospital specific wage index market data during the next three years and develop and implement a New Medicare wage index based on hospital-specific labor market areas by FY 2003. The new wage index calculation would base wage-related costs on the costs incurred by neighboring hospitals.
Recommendation 99-5: Low-volume adjustment for the Medicare Outpatient Prospective Payment System for Rural hospitals
The Committee recommends that the Secretary include a low-volume adjustment in the final rule for the Medicare outpatient prospective payment system to compensate rural providers who may be at a disadvantage under the new payment system if they serve low numbers of patients.
Recommendation 99-6: Low-volume adjustment for the Medicare Home Health Prospective Payment System for Rural Providers
The Committee recommends that the Secretary include a low-volume adjustment in the final rule for the Medicare home health prospective payment system to compensate rural providers who may be at a disadvantage under the new payment system if they serve low numbers of patients.
Recommendation 99-7: Low-volume adjustment for the Medicare Skilled Nursing Facility Prospective Payment System for Rural Providers
The Committee recommends that the Secretary include a low-volume adjustment in the Medicare skilled nursing facility payment system to compensate rural providers who may be at a disadvantage under the new payment system if they serve low numbers of patients.
Recommendation 99-8: Low-volume adjustment for the Medicare Ambulance Fee Schedule for Rural Providers
The Committee recommends that the Secretary include a low-volume adjustment in the final rule for the Medicare ambulance fee schedule to compensate rural providers who may be at a disadvantage under the new payment system if they serve low numbers of patients
Recommendation 99-9: Revision of the Medicare Disproportionate Share Payment Adjustment for Rural Hospitals
The Committee recommends that the Secretary revise the formula by which rural hospitals receive disproportionate share payments under the Medicare program to more adequately compensate those rural providers that shoulder a large burden of indigent care.
Recommendation 99-10: Creation of a Rural Hospital Capital Need Loan Program
The Committee recommends that the Secretary to support the creation of a loan program for physical capital needs in licensed acute care rural hospitals that encourages consolidation and coordination of services at the local level.
Recommendation 99-11: Critical Access Hospital Grant Incentives
The Committee recommends that the Secretary give a preference in the reviewing of grant proposals to projects that include a Critical Access Hospitals as a part of the applicant consortia or network under Federal health grants administered by the Department of Health and Human Services.
Recommendation 01-5: Refine the Methodology for Determining the Disproportionate Share Adjustment for Hospitals
The Secretary should continue to refine the methodology for the disproportionate share adjustment for hospitals to treat all hospitals equally.
Recommendation 02-1: Require a Uniform Medicare Disproportionate Share Hospital Adjustment Policy
The Secretary should work with Congress to require the use of a uniform Medicare Disproportionate Share Hospital adjustment policy that treats all hospitals the same regardless of their urban or rural location.
Recommendation 02-2: Raise the Cap on Medicare Disproportionate Hospital Payments
The Secretary should work with Congress to raise the cap on Medicare Disproportionate Share Hospital payments for rural hospitals to an appropriate level that provides equity for rural hospitals.
Recommendation 02-3: Expand Options for Using Medicaid Disproportionate Share Hospital Payments for Eligible Rural Hospitals
The Secretary should work with States to expand options for using Medicaid Disproportionate Share Hospital Payments for eligible rural hospitals, including the ability to upgrade the financial stability of rural hospitals or to assist rural hospitals to develop physician or clinic networks.
Recommendation 89-12: Medicare Physician Payment Policies
The Committee recommends that any policy positions adopted by the Department that relate to a restructured reimbursement system for physicians should adhere to the following principles:
1) Medicare payments to all physicians practicing in rural areas should be increased to eliminate existing urban-rural differentials.
2) Payment increases for rural primary care physicians should be accelerated. During the transition period to any new reimbursement system, the payment floor for primary care services should be increased from 50 percent to 80 percent of national average prevailing charges to be effective January 1, 1990. The increased payment schedule should be restricted to physician specialists in family practice, general practice, general internal medicine, obstetrics and gynecology, and general pediatrics who practice in designated rural (i.e., non-metropolitan statistical) areas of the Nations.
3) Provisions for updating any physician fee schedule should allow for differential updates according to geographic locations, category of service, or other pertinent variables explicitly related to addressing access problems of the underserved.
4) Attempts to define, by legislation, a geographic practice cost index should be deferred until 1991 to allow sufficient time for the Physician Payment Review Commission to complete proposed studies and subsequent evaluations related to alleged variations in the geographic costs of practice.
5) In the event a restructured payment system is not adopted by Congress, the Secretary should recommend an increase in the payment floor as noted above in Principle 2.
Recommendation 90-1: Medicare Payment for Mid-level Primary Care Services (Part e. repeated in 1992)
By October 1, 1991, the Secretary should draft legislation to establish direct payment of mid-level providers practicing in rural areas according to the following criteria:
a. Definition of Mid-level Providers: Mid-level providers are primary care physician assistants and advanced practice nurses (nurse practitioners and clinical nurse specialists) who meet state licensure requirements.
b. Services and Settings: Payment should be made for primary care services covered by Medicare physician payment policies. The existing Medicare definition of primary care services include: office and clinic visits, hospital visits, nursing home visits, emergency care, and home visits.
c. Geographic Areas: Payments for such services should be limited to mid-level providers practicing in rural Health Manpower Shortage Areas (HMSAs), rural Medically Underserved Areas (MUAs) designated by the U.S. Public Health Service, or non-metropolitan counties with a primary care physician-to-population ratio less than the national rural average for the same ratio. Primary care physicians are defined as physician providers in the fields of Family Practice, General Practice, General Internal Medicine, General Pediatrics and Obstetrics/Gynecology, excluding medical residents and fellows.
d. Collaboration with Physicians: Formal collaboration and referral arrangements between mid-level providers and primary care physicians should be an essential condition of participation in the Medicare program. Consultations provided by primary care physicians should be reimbursed appropriately under a relative value scale, except as already provided through other payment programs such as the Rural Health Clinics Act.
e. Payment Policy: The payment level for mid-level providers should be set at a level of 100% of primary care physician payment for the same services.
f. Assignment Policy: The assignment policy for mid-level providers should be the same as the assignment policy for primary care physicians.
Recommendation 91-3: Adjustments for Budget Neutrality in Transition Rules for Medicare Physician Payment System
Any adjustments for budget neutrality in the transition rules for phasing in the new fee schedule should incorporate only those adjustments which can be shared equally by all physicians, not just those whose fees are, by design, significantly increased under the new fee schedule.
Recommendation 91-4: Targeted Adjustments for Volume Increases in Medicare Physician Payment System
The Secretary should direct the Health Care Financing Administration (HCFA) to examine the expected volume response to the new system by specific specialty groups and for specific procedures. Based on this examination, HCFA should develop methods to penalize only those providers whose volume of services increases inappropriately, rather than all physicians.
Recommendation 91-5: Elimination of Geographic Payment Adjustments Under the Medicare Physician Payment Fee Schedule
The Secretary should seek legislative change which would eliminate all geographic payment adjustments under the new fee schedule for physicians.
Recommendation 91-6: Malpractice Adjustment
The Secretary should direct HCFA to refine its malpractice adjustment in the Medicare physician fee schedule formula to recognize the actual services provided by rural primary care physicians.
Recommendation 92-4: Targeted Adjustments for Volume Increases Under the Medicare Physician Payment System
The Secretary should support a legislation change that would allow for different adjustments in fees paid to rural and urban providers if volume of services rendered by urban providers rises faster than for rural physicians.
Recommendation 92-5: Incentives for Rural Physicians
The Secretary should propose legislation that provides additional financial incentives for physicians to practice in rural areas. The incentives should be greatest for physicians practicing in rural Medically Underserved Areas (MUAs) and rural Health Professional Shortage Areas (HPSAs).
Recommendation 93-14: Align Payment Incentives with Educational Incentives
The Secretary should support, both through policy development and legislation, a restructuring of the Medicare physician payment system so it contributes toward achieving the goals of the health professions workforce plan.
Recommendation 94-03: Payments for Physician Services
The Committee supports the goal of providing incentives for physicians to provide primary care, as contained in the Health Security Act, and urges the Secretary to continue to support such provisions in the absence of national health reform.
Recommendation 94-05: Historical Costs
The Committee recommends that the Secretary consider alternatives to the use of historical costs as the basis for setting fee schedules, premium caps, or any other cost containment mechanisms introduced as part of health care reforms.
Recommendation 02-5: Eliminate the Medicare Per-Visit Payment Cap
The Secretary should work with Congress to eliminate any financial challenges to FQHC's providing care to the uninsured by eliminating the Medicare per-visit payment cap.
Recommendation 02-8: Increase Rural Health Clinics Payment Limit
The Secretary should work with Congress to increase the RHC payment limit under section 1833 (f) of the Act to more closely correspond with the increase in payments for primary care services resulting from the full transition to the physician fee schedule.
Recommendation 02-9: Amend Reimbursement Methodology for Rural Health Clinics
The Secretary should amend the reimbursement methodology for Rural Health Clinics (RHCs) payment so that RHCs that 1) are non-profit, 2) see all patients regardless of ability to pay, and 3) elect to use a sliding fee scale do not have to count uninsured patients in determining the aggregate number of patients seen for calculation of the per-visit payment rate.
Recommendation 02-10: Work with Congress to Conduct Strong Oversight of the Implementation of the Medicaid PPS
The Secretary should work with Congress to conduct strong, ongoing oversight of the implementation of the Medicaid PPS to ensure that States comply with requirements in the Federal PPS statute and that access to FQHC and RHC services are protected.
Recommendation 02-11: Work with Congress to Evaluate the Medicaid PPS to Ensure that FQHCs and RHCs are being Adequately Reimbursed
The Secretary should work with Congress to evaluate the Medicaid PPS to ensure that FQHCs and RHCs are being adequately reimbursed to protect access to care, including access to care for the uninsured. This includes examining whether the Medicare Economic Index (the current measure of inflation used in PPS) is sufficient to protect Medicaid reimbursement for these critical safety next providers.
Recommendation 02-12: Issue an Advisory Letter Disseminating the Legality and Specific Requirements of the Income-Related Sliding Fee Scales
The Secretary should issue an advisory letter that spells out the legality and specific requirements of income-related sliding fee scales and disseminate it widely.
Recommendation 02-19: Eliminate Medicare Payments to Urban Specialists
The Secretary should work with Congress to eliminate Medicare Incentive Payments to urban specialists.
Recommendation 05-9: Increase Medicaid Payments for Obstetrics Services
The Committee understands that Medicaid payments for services are determined by the States; however, the Secretary does have authority over State Medicaid waivers that affect the scope of services that Medicaid provides and populations served. The Secretary should explore ways in which the waiver approval process could be sued to provide incentives for the States to increase payments and improve access to obstetrics services in rural areas.
Recommendation 90-2: Delay Implementation of the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88)
The Secretary should delay implementation of CLIA '88 until its impact on access to care in rural areas can be adequately assessed.
Recommendation 91-10: Coverage of Certified Nurse-Midwife Gynecological and Family Planning Services Under Medicare (repeated in 1992)
The Secretary should direct the General Counsel of the Health Care Financing Administration (HCFA) to review the Administration's (HCFA's) original interpretation of OBRA-87 -- Section 4073 relating to the coverage of nurse-midwife services under Medicare.
If, upon review of the original interpretation, a decision is made to cover gynecological and family planning services provided by CNMs under Medicare, HCFA should issue revised manual instructions to the carriers in an expeditious manner and issue regulations pertaining to the statute no later than March 1, 1992.
If, upon review, the General Counsel concludes that the original interpretation of the statute is the best (in light of the legislative language), the Secretary should propose that Congress amend the statute to provide for coverage of CNM services outside of the maternity cycle.
Recommendation 91-17: Medicare Payment Formula for Home Health Services
The Secretary should instruct HCFA to amend the Medicare reimbursement formula for home health services to cover additional costs of delivering health care in rural areas that result from such factors as increased travel distances.
Recommendation 91-18: Implement the "Social Factors" Medicare Payment Provision of the Peer Review Norms Amendments in OBRA '87
The Secretary should instruct HCFA to issue specific regulations or instructions to implement the "social factors" provision contained in OBRA '87. This provision directs Peer Review Organizations (PROs) to approve, under specific circumstances, inpatient hospitalization for treatment that would otherwise be on an outpatient basis. Specific circumstances that justify inpatient hospitalization include special problems associated with delivering care in remote rural areas, the availability of service alternatives to inpatient hospitalization, and other factors that could adversely affect the safety or effectiveness of treatment provided on an outpatient basis (Public Law 100-203, sec. 4094(a)).
Recommendation 92-6: The Clinical Laboratory Improvement Amendments of 1988 (CLIA) and Rural Health Clinics (RHCs) (repeated in 1993)
The Secretary should reconcile the regulatory requirements for clinical laboratories and the regulatory requirements for RHCs to make it possible for RHCs to comply with the requirements of both programs as "certificate of waiver" laboratories.
Recommendation 93-1: Personnel Qualifications for Physician-performed Microscopy
The Secretary should expand the personnel qualifications for physician-performed microscopy procedures to include other primary care practitioners, i.e., nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (Pas), and certified nurse-midwives (CNMs).
Recommendation 93-2: Requirements for General Supervisors of High Complexity Laboratories
The Secretary should extend the grandfathering clause for general supervisor of a high complexity laboratory to all individuals who were qualified, as of February 28, 1992, to serve as the general supervisor of a hospital laboratory under the clinical laboratory requirements published March 14, 1990.
Recommendation 93-4: Rural Representation on the Clinical Laboratory Improvement Advisory Committee
The Secretary should appoint a rural representative to the Clinical Laboratory Improvement Advisory Committee (CLIAC).
Recommendation 94-14: Medicaid Eligibility for Farm Families
The Committee recommends that the Secretary initiate a change in the federal regulations for AFDC (aid to Families with Dependent Children) regarding self-employment income for farmers. AFDC regulations at 45-CFR 233.209(a)(6)(V)(B) require that states include the depreciation of business investments when calculating earned income from self-employment. The Committee recommends that depreciation of farm investments not be included in farmers' incomes when calculating their eligibility for AFDC because AFDC guidelines generally drive a family's eligibility for Medicaid.
Recommendation 97-1: Adjustment to the Medicare AAPCC Rate for Managed Care
The Committee urged the Secretary to support changes to the way Medicare pays for managed care services. Medicare pays a set amount for each beneficiary under the Average Adjusted Per Capita Cost (AAPCC) rate. Specifically, the Committee urged a new formula that would allow greater equity of payment between rural and urban areas.
Recommendation 97-2: Imposition of a Cap on Provider-Based RHCs
The Committee urged the Secretary to impose a cap or per-visit limit on provider-based rural health clinics.
Recommendation 98-1: Allow Referring Practitioner to Bill For Telehealth Consultations
The Committee recommends that the Secretary ensure that the new regulations for telehealth reimbursement allow a referring practitioner, usually located in a rural area, to bill for a primary care visit on the same day as a video consultation if the primary care visit is the basis of the consultation or was for a medical problem unrelated to the consultation.
Recommendation 98-2: Reimburse for Telehealth Services in All HPSAs
The Committee recommends that the Secretary ensure that the new regulations for telehealth reimbursement interpret "rural health professional shortage" area as being all rural health professional shortage areas, including partial county, whole county and multiple county as well as governor-designated HPSAs. The original legislation did not specify which HPSAs were eligible.
Recommendation 98-3: Base Telehealth Payment on Consultant Setting
The Committee recommends that the Secretary ensure that the new regulations for telehealth reimbursement require that the fee schedule be based on the location of the consultant rather than the referring clinician. The original legislation did not specify whether the payment should be based on the patients location in the rural area or the specialists location, which is usually in an urban area. The urban payment tends to be higher.
Recommendation 98-4: Medicare Adopt a Broad Telehealth Consultation Definition
The Committee Recommends that the Secretary ensure that for the purpose of telemedicine payment, interactive consultation should be interpreted in as broad a manner as is possible. A video interaction between two practitioners where enhanced information is provided by the referring practitioner involving tele-imaging and appropriate medical history, physical findings, and diagnostic/management concerns for use in the consultation should count as an interactive consultation, even if the patient is not present.
Recommendation 98-5: Allow Same-Day Office and Telehealth Consult Billing
The Committee Recommends that the Secretary ensure that the referring provider should be permitted to bill for a primary care visit on the same day as a video consultation if the primary care visit is the basis of the consultation, or was for a medical problem unrelated to the consultation.
Recommendation 98-6: Allow Unbundling of Telehealth Consultation Fee by Participating Providers
The Committee Recommends that the Secretary ensure that the unbundling of the fee between the two providers should be left to the discretion of the two providers (institutions or practitioners) involved and should not be specified in regulation. In the event that it is determined that this is not permissible because of the provisions of other legislation, then the unbundling should be designed to ensure that there are incentives for both the referring and consulting physician to participate in telemedicine consultations.
Recommendation 98-7: Adopt a Broad Definition of Interactive Consultations
The Committee Recommends that the Secretary should support a technical amendment that defines an interactive consultation. For the purpose of telemedicine payment interactive consultation should be interpreted in as broad a manner as is possible to include video interactions between two practitioners in which enhanced information is provided by tele-imaging and appropriate medical history, physical findings and diagnostic/management concerns are provided by the referring practitioner for use in the consultation, even if the patient is not present.
Recommendation 98-8: Allow Nurse Presenters in Medicare Telehealth Consultations
The Committee Recommends that the Secretary support a clarification of the statute that would allow a nurse, under the supervision of a practitioner who is not physically present in the room, to present a patient for a teleconsultation.
Recommendation 99-5: Encourage Development of Rural-Specific Quality Standards
The Committee recommends that the Secretary encourage national and state accrediting bodies to examine rural-specific quality issues and work with the Department to develop relevant standards appropriate to the size, setting, and services provided by rural hospitals, health systems, rural provider practices and health plans serving rural areas. The Secretary should also support recognition of these issues by Congressional members and staff.
Recommendation 99-6: Development of Two Sets of Definitions for Rural Areas
The Secretary recommends that the Secretary support the development of two sets of standards for the delineation of metropolitan and nonmetropolitan areas. This would include:
- A county-based set of standards as OMBs official standards, for statistical reporting purposes and as one option for federal funding programs.
- A Census tract-based system, to be available as an alternative option for federal funding programs and experimental use for reporting federal statistics.
Recommendation 01-11: Amend the Medicare Conditions of Participation
The Secretary should amend the Medicare Conditions of Participation. Also, the Secretary should provide resources through entities such as the Peer Review Organizations to develop quality improvement tools to fit the rural environment with appropriate flexibility and an emphasis on outcome standards.
Recommendation 01-15: Support Changes to Medicare Policy to Provide Exceptions for Rural Training Programs
The Secretary should support changes to Medicare policy to provide exceptions to the residency cap for rural training programs and provide direct and indirect GME funding for these programs.
Recommendation 02-17: Increase the Amount of Medicare Incentive Payment to 20 Percent
The Secretary should work with the Congress to increase the amount of the Medicare Incentive Payment to 20 percent.
Recommendation 02-18: Allow Nurse Practitioners and Physician Assistants to Qualify for the Medicare Incentive Payments
The Secretary should work with the Congress to allow nurse practitioners and physician assistants to qualify for the Medicare Incentive Payments.
Recommendation 02-20: Change the Current Auditing Procedures Used By Medicare Contractors
The Secretary should change the current auditing procedures used by the Medicare Contractors to ensure that providers who claim the Medicare Incentive Payment will not have any greater likelihood of being audited than providers who do not claim the extra payment
Recommendation 04-1: Allow Behavioral Health Providers to Provide Behavioral Health Services as Qualified Mental Health Care Service Providers
The Secretary should work with the Congress to amend Section 1861(s) (2) of the Social Security Act to authorize State-licensed marriage and family therapists, licensed professional counselors and other behavioral health providers to provide behavioral health services as qualified mental health care service providers. The Secretary should also work with Congress to authorize Medicare payments for those services by amending Section 1833(a)(1) of the Social Security Act, as needed, to ensure that payment.
Recommendation 04-2: Broaden the Definition of Originating Sites for Telehealth Services
The Secretary should seek to broaden the definition of originating sites for telehealth services to include private physician offices under Title XVIII of the Social Security Act and ensure that all Medicare-eligible providers can offer mental health services via telehealth consultation.
Recommendation 04-7: Amend Title XVIII and Title XIX of the Social Security Act to Require Parity in Payments
The Secretary should work with the Congress to amend Title XVIII and Title XIX of the Social Security Act to require parity in payments and the resulting co-payments for mental health care services under Medicare and Medicaid.
Recommendation 04-8: Clarify that Critical Access Hospitals Can Provide Mental Health Services
The Secretary should work with the Centers for Medicare and Medicaid Services in administration of Section 1834(g) of the Social Security Act to clarify that Critical Access Hospitals can and should have the flexibility to provide mental health services as dictated by community need within the normal protections for patients.
Recommendation 05-4: Require Grant Recipients Engaged in Direct Delivery of Services to Demonstrate an Effect on Community Development
The Secretary should require that all grant applications in program supporting service delivery in rural areas include an analysis of how the program will relate to broad-based efforts in community development. CREATE, in Mississippi, is measuring its success based on community indicators, such as the economy, education, public safety, social environment, health, housing and infrastructure.
Recommendation 05-10: Address the Malpractice Insurance Issue by Supporting Legislation that will Extend the Federal Tort Claims Act to Rural Obstetrics Providers in Federally Designated Shortage Areas
The malpractice insurance program for Federally Qualified Health Centers and Free Clinics should be extended to cover rural hospitals and physicians providing obstetrics services in underserved rural areas. The Committee believes that the current system for designating Health Professional Shortage Areas (HPSAs) may not be able to identify the rural areas most underserved by obstetrics services. Data are available to identify rural areas that have the lowest ratios of obstetrics providers to women of childbearing age, which may be a more effective access measure. Another approach would be to give greater weight to obstetrics services as a variable used in the HPSA designation process. The method used must be limited to those rural areas where access to obstetrics care is mot severely limited by provider shortages.
Recommendation 05-11: Encourage the States to Revise Their Medicaid Policy to Remove Any References of Obesity Not Being an Illness
The Department should take the lead in working with the States to classify obesity as an illness and cover procedures related to treatment of obesity. This change is even more critical in Medicaid than it is in Medicare since it will allow health care providers to aggressively treat those with obesity and it will potentially help patients avoid more serious obesity-related health complications in the future.
Recommendation 06-11: Work to Allow the Use of USF for Rural Health Care Providers to Build Greater Infrastructure for Broadband Access in Rural Communities
The Secretary should work with the Congress and the Federal Communications Commission to allow the use of Universal Service Funds for rural health care providers to build greater infrastructure for broadband access in rural communities.
Recommendation 06-17: Expand the Eligility for the DOQ-IT Program to Allow Assistance to RHCs and FQHCs
The Secretary should expand the eligibility for the Doctors Office Quality - Information Technology (DOQ-IT) program available through the Medicare Quality Improvement Organizations to allow assistance to rural health clinics and Federally Qualified Health Centers.
Recommendation 06-21: Expand Eligibility for Family Caregiver Support Services to Include Persons 40 and Older
The Secretary should expand eligibility for Family Caregiver Support services to include persons 40 and older.
In recognition of the growing contingent of younger caregivers, the Department should work to lower the eligibility age from 60 to 50 and older.
Recommendation 06-27: Lower the Match Requirement for the Title III E Program from 25 Percent to 15 Percent
The Secretary should lower the match requirement for the Title III E program from 25 percent to 15 percent, thus aligning it with the match required of other AoA programs.
Recommendation 89-8: Improve Access to Capital for Rural Facilities
The Secretary should work with the Department of Housing and Urban Development (HUD) and the U.S. Department of Agriculture to improve access to capital for rural facilities through increased availability of Farmers Home Administration direct and guaranteed loans (non-farm), HUD 242 and 232 loan guarantees, and PHS Section 1610(a) and (b) grants for construction and modernization. Such funding would be limited to those facilities determined to be critical for access to health care in the community.
Recommendation 89-9: Support the Rural Hospital Transition Grant Program and Broaden Its Scope to Include Community Needs Assessment
The Secretary should support the rural Hospital Transition Grant Program through FY 1990. Beginning in FY 1991, legislation should be proposed to the Congress that would make non-hospital health organizations, community organizations, agencies, or political subdivisions eligible as grantees. The program's title should be changed to "Rural Health Services Transition Grant Program" and be broadened in scope to include a community needs assessment which encompasses comprehensive health care, health promotion, alcoholism, substance abuse, mental health, and emergency medical services.
Recommendation 89-10: Implement Federal Grant Programs to Promote the Integration and Coordination of Services in Rural Areas
By October 1, 1992, the Secretary should develop a series of programs that would facilitate integration and coordination of services in or among rural communities. The programs should include new demonstrations and increased emphasis in current programs on improving both horizontal and vertical linkages, integration, and cooperation between community and migrant health centers, local primary care providers, hospitals, medical group practices, and public health departments. These programs should be the result of a careful analysis by the Office of Rural Health Policy of existing demonstrations and should reflect a thorough review of existing Federal and state barriers, both legislative and regulatory, that impede integration.
Recommendation 89-11: Establish a "One-Stop Shopping" Demonstration Program
The Secretary should propose legislation to the Congress establishing a demonstration program (10 rural sites) that would consolidate all categorical funds and programs for health into a single "one-stop" office, particularly in very poor or small communities.
Recommendation 89-18: Fund the "Health Care for Rural Areas" Program
The Secretary should seek an appropriation of $5 million for the "Health Care for Rural Areas" program, authorized in 1988 (P.L. 100-607). The program would provide grants to develop innovative, interdisciplinary training programs that would educate health professionals for rural practice.
Recommendation 89-20: Support Increased Funds for Community and Migrant Health (C/MHC) Programs
The Secretary should propose an increase for the C/MHC programs in the Department's FY 1991 budget. At least 50 percent of the increase should be earmarked for projects in rural and frontier areas.
Recommendation 89-21: Maintain the Current Process for Designating Heath Manpower Shortage Areas and Medically Underserved Areas (HMSAs and MUAs)
The Secretary should ensure that the current process for designating HMSAs and MUAs is maintained until a full evaluation is conducted on the implications that any change would have on the myriad of programs that utilize the designations.
Recommendation 89-22: Improve the Administration of the Rural Health Clinics (RHC) Act Program
The Secretary should disseminate information to promote an increase in the number of RHCs. Technical assistance should be provided to assist potential providers in qualifying for RHC designation.
Recommendation 89-23: Convene a Federal Interagency Rural Health Work Group and a Presidential Rural Health Council
The Secretary should direct the Office of Rural Health Policy to convene and staff a Federal Rural Health Work Group composed of all Federal agencies that have programs/activities with a rural health-related mission (e.g., Departments of Agriculture, Transportation, and Veteran's Affairs). Further, the Secretary should recommend establishment of a Presidential Rural Health Council to mobilize the public and private sectors to better address rural health problems.
Recommendation 89-24: Expand Federal Activities to Improve the Availability of Emergency Medical Services
The Secretary should establish a focal point within the Department for the planning and coordination of emergency medical services (EMS) activities. The Secretary should propose legislation to improve the availability of EMS in rural areas through matching grants to states.
Recommendation 89-25: Ensure that Federal Block Grants Address Rural Health Problems
The Secretary should issue a policy directive to states that implementation of all block grants address the unique service needs of rural areas.
Recommendation 89-26: Ensure a Rural Focus in the "War on Drugs"
The Secretary should ensure that current departmental efforts to address education and treatment in the "war on drugs" include a focus on rural communities.
Recommendation 89-27: Establish a National Occupational/Environmental Health Program and a National Network of Rural Occupational/Environmental Health Services Centers
The Secretary should propose legislation to the Congress that would establish a national occupational/environmental health program to address major health hazards through an interdisciplinary educational program in conjunction with high schools, colleges, academic health centers and Cooperative Extension Services.
In addition, the Secretary should propose legislation to the Congress that would establish a national network of 10 rural occupational/environmental health services centers in conjunction with academic health centers or major medical centers. These would provide screening, diagnosis, treatment, research, and educational services using an interdisciplinary team approach.
Recommendation 89-28: Establish a National Adolescent Health Demonstration Program
The Secretary should propose legislation to the Congress that would establish a national demonstration program (five rural community sites), in cooperation with states and the private sector, to establish different types of adolescent health programs. Such demonstrations would include implementation of a comprehensive K through 12 health education curriculum in combination with on-site counseling, preventive and social/health services within a school district. These services would be provided by a health professional.
Recommendation 89-30: Develop a Compendium of Model Rural-Focused Health Professions Education and Training Programs
The Secretary should direct the Office of Rural Health Policy to identify and catalog models of rural-focused health professions education and training programs, including those programs which address leadership, management and governance. A compendium of these models should be developed and disseminated.
Recommendation 89-32: Provide Adequate Funding for the National Library of Medicine's Rural Outreach Activities
The Secretary should seek adequate funding to enable the National Library of Medicine (NLM) to implement its outreach program. The Committee believes priority should initially be given to the following areas:
- Increasing the marketing of Grateful Med and other NLM services to rural and other underserved health care individuals and agencies, and provide opportunities for individuals to learn how to access the Grateful Med system.
- Expanding the capabilities of entities that enable rural professionals to access information in rural communities (e.g., regional medical libraries and health facility libraries). Existing networks such as Area Health Education Centers and community colleges and universities should be utilized whenever feasible.
- Augmenting the biomedical database to include pharmacy, social work, nursing and other allied health listings and increase listings relevant to rural health.
Recommendation 90-4: Modification of the Rural Hospital Transition
Grant Program
The Secretary should create a set-aside fund under the Rural Hospital Transition Grant program specifically earmarked for rural hospitals that propose a transition from a full service acute care facility to an institution which offers less intensive but essential services to its community. The fund would also support experimental efforts toward the development of the "primary care hospital" concept.
Recommendation 90-5: Provide a Rural Focus in the Department's Efforts to Improve the Health Status of Minority Populations
To ensure a rural focus in the Department's efforts to improve the health status of African Americans, Hispanics, Native Americans and Asian/Pacific Islanders, the Secretary should direct the Office of Minority Health, in cooperation with the Office of Rural Health Policy, to:
1) Sponsor and conduct a national conference on improving minority health in rural areas; and
2) By September 1, 1991, subject a report which outlines recommendations for departmental initiatives to reduce the health disparity of minorities living in rural areas.
Recommendation 90-11: Improve Federal Data Collection on HIV Disease in Rural Areas
The Department of Health and Human Services should collect accurate, comprehensive information about the extent, characteristics, and impact on HIV disease in rural areas. The Agency for Health Care Policy and Research, the Centers for Disease Control, the Alcohol, Drug Abuse, and Mental Health Administration, and other Federal agencies or programs, as appropriate, should fund studies to improve understanding of the epidemiology, demographics, impact, and trends of HIV disease in rural areas.
Recommendation 90-12: Require States to Have a Statewide Plan which Designates a Single State Agency as Responsible for Coordinating State Response to HIV/AIDS and which Addresses Rural HIV/AIDS Needs as a Condition of Receiving Federal AIDS Block Grants
Federal block grants to states for HIV disease prevention and treatment services should be contingent upon the existence of a statewide plan which effectively addresses rural HIV/AIDS needs and the designation of a single state agency responsible for coordinating the state's response to HIV disease.
Recommendation 90-13: Provide Federal Support for Technical Assistance to Community-Based Organizations which Address the Needs of HIV Infected Persons in Rural Areas
The Centers for Disease Control and the Health Resources and Services Administration should develop and support a coordinated program of technical assistance for community-based organizations doing HIV prevention and providing services to HIV-infected persons in rural areas.
The community-based organizations play a critical role in preventing the spread of HIV and providing services to HIV-infected persons. These programs need technical assistance with organizational development and programming. Currently technical assistance is provided by a number of agencies and programs. These are not well coordinated, and there is no assurance that all important areas of training are addressed. Training and technical assistance should address at least:
- Targeted prevention programs;
- Service programs;
- Organizational development;
- Program evaluations; and
- Fund Raising.
Recommendation 90-14: Provide Federal Support to Foster Local Leadership
to Respond to the HIV/AIDS Challenge in Rural Areas
The appropriate Federal agencies, in particular the Centers for Disease Control and the Health Resources and Services Administration, should support programs to promote and foster local leadership to orchestrate the HIV response in rural areas.
Recommendation 90-15: Expand the AIDS Education and Training Center Activities to More Effectively Reach Rural Primary Care Providers
The AIDS Education and Training Centers should establish or expand telephone hot line services and other programs to assure that rural primary care providers have easy, rapid access to HIV/AIDS treatment information, drug trials and referrals. Further, the AIDS Education and Training Centers should expand networks linking rural health care providers with major medical centers, to ensure access and quality care to persons with HIV disease.
Recommendation 90-16: Establish State 800 Numbers to Provide Information on Medicaid Eligibility and Coverage of Services for HIV Infected Persons
State Medicaid Offices should establish 800 numbers to provide information on Medicaid eligibility for and coverage of HIV-disease to HIV-infected persons, providers, patient advocates, and the state's local social service offices.
Recommendation 90-17: Provide Federal Guidance to States on Implementation of Ryan White Act
The Secretary should provide guidance to states in their use of the Ryan White Act HIV/AIDS funds to assure attention to the needs of the increasing number of HIV-infected persons in rural areas.
Recommendation 90-18: Accept the Recommendations of the National Commission on AIDS
The Secretary should accept the recommendations of the third report of the National Commission on AIDS, especially their recommendations to develop comprehensive community-based primary health care systems and to expand AIDS education and outreach services to rural communities. (National Commission on Aids, Report No. 3, Recommendations One and Two.)
Recommendation 90-19: Develop a Compendium of State Initiatives Undertaken to Address Obstetrical Malpractice
The Secretary should direct the Health Resourcesand Services Administration to develop a compendium of state initiatives that have been undertaken or are currently underway to address obstetrical malpractice. In addition, the compendium should describe state initiatives to train and place practitioners of all levels (physicians and mid-level practitioners) in rural areas to more effectively meet these areas need for obstetrical practitioners. The compendium should include copies of legislation (proposed and enacted) and should be disseminated to the National Governors Association, National Conference State Legislatures, Council of State Governments, the National Association of Counties, state offices of rural health, and other appropriate entities.
Recommendation 90-20: Monitor State Initiatives which Address Obstetrical Malpractice
The Health Resources and Services Administration should work with the Agency for Health Care Policy and Research (AHCPR) to track or monitor ongoing state initiatives that address obstetrical malpractice issues and evaluate their effects.
Recommendation 91-1: DHHS Program Priority: Improving Health Care Access for Rural Citizens
At least one of the annual policy objectives or program priorities of the Secretary, the Assistant Secretary for Health, and the Administrator of the Health Care Financing Administration should address improving access to health care for America's rural citizens.
Recommendation 91-2: Impact on President's Budget on Health Care Access in Rural Areas
Concurrent with the annual submission of the President's budget, the Secretary should prepare an analysis of the budget's impact on programs that provide access to health care in rural areas.
Recommendation 91-11: FQHC Payments Based on Actual Cost Experience Without Arbitrary Urban and Rural Distinctions
Any cost-based payment system for FQHCs should reflect their actual cost experience, without imposition of arbitrary limits. The FQHC payment system should not incorporate arbitrary distinctions between urban and rural areas.
Recommendation 91-12: FQHC Reporting Requirements for Look-Alikes
The Secretary should require annual reports from FQHC look-alikes and develop a recertification process for them that occurs at least every three years.
Recommendation 91-14: Community and Migrant Health Centers - Federal Tort Claim Coverage and Risk Management
The Secretary should continue to work closely with the Department of Justice to support legislation that would provide relief to community and migrant health centers from excessive malpractice insurance costs. This relief could be provided by amending the Federal Tort Claim Act to extend coverage to community and migrant health centers (C/MHCs) and to health professionals who are employees or contractors of C/MHCs, or through some alternative mechanism.
The Secretary should allow dollars currently being utilized by health centers for malpractice premiums to remain in the health centers. The dollars should be directed to risk management and quality improvement activities, as well as activities to expand or enhance patient care. The Secretary, through the Bureau of Health Care Delivery and Assistance, should continue to support rigorous risk management and quality improvement activities in C/MHCs.
Recommendation 91-15: AHCPR User Liaison Program: Rural Focus on Medical Malpractice and Liability
The User Liaison Program of the Agency for Health Care Policy and Research (AHCPR) should include a rural focus in programs developed to educate state legislators and executive staff about medical malpractice and liability issues.
The Committee further recommends that AHCPR include the 1987 DHHS Report of the Task Force on Medical Liability and Malpractice in its program materials. Last, it recommends that AHCPR provide the technical assistance needed to help implement the model Health Care Provider Liability Reform Act or a comparable comprehensive reform model act.
Recommendation 91-16: Rural Representation in the AHCPR Guideline Development Process
The Agency for Health Care Policy and Research should assure that rural representation is included in all phases of the guideline development process, including rural representation among peer review consultants and among the facilities in which clinical guidelines are pilot-tested. It should further seek to include rural representation, including rural consumers, on the guideline advisory panels. The AHCPR should work with the Office of Rural Health Policy to identify rural consultants for the peer review process and rural facilities for the pilot-testing of the standards.
Recommendation 91-19: Rural Initiative for Prevention, Health Promotion and Wellness with Older Persons
The Secretary should direct the Office of Disease Prevention and Health Promotion and the Administration on Aging to develop, in cooperation with the Office of Rural Health Policy, a health promotion initiative that focuses on rural communities. This effort should also involve the USDA Cooperative Extension Service, and any foundations that are investing in this issue.
Recommendation 91-20: Improve Transportation Services for Older and Disabled Persons Living in Rural Areas
A. The Administration on Aging
(AoA/DHHS) should work with the Urban Mass Transportation Administration
(UMTA/DOT) to:
- Conduct a study on the current status and problems that rural transportation pose to obtaining health care.
- Identify and remove Federal barriers to transportation service coordination in rural areas.
- Develop and implement programs to improve the coordination of Federal, State and local transportation services to older persons and others with special needs in rural areas.
- Identify "best practices" in transportation services for older and disabled people living in rural areas, disseminate information on these models to rural communities, and provide technical assistance to state and local agencies to help them apply this information to their own transportation programs.
B. The Secretary should request that DOT fund demonstration projects from
UMTA funds that will improve access to health services for the rural elderly.
Recommendation 91-21: Develop a Quality Assurance Strategy for In-Home Services and Extended Care Facilities
The Secretary should work with States to develop a quality assurance strategy for certified home health services and services provided at extended care facilities in rural areas.
Recommendation 91-23: Improve Information Dissemination on the Rural Elderly
The Secretary should improve the availability of information regarding the rural elderly through support of activities such as the Rural Information Center/Health Services (RICHS) at the National Agricultural Library, the National Resource Center for Rural Elderly at the University of Missouri-Kansas City, and the Rural Outreach Program of the National Library of Medicine (NLM).
Recommendation 92-1: Rural Hospital Transition Grant Program
The Secretary should support legislation to continue the Rural Hospital Transition Grant Program.
Recommendation 92-7: Utilizing Health Care Reform Principles
When reviewing health care reform proposals, the Secretary should use the principles developed by the Committee as a guide for evaluating the appropriateness of the reform proposal for rural areas.
Recommendation 92-8: Basic Health Care Benefits for All Americans
The Secretary should support legislation that will establish a set of minimum, portable, uniform benefits for all Americans. The program should not exclude individuals from eligibility for health insurance and access to health care due to employment status or lack of permanent residence. The benefits should provide a continuum of services ranging from preventive care to rehabilitative and long-term care.
Recommendation 92-10: Assuring Adequate Access to Health Care
The Secretary should support health care reform legislation that will assure that rural residents have adequate access to health care. Specifically, support should be given for the following areas:
- programs to increase the numbers of primary care providers -- physicians and mid-level practitioners;
- programs and payment levels that encourage primary care providers and other health care professionals to locate in underserved areas;
- transportation, emergency, and technological systems so rural residents of all ages can receive, and providers can render, health care;
- targeted programs that address the special needs of farm families, rural minorities, migrants, and Native Americans.
- policies and regulations that assure flexibility for communities and/or states to respond to local health care needs.
Recommendation 92-11: Integration of Health and Education Services
The Secretary should support health care reform legislation that encourages the integration of health and education services for all segments of society.
Recommendation 92-12: Rapid Resolution of Payment Disputes
The Secretary should support health care reform legislation that provides for rapid resolution of payment disputes.
Recommendation 92-14: Increased Support for State Offices of Rural Health
The Secretary should seek an increased appropriation for the State Offices of Rural Health Program (SORHs) to enable each State Office to take a leadership role in, and provide a forum for, addressing rural occupational health and safety issues (including farming, logging, fishing, and mining) within their respective state and local health communities.
Recommendation 92-17: Health Career Opportunities Initiative
The Secretary of Health and Human Services should work with the Secretary of Agriculture to develop cooperative programs and incentive funding to attract rural young people to health careers. This should be accomplished in cooperation with the Youth-at-Risk Initiative of the Extension Service's 4-H Development Program. Special attention should be paid to providing opportunities to young people from ethnic and cultural minorities. Whenever possible, this initiative should involve the State Offices of Rural Health, and should be developed with participation from AHECs, the Office of Minority Health, and local health departments.
Recommendation 92-19: North American Free Trade Agreement
In anticipation of the North American Free Trade Agreement (NAFTA), the Secretary of Health and Human Services should work with federal, state, local, and private agencies and businesses on both sides of the U.S./Mexico border to identify and create effective working models that address the health care challenges faced by populations living along the border. The models should address housing, sanitation, water quality, infectious disease, pesticide and other environmental hazards, and occupational health and safety. In addition, the models, should, as much as possible, reflect a community organization approach that empowers local residents.
Recommendation 92-22: Models for Intergovernmental Collaboration
The Secretary should direct the Administration for Native Americans to develop and disseminate a technical assistance document that reviews current roles and responsibilities of federal, state, local and tribal governments for rural Native Americans' and Alaska Natives' health. It should provide examples of rural models for collaboration among these governmental entities.
Recommendation 92-23: Expansion of Initiatives to Address Native American Health Problems
The Secretary should direct the Indian Health Service to develop strategies for improving health services to Native Americans through the expansion of specialized women's clinics, school-based clinics, enhanced support of substance abuse and fetal alcohol syndrome prevention initiatives, and increased training and use of physician assistants and nurse practitioners.
Recommendation 92-24: Technical Assistance: Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHC)
The Secretary should provide technical assistance regarding FQHC and RHC programs by: 1) offering a technical assistance hotline so that questions about program elements, distinctions of the two programs, and requirements can be answered; and 2) offering regional workshops, marketed to a broad spectrum of practitioners and facilities, to assist attendees in understanding the similarities and differences in the programs.
Recommendation 93-6: Outcomes-based Funding of Health Professions Education Programs
The Secretary should support legislation to restructure federal funding of education programs for health professionals so the funding decisions are based on the success with which the training programs contribute toward achieving the goals of the health professions workforce plan.
Recommendation 93-15: Assimilate Medicare Beneficiaries into the Health Alliances (repeated in April 1994)
The Secretary should support legislation to assimilate Medicare beneficiaries into the health alliances of the reformed health care system as quickly as possible.
Recommendation 94-01: Rural Representation
The Committee recommends that all governing and advisory boards that are established to implement any future health reform be specifically required to have rural representatives among their members. In particular, any alliance (or similar body) that includes a rural population should be required to have substantial rural representation on its governing board and professional advisory board. In addition, any requirements for these boards to consult with outside interest should include a requirement to consult with individuals and organizations representing rural interests.
Recommendation 94-06: Technical Assistance Programs
The Committee recommends that the Secretary develop technical assistance programs to strengthen rural health care delivery systems and prepare rural areas for health care reforms.
Recommendation 94-08: Antitrust
The Committee recommends that the Secretary, in conjunction with the Department of Justice and the Federal Trade Commission, use the federal Office of Rural Health Policy (or any other appropriate office) and the State Offices of Rural Health to educate rural providers and health professionals about antitrust aspects of developing alternative health delivery systems.
Recommendation 94-10: Telemedicine Pilot Projects
The Committee endorses the Secretary's current efforts to evaluate and test payment methodologies for telemedicine. The Committee recommends that additional pilot projects be established within the next fiscal year to test payment methodologies and collect data on costs, utilization, outcomes, provider and patient satisfaction, etc. The pilot projects should be non-proprietary, open architecture systems using a variety of telemedicine technologies and configurations. These projects should be evaluated on an ongoing basis with annual reports to the Secretary. After two years, each annual report should include information that will assist the Secretary in developing appropriate payment policies.
Recommendation 94-11: Increasing the Rural Sample of Leading National Health Surveys
The Secretary should increase the rural samples and take other steps to improve the rural analytic capability of two key national health surveys -- the National Medical Expenditure Survey and the National Health Interview Survey. This improved capability is critical to assessing differences in access to health care for citizens living in communities that vary by degree of rurality, for example, by population density and distance to an urban area. In addition, the Secretary should direct the National Center for Health Statistics to explore augmenting the rural sample of the Health and Nutrition Examination Survey.
Recommendation 94-12: Risk Adjustments
The Committee recommends that explicit attention be paid to rural concerns as risk adjustment methodologies are developed in conjunction with health insurance reforms. Such concerns include the lack of good cost data on rural minority populations and occupational illness and injury. The Committee urges the Secretary to consult rural experts, including the Committee, in developing data bases and methodologies for risk adjusters that include rural populations.
Recommendation 94-15: Fair Competition for Rural Grants and Contracts Applicants
The Committee recommends that
the Secretary take steps to ensure that grant and contract program announcements
issued by the Department do not ignore rural realities and disadvantage
rural applicants. The Committee also recommends that the Secretary find
additional methods for announcing program opportunities in rural areas,
rather that relying exclusively on the Commerce Business Daily and Federal
Register.
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Recommendation: Medicare under Health Care Reform The Committee reiterates recommendation 93-15 from the Sixth Annual Report on Rural Health asking the Secretary to assimilate Medicare beneficiaries into the health alliances of the reformed health care system as quickly as possible. Recommendation: Medicare Dependent Hospitals The Committee recommends that the Secretary establish a short-term task force to study the need to continue the Medicare Dependent Hospital program under health care reform. Recommendation: Migrant Workers The Committee recommends that the Secretary consider development of separate health alliances for migrant workers in each of the migrant streams. |
Recommendation 00-1: Improve Coordination of Federal Public Health Activities
The Secretary should seek an Executive Order for the creation of a Federal Interagency Public Health Coordination Committee comprised of senior representatives from the various public health agencies and federal departments. The committee would study current efforts by each of the Federal Agencies involved in public health activities overall while evaluating ways to integrate funding stream to benefit rural communities in the areas of leadership development, workforce development, viability of the safety net, impact of managed care, and telecommunications. The newly formed committee would produce an annual report based on their studies. This committee would include appointed representatives from the Department of Health and Human Services, the Department of Agriculture, the Environmental Protection Agency, the Department of Commerce, the Department of Veteran Affairs, the Department of Labor, the Department of Education, the Department of Housing and Urban Development, the Department of Transportation, the Department of Defense and any other relevant Federal agencies.
Recommendation 00-2: Create a Dedicated Funding Stream for Public Health Activities
The Secretary should support the development of a dedicated funding stream for public health infrastructure activities with assurances that funding is equitably distributed among rural and urban health departments at the local level.
Recommendation 01-1: Evaluate the Need for a Low-Volume Adjustment in Medicare
The Secretary should evaluate the need for a low-volume adjustment within all of the Medicare prospective payment systems.
Recommendation 01-6: Develop a Standard Benefit Package for Medicare Beneficiaries
The Secretary should develop a standard benefit package that includes access to a reasonable prescription drug benefit under Medicare fee for service.
Recommendation 01-7: Provide Demonstration Waivers to Rural Communities for Innovative Health Care Models
The Secretary should provide demonstration waivers to rural communities for innovative models that improve access to care and that focus on chronic care, case management, and preventive care.
Recommendation 01-8: Examine Impact of Prospective Payment Systems in Home Health and Skilled Nursing for Medicare Beneficiaries
The Secretary should examine the impact of the new prospective payment systems for home health, skilled nursing, and outpatient services to determine what impact these changes have had on access to care for rural Medicare beneficiaries.
Recommendation 01-9: Monitor the Closures of Skilled Nursing Facilities
The Secretary should monitor the closures of skilled nursing facilities and the impact of moving swing beds under skilled nursing facilities prospective payment to determine the impact on access to care for rural Medicare beneficiaries.
Recommendation 01-10: Ensure Core Services are Available to all Medicare Beneficiaries
The Secretary should ensure that the core services (primary, preventive and chronic care management) and the full continuum of care are appropriately available for all Medicare beneficiaries.
Recommendation 01-12: Encourage Development of Appropriate Quality Measures for Rural Areas
The Secretary should encourage the development of appropriate measures that take into account a rural environment that features low volume of primary care and ambulatory services.
Recommendation 01-16: Promote More Community-Based Trainings
The Secretary should support changes to Medicare policy that promote more community-based training of residents.
Recommendation 01-19: Promote Rural Training in Title VII and Title VIII Programs
The Secretary should expand the scope and focus Title VII and Title VIII training grants to promote more rural training.
Recommendation 01-21: Protect and Strengthen the Medicare Fee-For-Service Program
The Secretary should protect and strengthen the Medicare Fee-For-Service delivery option under any redesign or reform of the Medicare program. This should include an acknowledgment that Medicare + Choice in its present form is not a viable option for bringing managed care and equity of benefits to rural beneficiaries. Consequently, the Secretary should recognize that fee-for-service delivery will continue to be the dominant service delivery mechanism for rural Medicare beneficiaries.
Recommendation 01-22: Ensure that Rural Health Care Providers are Kept in Mind during any Redesign of the Medicare Program
The Secretary should ensure protections for key rural service providers (critical access hospitals, sole community hospitals, Medicare-dependent hospitals, rural referral centers, rural health clinics and federally qualified health centers), in any redesign of the Medicare program to ensure access to care for rural beneficiaries.
Recommendation 01-23: Explore Potential New Service Delivery Models for Rural Areas
The Secretary should explore the development of new service delivery models for rural beneficiaries that recognize the special circumstances of providing care in sparsely populated rural areas. Options such as coordinated care, primary care case-management and other forms of partial risk or capitation that emphasize local control and flexibility should be explored.
Recommendation 02-4: Ensure Re-Authorization and Continued Funding of the Rural Hospital Flexibility Grant Program
The Secretary should work with Congress to ensure re-authorization and continued funding of the Medicare Rural Hospital Flexibility Grant Program, which is up for re-authorization in FY 2002.
Recommendation 02-6: Increase Access to Capital and Expand Eligible Uses of Grant Funds for Rural Providers
The Secretary should work with Congress to increase access to capital and to expand eligible uses of grant funds to include construction, renovation, and modernization of health center facilities.
Recommendation 02-7: Increase Federally Qualified Health Centers in Rural and Frontier Areas
The Secretary should encourage the development of criteria that will increase the number of FQHC sites in rural and frontier areas.
Recommendation 03-1: Promote Demonstrations through CMS that Examines How Reimbursement can Promote Quality Improvement
The Secretary should work with CMS to promote demonstrations that examine how reimbursement might be used to promote quality improvement in the rural setting.
Recommendation 03-2: Increase Funding for State Survey and Certification Activities
The Secretary should increase funding for state survey and certification activities. The survey and certification agencies are consistently under funded and this has a disproportionate effect on rural providers given their heavier reliance on using the survey and certification program and less reliance on accreditation compared to their urban counterparts.
Recommendation 03-3: Amend the Seventh Scope of Work for the Quality Improvement Program
The Secretary should amend the Seventh Scope of Work for the Quality Improvement Program to make this program more relevant for rural communities. This would include creating a stand-alone task focusing on rural health. It would also include a new evaluation methodology for reviewing the work of the Quality Improvement Organizations that includes more localized measures of areas with populations that suffer health disparities. The sole reliance on measures of state-wide improvement acts as a disincentive for working with harder-to-reach populations.
Recommendation 03-4: Increase Funding for the Quality Improvement Program
The Secretary should work with the Office of Management and Budget to increase funding for the Quality Improvement Organizations to encourage Quality Improvement Organizations to reach out more meaningfully to rural communities to rural communities and to help providers prepare for public reporting in hospital, home health and individual ambulatory provider settings.
Recommendation 03-5: Solicit Input from Rural Health Care Providers in Identifying Measures for Public Reporting
The Secretary should solicit (via Federal Register notice) input from rural health care entities in identifying which measures shall be used for public reporting for all healthcare providers and include not only outcome measures but also process measures. This activity should promote appropriate benchmarking that compares organizations with similar characteristics such as geography, size, and volume. This is very important as outcome measures require statistical significance frequently not available in a typical rural facility due to lower volumes or that may not be appropriate for rural facilities.
Recommendation 03-7: Fund the new Small Health Care Provider Quality Improvement Program
The Secretary should work with the Congress to fund the new Small Health Care Provider Quality Improvement Program authorized in Public Law 107-251.
Recommendation 03-8: Support Re-Authorization of the Medicare Rural Hospital Flexibility Grant Program
The Secretary should support re-authorization of the Medicare Rural Hospital Flexibility Grant program in a manner that strengthens the program's orientation to promoting quality in Critical Access Hospitals.
Recommendation 04-9: Increase the Federal Matching Funds for Oral Health Services by Five to Ten Percent
The Secretary, under Title XIX of the Social Security Act, should authorize a five to ten percent increase in Federal matching funds for oral health services. This increased match would encourage States to expand dental coverage and provide dental reimbursements at a level sufficient to attract additional providers to the Medicaid program.
Recommendation 04-10: Increase Funding for the Quentin N. Burdick Program for Rural Interdisciplinary Training, Health Careers Opportunity Program and Centers for Excellence Program
The Secretary should work with the Office of Management and Budget (OMB) and Congress to seek increased funding for the Quentin N. Burdick Program for Rural Interdisciplinary Training, authorized by Title VII, Section 754 of the Public Health Service Act. Priority should be given to Quentin N. Burdick applicants whose programs include dentists or dental hygienists. The Secretary should also attempt to obtain more funding for the Health Careers Opportunity Program (HCOP) and Centers for Excellence (COE) Program, authorized by Title VII, Sections 739 and 736, respectively. The additional funds should be used to increase the number of dental schools receiving HCOP and COE grants. This would provide more support for dental schools that seek to recruit additional minority and disadvantaged individuals and to expose students to practice opportunities in underserved communities.
Recommendation 04-13: Establish a Program that would Fund the Fluoridation of Small Community Water Supplies
The Secretary should work with the Office of Management and Budget and the Congress to explore the establishment of a new categorical grant program that would provide funding to States for the fluoridation of small community water supplies and provide ongoing technical assistance and maintenance for such systems.
Recommendation 04-14: Establish State Dental Offices in All 50 States and U.S. Territories
The Secretary should work with Congress and the Office of Management and Budget to establish a Federal-State partnership that is modeled after the State Offices of Rural Health Grant Program. This partnership would support the establishment of State Dental Offices with full-time directors in all 50 States and U.S. territories. Since the majority of oral health policy issues are under State jurisdiction, it is important to ensure that States have an adequate infrastructure to address pressing oral health issues and coordinate Statewide oral health initiatives.
Recommendation 04-16: Develop a Demonstration Program to Explore Innovative Approaches to Providing Transportation to the Rural Elderly
The Secretary should develop a demonstration project through Section 301 of the Public Health Service Act that would explore innovative approaches to providing transportation to rural elderly and would examine current Federal and State regulations and opportunities to use existing systems operated through Area Agency on Aging programs, Head Start and State and local transportation systems such as school buses.
Recommendation 04-18: Track Expenditures in the National Family Caregivers Support Program
The Secretary should work with the Agency on Aging to track expenditures in the National Family Caregivers Support Program to determine how much of the funding goes to rural communities.
Recommendation 05-1: Create a Web Resource Page for "Models that Work" for Collaborations
The Federal Office of Rural Health Policy (ORHP) should build this recommendation into it cooperative agreement with the Rural Assistance Center (RAC). A special page should be built that is devoted to describing successful rural-based collaborations and that can be accessed in one step from the home page of the RAC Web site. The funding to RAC should support a reporting function to collect and present information regarding those collaborations.
Recommendation 05-3: Support Leadership Development in Rural Communities
The Secretary should instruct all agencies with programs support local service delivery to include funds for leadership development in their grant-making portfolios. The Federal Office of Rural Health Policy program for rural leaders should be continued. The Secretary should consider supporting regional leadership academies by combining current programs from separate entities in HHS. The Secretary should encourage private foundations to expand their efforts to train future leaders. The Nebraska Community Foundation is one example of the important and crucial role a foundation can play in fostering leadership development in rural areas.
Recommendation 05-7: Support Program to Create Hospital and Physician Networks that will Sustain and Improve Access to Obstetric Services in Rural Areas
There are several existing grant programs in the Department (Healthy Community Access, Rural Network Development, Rural Hospital Flexibility Grants) that should be used to promote the development of hospital and physician networks in obstetrics care. The Committee believes that obstetrics services in many small rural hospitals and physician practices will be unsustainable over time, given the issues discussed in this report. Providers need encouragement and incentives to find more sustainable and efficient strategies for maintaining access to obstetrics care. Existing grant programs should be more aggressive in encouraging and funding grant applications that address the problem.
Recommendation 05-8: Promote the Development of Team Approaches to Obstetrics Care Involving Physicians, Nurse Practitioners, Certified Nurse Midwives and Other Non-Physician Providers
The Secretary should use this demonstration authority to develop a model program that supports regional approaches to improving access to obstetrics care in rural communities through networking and an emphasis on using interdisciplinary teams in several rural areas as a pilot project.
Recommendation 05-12: Make Refinements to the HealthierUS Community Grant Program so that Rural Concerns can be more Thoroughly Represented
The Committee commends the Secretary for launching the Steps to a HealthierUS community grant program, especially since it includes rural participation. However, the Committee is also hopeful that refinements will be made to assure that the concerns identified with respect to rural representation are addressed. Additional opportunities for direct granting to rural communities would be helpful, as many States did not include rural communities within their grants.
Recommendation 05-13: Ensure that the Next Publication of the CDC Chartbook includes more Rural-Specific Data and that Other, Future Publications Include References to Rural
The Committee commends the efforts the CDC has made to conduct studies that include rural areas. These studies have consistently shown that rural areas have higher rates of obesity and are, in general, less healthy than urban or suburban areas. The Committee would encourage the publication of a new CDC Chartbook to provide current, more rural-specific items compared to the previous 2001 publication, and to continue the inclusion of rural areas in its other studies. In addition, the Committee encourages NIH and the CDC to include studies of rural-specific prevention and intervention.
Recommendation 05-14: Ensure that Rural Residents are Seen as a Separate and Unique Segment of the Population in Funding, Research and Data Collection
The Committee commends the efforts CDC has made to conduct studies that include rural areas. These studies have consistently shown that rural areas have higher rates of obesity and are, in general, less healthy than urban or suburban areas. The Committee would encourage the publication of a new Rural-Urban Chartbook by no later than 2006 t provide current, more rural specific items compared to the previous 2001 publication, and to continue the inclusion of rural areas in its other studies. In addition, the Committee encourages the NIH and the CDC to include studies of rural-specific prevention and intervention.
Recommendation 05-15: Provide targeted technical assistance to States to Examine to How to Address the Transportation, Child Care, and Employment Needs of Rural TANF Recipients
The Secretary should work with the Administration for Children and Families (ACF) to provide targeted technical assistance that would encourage States to address the transportation, child care, and employment and training needs of rural TANF recipients.
Recommendation 05-16: Emphasize Collaboration and Encourage States to Utilize Best Practices in Efforts to Service Rural TANF Clients
The Secretary should emphasize collaboration and encourage States to utilize best practices, including those identified by ACF, particularly in efforts to serve rural clients.
Recommendation 05-17: Strengthen Department's Leadership and Work with Federal Partners
The Secretary should strengthen the Department's leadership among Federal partnerships and collaborations.
The Secretary should propose legislation to the Congress that would establish a Medicare inpatient payment floor for rural hospitals with less than 50 acute care beds and for Sole Community Hospitals (SCHs). The payment floor would be based on an individual hospital's current cost experience. The legislation would be effective for hospital cost reporting periods beginning on or after October 1, 1989, and end at such time that special Medicare payment provisions for essential access facilities are implemented. For the purposes of this legislation, acute care beds include swing beds, but exclude licensed beds for long- term care and newborn bassinets.
Recommendation 06-12: Encourage Groups to Consult with Rural Health Leaders about Impact of Their Decisions on Rural Communities
The Secretary should encourage groups like the American Health Information
Community to consult with the Federal Office of Rural Health Policy, HHS
Office of Intergovernmental Affairs and other key national rural health
organizations about the impacts of their decision-making on rural communities.
Recommendation 06-13: Devote Funding to Technical Assistance for VistA-Office EHR
The Secretary should devote funding resources to ensure that technical assistance is available for rural communities after the final release and dissemination of the VistA-Office EHR software.
Recommendation 06-14:Commission AHRQ to Conduct A Study Examining Costs and Benefits of EHR Use in Rural Communities
The Secretary should commission the Agency for Health Research and Quality to conduct a study examining the costs and benefits of EHR use in rural communities to determine the disconnect between the payers and the beneficiaries of adoption. In addition, this study should examine the benefits and pitfalls of adoption for rural communities in terms of public health and syndromic surveillance reporting. This study should include data collection that allows policy makers to differentiate between rural and urban, provider size, and impact of affiliation with larger integrated health systems.
Recommendation 06-15: Use Section 301 Demonstration Authority to Support HIT Networking Grants
The Secretary should use the Section 301 Demonstration authority within the Public Health Service Act to support rural HIT collaborative grants to encourage the collaborative networking model for HIT purchasing and information exchange.
Recommendation 06-16: Develop HIT Performance Measures for CAHs
The Secretary should develop HIT performance measures for post-conversion critical access hospitals with a focus on HIT and quality of care.
Recommendation 06-18: Encourage Standardization of Rural Caregiver Programs and Uniform Availability of Services in Rural Areas
The Secretary should encourage standardization of rural caregiver programs and uniform availability of services in rural areas across states and the nation.
The 50-State Study reveals that differences in program availability, design and benefit exist within states individually and across the nation. The Department should take the lead in efforts at standardization and uniformity of caregiver programs and services. Such an undertaking will require inter- and intra-state agreement about mission and philosophy, eligibility criteria, funding priorities, program design, and administration of services.
Recommendation 06-19: Require Capture of Rural-Specific Data
The Secretary should require the Administration on Aging, the Center for Medicare and Medicaid Services and the Health Resources and Services Administration programs to capture rural-specific data.
The Committee recommends that all survey instruments within HHS be required to collect and evaluate data in a way which identifies rural characteristics. The NAPIS database, specifically, should begin to capture data on rural caregivers. The Committee is aware that no Department-wide definition of "rural" exists. As long as this situation persists, researchers, program administrators and policy-makers will be unable to truly determine and report the extent of rural need because the key federal organizations do not evaluate programs with a uniform rural geographic standard.
The health-related components of HHS are slowly changing their data structures to illuminate urban/rural differences. The Committee would encourage the Secretary to require that all survey instruments within the Department collect, evaluate and report data in a geographically-specific way which identifies rural characteristics. Such standardization of efforts could be based on previous successes such as those realized in the Health Resources and Services Administration's Maternal and Child Health Bureau.
Recommendation 06-20: Determine Adequate Funding Requirements for Rural Family Caregiver Services
The Secretary should authorize a study to determine adequate funding requirements for rural family caregiver services under the NFCSP.
The Committee commends the work of the NFCSP and recognizes its success, however, the Committee realizes that the program is in great need of enhanced funding. Since it was authorized, the range and scope of NFCSP services have expanded but program funding, though increased annually, has not kept pace. Gaps in service and variation of availability of caregiver services in rural areas across states remain problematic due to inadequate funding.
Recommendation 06-22: Ensure the Identification and Dissemination of Rural Family Caregiving Best Practices
The Secretary should ensure that best practices in rural family caregiving be identified, studied, and publicized in a number of areas.
The NFCS programs should specifically identify and promote rural best practices. In addition, rural best practice models for state home-based family caregiver waiver programs should also be widely distributed. The Florida legislature is considering a bill (S.B. 88 & H.B. 49) to promote best practices among informal caregivers. The legislation under consideration promotes caregiving as a non-licensed paraprofessional activity and encourages the use of caregiving best practices. The bill would also create the Florida Caregiver Institute, an independent not-for-profit corporation which would develop policy recommendations to improve the skills and availability of direct care workers. The Secretary should establish a working group to consider piloting this work in other States.
In addition, the Secretary could use the Alzheimer's Disease Demonstration
Grant program a successful model which encourages the development of best
practices models that can be replicated in underserved areas, particularly
minority and rural communities, in all 50 states.
Recommendation 06-23: Encourage Better Assessment of Rural Caregiver Needs
The Secretary should encourage better assessment of rural caregiver needs as part of the NFCS program.
Caregiver assessment was identified in the 50-State Study as one of the top five needed technical assistance and training areas. Screening of caregivers should be done in the primary care setting as it has been shown that early assessment of caregivers needs helps prevent institutionalization of the care receiver upon crisis.
Recommendation 06-24: Create a Prominent, National Social Marketing Campaign on Rural Caregiving
The Secretary should create a prominent, national social marketing campaign on rural caregiving.
The Department's Administration on Aging should oversee a social marketing campaign to educate rural Americans about the difficult role of caregivers and the family caregiver support programs available to them. This campaign must use plain, easily understood language.
Recommendation 06-28: Consider Whether Centralizing State Unit and Area Agency on Aging Services is an Effective Model for Rural States
The Secretary should consider whether centralizing State Unit and Area Agency on Aging services is an effective model for rural states.
The Committee observed during its site visits that the centralized structure of the AoA administrative functions is problematic, especially in large rural states. The Committee discovered that uneven information distribution with in the State caused poor collaboration among local and state service providers. Committee members saw first hand, some of the short comings of centralization, for example, local program directors being unaware of the other state and local services that are available to their clients. The Committee concludes that the AAAs must be locally situated to be most effective. A single State office in the absence of local AAAs is too far removed from local issues, especially in geographically large rural states.
Recommendation 89-6: Continue and Increase Support for Research and Demonstrations on Innovative and Alternative Delivery Systems
The Secretary should continue the Department's support for the Medical Assistance Facility Demonstration Project in Montana. Additional research and demonstrations should be supported to encourage communities to test various transition strategies to ensure continued access to health services in their communities.
Recommendation 89-19: Expand the "Rural Medical Education Demonstration Projects" Program
The Secretary should propose legislation to expand the "Rural Medical Education Demonstration Projects" program to an additional 12 demonstrations, half of which utilize rural hospitals as a teaching site and half of which would utilize a rural ambulatory practice setting. The expanded program should incorporate flexible geographic criteria for awarding demonstrations that would result in a reasonable representation of provider sites across the Nation.
Recommendation 89-29: Increase the Quantity and Quality of Rural Research
The Secretary should support continuation of the HCFA "10 percent set-aside" of research and development funds for rural health research. The Office of Rural Health Policy should encourage the rural health research centers to sponsor a national conference.
Recommendation 90-3: Modification of the Essential Access Community Hospital (EACH) Program
The Secretary should propose legislation to modify the EACH Program. The legislation would be amended to give States and rural hospitals more flexibility in designing rural health care networks. The recommended changes would: 1) Provide for a waiver of the 72 hour limit on inpatient stays within a Rural Primary Care Hospital (RPCH) for states that submit acceptable proposals to establish a set of services which may be appropriately provided within the RPCH or for other alternative approaches to defining a RPCH; (2) Provide for waivers that would allow states to propose alternative definitions for the EACH; (3) Clarify that hospitals designated as a RPCH are allowed to participate in the swing bed program; 4) Stipulate that states may propose to include hospitals in adjacent states in a rural health network.
Recommendation 91-13: Obstetrical Access and Medical Malpractice
The Secretary should direct the Agency for Health Care Policy and Research (AHCPR) to establish obstetrical access and liability as a research priority within its legal-medicine program in 1992. As a component of this priority, the Agency should evaluate state health care malpractice and liability initiatives that address obstetrical access.
Recommendation 91-22: Expand Research on In-Home and Community-Based Health Care Services for the Chronically Ill Rural Elderly
The National Institute on Aging should direct its Exploratory Centers on Aging and Health in Rural America to work with the ORHP-funded Rural Health Research Centers, as appropriate to:
- conduct a study on the availability of and barriers to in-home services for chronically ill rural elders, including the costs of providing access to such services in rural areas, and