The National Advisory Committee
on Rural Health and Human Services
U.S. Department of Health and Human Services
NATIONAL
Advisory Committee RECOMMENDATIONS BY YEAR: 2006 | 2005
| 2004 | 2003 | 2002
| 2001 | 2000 | 1999
| 1998 1997 | 1996
| 1995 | 1994 | 1993
| 1992 | 1991 | 1990
| 1989 Recommendation 06-01: The Committee has identified several grant programs in the Department
that could be used effectively to promote and support accessto pharmaceuticals
and pharmacy services in rural areas. These include the Quentin Burdick
Interdisciplinary Grants authorized under Title VII of the Public Health
Service Act, the Rural Health Network Development Grants authorized under
Title II, Section 330A of the Public Health Service Act, the Rural Health
Outreach Grants authorized under Title II, Section 330A(f) of the Public
Health Service Act, grants to support schools of pharmacy authorized by
Title VII of the Public Health Service Act, and the 340B Medication Discount
Program. The Secretary should identify other programs as well. Programs
with appropriate authorizations should encourage applications from qualified
organizations that can present innovative ideas for improving or sustaining
access to pharmaceuticals and pharmacy services in rural areas, and for
integrating pharmacy services with other components of rural health care
delivery systems. Recommendation 06-02: The National Health Service Corps recently completed a demonstration
program that placed a small number of pharmacists in underserved areas
of the country. The Committee believes that the mission of the Corps should
now be expanded to include pharmacists among the other health professionals
eligible for loan repayments, scholarships and placements through the
Corps. Moreover, the Committee is aware of the potential difficulties
posed by the lack of criteria for designating pharmacist shortage areas
in rural parts of the country. The Committee believes, however, that the
existing criteria for designating Health Professionals Shortage Areas
are a reasonable proxy for shortages of pharmacists and could be used
by the Corps until such time as more specific criteria could be developed.
Recommendation 06-03: The AHEC program has been, and continues to be, an effective source of
support for educational programs and other efforts to help rural communities
and rural health care providers develop more integrated systems of care.
The critical role of pharmacy providers in rural areas and the need for
them to become a more integral part of local health care delivery systems
should be recognized and supported through the AHEC program. Recommendation 06-04: In presenting this chapter, the Committee was able to use some limited
information from a major study of the nation's pharmacy workforce conducted
by HRSA in 2000. That study (and others like it) did not provide data
on urban and rural differences in the pharmacy workforce. The Committee
believes that any future studies should attempt to identify and present
workforce data that allows comparisons between urban and rural areas.
Further, the Committee recommends that the Secretary require HRSA to do
an analysis of the urban/rural distribution of pharmacists in 2006. This
study is critical given the projected disparity in the nation's supply
and demand for pharmacists. Recommendation 06-05: The Committee has found that more research needs to be conducted as to
the potential factors that might place a rural community at risk of losing
their local pharmacy. In identifying those issues, the Committee believes
it will be easier to develop programs to target those risks. Recommendation 06-06: Under the 340B program, rural health clinics should qualify if they operate
on a sliding fee scale and Critical Access Hospitals should qualify if
they show that they have a Disproportionate Share Percentage greater than
11.75 percent if paid under the Medicare Inpatient Prospective Payment
System. Rural Health Clinics and Critical Access Hospitals that meet these
criteria must be considered a vital part of the health care safety net
in rural areas and should be recognized as such under the 340B program. The Committee also recommends that the Secretary provide additional resources
to the HRSA Office of Pharmacy Affairs that administers the 340B program.
Throughout the year, the Committee received testimony that many entities
eligible for the program are not aware of its benefits or have been unable
to seek participation because of staffing limitations and other factors.
Further, these entities often need technical assistance related to administration
of the program at the local level. Presently, the Office of Pharmacy Affairs
lacks sufficient resources to provide effective outreach to eligible entities
and the technical assistance they require. Moreover, the Committee recommends that the Office of Pharmacy Affairs
should conduct a study to determine the extent of urban and rural differences
in participation in the program and take steps to provide appropriate
assistance to eligible rural entities. Recommendation 06-07: In this chapter, the Committee has discussed some concerns about the
potential impact of the new Medicare Modernization Act on rural seniors
and pharmacy services providers. The validity of these concerns will not
be known until the new benefit has been implemented and tested. However,
the Committee believes that rural areas pose unique challenges for the
program and there is the potential for problems to surface over the next
few years. The Committee believes that the Secretary should support studies
and monitoring systems to determine how well the program is serving rural
beneficiaries and pharmacy providers so that problems can be identified
and resolved at the earliest possible time. There may be opportunities
to integrate such studies with other efforts that are already planned. Recommendation 06-08: The Committee recommends that the Secretary conduct a demonstration program
to examine the use of Medicare payments to provide medication therapy
management services to seniors who are taking multiple medications and
are at greatest risk for negative drug interactions. Medication therapy
management services can have a significant impact on the health of seniors
who are at high risk for negative drug interactions and other complications
stemming from dependence on multiple medications. Demonstration programs
should be conducted to identify those seniors most at risk in both the
Medicare fee-for-service and Medicare Advantage settings. Such programs
would also help to identify positive outcomes of medication therapy management
services, as well as their impact on the cost of the Medicare program. Recommendation 06-09: The Committee believes that telepharmacy has potential to increase access
to pharmaceuticals and pharmacy services, particularly in communities
that are unable to establish and sustain pharmacy services due to low
population density, unfavorable economic circumstances, geographic isolation
or other factors. However, the Committee is concerned that telepharmacy
applications must improve access without compromising the quality of services
that are available. The Committee believes that more information is needed
on how well telepharmacy applications are balancing the issues of access
and quality in rural areas. The evaluations should include studies on
best practices and outcomes. Recommendation 06-10: During its work on this chapter, the Committee received testimony describing
several recently developed software programs designed to help low-income
groups identify pharmaceutical assistance programs available to them and
streamline the application process. The Committee also learned that many
safety-net providers have been unable to aid their patients in applying
for pharmaceutical assistance programs due to staffing limitations. Thus,
these software programs would be able to mitigate that issue. The Committee
believes that the Department can play an important role in identifying
successful software programs, disseminating information about them and
assisting providers in their implementation. Recommendation 06-11: Recommendation 06-12: Recommendation 06-13: Recommendation 06-14: Recommendation 06-15: Recommendation 06-16: Recommendation 06-17: Recommendation 06-18: The 50-State Study reveals that differences in program availability,
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: 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: 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 06-21: 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 06-22: 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: 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: 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 06-25: The need for more providers and limited access to services in rural areas
were cited as two of the top five needs listed in the 50-State Study.
Recommendation 06-26: Recommendation 06-27: Recommendation 06-28: 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 06-29: The impact of providing long-term home care to loved ones is immensely
debilitating to the caregiver. Isolation, resentment, guilt, anger, financial
difficulties in addition to missed work, all plague the caregiver. One
out of three caregivers reports their own health to be fair or poor. Research
shows that informal caregivers suffer from high levels of stress, burnout,
and insomnia and are more likely to use psychotropic drugs. However, this
research does not identify differences between the stresses of rural caregivers
as compared to their urban counterparts. 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 05-2: Support
Research that Specify Opportunities and Barriers to Collaboration The Federal Office of Rural
Health Policy should dedicate a portion of its research budget to further
specify opportunities for and barriers to collaboration, funding activity
either through its research centers or its solicitation of independent
research proposals. Researchers should develop models that explain reasons
collaborations are successful, with success being defined, in part, as
long-term sustainability. Research findings should identify barriers to
successful collaborations as well as community, Tribal, State and Federal
actions that facilitate successful 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 05-4: 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 05-5: Increase
Support for Medical Schools that Have Distinct Program and a Proven Track
Record for Training Physicians to Practice Obstetrics in Rural Areas An increased supply of rural
physicians trained in obstetrics is essential to sustaining these services
in hundreds of small rural communities. The Secretary should increase
or reallocate funds under Title VII of the Public Health Service Act to
target medical schools that train obstetricians and family physicians
for rural practice, especially those that provide residents in family
medicine with training in high-risk obstetrics. Family physicians are
more likely to practice in rural areas than obstetricians, and programs
that prepare them for high-risk obstetrics must be supported. Support
for the training of CNMs and nurse practitioners who are interested in
obstetrics also should be increased. Recommendation 05-6: Make
the Recruitment and Placement of Physicians Trained in Obstetrics a Major
Goal for the National Health Service Corps The Committee believes that
the National Health Service Corps must focus more attention on rural areas
that lack adequate obstetrics services. Recruitment efforts should focus
on physicians who are trained in obstetrics and who are willing to deliver
babies in the communities they serve. Additional incentives for new physicians
are also needed and should be explored. One approach would be to pay the
malpractice insurance costs of new Corps physicians who are fulfilling
their obligation in areas with measurable and pronounced shortages of
obstetrics care providers. 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 05-9: 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 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 State 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 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 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 04-3: Identify
States with Model Licensure Laws and Scope of Practice Acts for Non-Physician
Behavioral Health Providers The Secretary, under the auspices
of Title XVIII and Title IX of the Social Security Act, should work to
identify States with model licensure laws and scope of practice acts for
non-physician behavioral health providers. The Secretary should share
them with other States and policymakers in order to facilitate similar
practices in rural areas of the country. The Secretary should also work
with States and behavioral health professional associations to increase
flexibility in State requirements for supervision of limited license behavioral
health providers that would allow more rural training, either in person
or through supervision delivered via telehealth technologies. Recommendation 04-4: Increase
Funding for the Quentin N. Burdick Program for Rural Interdisciplinary
Training The Secretary should support
increased funding for the Quentin N. Burdick Program for Rural Interdisciplinary
Training. The program is authorized under Title VII, Section 754 of the
Public Health Service Act. Grants awarded through the program can support
innovative models and demonstrations of interdisciplinary care in rural
areas. The program is uniquely suited to the support of programs that
foster the development of integrated primary care and behavioral health
care delivery systems. Recommendation 04-5: Increase
Funding for the Graduate Psychology Education Program The Secretary should support
increased funding for the Graduate Psychology Education Program authorized
under Title VII, Section 755(b)(1)(J), of the Public Health Service Act.
This program supports grants to schools accredited by the American Psychological
Association to help them plan and operate programs that foster an integrated
approach to health care service and that train psychologists to work in
underserved areas. The program was not included in the President's budget
for 2005. Recommendation 04-6: Increase
Support for Scholarships and Loan Repayment for Behavioral Health Care
Providers The Secretary should provide
increased support of scholarships and loan repayment for behavioral health
care providers under Section 331 of the Public Health Service Act. 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 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 04-11: Ensure
Adequate Funding for the National Health Service Corps The Secretary should ensure
adequate funding for the National Health Service Corps under Section 331
of the Public Health Service Act and should encourage it to pursue innovative
strategies that will attract more dentists and dental hygienists to take
part in the program. Recommendation 04-12: Seek
Additional Funding for the Recruitment and Loan Repayment of Indian Health
Service Dentists and Hygienists The Secretary should work
with the Office of Management and Budget to seek additional funding for
the recruitment and loan repayment of Indian Health Service dentists and
hygienists and to ensure the Indian Health Service dental facilities and
equipment are adequate to meet the demand for services. 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 04-15: Direct
the National Institutes of Health and the Agency for Healthcare Research
and Quality to Conduct Studies on Oral Health Disparities The Secretary should direct
the National Institute for Dental and Craniofacial Research and the Agency
for Healthcare Research and Quality to conduct a series of studies on
rural oral health disparities. These studies will provide additional information
on the oral health status of rural residents and will provide critical
information that will be used to guide evidence-based policymaking. 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 04-17: Support
Research that Examines How Rural Seniors Access the Services Provided
under the Older Americans Act The Secretary should support
research that examines how rural seniors access key services provided
under the Older Americans Act to determine if there are any service gaps
particular to rural communities. 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 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 03-6: Ensure
that Research Translated into Practice Include a Focus on Rural Health
Care The Secretary should work
with AHRQ and NIH to ensure that each Agency's efforts to translate research
to practice include a focus on rural health care quality issues as well
as translation of findings to rural practice, dissemination and adoption
of recommendations. AHRQ and NIH should also identify and examine "models
that work" in rural areas. 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 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 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 02-5: 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 02-6: 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 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 02-13: Support
and Enhance the 340B Discount Drug Program The Secretary should continue
to support and enhance the 340B Discount Drug Program and support Medicare
reforms that include access to prescription drugs. Recommendation 02-14: Propose
an Increase in Funding for the National Health Service Corps The Secretary should propose
an increase in funding for the National Health Service Corps at levels
sufficient to support the multi-year plan to expand health centers and
to meet the pressing needs of other rural areas for health professionals. Recommendation 02-15: Create
a Focal Point within the Department to Coordinate the J-1 Visa Waivers
The Secretary should create
a focal point within the Department to coordinate the J-1 Visa Waivers
issued by all Federal agencies and the communities in which they are placed
to ensure that the visa waivers are used to meet patient care needs. Recommendation 02-16: Consider
Allowing HHS to Issue J-1 Visa Waivers for Primary Care Physicians if
the USDA Declines to Continue Issuing Those Waivers The Secretary should consider
allowing HHS to issue J-1 Visa Waivers for primary care physicians if
the USDA declines to continue issuing those waivers. If USDA continues
to offer J-1 Visa Waivers, the Secretary should work with the Congress
to re-authorize and expand the scope of the Conrad State 20 program to
more adequately meet the primary care needs of rural communities. 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 02-19: Eliminate
Medicare Payments to Urban Specialists The Secretary should work
with Congress to eliminate Medicare Incentive Payments to urban specialists. Recommendation 02-20: Change
the Current Auditing Procedures Used the 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 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 01-2: Research
into the Cost of Providing Care to Medicare Beneficiaries in Rural Areas The Secretary should promote
research into determining the true cost of providing care to Medicare
beneficiaries in rural areas that take into account factors related to
access, geographic isolation and volume. The results of this research
should be used in redesigning the Medicare program to ensure equity of
benefits for rural beneficiaries. Recommendation 01-3: Continue
Collecting Data on Occupational Mix The Secretary should continue
collecting data on occupational mix and implement an adjustment to the
wage index as soon as possible. Recommendation 01-4: Collect
Wage Data for the Skilled Nursing and Home Health Service Areas The Secretary should collect
wage data for both the skilled nursing and home health service areas and
evaluate the impact of constructing an occupational mix adjustment within
the wage index for both of these payment systems. 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 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 01-11: 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 01-12: 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 01-13: Encourage
More Training of Health Professionals for Rural Communities In recognizing the link between
quality health care and the workforce, the Committee recommends that the
Secretary encourage more training of health professionals for rural communities
to ensure access to high-quality care for Medicare beneficiaries. Recommendation 01-14: Support
Research Related to Volume and Outcome for Primary and Ambulatory Care The Secretary should support
research that looks into issues related to volume and outcome in the rural
context based on primary and ambulatory care. 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 01-16: Promote
More Community-Based Trainings The Secretary should support
changes to Medicare policy that promote more community-based training
of residents. Recommendation 01-17: Require
Training Programs that Receive Graduate Medical Education Funding to Have
Rural Training Sites The Secretary should support
changes to Medicare policy so that residency programs receiving GME funding
would be required to provide training in rural settings. Recommendation 01-18: Support
Rural Graduate Medical Education Demonstrations The Secretary should support
Rural GME demonstration projects that address workforce shortages in rural
areas. 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 01-20: Increase
Funding for the National Health Service Corps to Promote More Clinicians
Serving in Rural Areas The Secretary should increase
funding for the National Health Service Corps to promote more placements
of Corps clinicians in underserved rural areas to serve Medicare and Medicaid
beneficiaries. 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 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. 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 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 99-12: 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 99-13: 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:
Recommendation 99-14: Improved
Coordination of Federal Public Health Activities The Committee urges the Secretary
to seek an Executive Order for the creation of a Federal Interagency Public
Health Coordination Committee comprised of senior representatives from
the various public health agencies and federal departments. The committee
would produce an annual report (the first of which would be produced within
12 months of the establishment of the Committee). The Committee would
study current efforts by each of the Federal Agencies involved in public
health activities overall while evaluating ways to integrate funding streams
to benefit rural communities in the areas of leadership development, workforce
development, viability of the safety net, impact of managed care, and
telecommunications. Recommendation 99-15: Creation
of a Dedicated Funding Stream for Public Health Activities The Committee urges the Secretary
to support the development of a dedicated funding stream for public health
infrastructure activities with assurances that funding is equitably distributed
among rural and urban health departments at the local level. 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 98-9: 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 98-10: Support
a legislative change to 1997 GME Legislation The Committee recommends that
the Secretary support legislation to make technical changes on a series
of GME provision from the Balanced Budget Act. Specifically, the legislation
should: The Committee recommends to
the Secretary that the Health Care Financing Administration consider not
only where a residency program is located but where its graduating physicians
practice in their definition of programs servicing rural or rural underserved. Recommendation 98-12: Assure
Access to Mental Health Care in Medicaid Managed Care The Secretary should assure
access to care for rural Medicaid eligible individuals served by managed
behavioral health care systems. Toward that end, the Secretary should Clinical records and reports
must exist to demonstrate the accomplishment of effective coordination
of physical and behavioral components of health care of individuals
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 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. NONE Recommendation 94-01: 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 94-02: 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 94-03: 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 94-04: 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 94-05: 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 94-07: 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 94-08: 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 94-09: 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 94-10: 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 94-11: 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. 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 94-12: Alternative
Rural Health Care Delivery Systems The Committee recommends that
the Secretary support legislation to authorize the Health Care Financing
Administration (HCFA) to conduct demonstrations of alternative rural health
care delivery systems that require waivers of the Medicare conditions
of participation for hospitals. Recommendation 94-13: Health
Professions Education The Committee reiterates the
recommendations it made in its Sixth Annual Report on Rural Health
addressing health professions education (93-5 to 93-14). Recommendation 94-14: Tax
Incentives for Practitioners in Rural HPSAs and MUAs The Committee recommends that
the Secretary support legislation to provide tax incentives to primary
health care practitioners who locate their practices in rural Health
Professions Shortage Areas (HPSAs) and Medically Underserved Areas (MUAs).
Such incentives should be offered both to new and existing rural practitioners. Recommendation 94-07: Mental
Health and Substance Abuse Services The Committee recommends that
the Secretary support enhanced mental health and substance abuse services. 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 93-3: Designation
of Rural Primary Care Hospitals The Secretary should support
legislation authorizing the Secretary to designate Rural Primary Care
Hospitals (RPCHs), as defined by law, in communities where hospitals have
been closed for more than one year. Recommendation 93-4: 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 93-5: National
Health Professions Workforce Plan The Secretary should develop
a national health professions workforce plan that specifies goals for
the types, specialties, and geographic distribution of health professionals
necessary to meet the health care needs of the nation. Recommendation 93-6: 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 93-7: All
Payers Contribute to Health Professions Education The Secretary should support
legislation requiring all health care payers to participate in funding
health professions education. Recommendation 93-8: Training
in a Variety of Settings The Secretary should support
legislation to make health professional education funding available to
health professional and residency programs in varied settings, not just
those owned or operated by a hospital. Recommendation 93-9: Rural
Training Sites The Secretary should support
the development of rural practice sites as training sites for both undergraduate
and graduate health professional training. Recommendation 93-10: Interdisciplinary
Training Programs The Secretary should encourage
the development of interdisciplinary training programs Recommendation 93-11: Train
Local Health Care Workers The Secretary should develop
initiatives to broaden access and innovation in health care delivery by
supporting local programs that utilize indigenous community workers and
paraprofessionals as essential members of community health care delivery
teams. Recommendation 93-12: Broaden
use of Medicare Graduate Medical Education Dollars The Secretary should support
legislation to modify the Medicare payment provisions for graduate medical
education to provide funding for undergraduate and graduate training of
physicians and other health care professionals. Recommendation 93-13: Medicare
Payment for Non-hospital Based Training The Secretary should support
legislation to provide Medicare funding for training in varied settings,
not just those owned or operated by a hospital. Recommendation 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 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 93-16: Consider
Rural Needs in Developing Mental Health and Substance Abuse Benefits under
Health Care Reform The Secretary should consider
the special needs of rural areas in the further development of mental
health and substance abuse benefits under health care reform, and the
need to improve access to these services in rural areas. The Committee
recommends several general principles to be considered in meeting the
needs of rural areas. Recommendation 93-17: National
Plan for Mental Health Professionals in Rural Areas The Secretary should direct
the Bureau of Health Professions to develop and implement (in collaboration
with the National Association of State Mental Health Program Directors,
the Center for Mental Health Services, and the Office of Rural Health
Policy) a national plan to respond to the severe shortage of mental health
professionals in rural areas. Recommendation 93-18: Substance
Abuse and Mental Health Services Administration (SAMHSA) Reauthorization
Act The Secretary should support
the Center for Mental Health Services, the Center for Substance Abuse
Treatment, and the Center for Substance Abuse Prevention in developing
the capabilities required to effectively carry out their respective missions
as stated in P.L. 102-321 (the SAMHSA Reauthorization Act) in ways that
are responsive to the needs and concerns of rural areas and populations.
In responding to this recommendation, each Center should: The Secretary should direct
the Substance Abuse and Mental Health Services Administration to develop
technical assistance programs to integrate mental health and substance
abuse service with "generic" rural service delivery systems (i.e., primary
health care, education, aging, developmental disabilities, criminal justice,
etc.) and increase the capacity of these systems to meet the needs of
their clients with mental health and substance abuse problems. Recommendation 93-20: Equal
Access to Federal Funding for Mental Health and Substance Abuse Services
The Secretary should support
the development of new ways to ensure that rural areas and populations
have equal access to federal funding and support in mental health and
substance abuse. Specifically, the Secretary should: Recommendation 93-21: Rural
Parent Education and Support Program The Secretary should establish
a demonstration grant program to rural communities to provide early parenting
education and support to first-time parents. the demonstration program
should include a three-pronged strategy that would involve the development
of local family resource centers, community-based assessment and home
visitation services, and the development of networks and referral agreements
between related programs and services. Recommendation 92-1: Rural
Hospital Transition Grant Program The Secretary should support
legislation to continue the Rural Hospital Transition Grant Program. Recommendation 92-2: Essential
Access Community Hospital/Rural Primary Care Hospital (EACH/RPCH) Program
The Secretary should convene
a meeting of the key participants in the EACH/RPCH program to resolve
problems and to develop legislative and regulatory strategies that will
facilitate implementation of the program. Recommendation 92-3: 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.
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 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 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 92-9: Demonstration
Programs to Encourage Collaboration Among Providers The Secretary should develop
demonstration programs that allow and encourage collaboration of all major
health care providers to make health care available in rural communities. Recommendation 92-10: 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: 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 92-13: Establish
a Coordinating Forum on Agricultural Health and Safety The Secretary should direct
the Office of Rural Health Policy to establish a coordinating forum on
agricultural health and safety for the purpose of sharing information
and coordinating agricultural health and safety activities across federal
departments or agencies. Recommendation 92-14: 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 92-15: Development
of Continuing Education Programs in Agricultural Health and Safety
The Secretary should seek
an appropriation for the Bureau of Health Professions (BHPr) of the Health
Resources and Services Administration to support the development of continuing
education programs in agricultural health and safety, including prevention,
diagnosis, and treatment. Recommendation 92-16: Safety
Training for Farm Children The Secretary of Health and
Human Services should ask the U.S. Department of Agriculture to request
that the Cooperative Extension Service begin a child farm safety course
for farm children and the parents of children who help on the farm. The
course should include a manual of information, similar to the Hunter Safety
Course now offered by the National Rifle Association. This manual could
be all inclusive, from equipment to pesticides, to hypothermia, to first
aid, and so forth. Recommendation 92-17: 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 92-18: Mandatory
Rollover Protective Structures and Seat Belts The Secretary should work
with the Secretaries of the Department of Labor, Commerce, and Agriculture
to seek legislation for the mandatory inclusion of Rollover Protective
Structures (ROPS) and seat belts on all new tractors, and a five-year
incentive program to retrofit ROPS and seat belts on tractors currently
in use. The cost of the tractor retrofits could be shared by state and
federal governments, equipment manufacturers, and tractor owners. Tractor-like
devices used in logging should be included under the provisions of this
recommendation. 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 92-20: U.S./Mexico
Rural Border Area Projects In cooperation with the Mexican
Ministry of Health, Pan American Health Organization (PAHI), and/or private
foundations, the Secretary of Health and Human Services is urged to support
six to eight binational U.S./Mexico Rural Border Area projects to demonstrate
improved, comprehensive, primary health care services. This would include
sanitation and preventive care focusing on maternal, infant, and adolescent
health. Recommendation 92-21: Shortage
of Mental Health Professionals in Rural Areas The Secretary should urge
the newly-created Center for Mental Health Services in the Substance Abuse
and Mental Health Services Administration (SAMHSA) to address the severe
shortages of mental health professionals in rural areas as one of its
first priorities. Recommendation 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 Sec
on Rural Health and Human Services
Recommendation 00-2: Create a Dedicated Funding Stream for Public Health
Activities
Recommendation 98-11: Include Residency Programs Producing Rural
Physicians in the Definition of Serving Rural Areas
The Secretary should require States, as part of defining the requirement
for the State Request for Proposals, to commission a study of the rural
impact of changing Medicaid provision of behavioral care services to delivery
by a managed care organization. This commission should:
The Secretary should disseminate best practice guidelines for managed
behavioral care organizations which recommend that managed care organizations
recognize, utilize, and reimburse properly trained primary care providers
as essential components of the behavioral health systems, especially in
rural areas. These guidelines should ensure that:
Recommendation 93-19: Technical
Assistance to Integrate Mental Health and Substance Abuse Services with
other Rural Health Care Services
Recommendation 92-11: Integration of Health and Education Services