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Rural Implications of Health Care Reform [1]
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�RURAL IMPLICATIONS
OF HEALTH CARE
REFORM
�RURAL HEALTH AND HEALTH CARE REFORM
TABLE OF CONTENTS
I.
BACKGROUND
A
B.
C.
D.
E.
F.
G.
n.
A Snapshot of Rural America
Rural Economics and Health Insurance
Rural Occupational Injury and Fatality
Rural Access to Health Care Services
Essential Community Providers
Difficulties with Recruitment and Retention
Special Service Needs
ISSUES
A.
Health Alliance Boundaries
B.
Benchmark Premium Areas
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
U.
Areas with Only Fee-For-Service Plans
Dual System States
Barriers to Community Plan/Network Development
Managed Competition or Managed Cooperation
Anti-Trust and Other Laws That Inhibit Network Development
Workforce Development
, Practitioners For Rural Areas
Scope of Practice
Trade-offs Between Specialty Residents and Mid-Level Practitioners
Rural Emergency Medical Services
Rural Mental Health
Governance
State Funding
Interim Cost Containment Strategies
Budget
What Do Rural Practices Really Cost?
Adoption of Medicare Payment Methodologies
Practice Guidelines
Clinical Laboratories
HI.
RECOMMENDATIONS AND RATIONALE
IV.
QUESTIONS AND ANSWERS
�IV.
QUESTIONS AND ANSWERS
V.
INTEREST GROUP CONSIDERATIONS
VI.
APPENDIX
1.
Health Care Reform Action Plan for Rural America
2.
Health Care Reform: Issues for Rural Areas by Jon Christianson and Ira
Moscovice
3.
Health Care Reform in Rural Areas Summary of an Invitational Conference
4.
Networking for Rural Health
The Essential Access Community Hospital Program
5.
Distribution of Community and Migrant Health Centers
President's Task Force on Health Care Reform
6.
A Collection of Recent Newspaper Articles
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Rural Areas May be Too Sparse for Managed Competition
Rural Health System Reform
How One Small Town Lured A Doctor
Rural Reformers Eye "Managed Cooperation."
How The Country Gets Things Done
Health-Care Proposals Based on Competition Are Viewed with
Skepticism in Rural Areas
Hillary's Health Planners
Health-Care Business Practices Spark Debate Over Impact of Antitrust
Rules
Clinton May be Creating a Monster, As Advisory Panel on Health
Swells
President's Health Plan Could Limit Americans' Beloved Choice of
Doctors
Medical Maze:Health-Care Experts Are Facing Sticky Problems in
Devising Clinton Proposals
Lay Midwives and the Law
W.V. Law Bans Lay Midwives
Managed Competition in Rural Areas: Will the Seed Take?
Proposing Surgery on the System to Meet Needs of Rural Patients
Starr County Doctors Threaten Baby Strike
�I. BACKGROUND
A.
A SNAPSHOT OF RURAL AMERICA
Approximately 22.5% of the U.S. population lives in rural (non-metropolitan) areas.
Some rural communities experience wide swings in population and employment during
the year from tourism and the seasonal migration patterns of retired persons and
migrant farm workers.
Rural communities vary across the country ranging from the wide-open spaces of the
West (where rural counties have population densities of less than six persons per
square mile) to the small towns of the South and Appalachia. Rural communities are
often defined as much by economics and topography as by distance from an urban
center.
Many residents of rural communities live in poverty. More residents of rural counties
earn incomes below 200 percent of poverty (40.5%), than those living in metropolitan
counties (28.1%). In addition, 56 percent of the 58 million people who live in
federally designated health shortage areas (where at least 30 percent of the population's
incomes are lower than 200 percent of poverty), live in rural America.
Rural areas have a greater proportion of elderly (14.5%) than urban communities
(11.5%). More elderly in rural areas live in poverty than elderly in urban areas.
About 50 percent of the rural elderly have incomes below 200 percent of poverty
compared to 37 percent of the urban elderly.
Problems with poverty and a disproportionate share of elderly are especially prevalent
in the rural South and Appalachia, where black families also make up a
disproportionate share of the poor.
Almost all of the counties with per capita family income in the lowest fifth of
all U.S. counties, are located in Appalachia, the Ozarks, and the Mississippi
delta.
Most rural black families live in the South. Moreover, one out of two rural
black families live in poverty.
�The South has the highest proportion of rural elderly: 43% of rural elderly
live in the South compared with 33% the Midwest and 24% elsewhere.
Ninety-five percent of minority elders live in the South and
45% of them live in poverty.
B.
PROBLEMS WITH ACCESS TO HEALTH CARE SERVICES
1.
Lack of Health Insurance
Lack of health insurance in rural areas is largely due to the declining economic vitality
of increasingly smaller rural communities. In 1991, the average median family income
in rural areas was $24,691, which is about three-quarters of the median metropolitan
family income of $31,975. In addition, govemment entities such as the local school
district or the county hospital are often the largest employer in the community.
The fragile financial state of the health care marketplace in most rural communities is
the result of the following:
A high percentage of small and individual business ownership. The national
rate for uninsurance among the self-employed is 21.6 percent.
An increase in the number of people insured by Medicare and Medicaid.
However, more people in urban areas have access to Medicaid (44.8%) than
people in rural areas (38.7%).
Higher rates of non-insurable individuals with chronic illness and disability
because they work in high risk industries such as mining, logging, and farming.
Farming is the predominant occupation in many rural counties (716 counties in
1979). Approximately 25 percent of the farm population is uninsured.
During a 28 month period ending in May 1987, 32 percent of rural residents
lacked insurance for at least one month. In addition, 16.9 percent of all nonelderly rural residents had no health insurance coverage in 1988, compared
with 15.4 percent of non-elderly urban residents.
�2.
Difficulty Recruiting and Retaining Health Care Providers
A number of factors contribute to the difficulty rural communities have attracting and
keeping primary care practitioners.
The fragile economies of rural areas often result in high proportions of
uninsured and underinsured individuals with correspondingly large burdens of
uncompensated care and limit the amount of money providers are able to
charge for their services.
Medicare pays both rural practitioners and rural hospitals less than urban
providers for the same services, based on geographic cost adjustments.
In states with disproportionately low Medicaid reimbursements, the
higher numbers of Medicaid residents in rural areas has a negative
impact on rural physician income.
High workloads, professional isolation, and inadequate educational and cultural
opportunities for practitioners and their families make it less likely that
physicians will stay in rural areas. Even practitioners who worked in
communities they knew from prior personal contact had roughly half the risk of
leaving.
Recent studies from Canada and North Carolina provide evidence that high physician
salaries are a major factor in the recruitment and retention of physicians.
Rural areas have 97 practicing physicians per 100,000 residents compared to 225 in
urban areas. There are differing opinions on the appropriate physician to resident
ratio. The federal definition of a health professional shortage areas (HPSAs) is one
primary care physician for every 3,501 people. Group Health Cooperative of Puget
Sound, an HMO, staffs family practitioners at a ratio of one for every 2000.
•
In 1988, 28.4 percent of the rural population lived in areas designated as
having a shortage of primary care physicians, compared to 9.5 percent of the
urban population.
�•
As of December 1991, it was estimated that it would take 2000 primary care
physicians to eliminate all rural HPSAs.
In 1985, 13 percent of rural physicians were age 65 or older compared to 9
percent in urban areas.
•
In 1990, there were estimated shortages of 45,000 registered nurses, 1200
psychiatrists, and nearly 1000 dentists in rural areas.
The trend toward specialty practice is not likely to change soon. In 1991, only
65 percent of family practice residency positions were filled, continuing the
trend toward specialty practice.
A 1990 survey of medical school graduates reported that only
13.5 percent of graduating medical students wanted to practice in
small cities (less than 50,000) and only 4.4 percent preferred
towns of less than 10,000.
3.
Lack of Transportation and Support Services
Residents of rural areas often have special needs that will not be met by improving
financial access to health care and increasing the numbers of health care practitioners
in rural areas.
More elderly who live in rural areas have to travel more than 30 minutes to
their doctor's office (13%) than elderly who live in urban areas (seven
percent). (National Medical Expenditure Survey).
Almost half of the rural counties in the United States do not have a public
transit system.
More than half of the rural poor do not have a car of their own, and nearly 60
percent of the rural elderly are not licensed to drive. Many of these people
must rely on friends or family for transportation.
�Social services and case management are necessary to make medical services
accessible for poor, underserved rural residents. For example, poor, pregnant women
may need nutrition counseling, parenting classes, and health education if their prenatal care is to be effective. These services are not found in many rural areas.
C.
ESSENTIAL COMMUNITY PROVIDERS
Historic isolation of smaller rural communities and discrimination against certain
populations have led to the development of essential community outpatient clinics
supported by govemment programs and services. These community health centers
(CHCs), migrant health centers (MHCs) and local health departments are the major
source of care for large segments of the population in many rural communities.
CHCs provide primary care services to medically underserved disadvantaged
populations and are located where there are financial, geographic, or cultural
barriers to primary health care for a substantial part of the population. About
60 percent of the 547 CHCs are in rural areas. They serve over 3 million
people. About 44 percent of these patients are uninsured.
MHCs provide comprehensive primary health care to migrant and seasonal
farmworkers and their families.
Sixty percent of CHC/MHC patients have incomes below the poverty line and
approximately 60 percent are members of minority groups.
CHCs and MHCs receive federal grant money which makes up about 40
percent of their total revenues. In FY 1993, the Federal grant contribution to
CHC/MHCs will total $616.2 million. Medicare and Medicaid, through
payments for patient services, contribute about 30 percent of total revenues to
CHC/MHCs. Private fees constitute the remaining source of funds.
As of December 1992, there were over 800 rural health clinics. These clinics
utilize mid-level practitioners and provide needed services in rural underserved
areas.
�Rural hospitals historically have been the center for organizing health services in rural
communities. In isolated rural areas, these facilities are often an essential source of
health care, especially for the elderly and the poor who may lack transportation to
services in other communities. Because of the higher proportion of elderly residing in
rural areas, rural hospitals are very dependent on Medicare as a source of funding.
While Medicare beneficiaries are 14.5 percent of the population
of rural areas, their higher use of health care accounts for 20.7
percent of patient visits for rural physicians and 51.8 percent of
all inpatient days in rural hospitals.
When Congress enacted a special payment program for rural
hospitals with fewer than 100 beds and at least 60 percent
Medicare inpatient days or discharges, more than 500 hospitals
qualified.
On average, rural hospitals lose money on Medicare patients.
The 1991 operating margin for rural Medicare payments was 5.6 percent.
D.
RURAL OCCUPATIONAL INJURY AND FATALITY
Rural industries are among the most dangerous of all occupations. As a result,
occupational illness and injury occur at high rates in many rural areas.
For every 100 residents in rural areas, there were 734 restricted activity days
associated with acute conditions during 1988, compared to 690 restricted
activity days per 100 urban residents.
Agriculture has the highest on-the-job injury rate of any occupation. In
addition, farm families and farm laborers are routinely exposed to pesticides,
gases, and airborne contaminants that can cause serious dermal, respiratory,
neurological, and genetic damage.
�Migrant and seasonal farm laborers also experience high rates of parasitic and
infectious disease, as well as chronic and acute conditions from inadequate housing,
sanitation, and drinking water.
The children of laborers and farm families are also part of the agricultural
workforce, and are exposed to the same occupational hazards. Each year,
almost 300 children die and another 23,500 are injured in farm-related
mishaps. Hundreds more injuries go unreported.
Timber and mining industries have high rates of serious injury and
occupational illness. A 1987 study found 58 percent of all injuries to loggers
resulted in permanent disability.
In recent years, meat packing and processing has evolved from an urban to
rural industry. Large plants are now located in rural counties. The injury rate
for this industry's workforce is now 35.1 cases per 100 workers.
�n. ISSUES
A.
HEALTH ALLIANCE BOUNDARIES
If the Health Alliances are to be a major force in addressing historic access
problems in rural areas, they will need to be large enough to have adequate
market power.
Large populations are necessary for adequate purchasing power to negotiate
with plans and providers and for equitable risk pooling under any insurance
scheme. Small groups tend to have poorer coverage and higher costs. The
most successful HMOs and insurance programs are based on enrolling large
groups. CALPERS has over 800,000 enrollees.
There is no clear consensus as to the optimal, or even the minimal feasible,
size of health alliances. It is clear, however, that many rural communities will
not, on their own, have sufficient populations to support an alliance. Rural
populations will need to be integrated into larger alliances.
In rural communities, where the market for health services is, or should be,
integrated with neighboring urban areas, there are distinct advantages to
combining urban and rural areas in the same health alliance. Such alliances
would have the financial resources to support the integrated systems of health
care which are necessary to ensure access to a full range of services for rural
residents. It has been suggested, however, that rural-only alliances may better
represent the interests of rural consumers and providers. The merits and
drawbacks of rural-only versus mixed urban/rural alliances are discussed later
in this section.
Emollment, not population size, is the key to determining the size of health
alliances. Population size does not take into consideration those groups that
may be excluded from the health alliance, such as Medicare beneficiaries or
employees of large firms.
Excluding Medicare beneficiaries, large employers, and govemment employees
from the alliances could potentially destroy their negotiating power in many
rural areas. In rural communities, Medicare enrollees on average account for
8
�51 percent of hospital inpatient days, and 21 percent of physician revenues.
Moreover, Medicare patients accounted for at least 60 percent of the inpatient
days in 20 percent of all rural hospitals.
B.
BENCHMARK PREMIUM AREAS
The benchmark premium determines the employer payment share and the low
income subsidy for an individual's health insurance premium. Selection of the
benchmark premium area, especially for employer subsidies, could significantly
alter the economic development of rural areas.
1.
Premium for Subsidies
The rural cross-cutting work group agreed that the benchmark area for low income
subsidies should be small (no bigger than the county). The plan that sets the
benchmark would have to serve the entire benchmark premium area. This would
assure that individuals receiving the low income subsidy would have access to a plan
where they live. The work group also was adamant that low-income individuals
should have a choice of at least two plans wherever possible.
2.
Premium for Employer Payment
The work group did not reach agreement on the size of the benchmark
premium area for the employer payment. In this case, the benchmark premium
determines how much the employer pays for employee health insurance. If the
areas are small (i.e. defined by counties), there could be wide differences in the
benchmark premiums across boundaries. Companies would likely make
decisions about where to locate new plants based on the benchmark premium
of the area. Those decisions would undoubtedly favor areas with low
benchmark premiums.
Rural areas are expected to have higher premiums because they are much less
likely to foster competition. In fact, some rural areas could end up with only a
high cost fee-for-service plan in the area. These rural areas would have
difficulty attracting new businesses if their benchmark premium for employer
payment is high. For purposes of employer payments and rural economic
development, it would make sense for the benchmark premium area to be large.
�Setting large benchmark premium areas (i.e. state-wide) creates several
problems. There might not be any plans that serve the entire area upon which
the benchmark premium is based. If all plans are used to determine the
benchmark premium, regardless of their service area, then in some areas, there
would be no plan available at the benchmark premium price. Employees in
these areas would end up paying more out-of-pocket for health insurance than
employees in areas with several plans below the benchmark premium.
C.
AREAS WITH ONLY F E E - F O R - S E R V I C E PLANS
Initially, some rural areas may have only fee-for-service (FFS) plans available.
However, as a disincentive to select a FFS plan, it is expected they will have high
deductibles and copayments. It is unfair to impose high deductibles and
copayments on people who have no option but to choose a FFS plan.
Over 60 percent of rural counties do not have managed care plans available. It
will take time to develop the networks upon which non-FFS plans depend.
Until non-FFS plans can be developed, it would be unreasonable to expect
rural residents to pay the extremely high deductibles and copayments that are
to be part of FFS plans.
Initially, members of the rural cross-cutting work group were concerned that
an open-ended reprieve from the FFS deductibles and copayments could act as
a disincentive to develop managed care networks in rural areas. Therefore, the
work group agreed upon a two-year reprieve to allow time to develop nonFFS plans in rural areas.
Ultimately, the work group adopted a recommendation that, at the time it
begins coverage of individuals, the health alliance be required to make its best
efforts to ensure that residents of its area have at least one non-FFS plan in
which to enroll. The health alliance would have many tools by which to do
this, including establishing its own non-FFS health plans. However, given the
many start-up activities of the health alliances, they may not be able to assure
access to non-FFS plans in all areas when they begin to cover individuals.
As long as a non-FFS option is available, there is no need to provide a
reprieve from the high deductibles and copayments of the FFS plans.
10
�However, in those areas without a non-FFS option, relief from the out-ofpocket expenses should be provided until a non-FFS is offered.
D.
DUAL SYSTEM STATES
Some states may adopt a dual system, with an urban health alliance organized
around managed care plans and a rural health alliance using a single payer
system.
State flexibility may result in dual system states, with separate urban and rural
health alliances and payment systems. Historical underfunding and
underemphasis of rural health care could be perpetuated in dual system states.
Strong federal regulation will be required to prevent a dual system from
becoming a two-tiered system.
Rural only health alliances could violate the concept that health care reform
will apply equally to everyone, regardless of income, race, age, health status,
and residence.
Rural communities will need financial assistance to develop adequate
infrastructure for health care delivery.
It may be necessary to redistribute funds between the two health alliances to
assure that all residents in the state have equal access to health care.
Rural areas have less robust economies, higher levels of poverty and
unemployment, and depend more on Medicare and Medicaid payments and
federal grant programs to support the delivery of health care services. This
disparity could require that resources from urban alliances be redirected to the
rural alliance in order to meet federal guidelines for state accountability.
Areas dependent on federal payments and subsidies are easy targets for future
funding cuts. They may be inherently less stable than alliances with adequate
private sources of revenues.
11
�The payment systems will be different, but the service areas will overlap.
Rural patients will undoubtedly rely on urban providers for some specialty care.
Arrangements will have to be made to pay urban providers under the rural
single payer system.
A single-payer system would reduce paperwork and administrative hassles.
Rural single-payer systems may find it easier to recruit and retain practitioners,
because they offer an alternative to working in managed care practices.
Alternatively, a dual system could contain disincentives to equitable distribution
health care personnel within the state.
E.
BARRIERS TO COMMUNITY PLANNING/NETWORK DEVELOPMENT
Rural communities, practitioners, and hospitals have little experience with the
capitated managed care arrangements envisioned by many as the standard for
health care reform. Because of the population densities and lack of economies of
scale, many communities cannot efficiently provide the range of services required.
In many of these communities, network development will be a necessary
precursor of, or adjunct to, managed competition.
In 1992, 64.2 percent of rural counties did not have an HMO providing
services to county residents. Even in Minnesota, which has a mature HMO
environment, almost half of the rural counties were not served by HMOs in
1991, and 86 percent had less than one tenth of their population enrolled in
HMOs (Christianson and Moscovice).
Development of rural risk-based plans is hampered by a lack of technical
expertise and capital to support establishment of the plans and insure against
insolvency.
Many rural providers, including primary care and mental health practitioners,
have little or no experience with integrated systems of care. Existing rural
networks tend to be groups of similar providers that form to address common
problems or respond to reimbursement opportunities (Christianson and
Moscovice). Examples of rural-based networks, which provide a range of
benefits comparable to those proposed under health reform, are relatively rare
12
�- mostly confined to a handful of successful rural HMOs.
Rural providers often are reluctant to establish formal relationships with urban
networks or plans because they fear that these plans will siphon off patients,
resulting in a loss of community facilities and practitioners. Rural practitioners
are also likely to resist plans that attempt to alter existing referral patterns.
These referral patterns have been constructed carefully, over time.
Where distances are not an overwhelming barrier, consumers with
financial means frequently bypass small rural providers to receive care
in nearby larger communities.
F.
MANAGED COMPETITION OR MANAGED COOPERATION
Health care reform in rural communities will require a variety of approaches
from "managed competition" to "managed cooperation."
In a recent article, Kronick et al. argue that meaningful managed competition
can only occur when providers have exclusive affiliation with health plans.
They have assumed that, at a minimum, three plans are required to have
effective competition. They estimate the minimum population necessary to
support three competing plans ranges from 360,000 persons for support of three
fully competing HMOs, to 30,000 for support of three independent primary
care networks that share hospital services.
In some rural areas, such as those with established rural-based HMOs, higher
population densities, or areas adjacent to urban communities, some managed
competition may be feasible. But there will be few rural communities that can
support a fully competitive system.
It is more than likely that rural communities will be able to adopt modified
versions of managed competition that focus on network development among
existing providers, such as the system developed in Minnesota. In these
systems, provider networks compete to attract enrollees from various plans.
The networks are able to contract with more than one health plan. Under this
scenario, networks would have financial incentives to promote efficient
resource use under capitated payment arrangements.
13
�Some have suggested that the Minnesota model represents a large
administrative burden to rural providers who have to handle claims from
multiple plans. Others counter that the administrative burden is not
overwhelming because rural providers are unlikely to simultaneously contract
with many plans and that under managed competition, benefits and claims
processing will be standardized, thus reducing the administrative burden
associated with participation in multiple plans.
Perhaps more relevant, participation of providers in multiple plans may make it
more feasible for rural providers to ignore meaningful participation in cost
containment, thus increasing overall costs to rural communities.
Providing incentives for cooperation and collaboration in capitated systems
could include a variety of strategies, such as technical and financial assistance,
peer support, medical school affiliations, development of rural training sites,
and development of telecommunications linkages.
G.
ANTI-TRUST AND OTHER LAWS THAT INHIBIT NETWORK
DEVELOPMENT
Health care reform will encourage development of health care networks. In rural
areas, where there are few providers, there is a concern that establishment of
networks may be viewed as anticompetitive. Rural providers will need a
mechanism by which they can determine whether proposed relationships violate
anti-trust laws.
Federal anti-trust laws have had a chilling effect on network development in
rural areas. However, in rural areas, network development may provide greater
access at lower cost, even when networks preclude competition.
To promote network development, rural providers need assurances that the
arrangements they make will not run afoul of federal anti-trust laws. The rural
cross-cutting work group has made a series of recommendations to assist rural
providers with legal network development.
Through technical assistance and the development of model legislation that
states can use to ensure that developing networks do not violate federal anti14
�trust laws, the federal govemment can help states balance the potential benefits
from network development — such as lower costs, greater access, and
improved quality — against the loss of competition.
Proposed safe harbor regulations have been developed within the Department
of Health and Human Services and should be published in the near future.
These safe harbors regulations will clarify the situations under which rural
providers can safely finance other health care entities such as rural hospital
purchase of physician practices; other financial arrangements to recruit and
retain practitioners; practitionerfinancingof ancillary services; and referral
relationships.
Current state laws that restrict corporate practice of medicine inhibit network
development by limiting the employment of physicians and other providers by
general business or non-profit corporations.
H.
WORKFORCE DEVELOPMENT
The total number of physicians and the mix of generalists and specialists has been
determined in a random process controlled by the medical schools, the teaching
hospitals, and the residency review boards. The driving forces are a combination
of technological andflnancialincentives that have little to do with national health
care needs. Federal funding has not been used sufficiently to influence these
institutions to train more primary care practitioners. A national health
professions workforce plan should be developed that specifies the numbers and
mix of health care practitioners necessary to meet national health care needs.
Without a national plan, health professions workforce development has lacked
direction. The result is too many specialists and too few generalists. In
addition, the contribution of mid-level practitioners is rarely included in
assessments of the need for health care practitioners.
There is need for planning that integrates the needs for all types of health care
practitioners — including mid-level practitioners, mental health professionals,
and dentists — for both primary care and specialties. Planning based on an
assessment of the health care needs across the United States could specify
goals for the numbers, professional mix, ethnic and racial distribution, and
geographic distribution of primary care practitioners and specialists.
15
�With direction and goals for workforce development, federal funding could be
more rationally directed toward programs that contribute toward the
achievement of the national goals.
I.
PRACTITIONERS FOR RURAL AMERICA
The new health care system will rely extensively on primary care practitioners
(physicians, nurse practitioners, physician assistants, nurse-midwives) to provide
basic health care services and serve as gatekeepers to specialty care. Increased
demand for primary care practitioners in urban areas will make it even more
difficult for rural areas to recruit and retain these practitioners. Increasing the
number of practitioners trained for primary care will not necessarily increase the
numbers of practitioners in rural areas. Therefore, it will be necessary to
develop training programs that prepare practitioners specifically for rural
practice and to make rural practice more attractive.
Only about 30 percent of physicians are generalists. Work Group 12
(Workforce Development) recommends a number of steps to increase the
number of primary care practitioners trained in the U.S. These steps will be
necessary to achieve a balance between the health care workforce and the
demands for primary care created by health care reform.
Competition for primary care practitioners in urban practices will intensify.
Practitioners will have many options when determining a practice location.
Rural areas could find it even more difficult to recruit and retain practitioners
in this environment.
Several steps should be taken to better prepare practitioners for rural practice
and to make rural practice more attractive. Rural practices should have the
opportunity to participate in educational programs as training sites of health
care practitioners. Rural practice is sufficiently different from urban practice to
warrant rural site training programs. It is believed that practitioners trained in
rural locations are more likely to establish their practice in a rural area. Using
rural practices as training sites has the added benefit of linking rural
practitioners with training programs. This relationship can help solidify a rural
practice. It will provide the professional support and continuing education
necessary to sustain a more isolated practice.
16
�Other steps will make rural practice more attractive to practitioners. Payments
to rural practitioners must reflect the higher price that must be paid to make
rural practice appealing to them. In addition, locum tenems must be available
so rural practitioners can leave for vacations and continuing education.
J.
SCOPE OF PRACTICE
State scope of practice laws and regulations define the types of medical care and
treatment that can be provided by different categories of practitioners within the
state. For example, state scope of practice laws determine whether nurse
practitioners can prescribe drugs or not. Successful implementation of health
care reform will require that all primary care practitioners be able to practice to
the full extent of their training and professional certification. Federal model
scope of practice legislation would help states adopt appropriate scopes of
practice.
Historically, states have had the responsibility to license health care
practitioners. They regulate the services of practitioners through scope of
practice laws and regulations.
The variation in scope of practice among states for some provider types can be
dramatic. Some states allow physician assistants to practice only with a
physician under the same roof while other states allow them to practice with
biweekly visits from their physician. The more restrictive scopes of practice
prevent practitioners from practicing to the full extent of their training.
Increased demands for primary care practitioners as a result of health care
reform will put pressure on states to liberalize their scope of practice laws and
regulations. The federal govemment should develop model scope of practice
laws and regulations for the various types of practitioners and encourage states
to adopt these laws and regulations.
The concept of model scope of practice legislation or regulations developed by
the federal govemment is supported by Work Group 12 (Workforce
Development).
17
�The American Nurses Association (ANA) does not support national practice
acts, but prefers to have the states maintain authority over licensure of health
care professionals.
K.
TRADE-OFFS BETWEEN SPECIALTY RESIDENT AND M I D - L E V E L
PRACTITIONERS
When specialty residency slots are eliminated, teaching hospitals will look to midlevel practitioners to provide the services once provided by those residents. This
will further increase the career options for mid-level practitioners, reducing the
likelihood they will choose primary care practice in rural areas.
It is generally believed that midlevel practitioners — nurse practitioners,
physician assistants, nurse-midwives — are more likely than physicians to
establish their practice in rural areas. However, there is little evidence to
support this belief.
In fact, the urban career options for midlevel practitioners can be expected to
expand as a result of health care reform. A reshuffling of residency training
priorities to primary care will result in elimination of numerous specialty
training residencies. This does not mean the teaching hospitals will necessarily
provide fewer specialty services.
The experience in New York, when the hours worked by residents was cut,
shows that teaching hospitals replace the residents with midlevel practitioners.
This opens new doors to midlevels and they are generally only too happy to
respond. Teaching hospitals pay well and specialty practice is becoming more
popular among midlevel practitioners.
Consequently, it should not be assumed that mid-level practitioners will be
available to provide primary care services in rural communities. More midlevel practitioners will need to be trained. Just as with physicians, they need to
be trained for rural practice in rural settings. Payment rates also should
adequately reward those who choose to practice in a rural community.
18
�L.
RURAL EMERGENCY MEDICAL SERVICES
Systems for providing emergency medical services are not well developed in rural
areas. The infrastructure for emergency care is fragile and many rural
communities do not have adequate EMS services.
Rural industries are the most dangerous (farming, mining, timber) and the risk
of dying from trauma in a rural area is three to four times greater than in urban
areas.
More traffic fatalities occur in rural areas than in urban communities.
The closure of rural hospitals (over 10 percent of all rural hospitals in the past
decade) has increased rural communities' dependency on rural EMS providers
as the only source of emergency care.
Rural EMS providers often rely on antiquated vehicles and insufficient
communication systems between dispatchers, ambulances, and hospitals.
The vast majority of rural EMS services are staffed by volunteers. Volunteers
are increasingly difficult to recruit and retain. It is difficult for them to
maintain and upgrade their skills when training courses are seldom available in
their own communities and the cost is from their own pockets.
Most EMS personnel in rural areas are trained to provide basic levels of life
support services. Advance life support personnel and paramedics are in short
supply.
•
There is a chronic shortage of rural physicians trained to provide emergency
care or to provide medical direction for ambulance services.
Only 69 percent of all rural and frontier areas are covered by 911 systems.
Some rural residents must make long-distance calls for emergency services.
19
�Most rural EMS services are heavily subsidized by states and localities. The
economic decline of many rural communities has made it difficult to maintain
these services.
Most rural areas are not part of an organized regional system for EMS services,
even though regional systems have proven to be efficient and effective in
providing emergency care. Emergency care is primarily a local responsibility.
This often results in underutilization of available resources, poor coordination
between providers and communities, and inappropriate treatment of patients.
M.
RURAL MENTAL HEALTH
Rural Americans are at equal (or greater) risk for mental illness compared to
their urban counterparts, but suffer much more serious shortages of mental
health services and professionals.
Rates of mental illness and substance abuse in rural states are about as high as
in non-rural states.
Sixty-one percent of rural Americans live in designated psychiatric shortage
areas. There are more rural counties (1,682) without any psychiatrists,
psychologists, and social workers than there are counties in the nation that have
any of these providers (1,393). Ninety-five percent of metropolitan counties
have psychiatric inpatient services compared to 13 percent of non-metropolitan
counties.
The difficulties of ensuring confidentiality in rural communities exacerbates the
stigma of mental illness and substance abuse in our society. Unless the family
member has very severe symptoms, rural people prefer to receive all of their
health care, including mental health care, from their primary practitioner. In
rural communities, primary care settings are more available and are preferred
over dedicated mental health or substance abuse centers, where patients can be
stigmatized by their neighbors simply by walking through the clinic door.
Unfortunately, primary care practitioners are often overworked and underprepared to treat mental illness and substance abuse.
20
�Mental health centers are the most common sites for alcohol treatment in rural
communities, accounting for 42 percent of the alcohol treatment caseload.
N.
GOVERNANCE
Without special designation in law, rural populations have generally been
unrepresented or under-represented on national boards or commissions.
Approximately 25 percent of the U.S. population resides in rural areas. This
population experiences unique problems with access, delivery and financing of
health services that frequently goes unrecognized in federal policy.
Recent experience with Medicare and other federal health programs have made
rural residents and their advocates wary of federal govemment initiatives.
Even those initiatives that were designed, in part, to help rural communities
(e.g., Medicare's RBRVS Physician Payment System), ultimately have not lived
up to their promise. Others, such as the federal rules implementing the
Clinical Laboratory Improvement Act (CLIA), are being refined with counsel
from advisory boards that have no rural representation on them.
Rural residents are often characterized by extreme independence and a desire to
control their own institutions. They are likely to resent changes in the delivery
and financing of their health care that appears to be dictated from Washington
or the state level.
On the other hand, residents of many rural communities show a great
willingness to work together in finding solutions to their health care problems.
Experience with the Federal EACH/PCH program and the Rural Outreach
Grant program have provided cogent examples of this creative energy.
Because extensive change is likely to be required over time, it is critical that
rural communities participate and believe they are well represented in shaping
the nature of that change.
21
�O.
STATE FUNDING
While some states are ready and able to implement sophisticated health reform
systems, others are not. In particular, rural states may be less likely to have the
administrative machinery to implement the system.
Under the Clinton Plan, states will be provided a great deal of flexibility to
implement the system in the most effective manner to meet the needs of their
populations. At the same time, however, they will be accountable to the
federal govemment for meeting access, quality, and budgetary standards.
As with the Medicaid program, health care reform will be a federal/state
partnership. Under that program, states were given federal funds to assist in
managing the program and meeting federal standards. States are afraid that,
parallel to their experience under Medicaid, these funds will not be sufficient.
That is, they will be the partner stuck with all the duties and insufficient funds
and technical expertise to carry them out.
Rural states, with small bureaucracies, will require technical assistance and
front-end dollars to allow them to develop the necessary capacity to implement
health care reform (e.g., development of state infonnation systems for
reporting, expertise in evaluating adequacy and quality of health plans). This is
especially critical if the states are to provide ongoing assistance to rural
communities on the development of networks and community-based plans.
P.
INTERIM COST CONTAINMENT STRATEGIES
Interim cost containment strategies may be necessary to hold down health care
costs until the new health care system can be put in place. These strategies
provide an opportunity to shift payment policies toward higher payments for
primary care and all rural practitioners.
•
Several interim cost containment strategies have been proposed, including price
controls (voluntary or involuntary), a surtax on increases in provider revenue,
or caps on increases in health insurance premiums. In any case, the controls
would ultimately affect provider incomes.
22
�The rural cross-cutting work group believes these interim cost containment
strategies provide an opportunity for early implementation of policies that
would pay primary care and all rural practitioners more relative to specialty,
urban practitioners. For example, price freezes could be applied
disproportionately, so primary care and rural practitioners' prices are frozen at
higher rates than specialty, urban practitioners. A cap on premiums could carry
with it the stipulation that insurers could not reduce rural and primary care
practitioners payments as much as urban, specialty practitioners.
Early implementation of a policy to pay more to primary care and all rural
practitioners is necessary to demonstrate that these practitioners are needed and
valued as health care providers. Disproportionately higher payments to these
practitioners will send a clear signal to students in practitioner training
programs that primary care and rural practices are good career choices.
Q.
BUDGET
Budget caps, based on historical spending patterns, could have a detrimental
effect on the development of needed services in rural areas with health care
shortages.
Budget caps that are based on historic spending reward those who have charged
more and who have had higher costs in the past. They do not necessarily
reflect the costs of providing efficient care or ensuring access to services.
If budgets are allocated based on historic spending patterns, they are likely to
perpetuate or exacerbate the shortages found in rural communities. Budgets
need to be predicated on the amount of funds required to ensure access.
For example, payments based on historic physician charges have contributed to
the shortage of health care providers in rural areas. Historically, physician
charges have been depressed by the economic status of rural communities.
Rural physicians are compelled to charge less for their services because local
incomes are lower. Consequently, rural physicians must work harder to earn
incomes comparable to their urban counterparts. The result is a chronic,
structural shortage of health care practitioners in rural areas because too few
physicians are willing to practice at the price rural residents are willing or able
to pay.
23
�The budget will need to account for geographic differences in the true costs of
providing access to health care in different areas. Rural experts contend that
input price indices, such as those developed for Medicare payments to hospitals
and physicians, do not adequately measure the economic costs of attracting and
retaining providers in rural communities. As such, they are inadequate
measures to be used in budget allocation.
According to most rural experts, advocates, and congressional staff consulted
by the rural work group, the budget should be based on a national per capita
average that is adjusted for the higher fixed costs of maintaining adequate
health care resources in low density, rural communities.
The time frame for moving towards a national average is subject to strenuous
debate. Immediate adoption of a national average could create a highly
disruptive and destabilizing reallocation of resources. At the same time, unless
a relatively short time frame is set, the inequities of past policies will be
perpetuated, to the substantial detriment of rural communities. Moreover, the
Clinton promise of universal access and equal sacrifice may be viewed as
hollow if rural residents perceive that they continue to be locked into a twotier system by an inadequate budget.
R.
WHAT DO RURAL PRACTICES REALLY COST?
One of the common myths about health care in rural areas is that it costs less to
provide health care in rural communities than in urban communities. As with all
myths, there are shreds of truth amidst a core of misinformation. Historic
charges for health care services in rural areas have fueled this myth. Using
physician practices as an example, one can see how basing payments on historic
charges can create shortages of health care resources in rural communities. One
goal of health care reform should be to assure that there are sufficient funds in
the system to develop and maintain adequate health care resources in rural areas.
1.
Living Expenses
One reason for the myth is the belief that it costs less to live in rural communities.
According to the 1990 Census, the median rent in rural (non-metropolitan) areas is
$323 compared to $474 in urban (metropolitan). The median mortgage in rural
communities was $541 versus $789 in urban areas. Certainly, incomes are lower in
24
�rural areas. Median household incomes were $23,075 in rural areas, and $32,086 in
urban areas.
Other living expenses may be similar or higher in rural areas compared to urban areas.
Food, electricity, and phone services may cost about the same or more. Rural
residents probably pay more for transportation, both in higher gasoline prices and by
having longer distances to travel. It is difficult to ascertain the net difference in the
costs of living between rural and urban communities, although it is likely that rural
communities are somewhat less expensive to live in than urban communities.
2.
Physician Practice Expenses
Does a lower cost of living translate to lower costs for delivering health care services?
Not necessarily. There is no evidence that rural physician practice expenses are
significantly lower than urban practice expenses. In fact, for some practice
components, the costs are higher. The American Medical Association's Socioeconomic
Monitoring System has collected infonnation on the practice expenses of about 4000
physicians each year since 1982. Data from 1990 indicated that the mean professional
expenses (excluding physician income) for all rural physicians were $140,800
compared to $157,700 in urban areas with a population below one million, and
$144,400 in urban areas with a population greater than one million. For general and
family practitioners, the mean professional expenses were $138,900 in rural areas, and
$142,100 and $120,900, respectively in urban areas. This is a truer comparison of
practice costs because urban practices are weighted heavily toward specialty practices.
Expenses for non-physician personnel payroll, offices, and medical equipment are
similar for rural and urban physicians. Rural physicians pay more for medical
supplies ($18,600) than do their urban counterparts ($15,900 for general practitioners
and $16,700 for family practitioners). Expenses for medical supplies by rural
physicians may be higher because they are less able to take advantage of volume
discounts.
3.
Physician Incomes and Charges
For family practice physicians, incomes in rural areas are slightly higher than in urban
areas. In 1990, general and family practice physicians in rural areas earned $110,400
compared to $105,200 and $92,700 for the respective urban areas. This can be
explained by the fact that rural physicians work longer hours, see more patients, and
25
�have been practicing for more years. For example, rural physician hourly wages are
lower than the hourly wages of urban physicians. Data from the HCFA Practice Cost
and Income Survey (1988) showed that annual incomes of all rural physicians were
87.8 percent of the annual incomes of all urban physicians. However, rural hourly
incomes were only 81.2 percent of urban hourly incomes. This is because rural
physicians have historically charged less for their services. The Physician Payment
Review Commission estimated that for 1988, the average allowed charge for physician
services in rural areas was 10 to 13 percent below the national average.
4.
Payments Based on Historic Costs Contribute to Physician Shortage
The historic accounting costs of physician practices are depressed by the economic
status of rural communities. Rural physicians are compelled to charge less for their
services because local incomes are lower. Consequently, rural physicians must work
harder to earn incomes comparable to their urban counterparts. The result is a
chronic, structural shortage of health care practitioners in rural areas because too few
physicians are willing to practice at the price rural residents are willing or able to pay.
What price would have to be paid to attract and retain adequate numbers of physicians
to rural communities? This is the economic cost of a rural physician practice. It
includes not only the costs of operating the practice, but the additional price that must
be paid to induce physicians to practice in rural communities. The fundamental
problem underlying the rural shortage of practitioners is that the economic costs are
substantially higher than the historic accounting costs, but payment policies
consistently have been based on accounting costs. Payment policies based on historic
accounting costs will do nothing to solve the shortages of practitioners in rural areas.
Rather, they will result in continued shortages of health care professionals that will
make it nearly impossible to create rational systems of care for rural residents.
5.
Quebec's Approach to Rural Physician Payments
In the province of Quebec, this problem has been recognized and steps have been
taken to increase the supply of physicians in rural areas. For example, physicians
practicing in remote areas of Quebec (population below 10,000) earn 115 percent of
the fee schedule. Physicians setting up a practice in a remote rural area can also
receive $10,000 per year for the first four years along with financial assistance for
establishing a practice. New physicians in large urban areas are paid only 70 percent
of the schedule for their first three years of practice. Physicians in mid-size
communities (population between 10,000 and 100,000) are paid 100 percent of the
26
�schedule. These payment incentives have been helpful in increasing the number of
physicians practicing in remote rural areas.
6.
North Carolina Study of Income and Retention
A study by Pathman and Konrad at the University of North Carolina supports the
concept that.physician income is associated with the likelihood that a physician will
locate and remain in a rural practice. In addition, they found that growth in income is
a significant factor in explaining physician retention.
7.
Implications for Physician Payments after Health Care Reform
No one believes that higher incomes, alone, will completely solve the shortage of
physicians in rural areas. Particularly in remote areas, the economic costs of
supplying health care providers may be prohibitive. It will be important to supplement
higher incomes with support services, such as replacements during vacation, access to
continuing education, interaction with colleagues, etc.
However, a vital part of the solution to the shortage of health care practitioners in
rural areas will be to operate under a new paradigm. Rather than continuing to base
payments on historic costs and charges, it will be essential to base payments on the
economic costs of supplying practitioners to rural communities. However, such a
restructuring of physician payments would result in a redistribution of funds among
physicians. Therefore, it would be necessary to seek both short-term and long-term
solutions to ease the transition from one system to another.
S.
ADOPTION OF MEDICARE PAYMENT METHODOLOGIES
One mechanism for interim cost control or long term budget development is to
adopt Medicare payment methodologies for all payers. However, Medicare
payments to rural providers have been consistently less than to urban providers.
Rural hospitals generally lose money on services to Medicare beneficiaries.
Moreover, Medicare payments to physicians are inadequate to help attract
physicians to rural practice.
•
Medicare payment methodologies for hospitals, based on prospective payments
for particular diagnoses, are well established and have been the most effective
27
�means in recent years of controlling inpatient health care costs. A new
methodology for Medicare payments to physicians was implemented in January
1992. This methodology pays physicians for the relative value of the resources
required to provide a particular service. The system is supposed to pay more
for primary care services and less for surgical services than under the previous
payment system. The results to date have not been significant.
Rural hospitals have consistently fared worse under Medicare than urban
hospitals. In 1995, the standardized amount, from which the Medicare payment
is calculated, will be the same for urban and rural hospitals (for the first time).
When this payment system began, the standardized amount for rural hospitals
was more than 20 percent below the amount for urban hospitals.
Even with a single standardized amount, payments to rural hospitals will
continue to be less than to urban hospitals. This is because the standardized
amount is adjusted for the costs of labor. The labor adjustment applies to
about 70 percent of the standardized amount.
Two problems with the wage index as it is currently defined persist. The wage
index for rural hospitals is determined by the average wages paid by all rural
hospitals in a state. This creates inequities across rural hospitals within a state.
The Prospective Payment Assessment Commission (ProPAC) has recommended
adoption of an alternative definition of labor market areas. They would define
individual labor market areas for each hospital by the other hospitals within a
certain distance. This proposal deserves further consideration if Medicare
methodologies are adopted.
The second problem is that the data used to develop the wage index is always
about four years old. The wage index also is based on wages paid and does
not include any additional recruitment costs incurred by rural hospitals, such as
sign-on bonuses, fees to recruitment agencies, moving costs, or scholarship
programs to train local residents. Rural hospitals have a difficult time
recruiting professional staff and must often offer special incentives to recruit
staff.
Similarly, physician payments are adjusted for geographic differences in costs.
The geographic practice cost index (GPCI) adjusts for the historical costs
(professional and employee wages, rent, medical supplies and equipment,
malpractice premiums) incurred by a physician practice. It does not adjust for
28
�the actual price that must be paid to get practitioners to work in rural areas.
Medicare does pay a 10 percent bonus to physicians practicing in health
professional shortage areas (HPSAs). However, this is not considered high
enough to alter practice location decisions. In Canada, new physicians in
remote areas are paid as much as 45 percentage points more than new
physicians in urban areas (115 percent of the fee schedule compared to 70
percent).
Any decision to adopt Medicare payment methodologies must examine the
effects of these methodologies on rural providers. Medicare payment
methodologies should include the additional costs of recruiting and retaining
practitioners and health care professionals to rural areas.
T.
PRACTICE GUIDELINES
Practice guidelines direct practitioners to the effective diagnosis and treatment of
a patient's medical condition. They are used to assure quality and assess
practitioners' liability in malpractice cases. If practice guidelines are based on
the high technology readily available in urban settings, rural practitioners will be
disadvantaged.
There is concern among rural practitioners that practice guidelines will focus
on high technology diagnostic tools and interventions that may not be available
or appropriate in rural and frontier areas. Efficient and effective health care
does not necessarily require the use of the latest technology.
The Agency for Health Care Policy and Research (AHCPR) has made efforts to
assure that the practice guidelines they develop are practical for rural practice.
However, rural practitioners remain concerned about future guidelines.
AHCPR is currently establishing 3-10 rural research centers to assist them with
development of appropriate practice guidelines for rural practitioners.
The rural-cross-cutting work group believes that practice guidelines should be
outcomes oriented. They should identify effective and appropriate low
technology services.
29
�Practice guidelines also should recognize that, for some medical conditions, the
use of high technology is necessary. For these conditions, referrals to facilities
that can provide the necessary level of care are appropriate and expected.
Rural practitioners need practice guidelines that specify the level of care that is
necessary to achieve the desired outcomes and consider the resources readily
available in rural areas.
U.
CLINICAL LABORATORIES
The Clinical Laboratory Improvement Amendments of 1988 (CLIA) are supposed
to assure the quality of laboratory testing wherever it takes place. The
regulations implementing CLIA have proved burdensome to rural laboratories
because of the new personnel requirements and the cost of participating in CLIA.
Many rural providers have stopped performing laboratory tests rather than
participate in CLIA. A reexamination of the CLIA regulations that considers the
effect of CLIA on access to laboratory testing in rural areas should be conducted.
Implementation of the CLIA regulations is causing reduced access to laboratory
testing in some rural areas. When rural providers stop providing laboratory
testing rather than participate in CLIA, patients either must travel for tests or
wait up to 24 hours for results from remote laboratories.
Workgroup 9 (Quality) proposed exempting small physician offices and clinics
from CLIA regulation if no significant quality problems are discovered during
the first two years of laboratory inspections under CLIA. A wholesale
exemption of specific types of laboratories is unwarranted and could return us
to the conditions that led to the passage of CLIA in the first place.
Physicians and small clinics are able to purchase sophisticated laboratory
equipment that can perform multiple tests at the push of a button. Without
regulation of these sites to assure that appropriate quality controls and routine
maintenance are conducted, there is no way to assure that accurate laboratory
test results are achieved. In addition, small physician offices and clinics are
common in rural America. Exemption of these sites could give the perception
that a separate standard of quality is acceptable in rural areas.
30
�The rural cross-cutting work group recommends a reexamination of the CLIA
regulations to assess the effects on access to laboratory testing in rural areas.
As an alternative to wholesale exemption of small testing sites, the work group
suggests an exceptions process be developed to exempt practitioners from
CLIA requirements for tests that are necessary for immediate diagnosis or
treatment when there is no alternative testing site available that can produce
results within 12 hours. The goal of this exceptions process would be to assure
access to essential laboratory testing when no reasonable alternatives exist.
31
�HI. RECOMMENDATIONS AND RATIONALE
Note: The features of health care reform which benefit rural areas are outlined below.
These features are based on the recommendations of multiple workgroups. The
detailed recommendations of the rural cross-cutting workgroup are in the
appendix.
A.
SECURE COVERAGE FOR RURAL AMERICA
RECOMMENDATION
Provide rural Americans a more secure health care system by expanding
affordable coverage, improving health care services, and providing
incentives to increase the number of rural health care practitioners.
Give small rural and individual business owners and employees the cost
advantages of being part of a large insurance purchasing group.
•
Provide a comprehensive benefit package that covers primary and
routine care as well as specialty and acute care services.
•
Reform insurance to eliminate policy denials and cancellations based on
risk status or pre-existing conditions.
•
Provide rural communities and their residents with increased preventive
and community-based public health services.
RATIONALE
The economics and demographics of rural health care result in a larger number
of uninsured and under-insured citizens.
32
�The primary base of rural employment is small businesses or individually
operated enterprises with substantially higher insurance costs for fewer services
and larger deductibles and co-payments.
Because the insurance market operates onrisk-selection,the age, disability
rates and pre-existing conditions of rural Americans frequently mean that they
cannot purchase insurance at all or only at prohibitive cost.
The cost of primary and routine care is rarely paid by current insurance
practices, so low income rural residents often forgo need preventive and
primary care services until they are truly sick and must seek more costly
specialty and acute care.
B.
CREATE HEALTH ALLIANCES TO GIVE RURAL CONSUMERS THE
ADVANTAGE OF LARGE GROUP INSURANCE AND PROVIDE BETTER
HEALTH CARE CHOICES
RECOMMENDATION
Rural Americans achieve the advantages of large group insurance through the
health alliance as it works to ensure that every rural resident has access to
quality, affordable health insurance even if they work for a small business,
farm or are in business for themselves.
Use the health alliance's flexible powers to require plans to serve rural
areas through:
(1) expansion of urban-based plans,
(2) franchising,
(3) direct fee-for-service provider contracting, and
(4) development of alliance-sponsored plans or other means.
Offer long term contracts for plans serving rural areas.
33
�•
Foster cooperative relationships between rural providers and their urban
counterparts.
Establish reimbursement policies which increase payment to primary
care practitioners serving in rural areas.
•
Provide capacity-building support for essential community providers.
•
Allow rural-based providers to contract with more than one health plan.
RATIONALE
Most rural Americans purchase coverage as individuals or through small businesses,
and negotiate their premium costs without expertise or the purchasing leverage of large
numbers. Rural Americans lack the safety of a large group which provides more
stable insurance premiums year to year.
Delivery systems will vary with the diversity of rural areas. In many, a fee for service
plan may be the only choice. In others, there will be multiple health plans offered
which contract with local providers for primary and routine health care. The alliance's
responsibility is to ensure good coverage is available in all areas.
Long term contracts with urban-based health plans ensure that plans will not exit
precipitously and destabilize rural areas.
C. ENCOURAGING RURAL COMMUNITY-BASED HEALTH PLANS
RECOMMENDATION
•
Use Health Alliance powers to promote integration of services through
(1) reimbursement incentives,
34
�(2) urban-based plan contracting requirements, and
(3) administrative simplification.
Provide technical assistance and capacity building for network/plan
development.
Relieve anti-trust and other legal barriers to network/plan development.
Develop special solvency requirements for integrated rural networks or
plans.
•
Provide incentives for providers to practice in cooperative or
collaborative relationships.
•
Simplify administrative procedural requirements for integrated rural
networks/plans.
RATIONALE
Rural community-based networks/plans give providers the option of local control keep
and medical care dollars local, thereby creating a more stable financial base.
Because they are an integral part of the area which supports them, communitybased plans are likely to provide greater long term stability.
35
�D.
CREATION OF MORE ATTRACTIVE PRACTICE SETTINGS FOR RURAL
PROVIDERS.
RECOMMENDATION
•
Provide better provider reimbursement through:
(1) the elimination of uncompensated care,
(2) timely payment and
(3) reimbursement strategies that encourage practice in rural
areas.
•
Improve the provider practice environment through
(1) simplification of administrative and financial requirements
(2) development of less intrusive, internalized utilization
management methods
(3) support for respite, and relief services.
Develop telecommunications capacity to link rural providers with
medical education sites and institutions for continuing education,
consultations and practice support purposes.
Provide technical assistance in the formation of rural community-based
health plans and incentives to link local providers with other integrated
health care systems.
Link rural providers with regional emergency service support.
36
�RATIONALE
Improving financial stability and decreasing isolation is central to increasing the
capacity of rural health care delivery systems.
Provider turnover in rural areas is a major problem which can only be
addressed by making the practice environment more hospitable.
E.
TRAINING AND RECRUITMENT OF RURAL HEALTH CARE PROVIDERS
RECOMMENDATION
•
Develop loan forgiveness programs for health care practitioners
choosing to practice in rural areas.
•
Expand the National Health Service Corps.
•
Develop and provide medical education funding to support rural medical
students and residency training sites.
•
Maintain linkages between rural physicians and regional medical
schools.
RATIONALE
Financial incentives and rural training experiences are important tools for recruiting
providers to rural areas.
F. NATIONAL HEALTH PROFESSIONS WORKFORCE PLAN
RECOMMENDATION
•
Develop a national health professions workforce plan based on an
assessment of needs for all types of health care practitioners for both
primary care and specialties (and including dental and mental health
professionals).
37
�Specify within the plan goals for numbers, classes, ethnic and racial
diversity and geographic distribution required to fill national needs.
Re-examine the criteria and process for the designations of health
professional shortage areas and revise as appropriate.
Tie federal funding for health professional education and training to
national and state workforce goals achievement.
RATIONALE
Federal funding for health care professional education and training has lacked
coordination and direction. Rural workforce development, in particular, has
been neglected. Moreover, current funding policies have contributed to both an
undersupply of primary care physicians and an oversupply of specialists. By
including geographic distribution in the goals, rural workforce concerns are
more likely to be addressed.
G.
RURAL PUBLIC HEALTH SYSTEMS
RECOMMENDATION
•
Invest in rural health clinics, community and migrant health centers
•
Invest in rural school-based clinics.
•
Invest in public health and prevention initiatives in rural areas.
RATIONALE
In many areas, public health facilities are the major health care delivery site.
38
�H.
EMERGENCY MEDICAL TRANSPORTATION
RECOMMENDATION
Provide grants to states to ensure that quick response emergency medical
systems are available in each region.
RATIONALE
Rural areas require dependable emergency medical systems for transportation
between remote areas and specialized trauma facilities.
39
�IV. QUESTIONS AND ANSWERS
1.
How are you going to make health care reform work in rural America?
Rural areas are hardest hit by the health care crisis. Rural Americans have insecure
insurance coverage and pay high medical care charges.
The reform provides secure coverage for rural Americans to a good benefit package.
Through the health alliance, it gives rural Americans the advantages of being part of a
large group in purchasing insurance coverage. Most rural Americans now have to
purchase their coverage as individuals or as part of a small business. As a part of the
Alliance, rural Americans will have the advantage of real purchasing power, expert
negotiators working on their behalf, and the safety of being part of a large group.
The reform also makes rural areas a more attractive place for doctors and
nurses to practice by improving the economic stability of their practice and
decreasing the isolation.
2.
How will health care reform change the urban bias in our current health care
system?
The development of the reform involved rural Americans and rural health care experts.
These people raised the problems with the current systems which disadvantage rural
areas: bias in payments; insufficient support of infrastructure development; regulatory
requirements developed for urban systems; and a critical shortage of practitioners and
facilities.
By providing secure coverage and the advantages of large group purchase, the reform
makes our health care system more secure and workable in rural areas. The urban
drain on our health care system will be changed.
3.
How will health reform work in a rural area where there are not enough
providers to compete against each other?
The Clinton reform provides secure coverage to all Americans regardless of where
they live. In some rural areas, providers will cooperate by forming networks and
health plans together rather than competing to provide coverage. We call this managed
cooperation.
We are also working hard to make rural areas a more attractive place to practice by
improving providers' economic stability and removing some of the isolation.
40
�4.
How will the plan help rural areas?
The biggest help for rural areas is the reform's provision of secure coverage for all
Americans. That means that all rural Americans — regardless of where they work or
live — can get secure coverage to a good benefit package. Rural Americans who
have insurance typically have policies which cover less and cost them more out-ofpocket.
This security for rural families provides security for rural providers. No longer will
they have to provide even more uncompensated care than urban providers. They will
get paid and paid on time.
The plan also provides incentives for doctors to go to rural areas and provides support
and linkages to relieve the isolation of practice.
5.
If Medicare and large businesses are excluded from health alliances, will the
health alliance control enough market share in rural areas to negotiate with
providers and develop health care plans?
States will have the option of including Medicare and large businesses in the alliance.
Rural states may want to do this to have enough purchasing clout. Even without these
groups, however, the alliance will have much greater clout than currently exists. Now
most rural Americans have to purchase coverage on their own without the help of a
large group. The alliance will provide purchasing leverage, expert know-how, and the
safety jthat comes from large numbers.
6.
If rural communities have only a fee-for-service (FFS) option available, will they
have to pay the same high deductibles and copayments (25 percent) that
accompany FFS plans?
Rural Americans, like all Americans, will have the option of a fee-for-service plan.
Because these plans are typically more expensive, some rural Americans may prefer a
health plan. Local community-based health plans or urban-based health plans will be
available from the start in many rural areas and will expand rapidly. In Minnesota
where this approach is underway, rural health plans have started rapidly.
The health alliance also has the option of operating its own health plan or preferred
provider organization (PPO) in conjunction with the state to offer more affordable
coverage.
41
�7.
Will stateflexibilitybe deflned broadly enough to permit states to develop two or
more health alliances that operate under different payment systems? Could a
state have both a public system (single payer) and a private market system?
A state can have more than one alliance. A single alliance can also use different
approaches in different areas. The state and the alliance must assure equal access to
care for all residents regardless of approach.
8.
Won't rural-only alliances be the same as "redlining?" What protections will
rural residents have that they are not in a second class system?
The state and the alliance must ensure that all residents, regardless of where they live,
have access to good quality health care. Some states may find that rural health
alliance are more effective because they can respond better to community needs. The
state will decide whether it will group urban and rural areas together in an alliance or
keep them separate. In either case, the state has to ensure good coverage in all areas.
The alliance and the state will collect and report performance measures which will be
monitored to ensure the system is working.
9.
What does the plan do to promote effective networks of care in rural America?
Development of health care networks in rural America will be an important part of
this plan. Networks will provide many benefits to rural communities, including:
increased stability for health care providers; improved professional relationships among
providers; the opportunity for rural practitioners to help train new practitioners;
improved quality; greater access; and more cost-effective care.
The plan facilitates rural network development in a variety of ways. Health alliances
will have a number of tools available to develop health plans in rural areas, including:
1) negotiating the service area of health plans to include rural areas; 2) operating or
contracting with others to operate a non-fee-for-service plan.
States will have funding available to develop their state plans and assure all residents
have access to health care. Part of this funding could be used to support rural network
development.
Relief from state and federal anti-trust laws will be available. Three federal grant
programs will support rural network development. The Community Plan Development
Grant program will help rural communities start their own health plans. The Rural
Practice Development Grant program will help practitioners establish their practices in
rural areas. Finally, the Rural Training Site Development Grant program will help
rural practitioners expand their practices so they can be used as sites to train new
42
�practitioners. This will help link rural practices with educational programs.
10.
Anti-trust and other state anticompetitive laws seem to be hampering rural
network development. What does the plan intend to do to alleviate this problem?
We recognize that federal anti-trust laws have had a chilling effect on network
development in rural areas. The federal govemment will develop model legislation,
which can be adopted by the states, to protect developing networks from federal antitrust laws.
The model legislation would specify the situations under which networks could
develop and the criteria by which the networks would be reviewed. The goal would
be to balance' the potential benefits of the network —lower costs, greater access,
improved quality — against the loss of competition. Networks would apply to their
state for protection from federal anti-trust laws.
In addition, the Department of Health and Human Services has developed safe harbor
regulations that clarify the situations under which rural providers can safely finance
other health care entities. For example, they describe the conditions under which a
hospital can safely purchase a physician practice. We expect these proposed
regulations to be published shortly.
Finally, the govemment will preempt state laws that inhibit network development by
limiting the employment of physicians and other practitioners by general business or
non-profit corporations.
11.
Because the focus of national health care reform is on preventive and primary
care, rural communities are worried that their primary care providers will be
recruited to urban areas resulting in a reduced professional pool for rural areas.
How will the plan improve and not worsen the supply of rural providers?
Throughout the development of the national health reform plan, numerous groups
addressed the issue of the health care workforce in a reformed system. One work
group focused solely on this issue. The rural cross-cutting work group and others
spent a great deal of time developing recommendations for improving — not
worsening — the training and distribution of primary care providers.
In order to guarantee that federal mandates for universal access are met, state and
federal governments will have to assure that there is an appropriate distribution of
primary care providers to rural communities. Some of the methods being considered
43
�are: changes in the financing of health professionals' education and training; expansion
of the National Health Service Corps and Community and Migrant Health Centers;
financial incentives for rural primary care practices; support for training programs in
rural settings; and market-based incentives related to network and plan development.
During the first two years of the new health care system, the federal govemment will
develop a national health professions workforce plan that will specify goals for the
numbers, mix, ethnic and racial distribution, and geographic distribution of all health
care practitioners. The plan will be used to direct federal funding of health
professions education toward accomplishing these goals.
12.
Who is going to participate on the boards of the health alliances? How will rural
health interests be represented and assured?
Health alliances will represent the interests of their members in the purchasing and
delivery of health care services. The boards of the alliances will be representative of
their membership including rural representation.
13.
How will consumer involvement be assured by the federal government?
States will be required to involve consumers and communities in the planning process
for the state plan. When states submit their plans, they must demonstrate the amount
and type of consumer and community involvement.
Membership on the health alliance boards will be restricted to consumers. This will
assure that consumers have a strong voice in the health care system.
14.
How will short-term cost containment provisions affect rural areas?
A variety of short-term cost controls have been proposed. Whatever the controls
ultimately adopted by the Congress, they are likely to affect provider incomes. And
therein lies an opportunity for rural communities.
Interim cost containment strategies provide a chance for early adoption of policies that
pay rural practitioners more than their urban counterparts. Although states should be
able to exercise a great deal of flexibility in implementing health care reform, our
policies will promote short-term controls designed to benefit primary care and rural
practitioners. Such policies are consistent with our overall goal to promote primary
care practice and reduce shortages in rural areas.
44
�V. INTEREST GROUP CONSIDERATIONS
A.
Rural Advocates
Rural advocates are concerned that the rural 25 percent of the U.S. population not be
considered a " special population." They also recognize that a model developed for
urban America is unlikely to fit rural America. Consequently, it is of vital importance
for the new health care system to be sensitive to rural needs without isolating rural
populations.
Rural residents want a say in development of health care systems that meet local
needs. State flexibility is generally favored among rural advocates, because it is
perceived that state governments will be more responsive to rural needs. On the other
hand, rural advocates recognize that federal guidelines will be necessary to endure that
certain standards are met regarding access, quality, and cost. However, there is
considerable skepticism about the federal government's ability to mandate a system
that works in rural areas.
A major issue for rural Americans is whether there will be adequate numbers of
providers in rural areas to deliver the health care services promised under health care
reform.. Rural residents are concerned about both numbers of practitioners and the
availability of hospitals or alternative facilities for inpatient and emergency health care
services.
B.
Economic Development
Rural economic development could live or die based on the outcome of health care
reform and the costs of providing health insurance to rural residents. If rural
residents end up paying higher health insurance premiums, businesses, which would
pay a portion of those premiums, will be less likely to locate in rural communities.
The benchmark premium could be a defining factor in determining where business
locate.
Alternatively, budget controls to keep health care costs down could drive providers out
of rural areas. Budgets based on historic costs that do not reflect the higher costs that
must be paid to get practitioners into rural communities will be insufficient to develop
an adequate workforce in rural areas. In addition, rural hospitals must receive
adequate payments if they are to stay open. Rural health care providers especially
hospitals are major employers in rural communities and are vital for rural economies.
45
�C.
Health Professional Groups
In general, most health professional groups are supportive of the health care reform
expected under the President's proposal. However, each group has concerns about
various aspects of the reform, primarily dealing with the scope of practice for midlevel practitioners (physician assistants, nurse practitioners, nurse-midwives).
The American Academy of Family Physicians supports the increased use of midlevels, but has serious concerns about expanding the independent practice of midlevels. They believe there needs to be adequate supervision of mid-levels by
physicians.
Nurses' groups want barriers lifted that prevent them from practicing to the full extent
of their training. These barriers include, "nursing practice act restrictions, overregulation of non-physician providers, unnecessary limitations on prescriptive
authority, and lack of third party reimbursement by public and private payers." (see
paper from the ANA in appendix)
Mid-level practitioners are supportive of rural primary care training sites as a means
to develop practitioners for rural areas.
Direct-entry midwives are those who trained exclusively in maternal-child health
without studying nursing. This group desires to be defined as primary care providers
within the national health care plan.
Physician groups appear to recognize the need to train more primary care physicians.
However, it will take shifts in the financial incentives associated with federal training
dollars to realize this goal.
46
�INTEREST GROUP CONSIDERATIONS
A single rural message was communicated throughout the process of developing
national health reform; the historical second class treatment of rural healthcare has to change
with national reform. National reform must be truly national! Rural citizens must have
the same ability to take advantage of the benefits of health reform as urban residents. Rural
communities are wary about reform and will scrutinize all reform efforts very carefully to
assure that rural needs will be met.
Work group members attended many meetings with rural providers (physicians,
nurses, PA's) rural hospital administrators, rural mental health centers, community and
migrant health centers, legal services advocates, and public health providers) They all
presented data on how their ability to provide health care is impeded by the current system
because so many rural people are uninsured and underinsured — lacking the means to access
the health care system.
In particular, representatives of mid-level practitioners were supportive of rural
primary care training sites as a means to develop practitioners for rural areas. The nurses'
group was concerned about scope of practice laws and regulations (see paper in appendix).
Medical education, with its overemphasis on hospital-based specialty care, has trained
the wrong kinds of providers for rural practice. Primary care physicians, advanced trained
nurses, and physician assistants, despite their willingness to work in rural areas, have been
underpaid by a system that inequitably rewards specialty and high tech health care.
Medicare hospital fee schedules based on DRGs severely hurt rural hospitals.
Hundreds of rural hospitals were forced to close. Many others continue to suffer from
serious financial problems. Although some of these hospitals may have needed to close or
change their service mix, it was punitive action that closed them, not a rational planning
process based on the best health care system for rural communities. Congressional action
has changed the payment methodology, but it will still be another year until the urban and
rural payment rates are more equitable.
RURAL STRATEGY FOR PASSAGE OF THE LEGISLATION
If the concerns of rural advocates are met in the drafting of the legislation, rural
communities can play an important role in facilitating the passage of the legislation.
Numerous senators and representatives of both parties have been strong advocates for rural
health. If this bill guarantees improvements of the rural health care system, rural
communities will organize to pressure their senators to support passage of the national health
reform act.
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
�TA B 1
Health Care Reform Action Plan
for Rurual America
�HEALTH CARE REFORM ACTION PLAN
FOR RURAL AMERICA
Recommendations of the
RURAL CROSS-CUTTING WORK GROUP
MAY 7, 1993
�FOR OFFICIAL USE ONLY
Page 40
HEALTH CARE REFORM ACTION PLAN
FOR RURAL AMERICA
One quarter of the U.S. population lives in rural areas. These areas differ from each
other in many ways. Some rural areas are more densely populated and are located adjacent
to urbanized areas. Others are frontier areas with a sparse population spread over large
geographic areas. Although this paper refers to rural America as a general term, there is an
underlying recognition that frontier areas will need special consideration to facilitate the
successful implementation of national health reform.
The challenge of implementing health reform in rural America is to create a system
that meets the unique needs and circumstances of all rural communities no matter where they
fall on the continuum of population density. For health care reform to succeed, it must
provide acceptable and appropriate strategies for health care delivery and financing in rural
areas.
The President's plan offers much promise for improving the health of rural
Americans. First and foremost, this plan promises to remove many of the barriers to health
care posed by a lack of health insurance coverage. Rural residents experience higher
uninsurance and poverty rates than their urban counterparts. The President's plan would
provide these residents with universal coverage, a provision that would benefit both
consumers and the health care providers who serve them.
In rural communities, resolving financial access issues addresses only half of the
problem. Universal coverage alone will not address many of the non-financial barriers that
severely limit access to health care in rural areas. The most severe of these barriers include
inadequate numbers of providers, lack of primary and preventive health services and
fragmentation of those services that do exist in much of rural America. Building stable
systems of health care in these areas is a key to overcoming these barriers.
This paper suggests several actions, which if included, would strengthen the
President's plan in meeting the needs of rural communities. The budget specifications in this
paper provide a more detailed description of the budget figures prepared by Work Group 22.
HEALTH ALLIANCES
Underservice in rural areas is in large part due to the declining economic vitality of
increasingly smaller rural communities. The fragile financial stability of the health care
marketplace in most rural communities is the result of a reduced employment base, primarily
dependent on small and individual business ownership; more people insured by Medicare and
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Medicaid; and higher rates of non-insurable individuals with chronic illness and disability due
to their employment in high risk industries such as mining, logging, and farming. Large
employers in these communities are often govemment organizations (e.g., local school
district, county hospitals, state or federal correctional institutions) or a single fabricating
plant located to take advantage of the low wage employment available. If these employers
go out of business or relocate, the local marketplace for health care in rural communities is
often devastated.
Although national reform resolves the problem of insurance for many rural residents,
it does not directly address many of the underlying economic deficiencies of rural areas that
limit access to health services in rural communities. Therefore, health alliances must have
sufficient flexibility and powers to ensure that rural communities have an equal opportunity
to participate in health care reform and benefit from its goal of providing comprehensive
health care services to all citizens. In some rural areas, where the market does not respond
adequately, the health alliances may need to take specific actions to assure that rural residents
have access to health care services. If necessary, health alliances may have to develop their
own health plans to provide rural access.
The question of who is included and who is excluded from the health alliance is of
vital importance to rural communities and predominantly rural states. Health alliances need
to be sufficiently large, in terms of membership, to provide strong purchasing power for
negotiation with plans and providers. This is particularly true if rural residents are going to
have significant choices among competing plans. Large size is also necessary for equitable
risk pooling and community rating.
The effectiveness of health alliances in negotiating with providers also will depend on
the share of the market they control. This is especially relevant in communities with only a
few providers who are able to maintain their income simply by treating Medicare patients
and employees of a large plant that is excluded from the health alliance.
Size and Market Share
Action: Health alliances should have large numbers of enrollees to support adequate
purchasing power, risk pooling, and community rating. Federal guidelines should be
developed to help states assess the effective population for health alliances.
Rationale: Large populations are necessary for adequate purchasing power and equitable risk
pooling. It has been suggested that health alliances have a population of greater than one
million. For rural populations, the community rating area should be as large as possible.
Large health alliances will be better for redistributing risk and negotiating with the health
plans. Alternatively, small health alliances could result in certain populations being
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segregated based on income or geography, and have little power to negotiate with health
plans.
Measurement of the size of the health alliance should be based on enrollment, rather
than total population, because it best assures the size and strength of the health alliance. For
example, if Medicare beneficiaries and employees of large businesses are not part of the
health alliance, their absence could reduce the number of individuals in theriskpool
significantly. Consequently, the health alliance would control a much smaller share of the
health care market and would have limited effectiveness in negotiating with health plans and
providers and developing health care delivery systems. This is especially of concern to rural
areas that need a large health alliance to leverage purchasing power in order to effectively
negotiate affordable premium prices for health coverage.
Federal guidelines should be made available to assist states with assessing the
effective population base for the health alliance and community rating area. These guidelines
would also assist in assessing the market share of the health alliance that is adequate to
effectively control the market and develop delivery systems.
States may be tempted to develop rural-only health alliances. However, such
alliances may unintentionally disadvantage rural residents. Rural-only alliances are likely to
have fewer resources, and be more dependent on federal subsidies due to higher proportions
of poor, unemployed, and elderly residents. Moreover, such alliances will have more
difficulty garnering market share and distributing risk than would occur in mixed urban and
rural health alliances. Although states should have the flexibility to configure alliances in a
manner that best meets their needs, it may be desirable for federal guidelines to recommend
against rural-only alliances.
Action: All govemment employees should be included in the health alliance.
Rationale: Work Group 16 has recommended options for the Federal Employees Health Plan
that could exclude federal employees from the health alliance. For rural communities,
government employees are often the largest employers. Because federal govemment actions
set standards for state governments, exempting federal employees from the health alliance
could encourage state governments, as large employers, to follow suit. Aside from the
negative public perception of a health care system that mandates private employer
participation while exempting govemment employees, the exclusion of govemment
employees could significandy reduce a health alliance's market share in rural areas and, thus,
their capacity to negotiate effectively with health plans or local providers.
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Action: States should have the option to require that all employers in the state, including the
establishments of large national firms, participate in the health alliance.
Action: States should be able to seek waiver authority from the federal government to enroll
Medicare beneficiaries (and the payment for their care) in the health alliance.
Rationale: In many rural communities, where the employment base is likely to be made up
primarily of small employers and the self-insured, there may be a single large enterprise,
such as a processing plant or a mine, that comprises a large share of the workforce,
Excluding them could limit the bargaining power of the health alliance and impede the
development of managed care networks in these rural communities.
In addition, rural communities sometimes have larger elderly populations that
dominate the health care marketplace. Though the population may be less than a majority,
health care purchasing by this population may be as much as 60 percent of hospital and 50
percent of physician revenues.
Following the logic related to health alliance size, states should be able to assure a
sufficient health alliance population to negotiate equitable service and service networks in its
rural areas. Including all employers operating within the state or those individuals on
Medicare may often be key to achieving this sufficiency.
Action: States will be able to seek waivers from structural requirements (including Medicare)
that decrease the capacity of the health alliance to serve rural residents or discourage
competing health plans. The process will be administratively simple and have built-in federal
response requirements, including the following:
o
Coordinated federal agency waiver and plan approval responsibilities so states have
access to a single request process.
o
Stricter rules on the amount of time the federal govemment can take to act on state
waiver requests.
o
Rules governing Medicare waivers that allow states to demonstrate budget neutrality
periodically rather than year by year.
o
Federal waiver reviews on a periodic basis with mandatory continuation approval if,
and for so long as, the project meets minimum federal requirements.
o
Medicare waiver authority for states that intend to establish uniform rates among all
payers.
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Rationale: Flexibility is an important principle if states are to succeed in implementing
health care reform. This includes the capacity to use a wide range of innovative strategies to
meet the diverse local needs and circumstances of the nation's rural areas.
In the past, the processes for applying and granting federal waivers have been
cumbersome andtime-consuming,often creating insurmountable barriers to state innovation.
If states are to have the responsibility for achieving the cost containment and access goals of
national reform, the system must have procedures that provide states with the tools necessary
to achieve these goals.
Benchmark Premium
The benchmark premium determines the employer and employee payment shares, the
low income subsidy, and any tax limitations that may be recommended for national reform.
The selection of the benchmark premium could have a significant effect on rural residents.
Work Group 1 is currently recommending that a benchmark premium be set for each county
within a state. It also recommends that the benchmark level be set at the lowest premium of
any plan that can enroll all area residents who want to join. These recommendations were
made to assure that those with low incomes would have geographic access to an affordable
set of comprehensive health care services.
It is important to consider the impact of benchmark premium options on rural
residents and their communities. Plans may be unwilling to serve the smaller populations of
geographically isolated communities. Managed competition may result in fewer, more
expensive choices for these areas than at present, and fewer than found in urban areas.
Using the county to define the benchmark premium area could create wide differences
in the benchmark premiums across county boundaries. This could affect the decisions
companies make on where to locate new plants. Individuals, as well, may gravitate toward
areas with more reasonable health care costs. The result might be a diminished economic
future for already fragile rural economies.
In addition, some counties are very large, with both urban and rural areas. A
benchmark premium based on a plan that serves the entire county could have a fairly high
premium, even though lower cost plans are readily available in the urban parts of the county.
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Action: The benchmark premium area should be defined by rational service areas to ensure
that low-income residents of the area have access to an affordable, available health plan.
Rationale: It is essential that low-income residents of rural areas have an affordable health
plan that they can easily access. For purposes of the low-income subsidy, it makes sense to
use a small area to define the benchmark premium. This way, the subsidies will reflect
premiums that are affordable and available to low-income individuals. Otherwise, the
universal access goal of national reform may not be achieved.
Action: When more than one plan serves a rural area, the benchmark premium should be set
to allow choice between the two lowest cost plans.
Rationale: The benchmark premium should not be set by the lowest priced premium in the
area if there is a choice of plans in the area. Individuals receiving low-income subsidies
should have a choice of plans, rather than all being directed to the lowest cost plan. At a
minimum, the benchmark premium should be at or above the premiums of at least two plans
in areas where more than one plan is available. Fee-for-service plans should be excluded
from the benchmark calculation in areas with at least one managed care plan because of the
poorer cost containment practices and higher premium costs of indemnity plans.
Risk Adjustors
In the background papers for Cluster I , it is suggested that locational adjustments
might be used to adjust community rated premiums for plans that enroll higher percentages
of individuals from certain areas. The locational adjustments would serve as proxy measures
for plans enrolling a greater proportion of individuals with higher health care costs who may
be sicker or have higher medically related needs related to poverty.
The details of the risk adjustment process have not been outlined in any of the papers
to date. Moreover, it is unclear how the risk adjustment process would account for plans
that enroll a high proportions of individuals in high risk occupations, such as mining or
agriculture. At this point in time, we do not have sufficient information upon which to base
an equitable risk adjustment or risk adjustment process. However, we can make
recommendations regarding some of the parameters that should be considered in the risk
adjustment process.
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Action: We suppon the recommendation of Work Group 22 that the risk adjustment system
be designed to ensure that there is nofinancialdisincentive for plans to offer service in low
income or underserved areas. The use of an income-based adjustor as a proxy for the
potential higher costs associated with providing service in traditionally underserved areas
should be evaluated and reviewed annually, at least until low income people have been fully
integrated into the health plans.
Rationale: The literature appears to document that low income populations have inherendy
greater need for health care services and thus, higher costs. At a minimum, during the
period of transition, as uninsured and underinsured low income individuals are brought into
the system, an adjuster based on income should be reviewed and considered annually to make
sure that there is no financial disincentive for plans serving low income communities. When
low income individuals and families have been fully integrated into health plans, such an
adjustment may no longer be necessary.
Action: If the risk adjustment system includes locational adjusters, they should not be based
solely on historical costs.
Rationale: Rural residents in many communities are underserved and, therefore, often have
had significantly lower historic costs that do not reflect the true costs of providing adequate
access to health care in those communities. Health plans are likely to experience higher
developmental and other ongoing per capita costs as they expand services to these areas.
Thus, any locational risk adjustment should take into consideration the higher costs of
serving historically underserved rural communities.
BUILDING CAPACITY IN RURAL AMERICA
In general, rural communities have Umited capacity to financially develop health plans
and the provider networks necessary to support those plans. The federal and state
governments, and health alliances will have a variety of tools to ensure that such capacity is
developed.
First, health alliances will be required to ensure that all areas within the health
alliance area are served by plans. The federal government could jump-start the development
of networks in rural communities through direct technical assistance to those developing
networks. The health alliance could selectively contract with qualified health plans,
negotiating the service area to ensure that underserved areas receive service. It could also
provide technical assistance and other assistance to foster plan development in communities.
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To ensure that rural residents have a choice of plans in areas where organized plans
do not develop, the health alliance could operate or contract with others to operate a non-feefor-service plan. In the following section, several approaches are suggested for fostering
plan development in rural communities where it may not otherwise occur.
Moreover, rural providers generally have not developed the integrated networks of
care that will be the backbone of community-based health plans. Network development is
impeded by many factors including the instability of rural practices and rural hospitals,
inadequate billing and data systems, and concerns over anti-trust and other legal issues.
Rural communities will require technical and financial assistance to recruit practitioners and
develop efficient and stable health care networks. Two grant programs (described below)
will assist rural communities and practitioners with developing rural health plans and
establishing new rural practices.
Steps must be taken both to train practitioners for rural practice and make rural
practice more attractive. A third grant program (described on page 17 of the workforce
section) is designed to develop existing rural practice sites as training sites for health care
professionals. Rural training sites reduce the isolation felt by rural practitioners while
providing more appropriate experiences for rural practitioners than are found in urban
tertiary settings. At their best, rural training programs become an integral part of a
comprehensive strategy for building rural networks.
The following actions will help build the health care capacity necessary to assure
access to care in rural areas.
Access to Plans Throughout the Health Alliance Area
Action: At the point that it begins coverage of individuals, a health alliance should be
required to make their best efforts to ensure that residents of its area have the option to
enroll in at least one non-fee-for-service plan that provides accessible services within their
area. Wherever feasible and desirable, rural community-based plans should be encouraged.
Rationale; Health alliances will play a critical role in ensuring that the goal of universal
access to health care is achieved in underserved urban and rural communities. Network and
plan development is unlikely to spontaneously occur in some rural areas without technical
and financial assistance. This is especially true in sparsely populated rural areas where there
are few health care providers and no capacity for competing health plans. Even if assistance
is provided, network and plan development takes time. It is estimated that there will be
many areas in which fee-for-service (FFS) will be the only real system available to rural
residents. More specifically, given current HMO penetration in this country, perhaps as
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many as 70-90 percent of rural residents may only have FFS providers available to them
unless steps are taken to make it otherwise.
FFS plans tend to be more costly than non-FFS plans for the same set of benefits.
Moreover, the 25 percent cost sharing provision for fee-for-service plans, proposed as a
disincentive to select these plans, will further disadvantage many rural residents.
Thus, in many parts of rural America, rural consumers will continue to pay higher
premiums and be forced to bear higher co-pays because an alternative to fee-for-service is
not available to them. Rural residents should not be penalized by these higher costs when
they have no choice.
Health alliances should be provided the authority to require plans to expand their
service areas, to provide technical assistance, and if necessary, to contract for or sponsor
their own non-FFS plan (such as a preferred provider organization (PPO)) to ensure that all
communities in their area are served by at least one non-FFS plan. States could bear the risk
for non-FFS plan development under a state reinsurance pool.
Action: Health alliances responsible for rural areas should make adjustments in their
payments to plans serving rural areas for (1) incentives that encourage health professionals
to practice in rural communities and (2) "enabling services" such as transportation, child
care, outreach or social services case management.
Rationale: The capacity of health alliances to reverse historic patterns of underservice in
rural areas will require more than passive implementation of managed care or competitive
strategies. In addition to technical expertise, infrastructure building and negotiating leverage,
the development of plans in rural areas will require the expenditure of additional sums to
specifically address the causes of underservice, i.e., low provider reimbursement patterns and
low income geographic and other barriers to access. By placing these dollars within the plan
premium payments, they will be part of the competitive forces which will eventually come
into play to contain these additional costs.
Solvency Concerns
Action: States should ensure that development of community-based plans is not deterred by
fears of insolvency.
Rationale: Fear of insolvency is a major deterrent to the development of rural communitybased plans. On the other hand, smaller plans oftenfindit impossible to meet the solvency
standards required of larger plans. Cluster 1 has recommended that the solvency
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requirements be tailored to a plan's enrollment. As such, smaller plans would have lower
solvency requirements. For example, to facilitate development of community based plans in
smaller communities, background papers suggest that the smallest plans would need only a
net worth of $500,000 to meet solvency requirements. The Cluster I papers also recommend
that special trust funds be established to ensure that providers are paid and to assist
individuals in obtaining affordable coverage in the event that a plan goes out of business.
These are important steps in promoting community based plans.
States could create state-wide reinsurance pools that protect against catastrophic
expenses of individual enrolled members. Reinsurance could be provided for claims
exceeding a large deductible for any individual, with larger plans having larger deductibles
per individual. Small community-based plans are likely to be small and be at greater risk of
financial instability caused by unexpected large claims. While this could be a problem in
urban areas, it is far more likely to be a problem for rural community-based plans that
generally will be based on much smaller population and provider bases. A state-wide
reinsurance plan would help allay the fear of insolvency in smaller plans and assist in
overcoming disincentives by both larger and smaller plans to serve high risk individuals,
especially low income individuals.
Community Plan Development Grant Program
Action: The Department of Health and Human Services should provide technical assistance
and grant funding to consortia for the planning and development of community-based rural
health plans. The federal govemment would provide ongoing technical assistance on the
development of plans, including legal andfinancialmanagement advice. The grant program
would be an interim measure to provide immediate funding for front-end development of
networks and garnering expertise in network development, including legal and financial
expertise. Monies would also be used to develop the information systems necessary to
operate an information network in rural areas (including telecommunications).
Rationale: In the 1970s, many HMOs moved into rural communities to market their plans,
only to abandon these communities several years later. In the meantime, patients were
channeled away from local providers to the detriment of the communities' health care
systems.
Advocates of community-based plans argue that locally developed systems are more
likely to succeed in providing appropriate, cost-effective services to rural communities.
Development of these plans will require establishment of networks among providers in the
community and with providers outside the community. It is important for communities to
have the opportunity to develop their own plans to generate a sense of ownership and
participation among local residents and providers and to create plans that best meet
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community needs. However, communities often do not have the capital or technical
expertise to develop health plans.
Another important component of network development for rural communities is
linking providers in these communities to specialty back-up services in larger urban and rural
facilities. Electronic information systems will be critical to the efficient management of plans
in rural communities. Expanded telecommunications access can facilitate the development of
information networks. Funding under this program can be used to establish
telecommunications linkages, if such linkages are coordinated with other telecommunications
users in the community to avoid unnecessary duplication.
Consortia would be composed of three or more entities. The prime applicant would
be located in a rural area. Other members of the consortium could be based elsewhere, but
the locus of control should be in the rural community. This configuration would ensure that
the resulting grantee was responsible to the community. At the sametime,the community
could seek and utilize expertise of other consortia members that are not rural-based.
Applicants would be directed to work with their states in the development of their
applications.
The program would be modeled after the Rural Outreach grant program administered
by the Office of Rural Health Policy. This program uses rural-based consortia to promote
innovative health care delivery systems in rural areas.
Total funding for this program would be approximately $60 million, wherein $25
million would come from a redirection of the Rural Health Care Transition grant program.
The Office of Rural Health Policy would be directed to arrange and provide technical
assistance to the communities as they develop plans. The Office is well accepted as an
ombudsman in the Department for rural issues, and has had a long-standing focus on capacity
development in rural communities.
Rural Practice Development Grant Program
Action: The Department of Health and Human Services would fund a grant program to
health care practitioners, in conjunction with their health alliances, for the development of
rural health care practices. The funding could support initial start-up costs for the new
practice, including purchases of equipment, recruitment costs and initial salaries of
appropriate staff, telecommunications linkages, and other costs of establishing a rural
practice site. Eligible practitioners include physicians, nurse practitioners, physician
assistants, mental health professionals, dentists, etc. A service obligation would be
associated with this grant program.
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Rationale: In many rural areas, health care services do not exist because there are no
practitioners and no practice sites. To assure adequate access to health care in these areas, it
will be necessary to establish new or expand existing health care practices. Grant funding
would be available to health care practitioners, who would apply in conjunction with their
health alliance, to support development of rural practices.
Applicants would be required to coordinate with their health alliance and demonstrate
the need for the services to be provided at the new practice. Applicants also would have to
demonstrate that the new practice will participate in a health care network that has a contract
with, or is part of, the health alliance. Funding could be used to support initial start-up
costs, equipment purchases, recruitment costs, initial salaries, etc.
As a part of their practice development, applicants could request funds for
telecommunications linkages, but the request for any equipment or any information system
development should be coordinated with other telecommunications users in the community to
avoid unnecessary duplication of equipment.
Preference will be given to practices that provide a broad range of primary care
services, especially those that include mental health services. Research has demonstrated that
systems that integrate primary care and mental health services are more effective than a
system of referral to stand-alone mental health services.
Grants would be for one year. Total funding for the grant program would be $40
million.
LEGAL ISSUES
Alternatives to Federal Anti-trust Laws
Action: The Department of Health and Human Services, in conjunction with the Department
of Justice and the Federal Trade Commission, will develop model legislation that can be used
by the states to protect developing networksfromfederal anti-trust laws. States that adopt
laws meeting the specifications of the model legislation will receive federal assurance that
developing networks meeting state requirements will be protected from federal anti-trust laws.
The model legislation will specify the situations under which networks could develop and the
criteria by which they would be reviewed. A mechanism by which networks could apply to
the state for anti-trust law protection would be required.
Rationale: Federal anti-trust laws have had a chilling effect on the development of health
care networks. In rural areas, in particular, establishment of networks may preclude future
competition. Despite its anticompetitive nature, rural network development may promote
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more cost-effective and higher quality health care than would otherwise occur. Several states
(Maine and Minnesota) have already developed legislation to protect cooperative agreements
among health care providersfromfederal anti-trust laws. These states approve proposed
arrangements that might be considered violations of federal or state anti-trust laws if they are
found to be more likely to result in lower costs, provide greater access, or assure higher
quality to health care than would otherwise occur in the marketplace. Adverse impacts on
payers and other providers are considered in granting the protection. These state laws should
be considered in developing model legislation.
Technical Assistance on Anti-trust
Action: The Secretary of Health and Human Services should provide, in cooperation with the
Department of Justice and the Federal Trade Commission, technical assistance to health care
providers on anti-trust concerns that emerge during the development of health care plans.
Rationale: Development of health care plans in rural areas, where competition does not
occur, will require development of new relationships that may be viewed as anticompetitive.
Rural health care providers are nervous about establishing these relationships because they
fear legal action that istime-consumingand costly. Network development would be
facilitated if these providers could receive guidance before committing to these new ventures.
Safe Harbors for Rural Providers
Action: The Secretary should develop safe harbor regulations that clarify the situations
under which rural providers can safelyfinanceother health care entities.
Rationale: Rural areas may have limited capability to develop competitive health care
systems. In some rural areas, it is incumbent upon local providers to finance the
establishment of auxiliary health care services, such as laboratory and x-ray services. As
rural areas develop networks and managed care systems, rural hospitals and health care
practitioners may cultivate relationships that could be in conflict with the Department's fraud
and abuse regulations. Possible areas for safe harbor regulations include:
o
the situations under which rural hospitals can purchase physician practices;
o
the extent to which rural hospitals can offer special financial inducements to
recruit and retain health care practitioners;
o
when rural practitioners are permitted to have a financial interest in auxiliary
health care services, such as laboratory and imaging services; and
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the types of referral relationships that can be developed between rural primary
care practitioners and specialists.
Action: The Secretary should develop a process by which rural providers, health alliances,
and states can seek advice on proposedfinancialrelationships to assure that these
relationships will not be in conflict with fraud and abuse regulations.
Rationale: The use of capitated payment systems will eliminate some of the potential fraud
and abuse problems that are inherent in fee-for-service payment systems, such as problems
associated with referral relationships between general practitioners and specialists. However,
it is likely that fee-for-service arrangements will remain in many rural areas, at least initially.
Efforts to curb fraud and abuse in these areas will have to be carefully evaluated for their
effects on access and the development of new systems of care.
Federal Preemption of Corporate Practice of Medicine Restrictions
Action: We support the recommendation of workgroup IA that the federal govemment should
preempt state laws that restrict corporate practice of medicine.
Rationale: These restrictions inhibit network development by limiting the employment of
physicians and other providers by general business and/or nonprofit corporations. They also
may limit the ability of providers to form corporations as vehicles for providing services and
sharing risk in integrated care delivery arrangements. In rural areas with shortages of health
care providers, it may be particularly important to permit arrangements whereby hospitals
employ physicians or physicians have a financial interest in the hospital or other health care
facilities. These types of arrangements may be critical to developing and maintaining access
adequate health care services in rural communities.
WORKFORCE DEVELOPMENT AND MAINTENANCE
The new health care system will rely extensively on primary care practitioners to
provide basic health care services and to serve as gatekeepers to more specialized care. The
competition between urban and rural health plans for already scarce primary care
practitioners will only intensify. One possible outcome is that rural communities will have
increasing difficulty recruiting and retaining primary care practitioners. As recognized by
Work Group 12 (Workforce Development), it will be necessary, but not sufficient, to train
more primary care practitioners. It also will be necessary to train practitioners (primary care
and specialists) in rural practices and make rural settings more attractive to these
practitioners.
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Four recommendations from Work Group 12 offer the greatest potential help, if they
are coupled with the national workforce plan outlined below: 1) pooling all Federal health
professions training dollars, including GME dollars, into a workforce investment fund; 2)
utilizing the transferred GME funding for training in ambulatory settings; 3) achieving a
more equitable physician specialty distribution; and 4) increasing the number of physician
assistants and advanced practice nurses trained (using GME funding) and practicing within
their full scope. However, these recommendations must be part of a coordinated plan that
integrates the different types of providers and considers rural workforce development as it
relates to the reformed health care system, if the anticipated positive impact on rural areas is
to be realized.
In addition, adequate payment systems for rural practitioners are essential for
establishing and maintaining personnel in rural areas. Lower payments to rural practitioners,
based on historical charges, are a deterrent to establishing practices in rural communities.
Payments to rural practitioners should be adequate to attract and retain physicians in rural
areas.
Below are recommendations to accompany and support the recommendations of Work
Group 12. The recommendations are for immediate and long-term measures that, if adopted,
would help assure that rural communities have adequate numbers of practitioners.
Immediate Measures
Action: Medicare Graduate Medical Education (GME) funding should be restructured to
support training of residents in ambulatory care settings and rural areas, and to support
training of mid-level providers. Until a national workforce plan is developed, funding of
residency positions would be directed toward the goal of a 50-50 ratio between primary care
and specialty residents.
Rationale: Medicare funding contributes the largest portion of federal funding for physician
training ($5.2 billion in 1992). GME dollars carry inherent incentives to train specialists,
primarily because the money is only available for training provided in a hospital setting and
specialty care receives higher payments. Because much of a primary care residency program
takes place in ambulatory settings, where Medicare payment is not available, there is little
financial incentive to develop primary care residencies. Making Medicare GME payments
available for training in ambulatory and rural settings will be an incentive to develop primary
care residencies.
When teaching hospitals reduce the number of specialty residency positions, they are
unlikely to reduce the amount of services they provide. Rather, they will use clinical nurse
specialists (CNSs), physician assistants (PAs), nurse practitioners (NPs), and nurse-midwives
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in place of the residents. This will increase the demand for these mid-level practitioners. At
the same time, the new health care system will be looking to these same mid-level
practitioners to provide primary care services in rural and underserved areas. Therefore,
there will be an urgent need to train significandy more mid-level practitioners. Medicare
GME funding should be directed to support the training of mid-level practitioners.
The 50-50 ratio of generalists to specialists could be adopted as a goal for the short
term. It will taketimeto redirect residency training toward primary care and away from
specialty care. Adoption of this goal for the short term would provide a clear indication of
the direction desired for shifting the focus of residency training. However, long-term goals
should be established as part of the national health care personnel workforce plan described
below.
Action: Increase overall funding for the National Health Service Corps (NHSC) and other
federal health professional training programs, and expand the National Health Service Corps
Community Scholarship Program. Refund the NHSC Private Practice Option Loan Program.
Rationale; The NHSC provides scholarship or loan repayment to new physicians and midlevel practitioners who practice in underserved areas. The National Health Service Corps
Community Scholarship Program (CSP) is a scholarship program that provides scholarships
that are jointly funded by the federal govemment, the state govemment, and the student's
own community. CSP is based on the idea that students are more likely to stay and serve
underserved communities if they are chosen and financially supported by those communities.
Although CSP is only 3 years old and active in only 12 states, early results suggest that the
program holds much promise for recruiting health professionals to underserved rural
communities.
Through the mid-1980s, the NHSC Private Practice Option Loan Program provided
assistance to NHSC physicians and dentists to establish their practices, primarily for the
purchase of equipment. As funding for the NHSC declined overall, funding for this program
was discontinued. The rural cross-cutting work group believes that this is a useful program
for promoting rural practice, especially in frontier rural communities.
Overall, the NHSC has been effective in getting practitioners to serve in underserved
areas. However, it is too small in scope to eliminate current underserved areas.
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Action: Medicare payments to physicians and non-physician practitioners should be
restructured to provide incentives to practice in rural and underserved areas.
Rationale: One of the disincentives to practice in rural areas is that Medicare pays less to
rural practitioners. The difference in payments stems from the adjustment for the
Geographic Practice Cost Index. Although the difference in payments is supposedly quite
small, it creates a huge perception problem for practitioners that is a deterrent to rural
practice. If the difference from the health alliance is small, it would make more sense to
eliminate the health alliance adjustment entirely and pay rural and urban practitioners that
same amount for providing the same services.
Alternatively, one could argue that it costs more to recruit practitioners to rural areas,
so payments to rural practitioners should be based on the economic price of getting them to
practice in rural areas. This is particularly true in underserved areas. There are several
ways Medicare payments could be restructured to make practice in underserved areas more
attractive.
1.
Medicare mustraisepayments to physicians in shortage areas, beyond the current 10
percent bonus already added to reimbursement, relative to payments to physicians
practicing in urban and non-underserved areas. The current 10 percent bonus
payments, which are added to lower reimbursement levels, have proved inadequate to
attract physicians to rural underserved areas. Medicare payments must reflect true
practice costs in rural areas and the amount necessary to attract and retain physicians
in these underserved communities.
2.
All non-physician practitioners should be directly reimbursed for the services covered
under Medicare for which they are licensed and trained to provide under state practice
acts. Medicare payments to these non-physician practitioners should reflect the
amount necessary to attract and retain these providers in underserved communities.
Action: Establish a grant program for the development of rural practices as training sites for
health care practitioners, including sites for rural interdisciplinary training programs. The
grant program would also support the operations of the training programs. The grant
program would expire when other funding mechanisms for rural training programs are made
available, such as through the workforce investment fund proposed by Work Group 12.
Rationale: Using rural practice sites as training sites will have several benefits. Rural
primary care practitioners may be called upon to provide a wider range of services than their
urban counterparts. Specialists are further away and patients cannot be as quickly referred to
them from a rural practice. Practitioners trained in rural areas will be better prepared for the
unique aspects of rural practice and therefore, more likely to practice in a rural area.
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Linking rural practice sites to training institutions will stabilize the practice in that
community. The practitioners and their patients will benefit from the association with the
educational entity because of the improved access to consultations. The collegiality the
association provides would facilitate continuing education and reduce the isolation rural
practitioners often experience.
Grants would be available to local providers and teaching institutions, who would
apply together for the grant. The money would be used for development of existing rural
practice sites as training sites, including establishing telecommunications linkages between
the rural practice and the teaching institution, and paying for rural faculty salaries. The
grants would be available for training physicians, mid-level practitioners, mental health
professionals, dentists, allied health professionals, and others based on community need.
Development of sites and training programs for interdisciplinary training would be
encouraged. In rural health care, it is particularly Important for multiple levels of providers
to be able to work together to assure continuity of care. A total of $25 million per year
could be awarded.
Long-term solutions
Action: A national health professions workforce plan should be developed during the first
two years following enactment of health care reform. The plan should be based on an
assessment of the health care needs across the United States. It should integrate the needs
for all types of health care practitioners ~ including dental and mental health professionals for both primary care and specialties. The plan should specify goals for the numbers,
professional mix, ethnic and racial distribution, and geographic distribution of primary care
practitioners and specialists required to meet national health care needs.
Because health professional shortage area (HPSA) designations are likely to play a
critical role in the allocation of resources and the implementation of policy incentives, plan
development should include a reexamination of the designation criteria and the designation
process.
National and state goals for workforce development should be specified and include
priorities for federal funding. The national health professions workforce plan should be used
to coordinate and direct federal funding toward the achievement of national workforce goals.
The Departments of Labor, HHS, and Education should work cooperatively to meet the
national workforce goals.
Rationale: Without a national plan, federal funding for health care professionals has lacked
coordination and direction. Rural workforce development, in particular, has been neglected.
Moreover, current policies have contributed to both an undersupply of primary care
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physicians and an oversupply of specialists. Without a plan, we will be unable to see beyond
today's crisis to a better vision for tomorrow.
National and state goals for workforce development that include goals for the
geographic distribution of practitioners will be important for rural areas. The goals should
take into account the effect of health alliances and health plans on recruitment and retention
of practitioners to rural areas. The goals will be used to direct federal and state funding for
health professional training. By including geographic distribution in the goals, rural
workforce concerns are more likely to be addressed in federal funding policies.
Primary care HPSA designations are used to target federal funding and policy
incentives to underserved areas. However, there is debate over the adequacy of the
definition of HPSAs. The current definition is based solely on the number of primary care
physicians in an area, and does not include physician assistants, nurse practitioners, or nursemidwives. The current ratio of one physician per 3500 individuals is considered to be an
extreme measure of shortage. In addition, reduced federal support and varying state capacity
has resulted in long delays in the designation process. These issues should be considered in
reexamining the designation criteria and the designation process.
Development of the national workforce plan could be accomplished in a number of
ways. The Council on Graduate Medical Education and the Advisory Council on Nurses
Education could be combined into a single advisory board that would develop the plan and
consider other workforce issues. Alternatively, a sub-board of the National Health Board or
a federal agency could be charged with developing the plan.
Currently, federal funding for health professions education is spread across a variety
of different agencies. This decentralization makes it difficult to direct spending toward
meeting national workforce goals. Rural workforce development has often received short
shrift in this system. Directing federal funding toward the achievement of national goals that
include goals for geographic distribution will better ensure that rural communities have
access to providers.
Many of the recommendations from Work Group 12 could be adopted as measures to
achieve national goals. Examples include: expanding the National Health Service Corps;
redirecting Medicare dollars to foster training of primary care physicians; and increasing
support for training non-physician practitioners. In addition, Medicare GME dollars could be
used to train mid-level practitioners. Federal funding also should be used to support ruraloriented health professions training and rural training site development, including
telecommunications networks that link the rural sites with training institutions. Regardless of
the mechanisms used, federal funding should not be spent on training programs that do not
contribute to the achievement of national goals.
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EMS/TRAUMA DELIVERY SYSTEMS
Action: Under health care reform states will develop plans for regional EMS/Trauma care
systems and be accountable for their implementation. The States will submit their plans to
the Department of Health and Human Services (DHHS) where federal support for
EMS/Trauma care system care systems will be consolidated. The DHHS will approve states
plans and make funds available to states to support the infrastructure for emergency care.
Rationale: Since the end of the 1970s, the federal government has not played a major role in
the funding or development of emergency care systems. These responsibilities have been
relegated to the states. Only a few states have developed statewide or regional systems for
the delivery of EMS/Trauma care services. In rural areas, the organization and delivery of
emergency care is largely determined by local providers and their communities. Much of the
rural EMS system is dependent upon committed community volunteers who serve their
communities despite the difficulties inherent to a volunteer system. Too often, emergency
services are poorly coordinated among communities and providers are increasingly dependent
on scarce local resources for their survival. Federal EMS support for states and local
communities has declined and is fragmented across several different agencies. In general,
the states are not accountable for the limited federal dollars that are available.
Under health care reform, states would be responsible for strengthening existing
systems of emergency care in rural areas and developing new systems. Experience has
shown that organized regional networks of providers in rural areas can facilitate appropriate
access to emergency care within the limits imposed by distance and terrain. Regional
networks that make the most sense for rural areas will not always correspond with the
jurisdictions for health alliances and/or plans. Thus, the states must continue to exercise
their lead responsibilities for the organization and delivery of emergency care. They will
also need to work closely with each other when EMS systems cut across state boundaries.
The federal govemment would assist states by making resources available to support
the infrastructure for rural emergency care. This includes training programs for Emergency
Medical Technicians, Paramedics, Physicians, emergency nurses and other EMS personnel;
emergency transportation vehicles; emergency communications systems; etc. The
administrative responsibility and funds for federal support would be centralized in the
Department of Health and Human Services. A consolidation of existing programs could
make available approximately $25 to $50 million dollars for more coordinated effort in
emergency care.
Regional organizations designated by the states would be eligible for federal support.
These regional entities would be responsible for developing and implementing EMS systems
of care in their designated areas. States would assure that the regional organizations
represent both consumers and providers of emergency care. Regional EMS organizations
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would apply for federal support directly or through their states. In either case, the states
would be responsible for ensuring that applications for federal support are consistent with
state plans and the needs of rural communides. Federal support would include matching
grants, direct loans, insured loans, and other appropriate mechanisms to support these
organizations. States could apply for funds on their own if there is a statewide system of
emergency care.
This program would be compatible with the goals of health care reform and the need
to create better systems of care in rural communities. It would be superior to the haphazard
support of EMS that typifies current federal activities related to EMS/trauma care. It would
maintain the central role of states in developing the infrastructure for emergency care. It
would not supplant local support for emergency services or detract from the role of health
alliances and plans in making emergency care a standard, accessible benefit under health care
reform.
MENTAL HEALTH AND SUBSTANCE ABUSE
Rural residents experience the same rate of mental illness as urban residents. The
rate of substance abuse in rural areas is approaching that of urban areas. However, many
rural areas have severe shortages of mental health and substance abuse professionals and
therefore have limited access to these services. In addition, rural communities provide
unique challenges to maintaining patient confidentiality.
Providing mental health and substance abuse services to rural residents may be more
costiy than for urban residents. It may cost more to recruit and retain mental health
professionals in rural areas. Social services, vocational rehabilitation, and supportive
housing systems for the mentally ill and recovering substance abusers are often
underdeveloped or non-existent in rural communities. Additional support must be provided
to develop adequate mental health and substance abuse services in rural communities. Until
these services are developed, plans may need to account for the additional costs of
transportation to mental health professionals.
It is especially important in rural areas to integrate primary services with mental
health and substance abuse services. Integrated systems of care have been shown to be more
effective than systems of stand alone mental health services. Primary care practitioners are
the entry point for health care in most rural communities. They must be able to recognize
mental illness and substance abuse and make referrals for appropriate treatments. Prevention
programs for substance abuse also are important for rural residents.
The rural cross-cutting work group has integrated the development of adequate
mental health and substance abuse services with several other actions in this paper. Funding
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preference under the Rural Practice Development Grant program would be made to practice
that integrate mental health and primary care services. Actions for workforce development
incorporate education and training of mental health and substance abuse professionals. The
work group also supports inclusion of mental health and substance abuse benefits as an
integrated part of the benefits package.
GOVERNANCE
Rural representation on the National Board and Health Alliance Boards
Action: The National Health Board should include members with direct experience and
expertise in the unique aspects of health care access, delivery, andfinancingin rural areas.
The number of members with rural expertise should be two or more, up to 25 percent of the
total board membership.
Rationale: About one quarter of the U.S. population resides in rural areas. This population
experiences unique problems with health care access, delivery, and financing that will be
addressed by the National Health Board. However, without special designation, rural
populations are often unrepresented on national advisory boards. Therefore, it should be
specified that at least two members of the board have experience and expertise with issues of
vital concern to rural populations.
Action: The health alliance boards, which are composed of consumers, should include rural
residents in direct proportion to the percentage of the rural population within the health
alliance area.
Rationale: The health alliances have responsibility for assuring that everyone enrolled in the
health alliance has access to a health care plan. This responsibility includes development of
appropriate health care delivery systems, as necessary. Health alliance boards should reflect
the populations they serve. To assure that the health care plans and delivery systems are
responsive to rural needs, the board should include rural residents in direct proportion to the
rural population of the health alliance.
FUNDING FOR STATE INFRASTRUCTURE DEVELOPMENT AND ONGOING
STATE ACTIVITIES
There are a number of issues related to the development of state infrastructure that
will need to be addressed to assure the successful implementation of national health reform in
rural states. These issues build on the recommendations of Work Group 18, which relate to
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the implementation of the new system. This Work group has addressed a number of issues
related to state readiness for health reform and is recommending a direct appropriation to
each state to assist them in the expedited transition to national health reform without having
to go through a procurement procedure. Group 18 is recommending that all states receive a
base amount of funding with some adjustment factor for total population of the state.
Action: States will be required to assure that the needs of rural communities are specifically
addressed in the development of the state plan, infrastructure development, and ongoing state
activities to implement national health reform, including facilitating the development of health
care delivery systems in rural areas.
Rationale: While some states are ready and able to implement sophisticated health reform
systems, many are not. Under health care reform, states will be asked to perform a variety
of functions for which many have limited resources and technical expertise. These states will
require technical assistance and front-end dollars to allow them to develop the necessary
capacity to implement health care reform (e.g., information systems, plan evaluation
expertise). Work Group 18 has recommended a direct appropriation to each state for these
purposes. States also should be required to assure that rural concerns are specifically
addressed in their implementation of health care reform. This is especially critical if the
states are to provide ongoing assistance to rural communities and if they will be called upon
to make judgements about when and how exceptions should be made to accommodate the
needs of rural communities (e.g., exemptions from competition to allow franchises).
INTERIM COST CONTAINMENT
Several options have been proposed to place immediate controls on national health
care cost increases. They are:
A.
B.
C.
D.
E.
F.
price freeze on providers
surtax on increases in provider revenue
all payer rate setting
regulation of health insurance premiums
increased use of managed care
a cap on health insurance premiums (similar to D)
The rural cross-cutting group recognizes the importance of short-term cost
containment if national health care reform is to be successful over the long term.
Nevertheless, there is concern that the method chosen should not create additional
disincentives to rural practice. In anticipation of national health care reform, health care
insurers and other health care plans are beginning to develop new products that incorporate
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primary care. Interim cost containment initiatives should not exacerbate the aireadv
inequitable pavments to rural primary care practitioners. In fact, the need for short term cost
containment could be used as an opportunity to reduce the payment differentials between
urban and rural health care professionals.
The following actions oudine rural concerns with the interim cost containment options
and discuss modifications that must be made under each option to protect the already fragile
status of health care delivery in rural areas.
Action: Options D and F would have similar effects on rural areas. They are the preferred
interim cost containment options for rural areas. These options would regulate or cap health
insurance premiums by freezing or limiting premium growth to some percent of the Gross
Domestic Product (GDP). They also would prohibit benefit reductions, allow insurers to set
fees, and require assignment. Current policy holders would be protected by insurance
reforms such as guaranteed renewability and solvency adjustments. To ensure that payments
to rural providers are not diminished by this initiative, insurers should not be allowed to
reduce existing rural provider payment rates.
Rationale: Although health insurance premiums in rural areas are generally higher for the
same benefits than in urban areas, these options would at least limit the rates of increase for
rural policy holders. These options would also serve to "jump-start" health care reform by
implementing insurance reforms and incentives to develop cost effective, provider
contracting. These benefits would be negated in rural areas if insurers chose instead to
discount payments to already low-paid providers.
Discussion of other interim cost containment options:
Options A and B
Option A would freeze prices immediately and then implement a more flexible system
of limits within 3 to 9 months. The flexible system would limit price growth, establish
volume offsets, and allow exemptions for defined special circumstances. The initial freeze
would include percentage rollback provisions to offset anticipated increases.
Option B would impose a surtax on increases in provider income.
Action: If option A is chosen, (1) any price freeze rollback must exempt primary care and
other rural providers, and (2) the growth limits and volume offsets established for the flexible
system must be designed to encourage practice in undeserved areas.
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Option B, if based on historic revenues, could have negative effects on health care
delivery in rural underserved areas if applied across the board. Adjustments in the surtax
rate should recognize the inadequacy of existing incomes for most health care professionals
in rural areas.
Rationale: These options are based on historic costs. One of the reasons for underservice in
rural areas is the historic inadequacy of provider payments. To further exaggerate this
inadequacy, even temporarily, would have a deteriorating effect on the numbers of providers
who choose to practice in rural areas.
Over the longer interim period, the system should be designed to help underserved
rural areas compete more successfully for providers.
Option C
Option C would put an all payer rate-setting system in place, requiring all payers to
use the current Medicare payment methodologies (i.e. DRGs for hospitals and RBRVS for
physicians services). This option includes making necessary modifications to the existing
payment schedules, calculating new conversion factors, and using Medicare data as a proxy
to establish volume controls.
Action: Because short-term cost containment methods may continue for several years, if
option C is selected, any recalculation of the DRG and RBRVS payments must provide
incentives to encourage primary care providers to serve rural and other undeserved
populations. At the least, states should be allowed to modify the national payment rates to
include incentives for improving access and quality.
Rationale: Medicare payment methodologies have consistently paid rural providers less than
urban providers. The new RBRVS system for physician payments has made only marginal
improvements in payments to rural primary care physicians. Continuation of these
disincentives to rural practice will further disadvantage rural populations and require even
greater long-term investments of resources to overcome the disparity in access between rural
and urban areas.
Option E
Option E would increase the use of managed care by: providing large employer tax
incentives to offer plan choices; creating incentives for employees to choose the lowest cost
plans; and allowing small employers to join federal and state employee pools. It also
encourages managed care in Medicare and Medicaid.
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Action: This option would not control costs in rural areas because few rural communities
have managed care plans available. In addition, increases in managed care in urban areas
may place even greater demands on the scarce supply of primary care practitioners.
Nevertheless, if this option is chosen, funding of rural infrastructure development must begin
immediately to allow rural communities to participate in the development of rural primary
care networics and to compete effectively for rural health professionals.
Rationale: The group is concerned that increases in managed care in urban areas may well
place even greater demands on the scarce supply of primary care practitioners, leaving rural
communities at a competitive disadvantage for these professionals. Moreover, few rural
communities have managed care plans. For this option to be even remotely effective in rural
areas, the developmental resources required for health care reform must be made available
immediately to give rural areas an equal opportunity for participation.
BUDGET
Action: Legislation must specify that the budget will be based on an average national per
capita premium within 4 to 7 years. The transition towards a budget based on a national
per capita average should start when the budget is imposed. The national per capita average
will be adjusted for the input costs of providing health care and adjusted upward for the
extra costs and payments required for recruitment and retention of health care practitioners
to rural areas within a state. The National Board will be directed to develop both the input
cost index and the rural adjustment. The formula for the state allocation should not be
specified in law.
Rationale: Historical spending rewards those who have charged more and had higher costs
in the past. These providers have not necessarily been the most efficient. In addition,
payments based on historical costs have contributed to the shortage of health care providers
in rural areas. We should move away from historical per capita spending and towards an
adjusted national per capita average. Any national per capita average must be adjusted to
include the extra costs of maintaining adequate health care resources in rural areas. The time
frame for moving toward the national per capita average should be clearly specified in the
law, and be complete within 4 to 7 years.
The change to a national per capita average will result in a redistribution of funds that
could be disruptive if implemented immediately. On the other hand, unless we begin to
move toward a national measure immediately, we will continue to perpetuate the inequities of
past policies. A blended rate of historical spending/national per capita average should come
into use when the budget comes into effect. A consensus on the definition of "rural area" is
under development.
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The National Board should develop the formula for state allocations, rather than
specifying the formula in the law. At present, there is no basis upon which to develop a
formula. Once a formula is specified in law, it is difficult to change, even if it has obvious
flaws. In addition, specifying the formula in law brings a level of micromanagement to the
system that is not warranted. It is appropriate for the National Board to develop the formula
during the transition period, when there is time to develop it correctly, and the flexibility to
change it later if necessary.
Adoption of Medicare Cost Indices for Input Prices in the Budget
Action: The law should not specify that the Medicare hospital wage index and the
Geographic Practice Cost Index (GPCI) for physician payments will be adopted as the input
prices in the budget. The National Board should consider the adequacy of these indices as
measures of the input prices for providing health care services in rural areas. The Board
should determine whether these indices can be modified or if better input price measures can
be developed.
Rationale: The budget will need to account for geographic differences in the costs of
providing health care services in different areas. Because input price indices have already
been developed for Medicare payments to hospitals and physicians, it has been suggested that
these indices could be applied direcdy to the budget. However, these indices rely heavily on
historic costs and do not adequately measure the economic costs of providing health care
services in rural areas.
Currendy, the hospital wage index for rural hospitals is based on the wages paid by
all rural hospitals in a state. Even in large states, all rural hospitals are paid based on the
same wage index. Many alternative definitions of the labor market area for hospitals have
been proposed. The most promising recommendation came from the Prospective Payment
Assessment Commission (ProPAC) this March. They recommend using hospital-specific
labor market areas based on geographic proximity measured by the air-mile distances
between nearby hospitals. This proposal has not been adopted, but HCFA is considering its
use and soliciting public comment on it. ProPAC's definition should result in more equitable
adjustments for labor costs among rural hospitals than the current definition.
The data used to develop the hospital wage index is always about four years old, even
though it is now updated annually. In addition, the wage index is based exclusively on
wages paid, and does not include any additional costs rural hospitals incur to recruit
professional staff. Additional costs may include sign-on bonuses, fees to recruitment
agencies, moving costs, and scholarship programs offered to local residents who promise to
return and work in the local hospital.
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Similarly, the GPCI adjusts for the historical costs (professional and employee wages,
rent, medical supplies and equipment, malpractice premiums) incurred by a physician
practice, but does not adjust for the price that must be paid to get practitioners to work in
underserved, rural areas. Unless these costs are recognized, rural areas will continue to
struggle to recruit and retain an adequate health care workforce.
ADMINISTRATIVE SIMPLIFICATION AND INFORMATION SYSTEMS
The President's plan contains a comprehensive series of recommendations to simplify
administrative procedures and develop a national health care information system. They range
from standardizing data sets and formats to consolidating facility licensing programs.
These recommendations will use electronic technology for the collection,
transmission, maintenance, and analysis of data. Although the initial investment in such
technology is costly, the long term simplification for providers, plans, alliances, and
governments will substantially reduce administrative costs. In addition, the accuracy,
timeliness, and relevancy of the information will improve the quality and outcomes of health
care. More reliable data will enhance health policy and program decisions.
Rural providers ~ practitioners, clinics, hospitals ~ have small budgets and low
operating margins. Their record-keeping staff often have multiple responsibilities, and may
not be familiar with state-of-the-art computerized billing and data systems. Consequendy,
rural providers have been slow to adopt electronic data systems. Development of the
national information system must consider the additional support rural providers will need for
purchasing and learning to use electronic data systems. State funding for infrastructure
development (see page 22) should target funds for development of information systems in
rural areas.
Action: If electronic billing and data transmission is required, time frames for the conversion
to these systems must accommodate rural facilities that have not yet adopted electronic
information systems.
Rationale: If rural providers are to switch to electronic technology, they will need time and
assistance to procure the equipment and develop the skills of existing staff.
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Action: Immediate development of a single, standardized billing form for each class of health
care service is essential for reducing administrative costs of rural providers.
Rationale: Because rural providers, in general, handle patient encounter records, billing, and
payment accounting with fewer personnel, the proliferation of forms for multiple insurance
programs adds a substantial administrative burden. Standardization of the forms and the data
required would immediately improve this situation.
QUALITY AND ACCOUNTABILITY
Action: The accountability system outlined in the tollgate paper should be adopted as a part
of the health care reform package.
Rationale: Health plans need to be accountable for ensuring that the quality of services
available are accessible, affordable, and of acceptable quality. The accountability system
outlined in the tollgate paper goes a long way toward achieving these objectives without
bogging down plans in unnecessary regulatory requirements.
Practice Guidelines
Action: National practice guidelines should be outcomes oriented, prevention focused, and
community based.
Rationale: Practice guidelines direct health care practitioners to the most effective services
for a specified medical diagnosis. Primary care practice guidelines that include referral
criteria and general guidelines can be used to assess malpractice or risk of malpractice.
Current guidelines focus on high technology interventions that may not be available or
appropriate for rural and frontier areas. Efficient and effective care does not necessarily
require the use of the latest technology. Outcome oriented guidelines will identify the
effective low technology services and will appropriately value the preventive, public health,
nutritional, and social services that are as much a part of the total illness as the medical
condition.
Practice guidelines also will recognize that for some medical conditions, the use of
high technology is appropriate. In those conditions, referrals to facilities or services that can
provide the necessary level of care are appropriate and expected.
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CLIA
The Clinical Laboratory Improvement Amendments of 1988 (CLIA) were passed to
assure the quality of laboratory testing wherever such testing takes place. In particular,
Congress was concerned about the quality of cytology testing and testing in physician office
laboratories. CLIA regulates laboratories based on the tests they perform, not on the
location or size of the laboratory. New personnel standards, quality assurance controls, and
proficiency testing requirements were established. The cost of implementing CLIA is bome
completely by the regulated laboratories through registration fees. The CLIA regulations
were implemented last September.
Action: The regulations implementing CLIA should be reexamined to consider the effects of
CLIA on access to laboratory testing (particularly screening tests) in rural areas and to
reduce the burden on rural providers. An exceptions process should be developed that
exempts practitioners from CLIA regulations for certain tests -- exceptions would be granted
only for tests that are necessary for immediate diagnosis or treatment when there is no
alternative testing site available that can produce results within 12 hours. The rural crosscutting work group does not support the complete, broad-based exemption of small physician
practices and small clinics after two years, as proposed by Work Group 9.
Rationale; Rural providers, in particular, have been burdened by the new CLIA
requirements implemented last September. The CLIA regulations were developed without
consideration of the effect they would have on access in rural areas. Some rural practitioners
have chosen to stop providing on-site testing that is essential to making informed decisions
about diagnoses and treatments. In these situations, patients must wait 24 hours or more for
test results that are sent to another laboratory, or travel to another site for testing. In
addition, the personnel requirements exacerbate the difficulty rural hospitals and other
providers already have recruiting laboratory personnel. CLIA also has added costs that are
difficult for rural providers to absorb or pass on to their patients.
An exceptions process should be implemented that makes it possible for practitioners
to receive an exemption from CLIA for certain laboratory tests that are essential for
immediate diagnosis and treatment. The exemption would be granted only when there are no
reasonable, alternative sites for laboratory testing that can produce the test result within 12
hours.
Under Work Group 9's proposal, small physician offices and clinics would be
completely exempted from CLIA regulation if no significant quality problems are discovered
during thefirsttwo years of laboratory inspections under CLIA. However, testing in
physician office laboratories was one of the concerns that led to the passage of CLIA. Even
small physician offices are able to purchase laboratory equipment that can perform a number
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of laboratory tests with just a push of a button. Until CLIA, this testing was unregulated,
with no assurances that the equipment was maintained correctly or that quality controls were
performed regularly. Without these actions, there is no assurance that the test results are
accurate.
Exempting small physician offices and clinics, which predominate in rural areas,
suggests that a lower standard of quality is acceptable for rural residents. We agree that the
burden of the CLIA regulations should be reduced for rural providers. Reasonable
requirements should be adopted that assure quality and access to laboratory testing in rural
areas. An exceptions process should be developed for those tests that are essential for
immediate diagnosis and treatment decisions. However, the regulatory burden should not be
reduced to the point that rural practitioners are completely relieved from reasonable measures
that assure accurate laboratory testing for their patients.
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�RECOMMENDATIONS ON CURRENT ISSUES
Developed after the Rural Cross-Cutting Work Group's last meeting
Action: All states will be required to submit plans to the federal govemment that describe
how their health care system will be organized to provide universal access to the mandatory
benefit package to all residents of the state. The plan should include: organization of the
alliances; assurances of universal coverage; delivery system needs assessment and
improvement plan; personnel analysis and re-organization;financingplan; consumer
involvement; transition plan; and evaluation design.
Rationale: To assure that the national health reform act is truly national in scope, each state
must submit a plan indicating the system they will develop and how they will guarantee
access to health care for all residents.
Action: Community-based planning and decision-making methods need to be documented in
all plans submitted to the federal and state governments.
Rationale: Consumer involvement is key to the successful enhancement of the rural health
care system. It is important to have the community involved in planning so that the facilities
and providers in the system are those that the community wants.
71
�
Dublin Core
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Title
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Health Care Reform
Identifier
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2006-0810-F
Description
An account of the resource
<p>This collection consists of records related to Hillary Rodham Clinton's Health Care Reform Files, 1993-1996. First Lady Hillary Rodham Clinton served as the Chair of the President's Task Force on National Health Care Reform. The files contain reports, memoranda, correspondence, schedules, and news clippings. These materials discuss topics such as the proposed health care plan, the need for health care reform, benefits packages, Medicare, Medicaid, events in support of the Administration's plan, and other health care reform proposals. Furthermore, this material includes draft reports from the White House Health Care Interdepartmental Working Group, formed to advise the Health Care Task Force on the reform plan.</p>
<p>This collection is divided into two seperate segments. Click here for records from:<br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+1"><strong>Segment One</strong></a> <br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+2"><strong>Segment Two</strong></a></p>
Provenance
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Clinton Presidential Records
Publisher
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William J. Clinton Presidential Library & Museum
Text
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Paper
Dublin Core
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Title
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Rural Implications of Health Care Reform [1]
Creator
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Health Care Task Force
General Files
Identifier
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2006-0810-F Segment 1
Is Part Of
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Box 55
<a href="http://clinton.presidentiallibraries.us/items/show/36144" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12090749" target="_blank">National Archives Catalog Description</a>
Provenance
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Clinton Presidential Records: White House Staff and Office Files
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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Preservation-Reproduction-Reference
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5/5/2015
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42-t-2194630-20060810F-Seg1-055-009-2015
12090749