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Morris-2014
1. Rural is Not ā¦
Tom Morris
Office of Rural Health Policy, Health Resources & Services Administration
U.S. Department of Health & Human Services
A Smaller Version of Urban
Virginia Rural Health Association
December 11th, 2014
3. What Are the Differences?
ā¢ Infrastructure
ā¢ Mix of Clinicians
ā¢ Higher Poverty
ā¢ Geographic Isolation
ā¢ Weather as a Risk Factor
ā¢ Higher Percentage of Elderly
ā¢ Financial Viability/Payer Mix
ā¢ Shortage Areas
ā¢ Employment and Economics
ā¢ Patient Volume
ā¢ Health Disparities
ā¢ Population Trends
ā¢ Other?
6. This Week in Poverty:
Congress Turns Its Back on Rural America
ā āRural America often gets overlooked. We know Kansas is referred to as a
āFlyover Stateā,ā said Gray [head of a local Community Action Agency]. āBut there
are a lot of people here, and a lot of people in poverty. Sequestration is just one
cut. Itās the impact of that steady erosion of financial resources that is much
greater in rural communitiesābecause there are far fewer resources.ā ā
The Nation, June 14th 2013
As more move to the city,
does rural America still matter?
ā During the 1990s, people flocked to
rural areas to take advantage of the
growth in jobs. But with fewer positions
now available, a major incentive to move
out of the big city has vanished. ā
USA Today, January 13th 2013
Farm Bill Defeat Shows
Agricultureās Waning Power
ā The startling failure of the farm bill last
month reflects the declining clout of the
farm lobby and the once-powerful
committees that have jurisdiction over
agriculture policy, economists and
political scientists said this week.ā
New York Times, July 2nd 2013
7. So, why does this matter?
ā¢ Research and Data
ā¢ Funding Formulas
ā¢ Public Health
ā¢ Community
Development
ā¢ Perception and
Public Policy
ā¢ Unintended
Consequences
8. The Checkered History
of Top-Down Solutions
for Rural Health
ā¢ Prospective Payment Systems
ā¢ Risk-Based Managed Care
ā¢ Volume-Focused Quality
Measurement
ā¢ Health Care Provider Education and
Training
ā¢ Provider-Centric Evidence-Based
Programs
9.
10. Working Toward a Solution ā¦
Ensuring a Rural Voice Within HHS
http://www.hrsa.gov/ruralhealth/index.html
Section 711
Of the
Social
Security
Act
Sec. 711. [42 U.S.C.
912] (a) There shall be
established in the
Department of Health
and Human Services (in
this section referred to
as the āDepartmentā) an
Office of Rural Health
Policy (in this section
referred to as the
āOfficeā).
11. ā¢ Rural Specific Resources
ā¢ Grants
ā¢ State Offices of Rural
Health
ā¢ Population Neutral
Approaches in National
Programs
ā¢ Rural Reimbursement
Models
ā¢ CAHs, Swing Beds, RHCs
What works ā¦
12. Benefits of a Level Playing Field
ā¢ The Community and Migrant
Health Center Program
ā¢ The National Health Service
Corps
ā¢ Medicare Incentive Payments
ā¢ Head Start
14. http://www.whitehouse.gov/administration/eop/rural-council
The White House Rural Council
ā¢ Key Steps So Far ā¦
ā¢ Rural Provider Burden
Reduction
ā¢ http://www.hrsa.gov/ruralhealth/policy/p
olicyupdate03142013.pdf
ā¢ CAHs NHSC Expansion
ā¢ Access to Capital for Health
IT
ā¢ Health IT Pilots for Rural
Veterans
ā¢ Rural Health Philanthropy
Partnership
17. The Rural Uninsured: What We Know
ā¢ More likely to be eligible for coverage under the
Marketplace
ā¢ More likely to eligible for coverage under the
Medicaid Expansion
http://www.public-health.uiowa.edu/rupri/publications/policybriefs/2014/The%20Uninsured.pdf
Rating Areas & Rural
ā¢ Year One Quite Variable
ā¢ Link to Population Density
http://www.public-
health.uiowa.edu/rupri/publications/policybriefs/2014/Geographic%20Variation%20in%20Premiums%20in%20Health%20Insurance
18. ORHP Bi-Weekly
Outreach & Enrollment
ā¢ Highlight Innovative
Approaches
ā¢ Share Strategy
ā¢ Question and Answer with
Follow-Up
ā¢ Contact: Helen Newton
ā¢ hnewton@hrsa.gov
Promoting the Rural Coverage Expansion
19. From Crisis to Creativity
ā¢ Assessing Rural
Hospital Risk
ā¢ Re-Thinking Mix of
Models for Rural
ā¢ Learning from Current
Pilots and Demonstrations
20. ORHP Community Health
Funding and Resources
FY 2015/16 Competitive
Programs
ā¢ Small Health Care Provider
Quality Improvement Program
(FY 16) *
ā¢ Rural Health Network
Development Planning Program
(FY 15 and FY 16) *
ā¢ Care Coordination
ā¢ Allied Health
22. Workforce
ā¢ Presidentās 2015 Budget
ā¢ Re-Thinking Residency Training
ā¢ Expansion of the NHSC
ā¢ ORHP Investments
ā¢ Rural Training Tracks
ā¢ Health IT Training
ā¢ Allied Health
Seems simple and straight
Itās not
Been saying it for years
Paulās take
So, I keep a running list in my head of the key differences in health care between rural and urban communities
Here are some of them ā¦ (because itās always growing)
Touch on some of these
SRHs #s
PC vs Spec
Weather
M and M dependency
RHCs and FQHCs often the PC access points
Whatās missing?
So those are some of the differences ā¦
Think it also worth talking about the changing demographics of rural ā¦ because it serves to highlight some of the unique challenges for rural
2010 census brought a new focus on this
Clear face of RA is changing; population decline from 2000 but a lot of regional variation also
Had 104 counties switched ā¦ 67 rural counties now metro with 37 going from metro to non metro
So blue spots on this map show the key change
Recent story in Business Insider ā¦
Half US in 146 of largest counties (of more than 3k)
All adds up to a changing face of America and rural America.
William Fry ... Book "Diversity Explosionā ā¦ trends
1ST ā¦ pop growth Hispanics, Asians and multiracial; will double in size in next 40 yrs
2nd declining growth and aging of whites
These 2 factors will create generational competition in future decades over resources and governmental priorities
Wonder what rural take on that is?
Iām wondering If within rural communities you see generational or demographic competition you could also see a marginalization of rural as a whole since they may be arguing for different needs at a time when given the population decline do you run the risk of having factions cancel each other out?
Clear things are changing ā¦ RH issues and rural in general has benefitted from having a broad coalition of support ā¦ HC, ED, Ag
But ā¦ The demographic changes have consequences ā¦
Can affect how resources allocated
How folks are represented
Consider recent headlines
Note all this because it has implications for how rural tells its story
Because this is what youāre up against
Remember that famous New Yorker Cover
That perception lives ā¦ Flyover country
And perceptions can influence public policy
CLICK
Examples:
Survey data and rural
Funding Formulas
Public Health
CDBG; formula funding 50K; anything less must compete against each other
Perceptions and Assumptions tend not to do rural any favors
Assumptions ā¦
Pity
Scorn ā¦ just move
Problem not where you live but how we allocate resources fairly rather than just efficiently
Nod toward the advantages of rural ā¦
know your communities in a way urban and suburbans canāt;
There is an interconnectedness in rural communities
Example of facelessness of urban and suburban care
Can change faster and more efficiently
So, challenge for all of us is how we focus not on the problems but on the solutions
10
330A grants in ORHP ā¦ how and why created
SORHs, create a focal pt in every state
In my exp., when focus is on need and not tied to population tend to work better for rural
In Medicare, over past 25 yrs, have a base of provisions that explicitly take R into account
And we do have examples of national programs that work well for rural ā¦
CHCs ā¦
NHSC ā¦ just under 50% in R
MIPs: >60% of HPSAs in rural so 10 percent bonus
Head Start
Key factor ā¦ not tied to a pop requirement ā¦ in terms of impact our outcomes
Learned over yrs that easier to scale strategies up from rural than it is to scale it down from urban
Lot of examples of ideas that came from rural ā¦
Best is the RHC Act of ā77 ā¦ allowed NPs and PAs practice up to their training and a supportive reimbursement model
Showed it could work, that it improves access and the care was good
20 yrs later, finally got MC provider status
Can imagine PC now without these folks?
Another example ā¦ Conf recently in NE ā¦
Cited NY story ā¦ Camden .. CHW model ā¦ like theyād discovered a breakthrough
CHWs go back two and three decades in R; promotoras in 90s along border
AK village health aides before that
Glad urban folks are finally seeing benefit but all they had to do was ask
Perhaps best ex. Seen of thinking more creatively about rural is the work going on with the WHRC ā¦
EO in 2011 ā¦ 1st ever EB focus
Mention it because itās been the best forum Iāve seen for bringing a renewed focus to rural from Fed perspective
Jobs and ED as key focus ā¦ HC front and ctr
In past two yrs, reg burden reduction package w/ focus on R
NHSC CAHs
Projects on Health IT, improving access to capital and leveraging this tech for vets
Council also led to creation of the RH Ph Pship ā¦ effort to collaborate with and work with rural focused philanthropies and trusts that invest in rural America
Shift gears and talk about key rural opportunities in coming year
Just opened 2nd yr of HI MPs ā¦ enrollment thru Feb 15
Key priority for us in HHS, obviously
And early indications are the #s look good
But shorter enrollment period this yr so lot to do
Like to briefly talk to you about the rural implications of the coverage expansion
Historically, the pre ACA insurance market didnāt work well for R; heavily dependent on individual market; wasnāt affordable and had higher rates of UI in rural
Data from our RC at RUPRI pretty clear on benefits of ACA
More R eligible; particularly for Medicaid than U
And w/ tax credits, eligibility for Medicaid and cost sharing, more rural folks on average qualify.
That plays a key role in affordability but also a regional aspect to this ā¦ and a role for States
Research from RUPRI shows that larger rating areas can produce lower costs and overcome trend of seeing higher rates in low pop density areas
Would also like to put in a plug ā¦ Weāre funding 54 projects on O and E
Have a call w/them every other week ā¦ Call it O&E Office Hrs
Open to all; would welcome participation of anyone here with an interest
Highlight best practices; featured speakers on each call;
Answer Questions; highlight research
Belief is that rural O and E takes some unique approaches and we can all learn from each other
If have an interest, contact Helen ā¦ see her email here
Another issue weāre tracking in 2015 is recent uptick in rural hospital Closures ā¦ 28 since 2013 ā¦ see map here
Lot of driving factors ā¦ no one single thing
But we do want to know whatās going on and why
In process of doing this, itās prompted an interesting public policy question
What do you do in communities canāt support H but need > clinic ā¦ and ultimately that is an access question
Challenge is really only have two choices and need can lie between
Maybe there is a different way to do this ā¦
Cite Belhaven Ex; GA examples
Look at past FESC demo in AK and current Frontier CAH demo
Both offer clues but really only scratch surface
Can tell you this ā¦ best solution will come from ground up
Like to also highlight some of funding and resources for the coming yr
Grant currently out ā¦ NWP 15 awards; $100K
Will also compete it next yr
Key program coming next for us is SHCP QI ā¦ $200K/3 yr
Guidance out next fall
Care Coordination ā¦ Part of WHRC ā¦ hoping to partner with the Rural Health PP
Allied Health training ā¦ test out notion that exposure to rural may attract folks into taking jobs in R
Beyond our grants, would also highlight that in addition to funding grants, we also want to build up a rural CH evidence base
Toward that end, weāve created the Rural CH Gatway
Lessons learned and successful models from our past grantees and other rural projects
Toolkits, resources ā¦
Hope is that even if a rural community doesnāt get our funding, it does benefit from what weāre learning w/ these $
Noted earlier ā¦ WF training system has not been a good for rural ā¦ true for docs but man professions
Presidentās Budget in 2014 proposed a new way to focus on how we train docs
Took $5.23 billion ā¦
Create new residency slots with a focus on PC; with a focus on high need areas including Rural
Expand the NHSC to 15K providers from current 9k
Requests $4 m to support rural physician training gts
Those proposals align with what weāve talked about today ā¦ better aligning allocation of resources for R
On our end, weāll continue our efforts to emphasize successful WF approaches ā¦
RTT TA: Health IT WF and AH program noted earlier
In closing ā¦
Key point Iād leave you with is if we rely solely on the numbers, on urban notions of efficiency, itās not going to work.
Itās about making sure folks understand the context of your work
I would argue that those challenges are as true at state and regional level as they are at national level
Would imagine many have had to do a fair amount of educating folks in Richmond or elsewhere in the state
And we all have a role to play ā¦
RA not flyover country ā¦ and west va and eastern va are not just places you drive through on I 64 or I 81 on way to vacation ā¦ vibrant strong communities across state and country doing great things against the odds
Given chance, I believe RA can thrive and lead