Morris-2014
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This document summarizes differences between rural and urban health care and challenges facing rural areas. Key points include: infrastructure and resources are more limited in rural areas; poverty and health disparities are higher; and the aging population presents issues. Federal programs aim to address rural needs, but top-down solutions have had mixed results. Ensuring a rural voice in policymaking is important. Upcoming opportunities include the 2015 open enrollment period under the Affordable Care Act and workforce development programs.
![This Week in Poverty:
Congress Turns Its Back on Rural America
тАЬ тАШRural America often gets overlooked. We know Kansas is referred to as a
тАШFlyover StateтАЩ,тАЩ said Gray [head of a local Community Action Agency]. тАШBut there
are a lot of people here, and a lot of people in poverty. Sequestration is just one
cut. ItтАЩs the impact of that steady erosion of financial resources that is much
greater in rural communitiesтАФbecause there are far fewer resources.тАЩ тАЭ
The Nation, June 14th 2013
As more move to the city,
does rural America still matter?
тАЬ 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. тАЭ
USA Today, January 13th 2013
Farm Bill Defeat Shows
AgricultureтАЩs Waning Power
тАЬ 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.тАЭ
New York Times, July 2nd 2013](https://image.slidesharecdn.com/tommorris-141216131052-conversion-gate01/85/Morris-2014-6-320.jpg)
![Working Toward a Solution тАж
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 тАЬDepartmentтАЭ) an
Office of Rural Health
Policy (in this section
referred to as the
тАЬOfficeтАЭ).](https://image.slidesharecdn.com/tommorris-141216131052-conversion-gate01/85/Morris-2014-10-320.jpg)
Morris-2014
- 1. Rural is Not тАж 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
- 2. TodayтАЩs Presentation Rural Differences & Demographics Rural тАж The Policy Conundrum Successful Approaches 2015 Opportunities
- 3. What Are the Differences? тАв Infrastructure тАв Mix of Clinicians тАв Higher Poverty тАв Geographic Isolation тАв Weather as a Risk Factor тАв Higher Percentage of Elderly тАв Financial Viability/Payer Mix тАв Shortage Areas тАв Employment and Economics тАв Patient Volume тАв Health Disparities тАв Population Trends тАв Other?
- 5. Where Does Rural Fit In?
- 6. This Week in Poverty: Congress Turns Its Back on Rural America тАЬ тАШRural America often gets overlooked. We know Kansas is referred to as a тАШFlyover StateтАЩ,тАЩ said Gray [head of a local Community Action Agency]. тАШBut there are a lot of people here, and a lot of people in poverty. Sequestration is just one cut. ItтАЩs the impact of that steady erosion of financial resources that is much greater in rural communitiesтАФbecause there are far fewer resources.тАЩ тАЭ The Nation, June 14th 2013 As more move to the city, does rural America still matter? тАЬ 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. тАЭ USA Today, January 13th 2013 Farm Bill Defeat Shows AgricultureтАЩs Waning Power тАЬ 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.тАЭ New York Times, July 2nd 2013
- 7. So, why does this matter? тАв Research and Data тАв Funding Formulas тАв Public Health тАв Community Development тАв Perception and Public Policy тАв Unintended Consequences
- 8. The Checkered History of Top-Down Solutions for Rural Health тАв Prospective Payment Systems тАв Risk-Based Managed Care тАв Volume-Focused Quality Measurement тАв Health Care Provider Education and Training тАв Provider-Centric Evidence-Based Programs
- 10. Working Toward a Solution тАж 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 тАЬDepartmentтАЭ) an Office of Rural Health Policy (in this section referred to as the тАЬOfficeтАЭ).
- 11. тАв Rural Specific Resources тАв Grants тАв State Offices of Rural Health тАв Population Neutral Approaches in National Programs тАв Rural Reimbursement Models тАв CAHs, Swing Beds, RHCs What works тАж
- 12. Benefits of a Level Playing Field тАв The Community and Migrant Health Center Program тАв The National Health Service Corps тАв Medicare Incentive Payments тАв Head Start
- 13. YouтАЩre Welcome тАж тАв Rural innovations discovered by urban folks
- 14. http://www.whitehouse.gov/administration/eop/rural-council The White House Rural Council тАв Key Steps So Far тАж тАв Rural Provider Burden Reduction тАв http://www.hrsa.gov/ruralhealth/policy/p olicyupdate03142013.pdf тАв CAHs NHSC Expansion тАв Access to Capital for Health IT тАв Health IT Pilots for Rural Veterans тАв Rural Health Philanthropy Partnership
- 16. The 2015 Open Enrollment Period Runs through February 15 The Health Insurance Marketplace
- 17. The Rural Uninsured: What We Know тАв More likely to be eligible for coverage under the Marketplace тАв 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 тАв Year One Quite Variable тАв 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 тАв Highlight Innovative Approaches тАв Share Strategy тАв Question and Answer with Follow-Up тАв Contact: Helen Newton тАв hnewton@hrsa.gov Promoting the Rural Coverage Expansion
- 19. From Crisis to Creativity тАв Assessing Rural Hospital Risk тАв Re-Thinking Mix of Models for Rural тАв Learning from Current Pilots and Demonstrations
- 20. ORHP Community Health Funding and Resources FY 2015/16 Competitive Programs тАв Small Health Care Provider Quality Improvement Program (FY 16) * тАв Rural Health Network Development Planning Program (FY 15 and FY 16) * тАв Care Coordination тАв Allied Health
- 22. Workforce тАв PresidentтАЩs 2015 Budget тАв Re-Thinking Residency Training тАв Expansion of the NHSC тАв ORHP Investments тАв Rural Training Tracks тАв Health IT Training тАв Allied Health
Editor's Notes
- #2: Seems simple and straight ItтАЩs not Been saying it for years PaulтАЩs take
- #4: 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 тАж (because itтАЩs 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 WhatтАЩs missing?
- #5: So those are some of the differences тАж Think it also worth talking about the changing demographics of rural тАж 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 тАж 67 rural counties now metro with 37 going from metro to non metro So blue spots on this map show the key change
- #6: Recent story in Business Insider тАж 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 ExplosionтАЭ тАж trends 1ST тАж 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? IтАЩm 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 тАж RH issues and rural in general has benefitted from having a broad coalition of support тАж HC, ED, Ag But тАж The demographic changes have consequences тАж Can affect how resources allocated How folks are represented
- #7: Consider recent headlines Note all this because it has implications for how rural tells its story
- #8: Because this is what youтАЩre up against Remember that famous New Yorker Cover That perception lives тАж 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 тАж Pity Scorn тАж just move Problem not where you live but how we allocate resources fairly rather than just efficiently
- #10: Nod toward the advantages of rural тАж know your communities in a way urban and suburbans canтАЩt; 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
- #11: 10
- #12: 330A grants in ORHP тАж 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
- #13: And we do have examples of national programs that work well for rural тАж CHCs тАж NHSC тАж just under 50% in R MIPs: >60% of HPSAs in rural so 10 percent bonus Head Start Key factor тАж not tied to a pop requirement тАж in terms of impact our outcomes
- #14: 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 тАж Best is the RHC Act of тАШ77 тАж 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 тАж Conf recently in NE тАж Cited NY story тАж Camden .. CHW model тАж like theyтАЩd 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
- #15: Perhaps best ex. Seen of thinking more creatively about rural is the work going on with the WHRC тАж EO in 2011 тАж 1st ever EB focus Mention it because itтАЩs been the best forum IтАЩve seen for bringing a renewed focus to rural from Fed perspective Jobs and ED as key focus тАж 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 тАж effort to collaborate with and work with rural focused philanthropies and trusts that invest in rural America
- #16: Shift gears and talk about key rural opportunities in coming year
- #17: Just opened 2nd yr of HI MPs тАж 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
- #18: Historically, the pre ACA insurance market didnтАЩt work well for R; heavily dependent on individual market; wasnтАЩt 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 тАж 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
- #19: Would also like to put in a plug тАж WeтАЩre funding 54 projects on O and E Have a call w/them every other week тАж 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 тАж see her email here
- #20: Another issue weтАЩre tracking in 2015 is recent uptick in rural hospital Closures тАж 28 since 2013 тАж see map here Lot of driving factors тАж no one single thing But we do want to know whatтАЩs going on and why In process of doing this, itтАЩs prompted an interesting public policy question What do you do in communities canтАЩt support H but need > clinic тАж 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 тАж 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 тАж best solution will come from ground up
- #21: Like to also highlight some of funding and resources for the coming yr Grant currently out тАж NWP 15 awards; $100K Will also compete it next yr Key program coming next for us is SHCP QI тАж $200K/3 yr Guidance out next fall Care Coordination тАж Part of WHRC тАж hoping to partner with the Rural Health PP Allied Health training тАж test out notion that exposure to rural may attract folks into taking jobs in R
- #22: 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, weтАЩve created the Rural CH Gatway Lessons learned and successful models from our past grantees and other rural projects Toolkits, resources тАж Hope is that even if a rural community doesnтАЩt get our funding, it does benefit from what weтАЩre learning w/ these $
- #23: Noted earlier тАж WF training system has not been a good for rural тАж true for docs but man professions PresidentтАЩs Budget in 2014 proposed a new way to focus on how we train docs Took $5.23 billion тАж 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 weтАЩve talked about today тАж better aligning allocation of resources for R On our end, weтАЩll continue our efforts to emphasize successful WF approaches тАж RTT TA: Health IT WF and AH program noted earlier
- #24: In closing тАж Key point IтАЩd leave you with is if we rely solely on the numbers, on urban notions of efficiency, itтАЩs not going to work. ItтАЩs 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 тАж RA not flyover country тАж and west va and eastern va are not just places you drive through on I 64 or I 81 on way to vacation тАж vibrant strong communities across state and country doing great things against the odds Given chance, I believe RA can thrive and lead