Dr. Marcia Brand
Director,
Office of Rural Health Policy
Health Services and Resources Administration
United States Department of Health and Human Services
While we're getting the segue on the AV taken care of here for Dr. Brand, let me introduce her. Dr. Brand is Director of the Office of Rural Health Policy, also within in HRSA. She's been there a relatively short time but has made I think some significant impact to the direction of the office and she's going to tell you about what's going on there.
Good morning. I guess I should confess I am a recovering dental hygienist. I want to begin by thanking you for your leadership and seeking your partnership. I have the pleasure of directing the Office of Rural Health Policy. There is an Office of Rural Health Policy in each of your states. I also want to acknowledge that rural is regional and since I started this position about 18 months ago, I have been to Kentucky, Nebraska, Utah, Texas, Pennsylvania, New Hampshire, Rhode Island, Maine and Oklahoma. I currently have a staff member in Hawaii. He's been there for 5 days. I'm not completely certain he's coming back. He's doing technical assistance for grant writing on all of the Islands. I'm going to Minnesota in June so you are not to be left out. I have not yet gone to Iowa, Indiana or North Dakota, but they are on my list.
I think it's really important if you run the Office of Rural Health Policy that you try not to do it from inside the Beltway because it's very hard to understand issues from the Beltway perspective. I also believe in that so strongly that I live in West Virginia and commute in to Rockville and so I started this morning about 5:00 and if I nod off in the middle of my own presentation, someone just come up here and give me a jingle that would be a good thing.
I want to start off a little bit by talking about what the rural health policy environment is like these days, at least from the Washington perspective. I know that the way you experience it in your states is different but this is probably rural's best moment, at least its best moment in at least about 20 years. We have a very supportive administration. As you know the Secretary, Mr. Thompson, is from a large rural state and the President is from an even larger rural state; they seem to get rural issues and are very interested in doing things that would improve access to health care services in rural communities. As a matter of fact, the Secretary created a rural initiative in July of last year and I'll be telling you a little bit more about that.
The interesting thing about that, just the fact that the rhetoric has changed; that there are lots of folks who talk about access to rural services, rural health care services, and the fact that the Secretary has across, an across the department initiative has changed the way rural is being viewed as we make policy, as we make our grant. There are lots of activities taking place that aren't necessarily the direct outcome of that activity but are spin-off's from that activity. For example, yesterday, if you are following CMS's press releases, there was a press release yesterday that CMS has done a number of fixes for small rural hospitals and one of them would look at relieving some of the regulatory burden. That might not have happened in another environment but certainly there's a focus on rural issues.
The Administration has encouraged all of its entities to provide better support to rural areas. There's an across the department look, a regulatory reform, and in particular how we can make it easier for rural communities to function and for rural providers to function and there continues to be substantial congressional interest in rural. It is helpful to rural these days that a number of the committees of jurisdiction aren't shared by folks from rural states.
I want to start by talking a little bit about what has been on our agenda and then also focus on how it might be helpful to you in your states. The Office of Rural Health Policy, which we have described as an office in need of a much better acronym; ORHP is not something you want to say publicly and often but the Office of Rural Health Policy is required by statute; where in the Social Security law actually, to serve as an advocate for rural health within the department and particularly to provide recommendations to the Secretary and to Congress.
We've been around for about almost 15 years. We were created in 1987 and one of the interesting comments I've heard about our office is the fellow who preceded me was a fine gentleman, currently from Maine, named Wayne Myers and Dr. Myers said "you know, we are of the office of unintended consequences" and what he meant when he said that was we came about as a result of the fact that we moved to perspective payment in the mid '80's and immediately 300 small rural hospitals closed because we weren't paying attention to the impact in rural communities of those kind of broad sweeping changes that we make at the federal level. So our charge, as an office, is to try to make sure that those things don't happen again. So we certainly watch the policy front.
We also have 8 grant programs of about $140 million worth of resources; they go out to rural communities. We got a $40 million increase in 2002, in real dollars, not earmarked and we think that's reflective of this Congress and this Administration's interest in rural.
We are a growing office with a new staff. We have new programs that I'll tell you a little bit about. AED's, Automatic External Defibrillators; if you go out on a plane, to get here you walked through an airport. They probably had a couple posted. They are going to become as ubiquitous as fire extinguishers. There's going to be one on every wall. We have a new program for small hospital improvement that I'll tell you a little bit about.
We're working to strengthen our relationships with the 50 state offices of Rural Health. Our outreach and network grant programs that your states certainly are active in those; 47 of the states have a flex grant program, that's the Medicare Rural Hospital Flexibility Grant program and we're continuing to support that, rural hospital improvement. We have a new focus on EMS and emergency preparedness. We would have taken this up anyway because it's an important issue for many rural communities and yet the events of September 11th certainly heightened the interest and the need to take that up more immediately. We are continuing to support policy development and we are working like mad to support the Secretary's initiative from our office.
The outreach grant program, I want to focus on a moment, because many of your states have these grants in your states and these are demonstration grants but they're non-categorical and that I think is what makes them particularly interesting. There are about $37 million, $38 million in these grants, network grants, the programs are together, that allow your communities to define their own problems and develop programs to address those health care problems. You know right now if you're looking to support a particular kind of activity you have to look at the federal programs and A is for asthma and B is for birth weight and C is for chronic fatigue syndrome; you have to sort of shop the catalog of domestic assistance to find something that will satisfy the needs of this particular community. The way this grant program is set up, if your community has trouble with access to dental health care services, then that's the grant they submit. If they're having difficulty having access to mental health care services, that's the grant they submit. We work hard with your State Offices of Rural Health to insure that your communities know these opportunities are available.
Other activities that we support out of that grant line and a particular one that you might be interested in is an activity called "Seeds of Hope". It's a fairly new program that we're doing and the purpose of this grant program is to provide mental health care services for farm families in crisis in the Midwest.
We also have a focus in the Mississippi Delta. For our purposes the Mississippi Delta is the Delta Regional Authority, which is 8 states, Illinois, Louisiana, Mississippi, Missouri, Arkansas, Alabama, Kentucky and Tennessee. The Delta Regional Authority came into being in December of 1999 and we have a soft earmark in our outreach grant program to do some work in the Mississippi Delta which has certainly some of the longest standing unmet health care needs in the nation.
The reason I want to focus on this with you today is because of the small hospital improvement program. This is something that we're hoping to take nationally. As we begin to do work in the Mississippi Delta, as we begin to look at developing networks in the Delta, we found that the most fragile, most vulnerable hospitals were those small hospitals in those rural counties and that those places were also the places where most health care was being delivered. So if you were going to shore up access to health care services in those counties, you need to first insure that those hospitals, where in-patient, out-patient, home health nursing care is all being coordinated from, that those hospitals were functioning well.
We've got underway a technical assistance activity for those 8 states for the most vulnerable hospitals in those 8 states. What we're going to do is go in and provide technical assistance to improve hospital performance. Those of you who work closer with your hospitals know that access to appropriately scaled technical assistance is very difficult to find. The consultants who can come in and help your most vulnerable hospitals cost a lot of money. I heard somebody once say if I had $70,000 I could make payroll, let alone pay a consultant to help me improve my performance. What we're hoping to do is develop a set of tools and resources, pilot test them in these states and then make them available like a public utility on a website, so that any hospital administrator, any provider can go in and pull these down and see what he or she might do to improve performance. We've done a couple of pilots. The first hospital that we went into was in Mississippi, a small hospital in Mississippi. The folks that we've hired to do this, went in, spent some time talking to administrators and before lunch, before lunch, found $400,000 in accounts receivable. If they could just get their accounts receivable down, they'd be operating in the black, not in the red. So that's the kind of thing we're hoping to be able to do with that part of our outreach grant program.
We also have a network development grant program. Every state is eligible that has rural areas. What we seek to do is integrate and improve services delivery and let small hospital networks try to find some economies of scale. So they might collaborate, come in for network grant and get the resources they would need to organize so that they could do combined purchasing; that they could look at better improving their information systems or anything else they think would improve performance.
47 of the states have the Medicare Rural Hospital Flexibility grant program. For obvious reasons we call that FLEX. You probably know this as the Critical Access Hospital Program, that's probably the term that's more familiar to you. The purpose of this grant program is to stabilize the system and improve the hospital performance. We have a technical assistance services center that helps the 560 critical access hospitals and works with them directly. A critical access hospital is actually a payment designation. It's a Medicare payment designation for cost based reimbursement and to become a critical access hospital you have to have 15 beds or less, so this is the smallest in the system. You need to be more than 35 miles away from a similar facility and if you make some changes you can meet Medicare conditions of participation. You have to be 24/7 and these are the smallest hospitals. There are 560 and our experience so for is that a number of these facilities that would not have been able to survive, when they changed to critical access hospital, have been able to survive and you all know that in your communities, if you lose your hospital, you know your schools are not far behind. It's going to be very difficult for you to attract industry. This is one of those things that worked for a small investment.
We have new money in our Flex line this year; it's about $15 million. I think every state gets some of this money. It's to help implement perspective payment systems; help hospitals comply with HIPAA, which is the Health Insurance Portability and Accountability Act, but you all probably knew that act didn't you because you've heard about it from your folks in the field and to look at medical errors and also to support quality improvement.
There are about 1200 hospitals in the United States that are less than 50 staffed beds. Each of those hospitals is eligible for a cut of this resource. If you do the math they get about $11,000 apiece. So what we're encouraging is that hospitals come in as consortia and that they work with their states and combine that money. So that rather than going out and buying a fraction of a consultant to help them work with their HIPAA compliant, that the hospitals come in as a consortia and pool their $11,000 and are able to do something a bit more substantial. The announcement for that should go out within the next couple of weeks. We're working closely with your 50 state Offices of Rural Health to make sure that every hospital in your state gets its share.
Speaking of state offices, they had a great year. They had historically only been funded at $4 million for 50 states. They got a doubling of their resources and so they're very excited about what they've been able to accomplish and they've been able to expand. You should recall that this is a 3 to 1 match, that for every federal dollar there are 3 state dollars and that's really done a lot I think to leverage state support for the kinds of activities they carry out. Most of them are responsible for administering the FLEX grant program in your state.
As I said before our office is responsible for rural health policy development. There are 6 rural health research centers. If you look at the federal government's research portfolio, it's very hard to find a rural focus because although we are finally beginning to cut our data by minorities, for example, you can look at data now that tells you how the African American population or the Native American population is experiencing our health care system. There are very few places where you cut the data, urban and rural, and when you ask the researchers to do that, they say well, the cells are too small or doesn't really tell us anything. The responsibility of our office is to do policy-relevant research that focuses on rural health issues.
We also have a national advisory committee on rural health. We have a new chairman, his name is Governor Beasley; he was the governor of South Carolina, and we're very excited about the energy he brings to our committee.
We also have a rural health information system. You can go to this center and you can either by telephone or by web ask a question and there are real live people and they're librarians, the more obscure your question is the better they will like it. But their responsibility is to go seek out the answers to those questions. So if you called and said I'm looking to provide access to mental health services in my community, where can I go? Their job is to connect you with the right folks. We've been funding that for some time. We're getting ready to make some major changes in that and I'll tell you about those in a moment. We're going to do everything that we always did in policy and a few other things, I guess if you look at that, that's how you would interpret that.
I want to talk to you a little bit about the AED grant program. This is $12.5 million. It's new and our mortal fear is that every fire chief in the nation will back his or her truck up to the Park Lawn building and say I'm here for my AED. We did the math; that's a lot of trucks. So what we're encouraging is that the states develop state-wide partnerships with the EMS and their State Offices of Rural Health to determine where AED's should be placed and then to combine purchasing so that you can get the benefit of bulk purchasing. The announcement for the AED program should be out within the next two weeks. We will be working hard with your State Offices of Rural Health and your state EMS folks to make sure that your states compete.
One of the things that's going to be interesting for us to figure out is where you put them. If you're in North Dakota, and we all know that for every minute somebody is down the chances of their survival goes down by 20%. So if you're in North Dakota, where do you put your AED's? I'm from West Virginia; you put your AED's in the Wal Mart because that's where everybody is. So it's going to be interesting to see how folks determine their placement. We're really going to encourage AED placement first with sort of first line providers, first responders and then schools and libraries and other places.
We also have a number of other EMS related activities that I want to just highlight. EMS is hard in rural communities because historically it's been volunteer and also certainly a number of your communities are having trouble with their tax base and those things that would enable you to purchase new equipment, to do training. But there's no place that really talks about how rural communities and frontier communities experience EMS. So we're going to create a technical assistance center and their job is to help people in rural communities improve their EMS. They're going to focus on recruitment and retention.
The other thing we're doing with our EMS dollars is looking at rural emergency preparedness. Last November, the Deputy Secretary, Claude Allen from Virginia, originally asked that we take a look at rural communities preparedness to respond to terrorism and other kinds of events. So we went to your 50 state offices and said what does this look like where you are and it was really an interesting lesson for us. If you stop and think about it, on September 11th we all began to focus on the big cities as being most vulnerable and most appropriately we talked about placing the big push packs with the supplies near those major urban centers. But if you really stop and think about it, where are the missile silos? Where do we bury nuclear waste? Where are the nuclear plants? Where are the chemical plants? And if you wanted to waltz some particularly nasty pathogen into this nation, one of the easiest ways to do it, would be across the southern border or cross the northern border and it would be in this country in that part of the public health infrastructure that is weakest. So we did a report on the needs of rural communities around emergency preparedness. If you go to HRSA's website, you can click on rural health and you can access that report.
The other thing that we found was that most of the rural communities had a false sense of security; it could never happen here; we don't really have to focus on this, and yet those are the parts of our nation that have limited, if any, access to hasmat materials that have no surge capacity. The folks from New Hampshire and Vermont are saying God forbid something happen in Boston and New York because everybody is going to fly out in our direction and we don't the capacity. So it's certainly something that we need to think about. As the Administration has been preparing its response to bio-terrorism, it has required and requested that the states include their 50 State Offices of Rural Health in those discussions.
I want to close by talking about the Secretary's Rural Initiative. This was a really exciting thing for our office and I think it's been very useful for the department at large. Essentially what Secretary Thompson did was create an HHS wide task force to look at how the department serves rural America on both the health and the human services side. And so we did; we went back to all of the agencies, all of the operational divisions and staff divisions, and looked at our programs and looked at where we had investments in rural communities; the location of those investments and we asked each of the agencies to determine where there might be barriers to better serving rural America, whether they are regulatory, resource, administrative. After that we went and tried to determine ways that we might improve how we served rural communities and we've prepared a report and we've made some recommendations.
As you all know, this is Washington and one of the things that you can do to quickly get yourself in trouble is to scoop the people ahead of you or above you and so this has not been rolled out, but let me give you a sense for the kinds of things that we found and I would anticipate that within the next month Secretary Thompson will have an opportunity to talk more broadly about what we're proposing to do to help us better serve your folks.
The mantra that our task force came up with was "out of the silo and into the barn". Part of what we're done and made it hard to rural communities to access services is we've made them very categorical and if you think about it, if you are a mayor of a very small rural town and you want to access services, and you're really ambitious and there's lots to be done, and you want to improve access to some kind of service for your community, you have to figure out some way to engage a department with more than $300 billion in resources and 65,000 employees coming through more than 225 discreet programs that serve rural communities. It's a daunting task. So what we're seeking to do is make one place for rural communities to go to find information for both health and human services. To better coordinate our technical assistance, right now what we do, the Substance Abuse and Mental Health Services Administration does technical assistance for their grants and HRSA, Sam and I do technical assistance for our grants and ACF does technical assistance for its grants and you have to go to all of those to try to find resources to address your rural needs so we're going to improve that.
We're also looking at some community base planning and hopefully we'll find a better way to use technology to mapping our existing resources and target new ones. We should be able to. Put the states up, look at where our investments are and say okay, on the western part of this particular state we're not doing much around mental health services. What could we do to better improve access? So that's something else that we will engage, you and others focusing where we need to put our resources.
Just so you know, we asked the states, we asked all of our constituency groups about sort of as we go down the line we begin to look at the programmatic side rather than we the way we do business, more than what we do and what we could do to improve access in frontier and rural communities. The three things that came up most frequently were transportation. You can put it there but nobody can get to it, which I think is pretty instructive to the department. We need to work better with the Department of Transportation and others to find better ways to get either folks to the services or services to the folks. The other two areas we heard a great deal about were mental and dental health, access to dental health. 11% of the folks who live in rural communities have never seen a dentist. So you can imagine the incredible need that remains in rural America.
We've got suggestions about financing. CMS, it was really interesting the kinds of comments that we got. They ranged from "You go Tommy", those are the folks in Wisconsin, "You go Tommy" this is the great thing to do; to a 26 page discussion of the nuances of the wage index. So what we've done is taken those comments and essentially we've triaged them and we've sent them to the agency of jurisdiction. So if it has something to do with the Food and Drug Administration, if it has something to do with HRSA, we sent it to those agencies and said this is what we heard about the way we create barriers, a way folks can't access your services. That's been a pretty interesting lesson to us all, I think, that these are the things that came out that we could do first and foremost to make it easier.
Just a couple of things that might be of interest to you. We have a vehicle, the National Rural Health Association, NRHA that acronym, and they support your state rural health association meetings. We have asked them as a condition of getting that support to require some session at your state meeting that looks at how the states might better integrate health and human services. In rural communities, as you know, the infrastructure is so limited. If you have a head start, that's a place to begin. Then cobble other services on it but in many of the states, it's just as problematic as it is at the federal level where we have discreet health folks over here and human service folks over there. So we're encouraging a similar kind of discussion at the state level.
We're also trying to find ways to connect the tribes and local providers and we have a couple of demonstrations taking place. That's a real quick overview of what's happening at the federal level and how I'm hoping that we are interacting with you at the state level and with that Tim, I will close and take questions. Thank you.
QUESTION: First of all I want to say thank you for the work that you're doing nationally to help the rural areas such as Nebraska. We did pass a bill that I'm very excited about and it kind of ties into the previous session we just had. We now allow EMS personnel to work in a hospital setting under the supervision of either an RN, a physician's assistant or a doctor providing they have the EMS training and it's up to date, etc.. We have many hospitals that are 6, 8, 10 beds and if you have any kind of emergency, boy they need hands and this is an excellent place that they can get that personnel to help them, through an intermediate area or for whatever circumstance and we're really excited about it.
We've heard about that demonstration and one of the things that we think is interesting about that also is that if you are a rural EMS provider, you don't do a lot of runs and it's really hard to keep your skills up, but if you are based in the ER, then you are more likely to see and participate in those things that make you better in establishing a line or whatever you need to do. When we have our EMS technical assistance center and we showcase those things that are working we'll be sure to put Nebraska's up there.
QUESTION: Marcia, maybe you could talk a little bit more about this new money that the state offices are getting and the kinds of things they want to do beyond what they've been doing before. I think that might be of interest.
The new money that the state offices got in 2002 essentially allowed the states to increase the number of staff that they had, so if they had been in an office with one staff person they drew down additional resources, matched them with your state dollars and increased the size of their staff. The state offices vary from a one-person staff to Texas which has a staff that I envy, I think they've got in the 20's; they're fairly substantial.
One of the things that we're concerned about and certainly you all have been hearing is that as states seek, in economic downturn, to balance its budget that there are a couple of states that have not been able to match those additional resources and get additional resources for those State Offices of Rural Health. We're trying to work with them in any way we can and give them any flexibility that we can but the language is pretty specific that the dollars have to be matched. However, if your state needs to come up with creative ways to demonstrate it, they've made that match. There are several folks out there who have thought of ways to do that.
Other thing we're trying to do is insure that as we get new programs on line, the AED dollars, the hospital performance improvement dollars that go to HIPAA, that the state offices have a large role in coordinating and working with your community so that we get the largest economy of scale that we can because of the better coordination that the state office can provide.
QUESTION: One thing that I think maybe would be of interest to many of you is that most of you I think have some kind of state-wide entity that deals with economic development issues and one of the things that I know that we've talked about in NCSL through this new rural development task force that actually Marcia came and spoke to in San Antonio last summer, was the whole idea of how we can integrate health care more into this economic development process that happens at that level and also at the local level and I know Marcia has made some reference to that in her remarks. She more specifically made reference to some integration and other activities related to health and human services, but I think most of us would say fairly that economic development is a big driver in a lot of your rural areas and how you effectively integrate rural health issues into that and I'd like to know if any of you, in your own states, feel like you've made some progress in that area, if you'd like to speak to that.
One other thing I'd like to bring up, Sam reminded me that those of you who are from states that are frontier and I guess by definition that's 7 or less per county, depending on whose definition you're using and we can waste a lot of time squabbling about definitions but I think it's important to know that when we talk about rural, we're also talking about frontier, that that's sort of our intellectual shorthand for states that have frontier counties and that the department, certainly the agency, HRSA, is beginning to think about in some ways looking at our programs and seeing how we can do a better job of serving those most frontier counties. As Sam said we spent some time in Alaska where the Alaskans spent a great deal of effort insuring that we understood that Alaska was unique and oh, by the way so is Hawaii and so is Nevada and Utah and the other states that have frontier counties. In addition to hearing the Secretary begin to talk about his rural initiatives, I think you're going to hear more about frontier as well too.
We kind of got a charge out of the way that folks use to describe how Alaska was unique. In every room in Alaska there is some individual who has figured out how many times his or her state is bigger than yours and so if you say hi, I'm Betty James Duke and I'm from New Jersey, the person will say well you know, Alaska is 73 times bigger than New Jersey. Then there's the other one that I think that the folks from Texas might enjoy and that is that if you divide Alaska in half, it is still bigger than Texas; take that you Lone Star State. But the recognition, that distance and geography is a barrier in those areas that we've not begun to address through our programs is being realized with people who are in a position to do something about it. So with that I will let you break.
QUESTION: Judy Lee from North Dakota. It isn't just hospital and clinic services obviously they're involved with rural health. I've been serving several years on a Hospice board and one thing that's been of grave concern to us is that federal funding for rural Hospice services was reduced because of the idea that it cost less to provide those services in a rural area than it did in an urban one. Well perhaps the salaries might be higher but particularly for something like Hospice services, which are provided continually over the period of a 24-hour day. The mileage of somebody is 20 miles out in a farm or ranch setting means a lot of windshield time and not much face-to-face time. So I would really urge whoever has some influence on this to make sure that those kinds of home base services that are being provided, because a lot of Hospice services are not provided. We have no Hospice facility. All of the services in our Hospice are done in several counties, through homes and they can provide for them in hospital and long-term care facilities as well, but primarily in homes. It really is a difficult financial challenge with the constraints that exist, the number of volunteer hours and there's a lot of volunteer involvement but the reduction in funding was a critical issue. So I certainly would hope that we might see better support for that in the future.
We battled the myth that it is cheaper to provide health care in rural communities pretty much on a daily basis because there's this notion that there is slack in the system and if you just squeeze hard enough; the most rural communities were running pretty tight already and there's nothing to squeeze and there will never be the economy of scale that you might accomplish in a more urban setting. Certainly Hospice services and a number of other services have the same difficulties.
One of the things that's been really good, I mean really good about CMS; I don't know, they changed their name, they suddenly got more responsive. Center for Medicaid and Medicare Services, formerly known as HCFA, has really been interested in looking and listening to rural communities. There is a monthly rural listening session where providers can talk; usually Mr. Scully is on the phone but if not, it Mr. Drissler or someone else whose very close to Mr. Scully, and the conditions are bring to us things that are regulatory, not statutory, we can't fix them on the phone, but bring to us things that are regulatory and we will try to address them and there have been a number of changes that are the outcome of that direct communication.
The other thing that's been very helpful for us as an Office of Rural Health policy is that we monthly meet with CMS staff on those things that we see as issues that maybe haven't made it through those calls. So there's been a real change in willingness I think to respond to rural issues and certainly this is one that I will take back. Thank you.
QUESTION: Cora Sue Price, North Dakota. Being you've got tribal up there, one of the things that may enter into your discussion too is just the tribal attitude about some things. When we rolled out our CHIP program we had absolutely no enrollment on one reservation in particular so we made a trip up there to meet with them and basically the tribal leader and the liaison said we have INS; that's our treaty, or Indian Health Services, not INS and we shouldn't need CHIP or Medicaid. They were discouraging enrollment of the children into CHIP. So it's not just the fact on the providers and that. You might have the providers there but the tribal leaders may be recommending that they not sign up. And if we do invite you to North Dakota when you come we want to get you out of the Office of Rural Health because that's in one of our largest cities and we'd like to take you out in rural North Dakota. We have 36 of 53 frontier counties.
When I visit states they always make sure that we go at least 3 hours in some direction because that's how you make a day out of it. The tribal issues are particularly complicated but it's been very interesting, the Secretary's task force gave the folks from IHS an opportunity to interact with folks they had really been having difficulty getting traction with. So you might begin to see some of our programs become more culturally appropriate or be more thoughtful about how the tribes experience the federal programs.
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