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Rural Health Briefing Vol I, No. 2 August 22, 2000
An E-Health Newsletter published by the Arizona Critical Access Hospital (CAH) Program of the University of Arizona Rural Health Office
Table of Contents
1. Update: Critical Access Hospitals Program
a. Rural Health Office Receives CAH Grant Award
b. Rural Health Works Meeting
2. Arizonans Appointed to US-Mexico Border Health Commission
3. Arizona Tribal News: Navajo Nation to Establish Independent Health Care System
4. National Health Service Corps Emergency
5. Rural Ambulance Services Payment Problems
6. New Managed Care Technical Assistance Center
7. Kaiser Studies of Medicare Prescription Drug Issues
8. Senator Kyl Offers Prescription Drug Legislation
9. How to Contact Your Representatives
a. Congressional Delegation
b. State Legislators
10. Reminder: Rural Health Outreach Grants
a. Grant Application Information
b. Technical Assistance
11. Reminder: Rural Health Network Grants
a. Grant Application Information
b. Technical Assistance
12. Other Opportunities
a. Featured Grant Opportunity of the Month
b. Continuing Grant Opportunties
13. Conferences Relevant to Rural Health
14. Other Useful Information
a. HRSA Community Health Status Reports
b. HRSA State Profiles
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Editor’s Note: This online newsletter is a project of the Arizona Rural Hospital Flexibility Program, supported by the Federal Office of Rural Health Policy. The goal of the Flex Program is to improve the financial viability and stability of rural hospitals by creating a new designation for Critical Access Hospitals (CAHs). Designated CAHs are eligible for cost-based reimbursement for services provided to Medicare patients. For more information, please visit the project web site: http://www.rho.arizona.edu/cah/azruralflex.html.
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1. Update: Critical Access Hospitals Program
a. Arizona Rural Health Office Receives CAH Grant Award: The Rural Health Office has received notification from the Federal Office of Rural Health Policy, HRSA, that the Rural Hospital Flexibility Program will be funded in Arizona for another year. The "Flex" Program as it is commonly called, makes possible the designation of Critical Access Hospitals in the state. Plans for the coming year include completion of more fiscal analyses of rural hospitals which are considering requesting CAH designation, developing networks with those facilities, and focusing on improvement of emergency medical services. For further information about how a rural hospital can pursue this opportunity, contact Alison Hughes, Project Director, at 520/626-7946, or her Administrative Assistant, Anne Trombley, at the same phone number.
b. Rural Health Works Meeting: On August 21, the Rural Health Office, under the aegis of its Flex Program, sponsored a meeting to examine how the Rural Health Works Program can be implemented in potential Critical Access Hospital communities in the state. Representatives of the RHO, the Arizona Department of Health Services, the Arizona Association of Community Health Centers, and the Arizona Community Foundation were presetn for a five-hour training session led by Dr. Gerald Doeksen of Oklahoma State University. The session focused on how IMPLAN data can be used to show the economic impact rural hospitals have on their local community infrastructures. The steps will be to use the data for community development activities in the coming year in those communities where the hospitals are considering CAH designation.
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3. Arizona Tribal News: Navajo Nation to Establish Independent Health Care System: The Navajo Nation Division of Health recently announced that its Office of Self-Determination filed Articles of Incorporation with the Navajo Business Regulatory Department in April to establish the Navajo Health Care System (NICS) Corporation, an independent non-profit corporation to be governed by a central Board of Directors and managed day-to-day by its Chief Executive Officer. The purpose of the corporation is to establish a health care system that is neither federally nor tribally operated. The Nation reports that base funding (annual congressional appropriation) will continue, but flow directly to the Navajo Health Care System Corporation, rather than through the Navajo Nation government, and all revenues generated by the system will stay the NICS to supplement health care delivery services.
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4. National Health Service Corps Emergency: A recent Washington Post editorial distributed to members of the National Organization of State Offices of Rural Health calls for increased funding for the National Health Service Corps, which subsidizes doctors and other health professionals who agree to practice in urban and rural areas that lack sufficient health care providers. Medical students can apply for scholarships in exchange for service after graduation, or medical school graduates can get grants to help pay off student loans in return for a promise of two years’ service.
An article in the Arizona Daily Star, July 30, 2000, "Health Workers Left Holding the Bag," reports that approximately 700 doctors, dentists, psychologists and other health professionals have signed up for two-years of service in poor urban and rural areas, many them passing up other job offers in order to pay off student loans through the National Loan Repayment Program, and many of them already working in underserved communities, only to find out afterwards that the money is not available to pay them.
Reasons: Funding has been flat in recent years, meaning that in real terms it has declined, and both the scholarship and the loan repayment program have had to turn away applicants for lack of funds. Last year, the loan repayment program could fund only half its requests. This year, the Department of Health and Human Services cut the program’s budget to meet other spending requirements set by Congress. Grants were awarded to people still waiting for awards from the previous year, and some grants were awarded to providers who have already served two years, in order to retain them in those communities.
Associations of rural and urban health care centers, which employ doctors under this program, are lobbying for a doubling of the loan repayment budget as part of a reauthorization pending in the Senate. The 1989 law authorizing the grants is scheduled to expire September 30, and, because members of Congress are not familiar with the program and the issue does not receive the public attention that other health care issues receive, there is concern that the program may not be reauthorized.
As no one has championed NHSC funding in the past several years, grassroots support is needed to shore up a worthy program that brings needed health care professionals to underserved communities. We recommend that those concerned about this issue contact their Congressional representatives.
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5. Rural Ambulance Services Payment Problems: A July 2000 report of the General Accounting Office (GAO) analyzes current and proposed Medicare fee schedule payments for rural ambulance services. In the Balanced Budget Act of 1997, Congress directed HCFA to develop an ambulance fee schedule by January 1, 2000 that reflects the different types of ambulance services provided. Development of the new fee schedule was delayed, and is now scheduled to be implemented January 1, 2001.
Current Medicare reimbursements for ambulance services are based on historical charges for freestanding providers (non-hospital based) and reasonable costs for hospital-based providers. The proposed schedule will standardize payment rates across provider types and will be based on national rates for particular services.
"Because many rural ambulance providers serve a large geographic area with a low population density, they face a set of unique challenges. Unless they rely on volunteers, they tend to have high per trip costs because of the lower volume of tansports as compared to urban and suburban providers. Rural providers also tend to have longer ambulance transports than their urban counterparts, making the adequacy of reimbursement for mileage costs more central to their overall payments than for providers in more densely population areas. In addition, because rural residents may have fewer alternatives for transportation to hospitals, ambulances may transport some beneficiaires whose conditions do not allow for Medicare reimbursement. Furthermore, revenue sources are changing for rural providers with an increasing reliance on Medicare revnues. Moreover, maintaining volunteer staff,s which are more common in rural than urban areas, is becoming more difficult."
"The proposed Medicare fee schedule will alter the way rural ambulance providers are paid. Much of the variation in payment rates among similar rural providers will be eliminated. Some providers that now are paid more than the national average are likely to receive lower payments under the fee schedule. Others, including rural South Dakota providers, that are paid less than the national average are likely to receive increased payments. In addition, proviers that transport beneficiaries in rural areas will receive enhanced payments intended to help sustain essential ambulance service in sparsely populated areas. However, this adjustment does not sufficiently distinguish the providers serving beneficiaries in isolated areas and may not be applied appropriately. Therefore, . . . (it is recommended) that HCFA refine the payment adjuster to better target the necessary fixed costs of essential providers in isolated areas. HCFA agreed with this recommendation and said it would take action to obtain the information needed to enable better targeting in the future."
The full text of the GAO report is available online: http://www.gao.gov/new.items/he00115.pdf.
We recommend that those who are concerned about this issue make their views known to HCFA.
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6. New Managed Care Technical Assistance Center: HRSA has just announced the establishment of a new Managed Care Technical Assistance Center (MCTAC). It is accessible toll-free (1-977-832-8635). Its purpose is to offer on-site assistance and workshops about managed care issues, such as:
(a) Training clinicians and medical directors to deliver high-quality, cost-effective care to Medicaid and medically underserved people in a managed care system;
(b) Building relationships between public health and managed care;
(c) Securing and negotiating the best managed care contracts;
(d) Improving management information systems to serve Medicaid-covered patients.
You can learn about co-sponsoring workshops, technical assistance, or other MCTAC activities via the toll free number above or via the project website: http://www.jsi.com/hrsamctac.
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7. Kaiser Studies of Medicare Prescription Drug Issues: The Kaiser Family Foundation recently published three reports examining issues involved in providing prescription drug coverage for Medicare beneficiaries. "While there is broad consensus on the need for prescription drug coverage for Medicare beneficiaries, major differences remain on how to achieve that goal."
"The Implications of Medicare Prescription Drug Proposals for Employers and Retirees" (July 2000) examines the potential savings for employers who currently represent the largest source of drug coverage for seniors.
Among the findings of the report: (1) Employer prescription drug spending for 65+ retirees would be $22.5 billion in 2003 (the first year in which several major legislative proposals would take effect); employer drug spending will rise to $37.1 billion in 2009, absent any change in law and assuming continuation of current coverage; (2) Under a Medicare Part D prescription drug proposal, employers would save between $5.1 and $8.4 billion in the initial year of the proposed program (2003) and between $11.0 and $15.0 billion when the maximum benefit would be available in 2009; 3) Under the Premium Support approach, employers would save between $5.5 and $8.5 billion in 2003 and between $10.1 and $14.1 billion in 2009.
A second report, "Analyzing Options to Cover Prescription Drugs for Medicare Beneficiaries" (July 2000) provides a useful explanation of the potential impact on beneficiaries of three basic approaches taken by various proposals -- Full Medicare without Stop-Loss; Full Medicare with Stop-Loss, and Medicare/Private Plan.
Findings: (1) Coverage: All prototype proposals would significantly improve the proportion of Medicare beneficiaries with coverage for outpatient prescription drug expenses; more Medicare beneficiaries would have prescription drug coverage under the Full Medicare approaches (99%) than under the Medicare/Private approach (89%).
(2) Low-Income Protection: All prototype proposals would provide significant financial protection against the costs of outpatient prescription drugs for low-income beneficiaries through premium and cost-sharing subsidies up to an annual coverage limit; low-income beneficiaries would still be liable for prescription drug costs above that limit and below the stop-loss threshold in two of the prototypes; many low-income would be eligible to receive Medicaid assistance for those remaining costs (although experience has shown a significant number of the low-income do not participate in Medicaid programs).
(3) Stop-Loss: Under Full Medicare with Stop-Loss, the stop-loss threshold is $4,000 in 2003, compared with $6,000 under the Medicare/Private approach; these differences widen in 2009.
(4) Indexing: Full Medicare with Stop-Loss uses percentage change in drug prices to index benefit parameters; if total drug spending grows faster than drug prices, more enrollees would trigger the stop-loss threshold and the proportion of drug expenditures borne by the government would increase. The Medicare/Private prototype uses an index of the annual percentage change in total per capita drug spending for Medicare beneficiaries, which maintains the proportion of drug spending by the government at about the same level, but provides less protection to beneficiaries over time because it has the effect of raising the stop-loss threshold higher.
(5) Benefits: Full Medicare without Stop-Loss emphasizes providing very limited coverage to the broadest possible number of participants rather than targeting those with high drug expenditures; the addition of a stop-loss component, with the costs of that portion of the benefit paid fully by the government, provides significant financial protection to beneficiaries, but also significantly increases the government’s financial commitment. The Medicare/Private approach imposes a front-end deductible which reduces costs by lowering benefit payments and promoting less utilization; however, imposition of the deductible makes the coverage less attractive to those with less need for prescription drugs.
(6) Subsidy Levels and Government Spending: Full Medicare options have more generous subsidies and a much higher benefit level for enrollees, which would achieve greater participation and lower out-of-pocket expenditures for Medicare beneficiaries. Gross costs to government would be substantially higher under the Full Medicare with Stop-Loss approach ($75 billion in 2009) than under the Medicare/Private approach, with less generous subsidies ($35 billion).
(7) Role of Private Sector: Full Medicare approaches would have the government contract for administration of the benefit, but the benefit parameters would be federally defined and risk would be borne by the government. The Medicare/Private prototype seeks to subsidize the costs of coverage, but leaves more to the private market to define the benefit options and to assume the financial risk.
A third report, "A Side-by-Side Comparison of Selected Medicare Prescription Drug Coverage Proposals" (August 2000) analyzes several major congressional and/or executive proposals to extend Medicare coverage to prescription drugs.
The full text of these reports are available on the Kaiser Family Foundation website: http://www.kff.org/content/2000/20000725a/
For those who cannot access the website, copies of the reports are available through the Kaiser publications request line at 800-656-4533.
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8. Senator Kyl Offers Prescription Drug Legislation: Senator Jon Kyl’s Weekly Column, July 28, 2000, outlines proposed solutions he supports to provide prescription drug coverage for the elderly. "For seniors with no access to prescription medicines, or for those who have access but must choose between medicine and food, I believe the government must act."
In addition to working with the bipartisan group of Senators supporting the Medicare Prescription Drug and Modernization reform bill (described in Issue No. 1 of the Rural Health Briefing), Senator Kyl has offered a separate bill, with Senator Chuck Hagel of Nebraska, the Medicare Rx Drug Discount Card and Security Act. This proposal would cap annual costs for prescription drugs at no more than $1,200 annually for seniors with annual income below $16,700 and couples with incomes below $22,500. Catastrophic coverage through drug providers and backed by Medicare would kick in for all costs above $1,200. For drug costs up to the $1,200 annual limit, seniors would pay 100 percent out-of-pocket, but the discount drug card would reduce costs below the retail price to a negotiated price. There would be an annual fee of $35 to enroll, but there would be no monthly premium. For more detailed information, contact Senator Kyl’s office (see contact information below).
Senator Kyl’s office reports he is also meeting with HCFA representatives and the appropriate Senate Committees to bring MC+Choice plans back to serve the rural communities’ Medicare beneficiaries, and he has secured a commitment from Nancy-Ann Min DeParle, Administrator of HCFA, that, should plans submit applications to enter or re-enter counties which have lost their MC+Choice plans, the agency will expedite the application process to get those seniors covered by an HMO type product as soon as possible.
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9. How to Contact Your Representatives
a. Arizona Congressional Delegation: Available through the Publication Technology Project at Arizona State University: http://aspin.asu.edu/~pctp/azdeleg.html. To get Congressional Handbook, http://www.congresshandbook.com. Links to Representatives are available at http://www.house.gov. Links to Senators are available at http://www.senate.gov.
Senate:
John McCain (R-AZ) DC Phone 202-224-2235; DC Fax 202-228-2862
State Offices: Phoenix 602-952-2410; Tucson 520-670-6334; Mesa 602-491-4300; Email: John_McCain@mccain.senate.gov
Jon Kyl (R-AZ) DC Phone 202-224-4521; DC Fax 202-224-2207
State Offices: Phoenix 602-840-1891; Tucson 520-575-8633; Email: info@kyl.senate.gov
House of Representatives:
Matt Salmon (R-1-AZ) DC Phone 202-225-2635; DC Fax 202-225-3405; Tempe 480-946-3600; Email: msalmon@mail.house.gov
Ed Pastor (D-2-AZ) DC Phone 202-225-4065; DC Fax 202-225-1655; Tucson 520-624-9986; Phoenix 602-256-0551; Yuma 520-726-2234; Email: edpastor@mail.house.gov
Bob Stump (R-3-AZ) DC Phone 202-225-4576; DC Fax 202-225-6328; Phoenix Phone: 602-379-6923.
John Shadegg (R-4-AZ) DC Phone 202-225-3361; DC Fax 202-225-3462; Phoenix 602-263-5300; Email: j.shadegg@mail.house.gov
Jim Kolbe (R-5-AZ) DC Phone 202-225-2542; DC Fax 202-225-0378; Tucson 520-881-3588; Sierra Vista 520-459-3115; Email: jim.kolbe@mail..house.gov
J.D. Hayworth (R-6-AZ) DC Phone 202-225-2190; DC Fax 202-225-3263; Mesa 602-926-4151; Flagstaff 520-556-8760.
b. Arizona State Legislators: Available through the Arizona Legislative Information System (ALIS): Call 1-800-352-8404 http://www.azleg.state.az.us/members/members.htm.
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10. REMINDER !!!!: Rural Health Outreach Grants
a. Grant Information: Program Guidelines for the FY 2001 Rural Health Outreach Grant Program are now available: http://www.nal.usda.gov/orhp/orprog01.htm.
To obtain Application Kit: Call 877-477-2123 (Request Kit #93.912A)
Deadline for grant proposals: October 16, 2000.
b. Technical Assistance: A grant application technical assistance conference call will be held on September 12, 2000, 2:00 pm Eastern Daylight Time. To participate in the call, email Lilly Smetana at: L Ismetana@hrsa.gov. Provide your name, telephone number, and fax number, and confirm you want to participate in the conference call. Anyone without email can call 301/443-6884. Reservations must be received by noon, September 11, 2000.
Technical assistance workshops will be held August 22 (Chicago), August 25 (Atlanta), and August 29 (Philadelphia). Call 1/877-477-2123 to be put on list for applications.
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11. REMINDER !!!! Rural Health Network Development Grants
a. Grant Information: Program Guidelines for the FY 2001 Rural Health Network Development Grant Program are now available: http://www.nal.usda.gov/orhp/netgde-1.htm
To obtain Application Kit: Call 1-877-477-2123 (Request Kit #93.912B).
Application Deadline: October 23, 2000.
b. Technical Assistance: Technical assistance workshops scheduled for the Rural Health Outreach Grant Program (see list above) will also include technical assistance for the Rural Health Network Development Grant Program.
For more information about the Rural Health Outreach Grant and the Rural Health Network Development Grant: http://www.nal.usda.gov/orhp/funding.htm
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12. Other Opportunities
a. Featured Grant Opportunity of the Month: Community-Initiated Prevention Interventions, sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA).
The purpose of the grant is to support knowledge development by soliciting applications for studies that field test effective substance abuse prevention interventions that have been shown to prevent, delay, or reduce alcohol, tobacco, or other illegal drug use and/or associated social, emotional, behavioral, cognitive, and physicial problems among at-risk populations in their local communitiy(ies) and/or other domains, including the individual, the famiy, the school, the health care provider, and the workplace.
Deadline: September 10, 2000
Contact: Application Kits: National Clearinghouse for Alcohol and Drug Information (NCADI) 800-729-6686. Programmatic Information: Soledad Samrano (301) 443-9110.
b. Continuing Grant Opportunities:
Current federal grant opportunities related to rural health are available at http://www.nal.usda.gov/ric/richs/grants.htm.
Foundations: Current Funding Programs and Master List is available at http://www.nal.usda.gov/ric/richs/foundat.htm.
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13. Conferences Relevant to Rural Health
AUGUST
* Strategic Planning for Rural Health Networks, Academy for Health Services Ressearch and Health Policy, Cambridge, Maine, August 24-25, (202) 292-6730.
SEPTEMBER
* Association of Telemedicine/Telehealth Service Providers Fourth Annual Conference, "Telemedicine and E-Health: Common Paths to the Patient," Minneapolis, MN, September 6-8 (800-852-3591 or 503-222-2406).
* Eleventh Annual Conference, National Organization of State Offices of Rural Health (NOSORH), Park City, Utah, September 13-16 (816-756-3140).
* Twelfth Annual Rural Nursing Conference, Centennial Area Health Education Center, Estes Park, Colorado, September 14-16 (970-330-3698).
OCTOBER
* Enhancing Outcomes in Women’s Health:Translating Psychosocial and Behavioral Research into Primary Care, Community Interventions, and Health Policy – An Interdisciplinary Conference, American Psychological Association, Washington DC, October 4-6 (202-336-6120).
* 2000/2001 Migrant Farmworker Stream Forums, Midwestern Stream, National Center for Farmworker Health, Albuquerque, New Mexico, October 26-28 (512-312-2700).
NOVEMBER
* 128th Annual Meeting of the American Public Health Association (APHA): Eliminating Health Disparities, Boston, Massachusetts, November 12-16 (202-777-2478).
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14. Other Useful Information
a. HRSA Community Health Status Reports: A new HRSA web site providing "snap shots" of the health status of 3,082 counties is now available: http://www.communityhealth.hrsa.gov.
The data (covering the years 1988 to 1998) is published in the Community Health Status Indicators Reports (CHSI) funded by HRSA and produced in collaboration with the National Association of County and City Health Officials (NACCHO), the National Association of State and Territorial Health Officials (ASTHO), and the Public Health Foundation (PHF). Data sources are existing national data or estimates.
Each county’s report has demographic information with some 20 to 50 "peer counties" of similar population size, density, age distribution and poverty levels for comparison. Health indicators include causes of death, summary measures of health for Healthy People 2010 goals, health disparities by race/ethnicity, measures of birth and death, health status compared to U.S. rate and compared to peers, environmental health, vulnerable populations, infectious diseases, child and adult preventive services use, risk factors for premature death, and access to care. Counties can submit additional information for inclusion as addenda to the reports.
We checked out the site by looking at the Cochise County data: The Relative Health Importance table has four categories of relative concern comparing Cochise County to its peers and to the U.S. Unfavorable Indicators: Cochise County rates are higher compared to U.S. and peers for premature births (<37 weeks), unmarried mothers with no care in first trimester, infant mortality, white infant mortality, post-neonatal infant mortality, breaast cancer, and motor vehicle injuries. Favorable Indicators: Cochise County rates compare favorably to both peers and the U.S. in low birth weight (<2500 g), teen mothers (<18), coronary heart diseasse, homicide, and lung cancer. Intermediate Indicators: Cochise County rates are higher than either its peers or the U.S., but not both in suicide, very low birth weight (<1500 g), older mothers (40+), neonatal infant mortality, colon cancer, stroke, unintentional injury.
HRSA expects this information to assist communities in health status evaluation and community health program planning. HRSA funds about $4.7 billion annually to communities and states for various health care initiatives, including a new $25 million Community Access Program, which will fund about 20 communities this fiscal year to build integrated health care networks to serve uninsured and underinsured residents. Grant applicants need to be aware of how their communities compare with others in the state, as well as around the country. If you cannot access the HRSA web site, contact your county health department.
b. HRSA State Profiles: Another new HRSA web site provides state health profiles: http://stateprofiles.hrs.gov/StateProfiles.asp. The site offers the ability to both view and print State Profiles data in a consistent 6-page format for each state for the years 1997, 1998, and 1999, as well as to create graphs to illustrate various health indicators. For example, we created graphs for Arizona illustrating (1) the percentage of the population living below 100% and 200% of the Federal Poverty Level (FPL), (2) the rate per 100,000 population for each of the 10 leading causes of death; and the percentages of insured by source of insurance compared to the percentage of uninsured.
In addition, hard copy versions of the State Profile for Arizona, Fiscal Year 1999 are available from the State Office of Rural Health (that’s us, folks! 520/626-7946) or the HRSA Information Center (888-ASK-HRSA (4472).\
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Please address comments, questions, requests, contributions, and suggestions to ahughes@u.arizona.edu. If you know of someone who would like to be added to our distribution list, or if you wish to be removed from the list, please contact atromble@rho.arizona.edu.
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