Recommendations by Year

Note: The bulk of the recommendations in the compendium focus solely on health care issues. Beginning in 2003, the Committee expanded its focus to also include human services. Recommendations on human services are only available from 2004 forward.

2021 | 2020 | 2019 | 2018 | 2017 | 2016 | 2015 | 2014 | 2013 | 2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 | 2005 | 2004 | 2003 | 2002 | 2001 | 2000 | 1999 | 1998 | 1997 | 1996 | 1995 | 1994 | 1993 | 1992 | 1991 | 1990 | 1989

2021 Recommendations

Rural Emergency Hospital

Recommendation 21-1

The Committee recommends that the Secretary provide flexibility in the enforcement of the 24-hour average length of service requirement at REHs to account for unexpected service volume surges (flu, COVID, accidents, etc.) and the relative availability of ambulance service transfer to an acute care hospital.

Recommendation 21-2

The Committee recommends that the Secretary allow for flexible staffing across the various clinical parts of an REH or in any other clinical operation it offers.

Recommendation 21-3

The Committee recommends that the Secretary ensure a flexible survey process for REHs that allows for the use of shared space (waiting rooms, furniture, entrances, etc.) to encourage co-location.

Recommendation 21-4

The Committee recommends that the Secretary allow for the doctor of medicine or osteopathy to be on-call, either in person or remotely (e.g., via telephone or electronic communication), to provide medical direction, consultation, and supervision for the services provided in the REH.

Recommendation 21-5

The Committee recommends that the Secretary ensure that Medicare Conditions of Participation allow the REH administrator to meet the requirement for a Nursing Home Administrator or that a licensed Nursing Home Administrator from a nearby facility can serve in that role.

Recommendation 21-6

The Committee recommends that the Secretary require REHs to report on the applicable measures specified in the CAH Medicare Beneficiary Quality Improvement Project (MBQIP) for Outpatient, Patient Safety, and Care Transitions.

Recommendation 21-7

The Committee recommends that the Secretary work with rural stakeholders to develop low-cost and efficient methods to appropriately measure patient experience quality of care in REHs.

Recommendation 21-8

The Committee recommends that the Secretary ensure that calculation of the Additional Facility Payment includes services provided in CAH swing beds as part of the actual Medicare payments made to CAHs in 2019.

Recommendation 21-9

The Committee recommends that the Secretary direct the Assistant Secretary for Planning and Evaluation to study and model the appropriateness of the Additional Facility Payment to maintain emergency and outpatient services as well as provide community benefits in the first year of REH implementation.

Recommendation 21-10

The Committee recommends that the Secretary include REHs as Essential Community Providers at 45 CFR § 156.235 for Qualified Health Plans through the Federally-facilitated Marketplaces.

Recommendation 21-11

The Committee recommends that the Secretary ensure that REHs have flexibility in establishing transfer agreements that link transfer to Level I or II trauma centers to patient need while also allowing transfers to other hospitals as clinically indicated.

Recommendation 21-12

The Committee recommends that the Secretary, working through the Assistant Secretary for Planning and Evaluation, assess whether REH eligibility should be expanded to meet health care access challenges in rural communities.

Recommendation 21-13

The Committee recommends that the Secretary work with Congress to provide needed technical assistance to communities considering the REH model.

Recommendation 21-14

The Committee recommends that the Secretary expand eligibility for the National Health Service Corps, the Nurse Corps, and the State Loan Repayment Program to REHs to help them address rural workforce needs and support a funding request to account for the additional eligible entities.

Recommendation 21-15

The Committee recommends that the Secretary work with Congress to expand eligibility for the 340B Drug Pricing Program to include REHs.

Recommendation 21-16

The Committee recommends that the Secretary engage in a formal consultation process with tribal communities on possible options for adapting the REH model to serve tribal communities.

2020 Recommendations

Maternal and Obstetric Care Challenges in Rural America

Recommendation 20-01

The Committee recommends the Secretary encourage the adoption of comprehensive, integrative, and intensive case management within the Healthy Start, Early Head Start, and the Maternal, Infant, and Early Childhood Home Visiting Programs.

Recommendation 20-02

The Committee recommends the Secretary develop guidelines and implement safety and treatment protocols in rural hospitals and clinics, both with and without OB services, to respond to obstetric complications.  In addition, the Committee recommends that the Secretary encourage states to utilize and implement the Alliance for Innovation on Maternal Health (AIM) bundles, particularly the AIM Maternal Safety Bundle for the Reduction of Peripartum Racial/Ethnic Disparities.

Recommendation 20-03

The Committee recommends that the Secretary enhance CDC funding for both the CDC Levels of Care Assessment Tool (LOCATe) program and the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) program to ensure all states have standardized assessments of levels of maternal and neonatal care and Maternal Mortality Review Committees.

Recommendation 20-04

The Committee recommends that the Secretary work with states to standardize scope of practice laws between and within maternal health care providers, and to expand the scope of practice for nurse midwives.  This issue is of particular concern in rural areas given the shortage of obstetric providers. Certified Nurse Midwives can play a critical role if allowed to practice to the extent of their training.

Recommendation 20-05

The Committee recommends that the Secretary, in support of the Administration’s broader graduate medical education goals, include an expansion of the current statutory cap on Medicare-supported residencies that allows for support of new rural residencies in high-need areas like primary care and obstetrics.

Recommendation 20-06

The Committee recommends that the Secretary address the obstetrical workforce shortage by working with Congress to increase support for the National Health Service Corps to expand the number of physicians, nurses and certified nurse midwives working in rural and underserved areas.

Rural HIV Prevention and Treatment Challenges

Recommendation 20-07

The Committee recommends the Secretary, in modernizing the Ryan White HIV/AIDS Treatment Extension Act of 2009, focus on enhancing the ability of the program to meet the needs of rural communities.  This includes:

• Increased rural-targeted funding to support pilot programs and capacity building and, when issuing Notices of Funding Opportunities, consider having rural as a funding factor and giving rural applicants in a designated Health Professional Shortage Area additional consideration through the use of Preferences.
• Expansion of the use of telehealth and telemedicine to increase access to services and reduce stigma in rural populations.

Recommendation 20-08

The Committee recommends the Secretary, in maximizing the scientific advances  made in HIV prevention, to increase access to Pre-Exposure Prophylaxis (PrEP) for rural residents through the existing statutory authority in Sections 330 and 330A of the Public Health Service Act (HRSA's Community Health Centers Program and the Rural Health Care Services Outreach Program, respectively).

Recommendation 20-09

The Committee recommends the Secretary support a streamlined grant application process for resource strapped rural providers, as well as more virtual grant writing technical assistance for rural communities to enhance their ability to successfully apply for health and human services funding.

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2019 Recommendations

Examining Rural Cancer Prevention and Control Efforts

Recommendation 19-01

The Committee recommends the Secretary support combined funding from the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the National Cancer Institute to develop, implement, and evaluate a rural patient navigation program to enhance care coordination, particularly in tribal communities and persistent poverty counties.

Recommendation 19-02

The Committee recommends the Secretary work with Congress to increase funding to expand the National Cancer Institute’s Rural Cancer Control Program and partnerships with rural and tribal providers in implementing cancer control projects.

Recommendation 19-03

The Committee recommends the Secretary and the Department of Health and Human Services implement a national educational campaign to promote the broad range of cancer-related clinical information and resources supported by the Department to enhance cancer care for clinicians in rural and underserved areas.

Recommendation 19-04

The Committee recommends the Department of Health and Human Services conduct more targeted outreach for rural providers on how to use existing Medicare codes (e.g., chronic care management) for cancer care coordination.

Recommendation 19-05

The Committee recommends the Centers for Disease Control and Prevention require states, territories, and tribes/tribal organizations to assess rural-urban cancer mortality rates as part of their cancer control plans and, where appropriate, develop and implement rural-focused cancer control goals, objectives, or strategies, particularly in areas with higher rural cancer mortality rates.

Supportive Services and Caregiving for Older Rural Adults

Recommendation 19-06

The Committee recommends the Secretary create a comprehensive resource on the aging and long-term services and supports offerings for older adults in rural areas.

Recommendation 19-07

The Committee recommends the Secretary continue to expand flexibility in Medicare telehealth billing and provide a comprehensive resource of telehealth offerings in rural areas.

Recommendation 19-08

The Committee recommends the Secretary ensure the promotion and encouragement of age-friendly concepts within rural health grant programs.

Recommendation 19-09

The Committee recommends the Secretary explore the entry of Medicare Advantage Dual-Eligible Special Needs Plans into rural areas, identify potential barriers, and work with states to adopt policies that encourage or expand the reach of these plans to rural beneficiaries.

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2018 Recommendations

Rural Health Insurance Market Challenges

Recommendation 18-1

The Committee recommends the Secretary require the alignment of insurance plan service areas with rating areas for insurance programs under HHS authority, utilizing models that integrate urban and rural areas in a region to increase risk pool size. Under this model, the Committee recommends requiring full participation across the rating/service area rather than allowing insurers to offer products to only a portion of the rating area.

Recommendation 18-2

The Committee recommends the Secretary require states have processes in place to streamline the transition from Medicaid to the individual market (or vice versa), reducing the churn between the two and minimizing lapses in insurance coverage.

Recommendation 18-3

In order to encourage insurer participation in rural areas, the Committee recommends the Secretary allow more flexibility in network adequacy standards in rural areas when there are provider and/or plan shortages.

Recommendation 18-4

The Committee recommends simplifying the process for requesting and justifying network adequacy exemptions.

Recommendation 18-5

The Committee recommends that HHS provide technical assistance for under-resourced rural providers to enhance their ability to effectively negotiate with insurers.

Recommendation 18-6

The Committee recommends the Secretary supports efforts to educate providers and consumers on the availability of insurance products for individuals and small employers to promote consumer engagement.

Recommendation 18-7

The Committee also recommends educating providers on insurance options to help inform their network  participation decisions.

Exploring the Rural Context for Adverse Childhood Experiences (ACEs)

Recommendation 18-8

The Committee recommends the Secretary develop and implement a comprehensive prevention strategy that identifies priority outreach/awareness, programming, research and policy areas to address toxic stress, trauma and the health consequences of ACEs for rural, tribal and other at-risk populations.

Recommendation 18-9

The Committee recommends the Secretary support research that that evaluates the long-term economic costs resulting from ACEs and benefits gained from federal investments in ACE-related prevention programming.

Recommendation 18-10

The Committee recommends HRSA’s MCHB establish and include a predefined variable for “Rural-Urban Status” in the NSCH to allow for standardized analyses of ACE prevalence.

Recommendation 18-11

The Committee recommends the Secretary seek additional funding for telehealth-supported SBHCs in rural areas as a way of increasing access to integrated primary and behavioral health care services.

Improving Oral Health Care Services in Rural America

Recommendation 18-12

The Committee recommends the Secretary consider the development of a rural dental practice capital grant program that would be contingent upon the provision of services to Medicaid recipients in rural and underserved areas.

Recommendation 18-13

The Committee recommends HHS support a research study to assess rural Head Start grantees’ ability to ensure that qualified oral health professionals screen enrolled children, develop a treatment plan, and follow the treatment plan to completion.

Recommendation 18-14

The Committee recommends HHS support a research study to examine opioid prescribing patterns for dental pain in rural and urban areas.

Recommendation 18-15

The Committee recommends HHS support research studies to examine differences in the utilization and scope of insurance coverage for dental services among Medicare Advantage enrollees in rural versus urban areas.

Recommendation 18-16

The Committee recommends the Secretary charge the Oral Health Coordinating Committee to focus on rural oral health issues and to develop an action plan on improving rural oral health.

Addressing the Burden of Chronic Obstructive Pulmonary Disease (COPD) in Rural America

Recommendation 18-17

The Committee recommends the Secretary and the Department of Health and Human Services undertake a national campaign to educate rural primary care providers and individuals with COPD symptoms about rural-urban disparities in COPD outcomes with an emphasis on the need to do more screening and referral for effective treatments to help manage the disease.

Recommendation 18-18

The Committee recommends that prior to the next revaluation of outpatient prospective payment rates, the Department of Health and Human Services consult with experts in pulmonary treatment to refine the definition of rehabilitation services and, in Medicare cost reports, confirm that there is adequate accurate data on this service to be used as a basis for the rate.

Recommendation 18-19

The Committee recommends the Secretary work with Congress to expand direct supervision of pulmonary rehabilitation to include physician assistants, nurse practitioners and other primary care providers under general supervision of a physician.

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2017 Recommendations

Social Determinants of Health

Recommendation 17-1

The Committee recommends that HHS should develop a federal “Healthy Communities” designation that recognizes place-based, community-driven plans to address the social determinants of health and provides inter-agency federal support through preference points, technical assistance, and consolidated funding streams.

Recommendation 17-2

The Committee recommends that HHS should facilitate coordination and collaboration among hospitals, health systems, and human service providers on Community Health Needs Assessments and Community Benefit Agreements to support the development of local strategies to address the social determinants of health.

Recommendation 17-3

The Committee recommends that HHS should structure grant review panels to allow rural applicants to be reviewed as a separate cohort in order to compete against similarly resourced communities.

Recommendation 17-4

The Committee recommends that HHS should encourage the use of priority points for rural applications that face unique structural challenges related to the social determinants of health such as but not limited to geographic isolation, low population density, higher poverty and lower life expectancy.

Recommendation 17-5

The Committee recommends that HHS should offer technical assistance and Funding Opportunity Announcements which highlight ways rural organizations can factor in the administrative costs of effectively managing grants into their budgets and project plans.

Understanding the Impact of Suicide in Rural America

Recommendation 17-6

The Committee recommends that the Secretary require HHS conduct a national comprehensive evaluation that assesses existing state and tribal efforts to reduce rural suicide rates and that identifies successful evidence-based, rural-specific strategies that can be implemented within states and tribal communities.

Recommendation 17-7

The Committee recommends the Secretary require AHRQ and NIMH conduct research on the use of CHWs to determine if these efforts can reduce suicide risk and increase referrals for at-risk individuals. The study should look at cost-and clinical-effectiveness of these efforts and broadly disseminate findings.

Recommendation 17-8

The Committee recommends HRSA expand and increase the promotion of the Rural Health Care Services Outreach, Network and Quality Improvement grant programs through HHS partners to inform rural communities about the opportunity to incorporate suicide prevention activities and increase access to mental health services using grant funding.

Recommendation 17-9

The Committee recommends HHS Agencies and Offices promote the broader use of the PHQ-9 in rural hospitals and clinics and to educate providers on how to bill for services.

Recommendation 17-10

The Committee recommends SAMHSA include rural-specific research and considerations for prevention into the National Strategy, if it is revised and updated, to reflect existing rural suicide trends and disparities.

Modernizing Rural Health Clinic Provisions

Recommendation 17-11

The Committee recommends the Secretary work with Congress to obtain authority to reexamine and pursue a change in the statutee to adjust the payment cap for RHCs. In doing so, the Committee urges the creation of a formula for payments that ties payment cap increases to the current average cost per visit for RHCs currently under the cap.

Recommendation 17-12

The Committee recommends the Secretary work with Congress to provide grants to State Offices of Rural Health to support a state program that would provide technical assistance on quality reporting and other services to support the transition of RHCs to value-based care.

Recommendation 17-13

The Committee recommends the Secretary work with Congress to obtain authority to allow RHCs to be distant site providers for telehealth services under Medicare.

Recommendation 17-14

The Committee recommends the Secretary work with Congress to obtain authority to allow all RHC (non-physician) providers to order hospice and home health services and also allow RHC providers to be attending clinicians for hospice services in hospice shortage service areas.

Recommendation 17-15

The Committee recommends the Secretary work with Congress to obtain authority to allow masters trained behavioral health providers (e.g., licensed professional counselors, mental health counselors, or marital and family therapists) to be RHC practitioners for purposes of Medicare reimbursement if they are licensed to provide those services in their state.

Recommendation 17-16

The Committee recommends the Secretary publish a Request for Information to RHC providers on current RHC laboratory needs. Based on this information, the Committee recommends the Secretary use the authority granted in Public Law 95-210 to review and modernize lab requirements to reduce regulatory burden and allow flexibility in requirements to reflect patient population services.

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2016 Recommendations

Families in Crisis: The Human Service Implications of Rural Opioid Misuse

Recommendation 16-1

The Committee recommends the Secretary develop a 2018 budget request to expand Medication Assisted Treatment to include Rural Health Clinics, Community Mental Health Centers and Critical Access Hospitals

Recommendation 16-2

The Committee recommends the Secretary develop a 2018 budget request to support a rural demonstration project extending community mental health worker programs to shortage areas in recognition of limited capacity to address opioid misuse in isolated communities

Recommendation 16-3

The Committee recommends the Secretary work with Congress to designate rural as a special population under the Substance Abuse Prevention and Treatment Block Grants

Recommendation 16-4

The Committee recommends the Secretary ensure that all U.S. Department of Health and Human Services research on opioid abuse, overdose and treatment include rural-urban data cuts nationally and regionally to better inform policy and resource allocation

Alternative Models to Preserving Access to Emergency Care

Recommendation 16-5

The Committee recommends that any model for Rural Free-Standing Emergency Departments must include a supplemental base payment, separate from fee for service payments for Emergency Department visits.

Recommendation 16-6

The Committee recommends that the Department seek comment on use of a combination of distance and demographic or social determinants of health such as poverty and health outcomes when setting eligibility criteria for any demonstration project on alternative models.

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2015 Recommendations

Intimate Partner Violence in Rural America

Recommendation 15-1 

The Committee recommends that the Secretary direct the Centers for Disease Control and Prevention to conduct analyses of the National Intimate Partner and Sexual Violence Survey data with a geographic variable to gain a better understanding of the unique needs of individuals in rural America of all ages and throughout the life course experiencing IPV.

Recommendation 15-2

The Committee recommends that the Secretary direct the Administration for Children and Families (ACF) to work with Centers for Medicare & Medicaid Services (CMS), Substance Abuse and Mental Health Services Administration (SAMHSA), and the Health Resources and Services Administration (HRSA) to train rural health care providers on integrating IPV screening and counseling into service sites.

Recommendation 15-3

The Committee recommends that the Secretary direct ACF to work with SAMHSA and HRSA to connect health care providers who have been trained in IPV screening to community organizations that help individuals in rural America experiencing IPV.

Telehealth in Rural America

Recommendation 15-4

The Committee recommends that the Secretary seek a change in legislation to allow Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) to serve as eligible distant sites.

Recommendation 15-5

The Committee recommends that the Secretary revise the regulations that allow one telehealth visit for patients in nursing facilities from one encounter every 30 days to as many visits as clinically necessary but also medically appropriate for managing unanticipated acute situations.

Recommendation 15-6

The Committee recommends that the Secretary seek a change in legislation allowing home health certification and re-certification to take place via telehealth equipment within patients’ homes for rural beneficiaries in qualifying telehealth areas

Recommendation 15-7 

The Committee reiterates its recommendation in its August 2013 brief on the Medicare Hospice Benefit that the Secretary seek a change in legislation allowing telehealth consultations to count as face-to-face encounters to certify and re-certify the need for hospice care, as proposed in a previous Committee policy brief.

Recommendation 15-8 

The Committee recommends that the Secretary direct Centers for Medicare & Medicaid Services (CMS) and other HHS agencies to create standardized rural-relevant reporting metrics for telehealth

Recommendation 15-9 

The Committee recommends that the Secretary direct the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality (AHRQ), and/or other HHS agencies to conduct more evidence-based research on telehealth effectiveness, quality, and outcomes in rural areas

Recommendation 15-10  

The Committee recommends that the Secretary extend to all Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) the waiver of the telehealth regulations as proposed under the MSSP Accountable Care Organization proposed rule.

Mortality and Life Expectancy in Rural America: Connecting the Health and Human Service Safety Nets to Improve Health Outcomes over the Life Course

Recommendation 15-11

The Committee recommends the Secretary support research projects that examine behavioral health and primary care integration in rural communities to expand the evidence base for these efforts

Recommendation 15-12 

The Committee recommends that the Secretary direct the National Institute on Drug Abuse to conduct research into the rural-urban implications of opioid use and overdose, including the use and/or potential use of heroin

Recommendation 15-13  

The Committee recommends that the Secretary increase funding for training for primary care providers and all levels of emergency medical providers on the use of opioid overdose treatment drugs including naloxone

Recommendation 15-14 

The Committee recommends that the Secretary include key programs from the Health Resources and Services Administration, the Administration for Children and Families, the Substance Abuse and Mental Health Services Administration, and the Centers for Disease Control and Prevention in future Promise Zone competitions

Recommendation 15-15 

The Committee recommends that the Secretary enhance the departmental assessment, evaluation, and lessons learned from existing Community Health Worker projects in a manner that makes the findings easily accessible by the public

Recommendation 15-16 

The Committee recommends that the Secretary consider a budget request for funding under Title XII of the PHS Act to support trauma system training and designation for small rural hospitals in high mortality areas

Delivery System Reform and Implications for Rural Communities

Recommendation 15-17

The Committee endorses the recommendation of the National Quality Forum (NQF) that the Secretary encourage the Centers for Medicare and Medicaid Services (CMS) to require all rural providers to participate in CMS quality measurement and quality improvement programs, while allowing full participation to phase in across program types and explicitly addressing low case volume.

Recommendation 15-18 

The Committee endorses the recommendations of the NQF that the Secretary fund the development of rural-relevant quality measures, develop and/or modify measures to address low case volume explicitly, and align measure specifications and data collection requirements across each of the CMS quality programs.

Recommendation 15-19 

The Committee recommends that the Secretary encourage CMS to incorporate rural-relevant quality measures endorsed by the NQF into each of its quality measurement and quality improvement programs, with emphasis on measures that assess outpatient services and behavioral health impacts.

Recommendation 15-20 

The Committee recommends that the Secretary encourage CMS to pilot test a broader set of community-level health determinants (e.g., housing needs, housing conditions, transportation access, food access) when stratifying and risk adjusting health outcome data in ongoing and future payment demonstrations that include rural providers, including analyses at finer levels of detail than the state level (e.g., counties, Census tracts), to determine their influence on rural providers’ performance.

Child Poverty in Rural America

Recommendation 15-21

The Committee recommends that the Secretary create a position within the Department of Health and Human Services to coordinate the integration of regional health and human service systems for rural communities.

Recommendation 15-22

The Committee recommends that the Department of Health and Human Services commission a study to identify areas for revised safety net program eligibility that allow for the gradual growth in income and assets for families receiving assistance.

Recommendation 15-23

The Committee recommends that the Secretary integrate family asset building policies across appropriate health and human service delivery programs through technical assistance for local coordination between community health clinics, community action agencies and other family support organizations.

Recommendation 15-24 

The Committee recommends that the Secretary encourage the creation of flexible grant funding streams to encourage linkages between health systems, community health needs assessments and rural community development efforts.

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2014 Recommendations

Rural Implications of the Affordable Care Act Outreach, Education, and Enrollment

Recommendation 14-1

The Committee recommends that the Secretary evaluate the geographic efforts of year one enrollment and use that information to drive subsequent outreach, education, and enrollment efforts.

Recommendation 14-2

The Committee recommends that the Secretary work with the Internal Revenue Service to finalize the Community Health Needs Assessment Community Benefit reporting rules and promote the use of outreach, education, and enrollment as a way for non-profit hospitals to meet their Community Benefit requirement.

Recommendation 14-3

The Committee recommends that the Secretary direct the Centers for Medicare and Medicaid Services Advisory Panel on Outreach and Education to consider the unique needs of rural communities in the future.

Recommendation 14-4

The Committee recommends that the Secretary continue to work with rural human service providers such as Community Action Agencies to engage their client base in outreach, education, and enrollment.

Affordable Care Act Plans and Premiums in Rural America

Recommendation 14-5

The Committee recommends that the Secretary continue to educate states on the premium pricing implications of using small rating area designs in areas of low population density.

Recommendation 14-6

The Committee recommends that the Secretary use the authority in ACA Section 1311(c)(1)(C) to include Rural Health Clinics under the definition of Essential Community Providers to ensure that low-income rural consumers are able to identify and obtain health coverage under their insurance network.

Recommendation 14-7

The Committee recommends that the Secretary evaluate all 2014 Marketplace data, including premium pricing, enrollment, and network adequacy by rurality, to assist in future Marketplace planning and understand its impact on rural area consumer market place offerings.

Recommendation 14-8

The Committee recommends that the Secretary provide hospitals maximum opportunity to conduct outreach and enrollment without limitations on the circumstances in which they can inform their patients about health coverage opportunities.

Homelessness in Rural America

Recommendation 14-9

The Committee recommends that the Secretary, working through HHS’s representatives to the Interagency Council on Homelessness, direct the Council and its member agencies to consider the unique needs of rural individuals and families experiencing homelessness as a special population by creating objectives for the Council and/or its interagency working groups around ending rural homelessness.

Recommendation 14-10

The Committee recommends that the Secretary work with the Office of the Assistant Secretary for Planning and Evaluation, as well as relevant research bodies in the Department of Housing and Urban Development, to develop a demonstration project focused on giving entities that serve individuals and families experiencing homelessness, or those in need of prevention services, in rural areas additional flexibility in using existing funding streams from both agencies to meet the unique needs of rural populations.

Recommendation 14-11

The Committee recommends that the Secretary direct federal health and human services programs to clarify policy guidance on use of alternative mailing addresses for receiving benefits for individuals and families experiencing homelessness in areas where the Federal government has authority, and to encourage states to clarify policy guidance on the same issue for state programs.

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2013 Recommendations

Rural Implications of Changes to the Medicare Hospice Benefit:

Recommendation 13-1

The Committee recommends that the Secretary work with the Congress to allow physician assistants and nurse practitioners at rural health clinics to furnish and bill for hospice services.

Recommendation 13-2

The Committee recommends that the Secretary examine allowing telehealth consultations to count as face-to-face encounters and allowing nurse practitioners and physician assistants to certify the need for hospice care through face-to-face visits in rural areas.

Recommendation 13-3

The Committee recommends that the Secretary examine allowing hospices serving rural areas greater flexibility in fulfilling covered service requirements that takes into account potentially higher costs in rural areas such as for durable medical equipment and pharmaceuticals.

Recommendation 13-4

The Committee recommends that the Secretary provide greater flexibility to Critical Access Hospitals (CAHs) in cost-reporting carve outs related to the provision of hospice services so as not to lower the CAHs’ cost-based reimbursement.

Recommendation 13-5

The Committee recommends that the Secretary consider allowing cost-based reimbursement for hospice services in the upcoming Frontier Community Health Integration Program Demonstration.

Recommendation 13-6

The Committee recommends that the Secretary request that the Institute of Medicine evaluate the current status of terminal prognoses and make recommendations concerning both documentation and medical review of such.

Recommendation 13-7

The Committee recommends that the Secretary solicit feedback from rural hospices about specific instances of inconsistency among Medicare Administrative Contractors in evaluating patient eligibility for the Medicare Hospice Benefit and work with these parties to improve consistency.

Recommendation 13-8

The Committee recommends that the Secretary reexamine disparities in costs incurred in travel (i.e., windshield time) between urban and rural hospice providers given changes in utilization patterns over the past decade.

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2012 Recommendations

Rural Implications of the Center for Medicare and Medicaid Innovation:

Recommendation 12-1

The Committee recommends that the Secretary direct CMMI to offer preliminary advice to rural facilities on the suitability of project ideas and offer ongoing technical assistance to them during the preparation of applications.

Recommendation 12-2

The Committee recommends that the Secretary direct CMMI to extend the FQHC Advanced Primary Care Practice demonstration to include RHCs in order to broaden the impact of the program on rural areas.

Recommendation 12-3

The Committee recommends that the Secretary direct CMMI to establish a group of rural advisors within the Innovation Advisors program to help assure the direction of the Center includes a rural voice, and to help establish measurement systems that are relevant to rural health care.

Recommendation 12-4

The Committee recommends that the Secretary direct CMS to develop specific evaluation and measurement incentives to encourage collaboration across urban and rural lines, including an urban-rural collaboration preference during grant scoring.

Recommendation 12-5

The Committee recommends that the Secretary direct CMS to develop specific evaluation and measurement incentives to encourage collaboration across urban and rural lines, including an urban-rural collaboration preference during grant scoring.

Recommendation 12-6

The Committee recommends that the Secretary direct CMS to review and implement the Committee’s 2011 recommendation that CMS fund quality and cost incentive payments for rural hospitals from actuarially projected savings resulting from increased efficiency.

Options for Rural Health Care System Reform and Redesign:

Recommendation 12-7

The Committee recommends that the Secretary continue to promote the benefits of the ACA and broader health care reform and raise awareness among rural providers about provisions and models that account for the unique nature of rural health care demands and delivery.

Recommendation 12-8

The Committee recommends that the Secretary ensure that rural providers are engaged in ongoing discussions about health care reform and that these conversations recognize the necessary level of flexibility, stability, and support the current configuration of Medicare payment designations provides the rural health care system in a rapidly changing health care environment.

Recommendation 12-9

The Committee recommends that the Secretary work with the Congress to continue the FESC demonstration project beyond the program’s scheduled expiration in April 2013 or seek to continue a form of the FESC demonstration under the authority of CMMI. This will help ensure a strong evaluation of the demonstration project given the low patient volumes that FESCs have encountered.

Recommendation 12-10

The Committee recommends that the Secretary encourage CMS to consider the full range of costs and savings, including those from private payers, avoided transfers, and prevented hospitalizations, when evaluating the FESC and F-CHIP demonstration projects.

The Need to Integrate Work Programs for Low-Income Rural Residents:

Recommendation 12-11

The Committee recommends that the Secretary request that the Center for Medicare and Medicaid Innovations identify any of its programs that focus on entry-level workforce jobs that offer career pathways into the field of health care to see if these include any successful, rural focused models that could be replicated.

Recommendation 12-12

The Committee recommends that the Secretary encourage the White House Rural Council to examine ways for HHS, Labor and the United states’ Department of Education to work together to focus on rural integration of workforce and training programs.

Implications of Proposed Changes to Rural Hospital Payment Designations - Policy Brief December 2012 

No recommendations

Challenges to Head Start and Early Childhood Development Programs in Rural Communities:

Recommendation 12-13

The Committee recommends that the Secretary work with Congress to increase collaboration between rural Head Start grantees and other federal programs on transportation

Recommendation 12-14

The Committee recommends that the Secretary work with Congress to pursue a temporary compliance waiver for grantees in good standing who meet a specified definition for rural and are located in a dental or mental health HPSA when their communities lose access to a sole dental health or mental health provider.

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2011 Recommendations

Rural Childhood Obesity:

Recommendation 11-1

The Secretary should create an interagency working group that will focus on rural childhood obesity and develop action steps to eliminate the higher rates of childhood obesity in rural communities.

Recommendation 11-2

The Secretary should ask departmental agencies to create a report card to demonstrate the current HHS investment and related results in addressing childhood obesity in rural communities.

Recommendation 11-3

The Secretary should ensure that at least 5 percent of funding from the Prevention and Public Health Fund goes directly to rural health specific grant competitions, specifically to rural counties that fall under the national poverty level.

Place Based Initiatives for Rural Early Childhood Development:

Recommendation 11-4

The Secretary should work with Congress to authorize and fund non- categorical, community-based outreach and coordination grants to support the development of place-based initiatives in rural communities.

Recommendation 11-5

The Secretary should require all Early Childhood grant guidance, both block and community-based, to require collaboration with other HHS funded program activities and designated funds for rural child care.

Recommendation 11-6

The Secretary should develop a data strategy that allows HHS programs to share client-level data to improve coordination and efficiency of services.

Rural Implications of Accountable Care Organizations and Payment Building:

Recommendation 11-7

The Secretary should use the authority granted to the Center for Medicare and Medicaid Innovation (CMMI) to determine whether HHS can support payment bundling demonstrations focused on those conditions for which care is contained in rural areas.

Recommendation 11-8

The Secretary should ensure that rural providers, particularly CAHs, RHCs, and rural FQHCs, are eligible to participate in the Accountable Care Organization demonstrations.

Recommendation 11-9

The Secretary should work with Congress to revise the Small Rural Hospital Improvement Program (SHIP) as authorized in statute 1820(g)(3) of the Social Security Act so that the funding can be targeted toward groups of providers that need support in forming an Accountable Care Organization.

Recommendation 11-10

The Secretary should report to Congress, particularly the Senate Rural Health Caucus and the House Rural Health Coalition, within one year of implementation of Accountable Care Organization and payment bundling demonstrations about the impact of these mechanisms on rural health care providers.

Rural Challenges for HHS in Implementing the Community-Based Care Transitions Program (CCTP):

Recommendation 11-11

The Committee recommends that in preparing guidance for the grant reviewers that CMS give strong consideration to whether the project gives evidence of good working relationships among the following partners: rural health clinics, principal rural or urban referral center(s), PPS hospitals, critical access hospitals, Aging and Disability Resource Centers, Area Agencies on Aging, home health agencies, skilled nursing facilities.

Recommendation 11-12

The Committee recommends that project proposals, especially those in rural areas, address at least three of the five interventions. 

Recommendation 11-13

The Committee also recommends that attention be given to proposals that offer a comprehensive transitions approach that is more likely to be sustainable upon the conclusion of demonstration funding. 

Recommendation 11-14

The Committee recommends that CMS include grant reviewers who have rural health experience in order to ensure a fair and unbiased review.

Recommendation 11-15

The Committee recommends that the CCTP (or future CMMI projects) give increased weight to applications that serve the dually eligible population.

Rural Policy Implications for Health Insurance Exchanges:

Recommendation 11-16

The Committee recommends that the Secretary use the maximum regulatory authority available to encourage early participation in the planning and establishment process.

Recommendation 11-17

The Committee recommends that States be encouraged and incented to adopt successful models emerging from this process that have demonstrated the ability to provide enrollees with varied choices, while maintaining an easily navigable marketplace. 

Recommendation 11-18

The Committee recommends that the regulations account for differences in broadband access, especially in the individual market.

Recommendation 11-19

The Committee recommends that the Secretary adopt standards with respect to provider networks that require insurers to enroll Critical Access Hospitals and other key rural health safety net providers within a reasonable distance of the individuals they insure such as Sole Community Hospitals, Medicare Dependent Hospitals, Rural Health Clinics and Federally Qualified Health Centers.

Recommendation 11-20

The Committee recommends that current Medicare payment levels serve as a floor for payments by non-public insurers who are required under the ACA to contract with essential community providers but not if those providers do not accept the plan’s “generally applicable payment rates.”

Rural Policy Implications for Maternal, Infant and Early Childhood Home Visitation Program:

Recommendation 11-21

The Secretary should provide technical assistance, as documented in the SIR, specifically addressing the issue of small sample size in rural areas.

Recommendation 11-22

The Secretary should provide technical assistance for evaluation of promising approaches to States who are implementing them in high-need rural communities.

Recommendation 11-23

The Secretary should require States to collect rural-urban community data so as to allow for meaningful rural-urban evaluation of program impact.

The Rural Implications of Key Primary Care Provisions In the Affordable Care Act:

Recommendation 11-24

The Committee recommends that the Secretary examine the feasibility of allowing NHSC participants to be placed in a geographic area of their choosing consistent with allocating resources to the areas of greatest need.

Recommendation 11-25

The Committee recommends that the Secretary allow part-time nursing students enrolled in advanced-practice training programs to be eligible for the NYHSC Scholarship program

Recommendation 11-26

The Committee recommends that the Secretary track the re-allocation of Graduate Medical Education Physician Residency positions to determine how many of the residents chose to practice in primary care and the proportion that elected to practice in a rural community

Recommendation 11-27

The Committee recommends that the Secretary require any programs funded under the Nursing Graduate Medical Education Demonstration Program include significant training and allocation of training dollars for community-based ambulatory training sites and that preferences by given to applicants that include rural community-based training sites.

Recommendation 11-28

The Committee recommends that the Secretary, under Section 301 of the Public Service Act, conduct a demonstration project to identify the most effective ways to expand the number of accredited community-based primary care residency programs.

Affordable Care Act Provisions Affecting the Rural Elderly:

Recommendation 11-29

The Secretary should require training for ADRCs on key aspects of the rural health care delivery system through the HHS Office of Rural Health Policy to better understand the unique challenges faced by rural seniors.

Recommendation 11-30

The Secretary should promote regional applications that include rural providers for the Community-Based Care Transitions grant program.

Recommendation 11-31

The Secretary should ensure that any evaluation of Section 3026 includes an analysis of the number of rural beneficiaries served and the number of awards that include rural providers.

Recommendation 11-32

The Secretary should allow CAHs to report hospice-related costs at the skilled nursing service rate on the Medicare cost report in order to ensure that the payment of these services is consistent with the overall cost- based reimbursement methodology as outlined in Section 1820 of the Social Security Act.

Physician Value-Based Payment Modifier Program:

Recommendation 11-33

The Committee recommends that the Secretary make additional efforts to inform rural physicians about the upcoming implementation of the VBM program and establish a system to create dialogue among rural practitioners facing implementation challenges.

Recommendation 11-34

The Committee recommends that the Secretary require, for a trial period of 1-2 years, that rural physicians report 3-5 common measurements and receive timely reports about their performance. After the reporting system has been established and proficiency has been gained, additional measures could then be added.

Recommendation 11-35

The Committee recommends that the Secretary make additional assistance available to rural practitioners for the implementation of EHR systems, especially upfront acquisition support and support to secure staff needed to fulfill VBM requirements.

Recommendation 11-36

The Committee recommends that the Secretary ease the burden of implementation by allowing flexibility in program requirements that place a disproportionate burden on rural practitioners.

Recommendation 11-37

The Committee recommends that the Secretary account for differences in patient populations in the peer-grouping for physicians in the VBM program.

Recommendation 11-38

The Committee recommends that the Secretary assure that costs unrelated to the medical decisions of the primary physician be excluded from the cost comparisons made in the VBM program.

Recommendation 11-39

The Committee recommends that the Secretary use authority granted in Sec. 3007 to exclude rural physicians from the VBM during calendar year 2015 and 2016 to determine the costs, impacts and specific problems of implementing the VBM program in rural areas.

Recommendation 11-40

The Committee recommends that the Secretary adjust the VBM to recognize the increased cost and decreased administrative support available while providing care in rural areas.

Reducing Health Disparities in Rural America: Key Provisions in the Affordable Care Act:

Recommendation 11-41

The Committee recommends that the Secretary instruct the CDC to conduct an assessment of the CTG program after one year to determine if rural communities received at least 20 percent of the available funds in the first funding cycle.

Recommendation 11-42

The Committee recommends that the Secretary requires any local or state government CTG applicant to formally partner with that state’s respective State Office of Rural Health to administer and distribute funds.

Recommendation 11-43

The Committee recommends that the Secretary compiles an index of evidence- based strategies implemented under the CTG program to be distributed nationally to other health care professionals.

Recommendation 11-44

The Committee recommends that the Secretary implements comprehensive data collection efforts in rural communities, as outlined in Section 4302, and integrate key determinant variables associated with rural populations into all health services work that is funded by HHS.

Recommendation 11-45

The Committee recommends that the Secretary directs the relevant agencies to increase the sample size of data collected on rural populations, or, if needed, aggregate data across regions (e.g. “Delta region”) with similar demographic characteristics.

Recommendation 11-46

The Committee recommends the Secretary evaluate the distribution of grants under the Public Health and Prevention Fund and implement data collection efforts similar to those in Section 4302.

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2010 Recommendations

Home and Community Care for Rural Based Seniors:

Recommendation 10-1

The Secretary should evaluate whether rural seniors who are dually eligible for Medicare and Medicaid are able to take part in programs such as Money Follows the Person, Cash and Counseling, Home and Community-Based Services (HCBS), the Program of All-Inclusive Care for the Elderly, and Medicare Advantage Special Needs Plans to the same extent as urban seniors.

Recommendation 10-2

The Secretary should support an evaluation of current law prohibitions against payment to family members for care otherwise covered under Medicare or Medicaid, with a view toward determining wheth­er they should be eliminated in light of current economic conditions.

Recommendation 10-3

The Secretary should instruct the Centers for Medicare and Medicaid Services (CMS) to develop a uniform assessment tool that works across post-acute care settings and Health and Human Services pro­grams, as required under current law.

Recommendation 10-4

The Secretary should work with the Congress to change the requirements for coverage of the “Welcome to Medicare” physical to include provision of information about available home-based options for seniors. This information should also be a discharge planning function with a “handoff” to the Community Living Programs, Eldercare Locator Service, and Aging and Disability Resource Centers (ADRCs).

Recommendation 10-5

The Secretary should instruct CMS to find a method for claiming and reporting hospice payments for general inpatient services on a Critical Access Hospital (CAH) cost report in a manner that permits the CAH to claim the full cost of caring for the hospice patient.

Recommendation 10-6

The Secretary should develop a report in coordination with the Secretary of Transportation to identify all available legal authorities that provide transportation for those in need of health and human services and to determine their effectiveness in serving the elderly population, with particular emphasis on the availability and effectiveness of programs for the isolated rural elderly.

Rural Primary Care Workforce:

Recommendation 10-7

The Secretary should work with the Congress to re-authorize Title VII and VIII of the Public Health Service Act to include the authority for allocating funding to better meet emerging workforce needs in the health professions based on the most current data and projections available.

Recommendation 10-8

The Secretary should work with the Congress to ensure that any reauthorization of Title VII of the Public Health Service Act includes demonstration authority.

Recommendation 10-9

The Secretary should expand the Critical Shortage Facility list used for Nursing Scholarship and Nursing Loan Repayment programs to include Critical Access Hospitals.

Recommendation 10-10

The Secretary should work with the Congress to revise the legislation that defines “primary care” used by the National Health Service Corps Scholarship and Loan Repayment programs to create an exclusion for awardees employed by rural hospitals with less than 50 beds, so that time spent seeing patients in the emergency room, a nursing home, or hospital outpatient clinic will count toward the 32 hours of required weekly clinical time.

Recommendation 10-11

The Secretary should revise regulations to define an “integrated rural training track” as:

• At least four rural block months to include a rural public and community health experience. During a rural block rotation, the resident is in a rural area for a minimum of four weeks or a month.
• A minimum of three months of obstetrical training or an equivalent longitudinal experience.
• A minimum of four months of pediatric training to include neonatal, ambulatory, inpatient, and emergency experiences through rotations or an equivalent longitudinal experience.
• A minimum of two months of emergency medicine rotations or an equivalent longitudinal experience.

Recommendation 10-12

The Secretary should revise the regulations for “Community Preceptors” to allow preceptors to volunteer their time in serving as preceptors to residents.

Recommendation 10-13

The Secretary should redefine the definition of “all or substantially all” to allow the cost of GME residency training to be shared between hospital and non-hospital based providers.

Recommendation 10-14

The Secretary should work with the Congress to increase the Medicare cap for RHCs and rural FQHCs to match the rate for urban FQHCs.

Recommendation 10-15

The Secretary should ensure that when regulations for shortage areas are updated the process should only update the Medically Underserved Areas and Medically Underserved Population process and maintain the basic methodology for the Health Professional Shortage Areas regulations.

Recommendation 10-16

The Secretary should ensure that when the shortage area regulations are revised, protections are put in place to reduce the “yo-yo” effect of removing resources from a community when it loses its Health Professional Shortage Area designation due to the addition of less than five primary care providers in the rational service area or county.

Recommendation 10-17

The Secretary should work with the Congress to revise the regulations for the Health Professional Shortage Area Medicare bonus payment to Advanced Practice Nurses and Physician Assistants.

Recommendation 10-18

The Secretary should remove the HPSA score requirement from the HHS J-1 Visa Waiver regulations and expand the list of potential practice sites to include Critical Access Hospitals, Sole Community Hospitals, Medicare Dependent Hospitals, and any Section 1886(d) hospital with less than 50 beds.

Rural Health Care Provider Integration:

Recommendation 10-19

The Secretary should work with the Inspector General to develop regulations so that rural practitioners can be compensated for driving time at a fair market value.

Recommendation 10-20

The Secretary and the Inspector General should work together to assess the impact of the inurement rules on the ability of rural hospitals to hire practitioners in Health Professional Shortage Areas.

Recommendation 10-21

The Secretary should ensure that future demonstrations on quality improvement and care coordination, such as Accountable Care Organizations, payment bundling, and Medical Homes, incent the cooperation of the full range of rural providers.

Recommendation 10-22

The Secretary should place a moratorium on approval of any new specialty hospitals in order to determine the impact on access to care for Medicare beneficiaries, with particular emphasis on access to specialty services for rural beneficiaries.

Recommendation 10-23

The Secretary should revise current regulations so the sole emergency medical service providers (EMS) owned and operated by Critical Access Hospitals must be only a minimum of 25 miles (15 miles in mountainous terrain) from the nearest EMS provider in order to qualify for cost-based reimbursement rather than the requirement of 35 miles.

Recommendation 10-24

The Secretary should work with Congress to reauthorize and support funding for the Healthy Communities Access Program with revisions to support projects that focus on development and implementation of Medical Home components, e.g., incorporation of HIT and EHRs, chronic care management, and medication management.

Recommendation 10-25

The Secretary should work with Congress to authorize and support the development of a Critical Access Hospital Health Information Technology Grant Program under the Medicare Flexiblity program.

Recommendation 10-26

The Secretary should encourage the use of existing authorities and funding from the National Library of Medicine at the National Institutes of Health to make competitive grants and contracts to support the adoption of HIT by rural health care providers, given their current low level of HIT adoption.

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2009 Recommendations

Recommendation 09-01

The Secretary should develop data tracking systems for the health and human services workforce. Workforce data should be periodically collected and analyzed so that rural areas can identify their current and projected workforce needs. The workforce data and analysis should be disseminated in a timely manner to employers, Workforce Development Boards, training centers, and educational institutions so that they may better predict workforce oversupplies and shortages. Based on this data, the Secretary should target resources and develop training programs for appropriate health and human services professions in “high-need” geographic areas. 

Recommendation 09-02

The Secretary should work with Congress to secure additional funding for the allied health training programs within Title VII of the Public Health Service Act and expand competitive opportunities for two-year educational and training programs for health and human services professions that are identified to have high vacancy rates, high demand, and high education and training costs associated with higher faculty salaries, laboratory fees, and clinical space. 

Recommendation 09-03

The Secretary should work with Congress to amend the Title VII authority to allow greater discretion over how to allocate funding for different health professional needs over multi-year periods. The Committee believes that the flexibility will allow specific targeting of resources to reflect current and future projected needs. 

Recommendation 09-04

The Secretary should work with Congress to secure additional funding for the Nursing Loan and Nursing Scholarship programs under Title VIII of the Public Health Service Act, so that these existing nursing programs can better meet current workforce shortages. 

Recommendation 09-05

The Secretary should use Section 301 authority under the Public Health Service Act to support demonstration grants for creative, community-based workforce training programs that address local geographical and financial constraints and are targeted towards rural communities through Critical Access Hospitals, Rural Health Clinics, and Federally Qualified Health Centers.  These demonstration projects should be evaluated to determine effectiveness and return on investment.

Recommendations related to the CMS Medicare Medical Home Demonstration Project:

Recommendation 09-06

The Committee recommends that the Secretary ensure that an appropriate number of rural practices, in each of the participating States, are selected for the Medicare Medical Home Demonstration for comparison with one another and with urban practices. The Committee recommends that these sites be located in varying regions of the country, to account for regional differences.

Recommendation 09-07

CMS should include physician assistants and advanced practice nurses as primary care providers, for reimbursement purposes, in the Medicare Medical Home Demonstration project and in any future medical home implementation projects.

Recommendation 09-08

CMS should ensure that the criteria and measures used for the Medicare Medical Home Demonstration are appropriate and relevant for rural practices. The Secretary should work with NCQA to bring their guidelines into the same framework.

1. Other Recommendations related to CMS:

Recommendation 09-09

CMS should work with the American Medical Association to develop Current Procedural Terminology (CPT) codes that describe the case management and coordination required for medical homes. The CPT codes should be priced so that Medicare and other payers can support implementation. CMS should also revise the RVRBS values to reflect billing under a medical home model.

Recommendation 09-10

The Secretary should clearly identify for the States which CMS Medicaid waiver authorities are available to support medical home demonstrations at the State level.

Recommendation 09-11

The Secretary should use Medicaid Transformation grants and Healthier U.S. grants to promote medical home implementation in rural areas.

1. Recommendations related to HRSA:

 Recommendation 09-12

The Secretary should work with Congress to reauthorize and support funding for the Healthy Communities Access Program with revisions to support projects that focus on development and implementation of medical home components, e.g., incorporation of HIT and EHRs, chronic care management, medication management, etc.

Recommendation 09-13

The Secretary should use existing Rural Health Care Services Outreach and Rural Health Network Development program grants to promote the medical home model in rural communities and use funding from these demonstrations to inform policymakers in developing medical home standards and regulations that take into account rural practice considerations.

Recommendation 09-14

The Secretary should examine and evaluate if low-population density in rural communities results in lack of adequate funding to implement and maintain prevention and intervention services for young children who are at-risk for maltreatment and adverse experiences, and their families.

Recommendation 09-15

The Secretary should work with Congress to secure additional funding for Subpart 2, Promoting Safe and Stable Families, of Title IV-B of the SSA, administered through ACF. This will help to support prevention services for at-risk children.

Recommendation 09-16

The Secretary should work with Congress to secure additional funding for ACF’s Child Care and Development Fund (CCDF). The additional funding should increase the required CCDF funding targeted to improve the quality of child care from 4 percent to a required minimum of 10 percent of the total funding received by States, and allow for additional services to parents. The Secretary should recommend that part of these funds be set aside specifically for training child care providers in evidence-based early childhood development services and for the mental health development of young children. 

Recommendation 09-17

The Secretary should work to improve mental health services for children, from birth to five years, through the following actions:

1. The Secretary should support more broad-based training in early mental health screenings and services for rural health care providers and recommend validated mental health and behavioral screenings, such as the Ages and Stages Questionnaire – Social Emotional (ASQ-SE), in well-child visits.
2. The Secretary should conduct research on the effectiveness of mental health interventions for young children, specifically from birth to three years. The Secretary should support demonstrations that implement evidenced-based practices in early mental health services in rural locations. 
3. The Department should work directly with States and provide technical assistance on how to use their flexibility within Medicaid (either directly or through a waiver) to provide more prevention and intervention mental health services for children. 

Recommendation 09-18

The Secretary should support a HHS demonstration project that would allow maximum flexibility of use of HHS funds with other Departmental programs, such as those administered by ED, to enhance prevention and intervention projects for children and families in rural communities with limited resources.

Recommendation 09-19

The Secretary should conduct a demonstration to determine the feasibility of developing a pilot model for the screening tools and an appropriate referral system for children at-risk for physical or emotional abuse or neglect with the disease collaborative model that is used by many community health centers. 

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2008 Recommendations

Recommendation 08-01

• Create an Inter-Departmental Rural Working Group for Cross-Program Collaboration

The Committee recommends that the Secretary of HHS create an Inter- Departmental Rural Working Group to determine how to improve collaboration among programs that serve rural communities.  The Rural Working Group should include all pertinent agencies or operating divisions with programs that serve significant rural populations, such as:  HHS, USDA, the U.S. Department of Veterans Affairs, the Treasury, Commerce, DOL, and DOT.  The Rural Working Group should consult closely with States to identify elements in regulation implementation that may complicate coordination (e.g., opposing definitions, different reporting time frames).  The Rural Working Group should produce an annual report to the Administration with recommendations to promote efficiency, coordinated service delivery, and integration and collaboration across programs that serve rural communities, emphasizing the reduction of administrative barriers, common reporting elements, and combined funding streams.  This report should serve as a basis for regulatory changes that improve coordination.

Recommendation 08-02:

• Use Demonstration Projects to Integrate Funding Streams

The Committee recommends that the Secretary use existing demonstration authority to support two rural-focused demonstrations.

• Demonstration 1:  Coordinated Services for Children and Families

This demonstration should foster the integration of health and human services for children and families through coordinated care, case management, and increased access to services.  This program should draw on the funding and programmatic intent of the following existing HHS programs:  the Health Center Program, ORHP’s Rural Health Care Services Outreach (Outreach) and Rural Health Network Development (Network) Grant Programs, the SAMHSA Mental Health Block Grant, Head Start, Early Head Start, and TANF.  Each of these programs plays a key role in supporting rural families but each addresses only one issue, which has resulted in a fragmented delivery system.  By funding programs that address all of these issues instead of just one, this demonstration should promote coordinated services and allow for advertising and outreach activities.

• Demonstration 2:  Coordinated Services for Elderly

This demonstration should foster the integration of health and human services for the elderly.  This demonstration should draw on the funding and programmatic intent of the following existing programs:  the Outreach and Network Grant Programs, Meals on Wheels, Elderly Family Caregiver Support, and the United We Ride initiative.  Integrating programs can help to simplify and coordinate navigation of services.  By creating a single funding stream, the demonstration would promote ease of access, care management, better coordinated services for the elderly, and allow for advertising and outreach activities.

Recommendation 08-03:

• Identify Statutory and Regulatory Provisions that Hinder Local Coordination

The Committee recommends that the Secretary work with the Administration to commission an independent study that would examine the statutory and regulatory provisions of the various Federally-funded health and human services programs now administered in rural areas.  This study should identify provisions that act as barriers to coordination and integration at the local level.  This analysis should be shared with the Rural Working Group, which should consider inconsistencies identified in the independent report and work with the Administration to develop recommendations to address the inconsistencies.

Recommendation 08-04:

• Require that all HHS Programs Collect Rural-Specific Data

The Committee recommends that the Secretary require that all HHS programs collect data that delineate the rural versus urban geographic location of each recipient of Federal funds through direct grants, transfer payments, and block grants. 

Recommendation 08-05:

• Require that Human Services Programs within HHS Implement a Standardized Rural Performance Measurement System

The Committee recommends that the Secretary require the following human services programs within HHS to evaluate their impacts in rural areas each year:  Head Start, TANF, Family Caregiver Support, and the Alzheimer’s Disease Demonstration Grants to States.  Performance measures that focus on how fully and effectively HHS programs serve rural communities could provide the tools necessary for Federal program administrators and policy makers to identify and account for the specific needs of rural communities.  In addition, data and performance evaluation will help policy makers measure the success of improvements.

Recommendation 08-06:

• Produce an Annual Report on HHS Rural Investment

The Committee recommends that HHS use this rural-specific data to produce an annual report that quantifies the annual investment of HHS programs in rural communities.  This initiative is most important for the Department’s human services programs, which historically have not supplied this information or evaluated their rural investment.

Recommendation 08-07:

• Require Rural Impact Statements on All Major HHS Regulatory Policies

The Committee recommends that the Secretary work with Congress to extend the intent of Section 1102B of the Social Security Act, so that HHS would prepare a rural impact statement on all major regulatory policy decisions that may have a significant economic impact on rural communities.  Currently, Section 1102B requires HHS to prepare an impact statement for public comment on any regulation under Title XVIII (Medicare) or Title IX (Medicaid) that may have a significant effect on the operations of a substantial number of small rural hospitals.  The Committee believes that similar provisions in the authorization laws for all HHS programs would help ensure that program changes and new program designs take into account the needs of rural communities.

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2007 Recommendations

Recommendation 07-01:

1. The Secretary should charge CMS with providing enhanced information that will allow beneficiaries to make well-informed decisions, particularly for rural beneficiaries who have less experience with managed care.

Nationwide beneficiaries have voiced frustrations at the complexity and difficulty in understanding MA plans. Navigating the variations in plan coverage, co-payments, out-of-network and in-network stipulations, and other factors has been challenging for many beneficiaries. CMS does provide some information to the beneficiaries, but the educational literature is often long and complex. The Committee recommends that CMS focus on presenting concise, easy-to- understand information that would allow beneficiaries to compare and contrast plans in a manner similar to that provided to beneficiaries comparing prescription drug plans.

Recommendation 07-02:

1. The Secretary should strengthen the CMS Regional Offices' roles as sources of definitive MA information.

In the past, CMS granted its regional offices considerable authority in answering questions and making determinations on certain policy issues. With the advent of Medicare Advantage, several Committee members noted that it appears that Medicare information and policy decision determinations are increasingly being centralized. These Committee members believe that location-specific decisions that were previously made in the CMS Regional Offices, such as those related to network adequacy and community standards of care, are increasingly being made in the CMS Central Office or in a single Regional Office. Rural providers can no longer travel reasonable distances to their local Regional Office to meet with CMS staff to ask questions or discuss concerns related to these decisions. The significant changes to Medicare through the MA program and the prescription drug benefit leave many rural providers with questions and a need for information. The Committee is concerned that any potential movement towards information centralization has the potential to leave many rural providers feeling removed from the changes and overwhelmed at the lack of direct assistance. The Committee believes CMS should consider strengthening the role of its Regional Offices to make some determinations on issues related to network adequacy and community standards of care as it relates to Medicare Advantage. Such a change will allow providers to better understand the market they operate in and respond to important coverage issues that relate to the Medicare Advantage beneficiaries they serve.

Recommendation 07-03:

The Secretary should mandate that CMS solicit input from rural health care experts in determining and enforcing adequate rural community access standards.

CMS has emphasized that rural community access standards are a priority for the agency. While the Committee is encouraged by that stance, it is concerned that the present rural community access standards applicable to MA plans are not sufficient to meet the health care needs of rural beneficiaries. Thus, the Committee would like CMS to solicit input from rural health care experts in determining the rural community access standards and how best to enforce those standards for MA plans.

Recommendation 07-04:

1. The Secretary should ensure that CMS provide current enrollment data in a timely manner, so rural enrollment can be tracked.

In researching this chapter, the Committee has been extremely frustrated by the delays in the expected release of county-level enrollment data for MA-only plans (i.e., those MA plans that do not include a Part D benefit). Typically, CMS reports the quarterly enrollment data within a few weeks after the end of the quarter. However, 2006 data was not released until September 2006 and was released in a format that prohibits rural-specific analysis. Further county-level data was not released until December. Since health plans are required to report enrollment data on a monthly basis, it is unclear why CMS has been so late in releasing the data to the public. The lack of data hampers efforts by the Committee and others to determine MA's full impact on rural communities.

Recommendation 07-05:

1. The Secretary should provide access to MA plan applications through the CMS web site.

The Committee has observed that there is a lack of transparency in how MA plans are approved. The Committee is especially concerned about the composition of plan provider networks and requirements for rural network adequacy. Thus, the Committee recommends that applications for MA plans be made accessible to the public via the CMS web site, allowing for more transparency and opportunities for rural advocates to comment on the plans.

Recommendation 07-06:

1. The Secretary should charge CMS with establishing a web site where providers can instantly verify beneficiaries' current plan enrollment.

Many rural providers have found it difficult to verify beneficiaries' plan enrollment. At times beneficiaries are unsure about their coverage and providers cannot easily access that information. Currently, there are two commercial services (MediFax and Passport Health Communications, Inc.) where Medicare enrollment can be verified. However, there are certain health insurers such as Blue Cross, Humana and United that do not participate in the sites. Though many providers have access to CMS' Common Working File, providers have discovered that information about a beneficiary's status in an MA plan is often not current. The Committee understands that CMS is working to ease access to beneficiaries' MA enrollment status via a secure web portal, and the Committee encourages this. The Committee urges CMS to ensure that the portal is easy to access for providers and provides real-time enrollment data. This web site would allow all providers ease of access and would ensure more efficient reimbursement transactions and less administrative work for the providers.

Recommendation 07-07:

1. The Secretary should work with the Congress to develop a payment formula for MA that moves away from prior utilization so as not to rely on a payment mechanism that rewards regions with high utilization at the expense of regions with lower utilization.

§1853(a) of the MMA requires that CMS adjust payments for local and regional MA plans to account for variations in "local payment rates" within each region the plan serves. This provision allows health plans to segregate rural providers within their region and offer them a substantially lower payment rate. The Committee is concerned that rural beneficiaries, plans and providers will continue to be disadvantaged as the proposed benchmarks for the health plans are significantly affected by some States' historically lower utilization rates. Historically, M+C was criticized for making extra benefits available in regions of the country that had high Medicare utilization, which could not be made available in regions with lower utilization. The Committee would like to prevent similar incidents from happening with the MA program.

Recommendation 07-08:

1. The Secretary should assure the efficient administration of PFFS plan payments to non-contracted providers.

Fiscal Intermediaries, at a minimum, should be allowed to release interim rate information directly to PFFS plans without requiring a Freedom of Information request from the plan. Plans should be required to pay the interim rate effective for the dates services were rendered. This is especially crucial for rural providers because PFFS plans are the most prevalent type of MA plan in rural areas. Additionally, plans should be required to pay for bad debt associated with services to their members and documented by the provider within a reasonable timeframe as uncollectible.

Recommendation 07-09:

1. The Secretary should require the Agency for Health Research and Quality to examine whether non-HMO MA plans provide additional preventive health benefits to those in traditional Medicare who are rural beneficiaries.

CMS has asserted that MA plans have the capacity to improve the quality of health care for Medicare beneficiaries. Additionally, one of the primary Congressional justifications for expanding M+C into Medicare Advantage was to provide more of the benefits of plan choice and the resultant services to rural beneficiaries. This would be a great improvement for rural health care; however, the Committee would like research to corroborate CMS' assertion and Congress' intentions. Thus, the Committee would recommend that the Secretary work with Congress to ask AHRQ to research the preventative services provided by non-HMO MA plans and to determine whether these services are beyond the level currently provided by traditional Medicare or local HMOs.

Recommendation 07-10:

1. The Secretary should work with Congress to give ORHP the authority to provide technical assistance and outreach on ways rural communities can collaborate on examining rural contract reviews of MA plans.

Many rural communities have not historically adapted to the managed care model. Thus, since the MA program will transform rural health care by increasing the prevalence of private plans, rural communities must be educated and informed on how to best collaborate in order to evaluate the rural contract reviews of the MA plans. Rural providers and other existing rural health care leaders need to ensure MA plans provide adequate community access for rural beneficiaries and fairness in payment to rural providers.

Recommendation 07-11:

1. The Secretary should provide the AoA with increased funding to local area agencies on aging to provide increased assistance to beneficiaries enrolling in MA plans.

With the transition to the prescription drug benefit (Part D), the aging network, including the local area agencies on aging, were instrumental in educating the elderly in regards to the Part D changes. The same effort needs to be utilized for MA plans due to their complexity. The Committee would like to see an increase in funding to organizations such as the local area agencies on aging, so that they can effectively inform and educate the elderly about MA plans.

Recommendation 07-12:

1. The Secretary should encourage State insurance commissioners' offices, in a manner consistent with existing Federal oversight of Medicare managed care plans, to act as ombudsmen for rural beneficiaries having difficulties with MA plans.

State insurance commissioners' offices are often knowledgeable about rural concerns, health issues facing their State and the managed care climate in their State. The Committee recommends that the Secretary actively encourage State insurance commissioners' offices to act as ombudsmen for rural beneficiaries. The Secretary should ensure these offices have the regulatory authority necessary to access information on MA plans and report violations of Medicare regulations.

Recommendation 07-13:

1. The Secretary should work with Congress to increase funding for the State Health Insurance Assistance Program (SHIP) to further assist seniors in rural areas with the MA program.

States currently receive a grant from CMS to provide advice and counsel to citizens on a number of subjects, including Medicare managed care. Rural beneficiaries have less experience with managed care products, and information about MA is often difficult to obtain and confusing to beneficiaries. The Secretary should work with Congress to increase funding for SHIPs and specifically charge them with helping beneficiaries in rural areas make appropriate choices with regard to MA.

Recommendation 07-14:

1. The Secretary should support research to determine the feasibility and impact of increasing the percentage of children who can be enrolled in Head Start from families with incomes that exceed the Federal poverty line, to help preserve small rural programs that may fall short of minimum enrollment requirements.

The Committee believes that small rural programs should not lose their grants when a small decline in the number of eligible children pushes them below the minimum enrollment standard. It recommends pursuing research into the effects of additional flexibility to enroll children from higher income families to avoid the loss of such programs. The Committee believes that this flexibility could be used with discretion to maintain programs in rural communities where there are few or no childhood education alternatives.

Recommendation 07-15:

1. The Secretary should support a long transition period for any increase in the qualification standards for Head Start teachers so that rural educators are able to complete the degree requirements.

As noted in the text of this chapter, both the House and Senate reauthorization bills for Head Start call for an increase in the percentage of Head Start teachers holding a bachelor's degree. In recognition of the disadvantages that rural communities face in recruiting Head Start educators (lower salaries, fewer educational opportunities, travel distance to educational institutions, etc.) the Committee urges the Secretary to support the longest possible transition period for this requirement. The Committee also believes that work experience in the Head Start program should count towards credit for continuing education requirements.

Recommendation 07-16:

1. The Secretary should support widespread dissemination of information about transportation waivers, especially to rural Head Start sites.

Transportation waivers that release rural grantees from some of the most difficult to meet and costly Federal requirements could help solve some of the most pressing concerns regarding transportation for Head Start in rural communities. The Committee believes that rural sites should be as informed about the waivers as possible, so as to provide more transportation options for Head Start children in rural areas.

Recommendation 07-17:

1. The Secretary should support grant programs to demonstrate and reinforce collaborative arrangements between Head Start grantees and other public and private programs in the areas of oral health and health care services for Head Start children.

During the past year the Committee learned about collaborative programs involving rural Head Start grantees, public schools, dental schools and other health care providers. The Committee believes that collaborative arrangements are especially important in the areas of oral health and general health care. The Department has begun cross- collaborative discussions to identify areas where they build partnerships. The Committee urges the continuation of these discussions, and requests that the Secretary work to identify best practices among rural Head Start programs and to disseminate that information.

Recommendation 07-18:

1. The Secretary should examine what impact current Head Start performance standards, specifically, the National Reporting System, have on rural Head Start programs.

The Committee found strong support for the Head Start performance standards among the many program officials who spoke with us during the year. However, some concerns were raised about portions of the National Reporting System that may not be appropriate for rural Head Start children. The Committee believes that all assessments should be administered in a culturally and geographically sensitive manner and requests that the Secretary examine this issue, consulting with rural Head Start grantees.

Recommendation 07-19:

1. The Secretary should examine the Substance Abuse Prevention and Treatment Block Grant program formula to determine if the reliance on population size puts rural areas at a disadvantage in qualifying for funding. Findings from this assessment should be shared with the Congress and the governors.

Recognizing its limited understanding of the formula by which funding decisions are made through the SAPT Block Grant, the Committee would like to see research conducted that examines the equity of the formula. The typical "rural/urban" split of data is not as helpful to smaller communities and frontier areas because funding decision- making usually emphasizes population size, rather than the incidence of the problem. To provide answers to the problems of substance abuse in these communities more weight should be given to the prevalence of the substance abuse problem in a given geographic area. The cost to provide any type of health or human service is greater in rural areas because of the geographic distances and low volumes of clients. These factors do not minimize the need for services. Ideally, the Secretary could commission a comprehensive look at program authorities and regulations that deal with substance abuse programs to examine whether services are limited by the formula's guidelines.

Recommendation 07-20:

1. The Secretary should ensure that NIDA Research Monograph 168, Rural Substance Abuse: State of Knowledge and Issues be updated as the findings are now a decade old.

The Committee specifically supports the following research priorities outlined in NIDA Research Monograph 168, Rural Substance Abuse: State of Knowledge and Issues:

1. Study of the varying use and abuse patterns for different cultural, ethnic, gender, generational, and occupational subgroups (e.g., farming, fishing, mining, lumbering, blue- and white-collar manufacturing, and service providers) within rural populations.
2. Evaluation of existing prevention/treatment services being delivered to rural populations, including studies of special subpopulations such as those living in economically depressed communities and mobile communities such as migrant farm workers.
3. Assessment of outreach strategies to expand prevention and/or treatment services to underserved populations in rural areas.

Recommendation 07-21:

1. The Secretary should work with SAMHSA to expand its National Registry of Evidence-Based Programs and Practices (NREPP) to include a section of rural-specific programs and practices.

The Committee believes this registry is an important tool for States, communities and practitioners to identify and replicate best practices in substance abuse prevention and treatment. It commends SAMHSA and HHS for its creation. The Committee also believes that collecting some information on rural-specific interventions and projects would provide even greater assistance to rural communities who struggle with unique funding, volume, resource and workforce challenges due to their isolation and distance from the standard substance abuse treatment and prevention infrastructure available in urban and suburban communities.

Recommendation 07-22:

1. The Secretary should initiate pilot programs to explore creative models for substance abuse prevention, treatment and recovery programs in rural school systems through a rural-focused expansion of the Safe Schools/Healthy Students initiative.

Such an initiative represents a unique partnership of Federal agencies and provides a necessary focus on preventing drug addiction among children and adolescents. In 2004 the Committee toured a Safe Schools/Healthy Students grantee site in Nebraska and was impressed by the scope of this collaborative initiative. The rural-focused projects funded by this grant program are numerous, and its mechanisms have been proven to work well for rural communities.

Recommendation 07-23:

1. The Secretary should conduct research and evaluation into the use of technology for meeting the needs of substance abuse treatment.

The Committee notes that mental health providers have achieved some level of success using telehealth technology to deliver needed services in rural communities. In the course of its work over the past year, the Committee believes that this technology may also hold great potential for providing substance abuse treatment. In addition, the use of this technology may also help decrease the stigmatization of substance abuse treatment in small rural communities since it may afford greater anonymity.

Recommendation 07-24:

1. The Secretary should require SAMHSA to increase sample sizes in its research activities by over-sampling rural zip codes in survey activities. This would allow sub-state and regional analyses, provide a more robust data sample and ensure adequate representation of rural residents.

HHS and SAMHSA spend considerable time and money conducting needed research on substance abuse and treatment. This research has provided an important base of information through which to inform policy and program decisions. However, due to sample-size limitations, there are often problems conducting sub-State and/or sub-regional analysis. This limits the ability of States and communities to use this important data in targeting scarce resources. Further, nationally representative survey samples are often not generalizable to rural communities when population data are collected proportionally. By increasing overall sample sizes and including an over-sample of rural residents, HHS can greatly increase the utility of this data to draw conclusions on rural populations and for specific rural communities.

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2006 Recommendations

Recommendation 06-01:

• The Secretary should include rural pharmacy services as a focus for existing Departmental grant programs.

The Committee has identified several grant programs in the Department that could be used effectively to promote and support accessto pharmaceuticals and pharmacy services in rural areas. These include the Quentin Burdick Interdisciplinary Grants authorized under Title VII of the Public Health Service Act, the Rural Health Network Development Grants authorized under Title II, Section 330A of the Public Health Service Act, the Rural Health Outreach Grants authorized under Title II, Section 330A(f) of the Public Health Service Act, grants to support schools of pharmacy authorized by Title VII of the Public Health Service Act, and the 340B Medication Discount Program. The Secretary should identify other programs as well. Programs with appropriate authorizations should encourage applications from qualified organizations that can present innovative ideas for improving or sustaining access to pharmaceuticals and pharmacy services in rural areas, and for integrating pharmacy services with other components of rural health care delivery systems.

Recommendation 06-02:

• The Secretary should seek authorization to allow pharmacists to be eligible for the National Health Service Corps, and to provide the funding for the National Health Service Corps to provide them with scholarships and loan repayments options.

The National Health Service Corps recently completed a demonstration program that placed a small number of pharmacists in underserved areas of the country. The Committee believes that the mission of the Corps should now be expanded to include pharmacists among the other health professionals eligible for loan repayments, scholarships and placements through the Corps. Moreover, the Committee is aware of the potential difficulties posed by the lack of criteria for designating pharmacist shortage areas in rural parts of the country. The Committee believes, however, that the existing criteria for designating Health Professionals Shortage Areas are a reasonable proxy for shortages of pharmacists and could be used by the Corps until such time as more specific criteria could be developed.

Recommendation 06-03:

• The Secretary should use the AHEC program to promote and support programs to better integrate rural pharmacy providers with other components of rural health care delivery.

The AHEC program has been, and continues to be, an effective source of support for educational programs and other efforts to help rural communities and rural health care providers develop more integrated systems of care. The critical role of pharmacy providers in rural areas and the need for them to become a more integral part of local health care delivery systems should be recognized and supported through the AHEC program.

Recommendation 06-04:

• The Secretary should require workforce studies conducted by the Health Resources and Services Administration to analyze any potential differentials between rural and urban in terms of health professions workforce. The Secretary should also charge HRSA to conduct a follow-up study to the 2000 pharmacy workforce report.

In presenting this chapter, the Committee was able to use some limited information from a major study of the nation's pharmacy workforce conducted by HRSA in 2000. That study (and others like it) did not provide data on urban and rural differences in the pharmacy workforce. The Committee believes that any future studies should attempt to identify and present workforce data that allows comparisons between urban and rural areas. Further, the Committee recommends that the Secretary require HRSA to do an analysis of the urban/rural distribution of pharmacists in 2006. This study is critical given the projected disparity in the nation's supply and demand for pharmacists.

Recommendation 06-05:

• The Secretary should support research on the potential risks of pharmacy closures in rural communities using evidence-based research centers supported by the Agency for Healthcare Research and Quality.

The Committee has found that more research needs to be conducted as to the potential factors that might place a rural community at risk of losing their local pharmacy. In identifying those issues, the Committee believes it will be easier to develop programs to target those risks.

Recommendation 06-06:

• The Secretary should recommend to Congress that the list of eligible entities for the 340B Drug Pricing Program be expanded to include Rural Health Clinics and Critical Access Hospitals.

Under the 340B program, rural health clinics should qualify if they operate on a sliding fee scale and Critical Access Hospitals should qualify if they show that they have a Disproportionate Share Percentage greater than 11.75 percent if paid under the Medicare Inpatient Prospective Payment System. Rural Health Clinics and Critical Access Hospitals that meet these criteria must be considered a vital part of the health care safety net in rural areas and should be recognized as such under the 340B program.

The Committee also recommends that the Secretary provide additional resources to the HRSA Office of Pharmacy Affairs that administers the 340B program. Throughout the year, the Committee received testimony that many entities eligible for the program are not aware of its benefits or have been unable to seek participation because of staffing limitations and other factors. Further, these entities often need technical assistance related to administration of the program at the local level. Presently, the Office of Pharmacy Affairs lacks sufficient resources to provide effective outreach to eligible entities and the technical assistance they require.

Moreover, the Committee recommends that the Office of Pharmacy Affairs should conduct a study to determine the extent of urban and rural differences in participation in the program and take steps to provide appropriate assistance to eligible rural entities.

Recommendation 06-07:

• The Secretary should support an annual study for the next five years that examines the impact of the Medicare Modernization Act on rural pharmacies and rural residents' access to pharmaceuticals and pharmacy services.

In this chapter, the Committee has discussed some concerns about the potential impact of the new Medicare Modernization Act on rural seniors and pharmacy services providers. The validity of these concerns will not be known until the new benefit has been implemented and tested. However, the Committee believes that rural areas pose unique challenges for the program and there is the potential for problems to surface over the next few years. The Committee believes that the Secretary should support studies and monitoring systems to determine how well the program is serving rural beneficiaries and pharmacy providers so that problems can be identified and resolved at the earliest possible time. There may be opportunities to integrate such studies with other efforts that are already planned.

Recommendation 06-08:

• The Secretary should conduct a demonstration to examine the use of Medicare payments in providing medication therapy management services to seniors who are taking multiple medications.

The Committee recommends that the Secretary conduct a demonstration program to examine the use of Medicare payments to provide medication therapy management services to seniors who are taking multiple medications and are at greatest risk for negative drug interactions. Medication therapy management services can have a significant impact on the health of seniors who are at high risk for negative drug interactions and other complications stemming from dependence on multiple medications. Demonstration programs should be conducted to identify those seniors most at risk in both the Medicare fee-for-service and Medicare Advantage settings. Such programs would also help to identify positive outcomes of medication therapy management services, as well as their impact on the cost of the Medicare program.

Recommendation 06-09:

• The Secretary should evaluate the impact of telepharmacy projects in rural areas.

The Committee believes that telepharmacy has potential to increase access to pharmaceuticals and pharmacy services, particularly in communities that are unable to establish and sustain pharmacy services due to low population density, unfavorable economic circumstances, geographic isolation or other factors. However, the Committee is concerned that telepharmacy applications must improve access without compromising the quality of services that are available. The Committee believes that more information is needed on how well telepharmacy applications are balancing the issues of access and quality in rural areas. The evaluations should include studies on best practices and outcomes.

Recommendation 06-10:

• The Secretary should evaluate existing software programs that have been developed to assist low-income citizens in obtaining access to prescription medications through pharmaceutical assistance programs offered by pharmaceutical manufacturers. After a thorough examination, the Department should disseminate information on these programs to Federally Qualified Health Clinics, Rural Health Clinics and other providers serving rural areas.

During its work on this chapter, the Committee received testimony describing several recently developed software programs designed to help low-income groups identify pharmaceutical assistance programs available to them and streamline the application process. The Committee also learned that many safety-net providers have been unable to aid their patients in applying for pharmaceutical assistance programs due to staffing limitations. Thus, these software programs would be able to mitigate that issue. The Committee believes that the Department can play an important role in identifying successful software programs, disseminating information about them and assisting providers in their implementation.

Recommendation 06-11:

• The Secretary should work with the Congress and the Federal Communications Commission to allow the use of Universal Service Funds for rural health care providers to build greater infrastructure for broadband access in rural communities.

Recommendation 06-12:

• The Secretary should encourage groups like the American Health Information Community to consult with the Federal Office of Rural Health Policy, HHS Office of Intergovernmental Affairs and other key national rural health organizations about the impacts of their decision-making on rural communities.

Recommendation 06-13:

• The Secretary should devote funding resources to ensure that technical assistance is available for rural communities after the final release and dissemination of the VistA-Office EHR software.

Recommendation 06-14:

• The Secretary should commission the Agency for Health Research and Quality to conduct a study examining the costs and benefits of EHR use in rural communities to determine the disconnect between the payers and the beneficiaries of adoption. In addition, this study should examine the benefits and pitfalls of adoption for rural communities in terms of public health and syndromic surveillance reporting. This study should include data collection that allows policy makers to differentiate between rural and urban, provider size, and impact of affiliation with larger integrated health systems.

Recommendation 06-15:

• The Secretary should use the Section 301 Demonstration authority within the Public Health Service Act to support rural HIT collaborative grants to encourage the collaborative networking model for HIT purchasing and information exchange.

Recommendation 06-16:

• The Secretary should develop HIT performance measures for post-conversion critical access hospitals with a focus on HIT and quality of care.

Recommendation 06-17:

• The Secretary should expand the eligibility for the Doctors Office Quality - Information Technology (DOQ-IT) program available through the Medicare Quality Improvement Organizations to allow assistance to rural health clinics and Federally Qualified Health Centers.

Recommendation 06-18:

• The Secretary should encourage standardization of rural caregiver programs and uniform availability of services in rural areas across states and the nation.

The 50-State Study reveals that differences in program availability, design and benefit exist within states individually and across the nation. The Department should take the lead in efforts at standardization and uniformity of caregiver programs and services. Such an undertaking will require inter- and intra-state agreement about mission and philosophy, eligibility criteria, funding priorities, program design, and administration of services.

Recommendation 06-19:

• The Secretary should require the Administration on Aging, the Center for Medicare and Medicaid Services and the Health Resources and Services Administration programs to capture rural-specific data.

The Committee recommends that all survey instruments within HHS be required to collect and evaluate data in a way which identifies rural characteristics. The NAPIS database, specifically, should begin to capture data on rural caregivers. The Committee is aware that no Department-wide definition of "rural" exists. As long as this situation persists, researchers, program administrators and policy-makers will be unable to truly determine and report the extent of rural need because the key federal organizations do not evaluate programs with a uniform rural geographic standard.

The health-related components of HHS are slowly changing their data structures to illuminate urban/rural differences. The Committee would encourage the Secretary to require that all survey instruments within the Department collect, evaluate and report data in a geographically-specific way which identifies rural characteristics. Such standardization of efforts could be based on previous successes such as those realized in the Health Resources and Services Administration's Maternal and Child Health Bureau.

Recommendation 06-20:

• The Secretary should authorize a study to determine adequate funding requirements for rural family caregiver services under the NFCSP.

The Committee commends the work of the NFCSP and recognizes its success, however, the Committee realizes that the program is in great need of enhanced funding. Since it was authorized, the range and scope of NFCSP services have expanded but program funding, though increased annually, has not kept pace. Gaps in service and variation of availability of caregiver services in rural areas across states remain problematic due to inadequate funding.

Recommendation 06-21:

• The Secretary should expand eligibility for Family Caregiver Support services to include persons 40 and older.

In recognition of the growing contingent of younger caregivers, the Department should work to lower the eligibility age from 60 to 50 and older.

Recommendation 06-22:

• The Secretary should ensure that best practices in rural family caregiving be identified, studied, and publicized in a number of areas.

The NFCS programs should specifically identify and promote rural best practices. In addition, rural best practice models for state home-based family caregiver waiver programs should also be widely distributed. The Florida legislature is considering a bill (S.B. 88 & H.B. 49) to promote best practices among informal caregivers. The legislation under consideration promotes caregiving as a non-licensed paraprofessional activity and encourages the use of caregiving best practices. The bill would also create the Florida Caregiver Institute, an independent not-for-profit corporation which would develop policy recommendations to improve the skills and availability of direct care workers. The Secretary should establish a working group to consider piloting this work in other States.

In addition, the Secretary could use the Alzheimer's Disease Demonstration Grant program a successful model which encourages the development of best practices models that can be replicated in underserved areas, particularly minority and rural communities, in all 50 states.

Recommendation 06-23:

• The Secretary should encourage better assessment of rural caregiver needs as part of the NFCS program.

Caregiver assessment was identified in the 50-State Study as one of the top five needed technical assistance and training areas. Screening of caregivers should be done in the primary care setting as it has been shown that early assessment of caregivers needs helps prevent institutionalization of the care receiver upon crisis.

Recommendation 06-24:

• The Secretary should create a prominent, national social marketing campaign on rural caregiving.

The Department's Administration on Aging should oversee a social marketing campaign to educate rural Americans about the difficult role of caregivers and the family caregiver support programs available to them. This campaign must use plain, easily understood language.

Recommendation 06-25:

• The Secretary should continue to work to eliminate the persistent health and human services workforce shortage in rural areas.

The need for more providers and limited access to services in rural areas were cited as two of the top five needs listed in the 50-State Study.

Recommendation 06-26:

• The Secretary should establish a research grant program to study the rural application and impact of the five required NFCSP service areas.

Recommendation 06-27:

• The Secretary should lower the match requirement for the Title III E program from 25 percent to 15 percent, thus aligning it with the match required of other AoA programs.

Recommendation 06-28:

• The Secretary should consider whether centralizing State Unit and Area Agency on Aging services is an effective model for rural states.

The Committee observed during its site visits that the centralized structure of the AoA administrative functions is problematic, especially in large rural states. The Committee discovered that uneven information distribution with in the State caused poor collaboration among local and state service providers. Committee members saw first hand, some of the short comings of centralization, for example, local program directors being unaware of the other state and local services that are available to their clients. The Committee concludes that the AAAs must be locally situated to be most effective. A single State office in the absence of local AAAs is too far removed from local issues, especially in geographically large rural states.

Recommendation 06-29:

• The Secretary should encourage more research on the links between caregiver stress and the consequence of poorer health among rural caregivers.

The impact of providing long-term home care to loved ones is immensely debilitating to the caregiver. Isolation, resentment, guilt, anger, financial difficulties in addition to missed work, all plague the caregiver. One out of three caregivers reports their own health to be fair or poor. Research shows that informal caregivers suffer from high levels of stress, burnout, and insomnia and are more likely to use psychotropic drugs. However, this research does not identify differences between the stresses of rural caregivers as compared to their urban counterparts.

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2005 Recommendations

Recommendation 05-1: Create a Web Resource Page for "Models that Work" for Collaborations

The Federal Office of Rural Health Policy (ORHP) should build this recommendation into it cooperative agreement with the Rural Assistance Center (RAC). A special page should be built that is devoted to describing successful rural-based collaborations and that can be accessed in one step from the home page of the RAC Web site. The funding to RAC should support a reporting function to collect and present information regarding those collaborations.

Recommendation 05-2: Support Research that Specify Opportunities and Barriers to Collaboration

The Federal Office of Rural Health Policy should dedicate a portion of its research budget to further specify opportunities for and barriers to collaboration, funding activity either through its research centers or its solicitation of independent research proposals. Researchers should develop models that explain reasons collaborations are successful, with success being defined, in part, as long-term sustainability. Research findings should identify barriers to successful collaborations as well as community, Tribal, State and Federal actions that facilitate successful collaborations.

Recommendation 05-3: Support Leadership Development in Rural Communities

The Secretary should instruct all agencies with programs support local service delivery to include funds for leadership development in their grant-making portfolios. The Federal Office of Rural Health Policy program for rural leaders should be continued. The Secretary should consider supporting regional leadership academies by combining current programs from separate entities in HHS. The Secretary should encourage private foundations to expand their efforts to train future leaders. The Nebraska Community Foundation is one example of the important and crucial role a foundation can play in fostering leadership development in rural areas.

Recommendation 05-4: Require Grant Recipients Engaged in Direct Delivery of Services to Demonstrate an Effect on Community Development

The Secretary should require that all grant applications in program supporting service delivery in rural areas include an analysis of how the program will relate to broad-based efforts in community development. CREATE, in Mississippi, is measuring its success based on community indicators, such as the economy, education, public safety, social environment, health, housing and infrastructure.

Recommendation 05-5: Increase Support for Medical Schools that Have Distinct Program and a Proven Track Record for Training Physicians to Practice Obstetrics in Rural Areas

An increased supply of rural physicians trained in obstetrics is essential to sustaining these services in hundreds of small rural communities. The Secretary should increase or reallocate funds under Title VII of the Public Health Service Act to target medical schools that train obstetricians and family physicians for rural practice, especially those that provide residents in family medicine with training in high-risk obstetrics. Family physicians are more likely to practice in rural areas than obstetricians, and programs that prepare them for high-risk obstetrics must be supported. Support for the training of CNMs and nurse practitioners who are interested in obstetrics also should be increased.

Recommendation 05-6: Make the Recruitment and Placement of Physicians Trained in Obstetrics a Major Goal for the National Health Service Corps

The Committee believes that the National Health Service Corps must focus more attention on rural areas that lack adequate obstetrics services. Recruitment efforts should focus on physicians who are trained in obstetrics and who are willing to deliver babies in the communities they serve. Additional incentives for new physicians are also needed and should be explored. One approach would be to pay the malpractice insurance costs of new Corps physicians who are fulfilling their obligation in areas with measurable and pronounced shortages of obstetrics care providers.

Recommendation 05-7: Support Program to Create Hospital and Physician Networks that will Sustain and Improve Access to Obstetric Services in Rural Areas

There are several existing grant programs in the Department (Healthy Community Access, Rural Network Development, Rural Hospital Flexibility Grants) that should be used to promote the development of hospital and physician networks in obstetrics care. The Committee believes that obstetrics services in many small rural hospitals and physician practices will be unsustainable over time, given the issues discussed in this report. Providers need encouragement and incentives to find more sustainable and efficient strategies for maintaining access to obstetrics care. Existing grant programs should be more aggressive in encouraging and funding grant applications that address the problem.

Recommendation 05-8: Promote the Development of Team Approaches to Obstetrics Care Involving Physicians, Nurse Practitioners, Certified Nurse Midwives and Other Non-Physician Providers

The Secretary should use this demonstration authority to develop a model program that supports regional approaches to improving access to obstetrics care in rural communities through networking and an emphasis on using interdisciplinary teams in several rural areas as a pilot project.

Recommendation 05-9: Increase Medicaid Payments for Obstetrics Services

The Committee understands that Medicaid payments for services are determined by the States; however, the Secretary does have authority over State Medicaid waivers that affect the scope of services that Medicaid provides and populations served. The Secretary should explore ways in which the waiver approval process could be sued to provide incentives for the States to increase payments and improve access to obstetrics services in rural areas.

Recommendation 05-10: Address the Malpractice Insurance Issue by Supporting Legislation that will Extend the Federal Tort Claims Act to Rural Obstetrics Providers in Federally Designated Shortage Areas

The malpractice insurance program for Federally Qualified Health Centers and Free Clinics should be extended to cover rural hospitals and physicians providing obstetrics services in underserved rural areas. The Committee believes that the current system for designating Health Professional Shortage Areas (HPSAs) may not be able to identify the rural areas most underserved by obstetrics services. Data are available to identify rural areas that have the lowest ratios of obstetrics providers to women of childbearing age, which may be a more effective access measure. Another approach would be to give greater weight to obstetrics services as a variable used in the HPSA designation process. The method used must be limited to those rural areas where access to obstetrics care is mot severely limited by provider shortages.

Recommendation 05-11: Encourage the State to Revise Their Medicaid Policy to Remove Any References of Obesity Not Being an Illness

The Department should take the lead in working with the States to classify obesity as an illness and cover procedures related to treatment of obesity. This change is even more critical in Medicaid than it is in Medicare since it will allow health care providers to aggressively treat those with obesity and it will potentially help patients avoid more serious obesity-related health complications in the future.

Recommendation 05-12: Make Refinements to the HealthierUS Community Grant Program so that Rural Concerns can be more Thoroughly Represented

The Committee commends the Secretary for launching the Steps to a HealthierUS community grant program, especially since it includes rural participation. However, the Committee is also hopeful that refinements will be made to assure that the concerns identified with respect to rural representation are addressed. Additional opportunities for direct granting to rural communities would be helpful, as many States did not include rural communities within their grants.

Recommendation 05-13: Ensure that the Next Publication of the CDC Chartbook includes more Rural-Specific Data and that Other, Future Publications Include References to Rural

The Committee commends the efforts the CDC has made to conduct studies that include rural areas. These studies have consistently shown that rural areas have higher rates of obesity and are, in general, less healthy than urban or suburban areas. The Committee would encourage the publication of a new CDC Chartbook to provide current, more rural- specific items compared to the previous 2001 publication, and to continue the inclusion of rural areas in its other studies. In addition, the Committee encourages NIH and the CDC to include studies of rural-specific prevention and intervention.

Recommendation 05-14: Ensure that Rural Residents are Seen as a Separate and Unique Segment of the Population in Funding, Research and Data Collection

The Committee commends the efforts CDC has made to conduct studies that include rural areas. These studies have consistently shown that rural areas have higher rates of obesity and are, in general, less healthy than urban or suburban areas. The Committee would encourage the publication of a new Rural-Urban Chartbook by no later than 2006 t provide current, more rural specific items compared to the previous 2001 publication, and to continue the inclusion of rural areas in its other studies. In addition, the Committee encourages the NIH and the CDC to include studies of rural-specific prevention and intervention.

Recommendation 05-15: Provide targeted technical assistance to States to Examine to How to Address the Transportation, Child Care, and Employment Needs of Rural TANF recipients

The Secretary should work with the Administration for Children and Families (ACF) to provide targeted technical assistance that would encourage States to address the transportation, child care, and employment and training needs of rural TANF recipients.

Recommendation 05-16: Emphasize Collaboration and Encourage States to Utilize Best Practices in Efforts to Service Rural TANF Clients

The Secretary should emphasize collaboration and encourage States to utilize best practices, including those identified by ACF, particularly in efforts to serve rural clients.

Recommendation 05-17: Strengthen Department's Leadership and Work with Federal Partners

The Secretary should strengthen the Department's leadership among Federal partnerships and collaborations.

The Secretary should propose legislation to the Congress that would establish a Medicare inpatient payment floor for rural hospitals with less than 50 acute care beds and for Sole Community Hospitals (SCHs). The payment floor would be based on an individual hospital's current cost experience. The legislation would be effective for hospital cost reporting periods beginning on or after October 1, 1989, and end at such time that special Medicare payment provisions for essential access facilities are implemented. For the purposes of this legislation, acute care beds include swing beds, but exclude licensed beds for long- term care and newborn bassinets.

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2004 Recommendations

Recommendation 04-1: Allow Behavioral Health Providers to Provide Behavioral Health Services as Qualified Mental Health Care Service Providers

The Secretary should work with the Congress to amend Section 1861(s) (2) of the Social Security Act to authorize State-licensed marriage and family therapists, licensed professional counselors and other behavioral health providers to provide behavioral health services as qualified mental health care service providers. The Secretary should also work with Congress to authorize Medicare payments for those services by amending Section 1833(a)(1) of the Social Security Act, as needed, to ensure that payment.

Recommendation 04-2: Broaden the Definition of Originating Sites for Telehealth Services

The Secretary should seek to broaden the definition of originating sites for telehealth services to include private physician offices under Title XVIII of the Social Security Act and ensure that all Medicare-eligible providers can offer mental health services via telehealth consultation.

Recommendation 04-3: Identify States with Model Licensure Laws and Scope of Practice Acts for Non-Physician Behavioral Health Providers

The Secretary, under the auspices of Title XVIII and Title IX of the Social Security Act, should work to identify States with model licensure laws and scope of practice acts for non-physician behavioral health providers. The Secretary should share them with other States and policymakers in order to facilitate similar practices in rural areas of the country. The Secretary should also work with States and behavioral health professional associations to increase flexibility in State requirements for supervision of limited license behavioral health providers that would allow more rural training, either in person or through supervision delivered via telehealth technologies.

Recommendation 04-4: Increase Funding for the Quentin N. Burdick Program for Rural Interdisciplinary Training

The Secretary should support increased funding for the Quentin N. Burdick Program for Rural Interdisciplinary Training. The program is authorized under Title VII, Section 754 of the Public Health Service Act. Grants awarded through the program can support innovative models and demonstrations of interdisciplinary care in rural areas. The program is uniquely suited to the support of programs that foster the development of integrated primary care and behavioral health care delivery systems.

Recommendation 04-5: Increase Funding for the Graduate Psychology Education Program

The Secretary should support increased funding for the Graduate Psychology Education Program authorized under Title VII, Section 755(b)(1)(J), of the Public Health Service Act. This program supports grants to schools accredited by the American Psychological Association to help them plan and operate programs that foster an integrated approach to health care service and that train psychologists to work in underserved areas. The program was not included in the President's budget for 2005.

Recommendation 04-6: Increase Support for Scholarships and Loan Repayment for Behavioral Health Care Providers

The Secretary should provide increased support of scholarships and loan repayment for behavioral health care providers under Section 331 of the Public Health Service Act.

Recommendation 04-7: Amend Title XVIII and Title XIX of the Social Security Act to Require Parity in Payments

The Secretary should work with the Congress to amend Title XVIII and Title XIX of the Social Security Act to require parity in payments and the resulting co-payments for mental health care services under Medicare and Medicaid.

Recommendation 04-8: Clarify that Critical Access Hospitals Can Provide Mental Health Services

The Secretary should work with the Centers for Medicare and Medicaid Services in administration of Section 1834(g) of the Social Security Act to clarify that Critical Access Hospitals can and should have the flexibility to provide mental health services as dictated by community need within the normal protections for patients.

Recommendation 04-9: Increase the Federal Matching Funds for Oral Health Services by Five to Ten Percent

The Secretary, under Title XIX of the Social Security Act, should authorize a five to ten percent increase in Federal matching funds for oral health services. This increased match would encourage States to expand dental coverage and provide dental reimbursements at a level sufficient to attract additional providers to the Medicaid program.

Recommendation 04-10: Increase Funding for the Quentin N. Burdick Program for Rural Interdisciplinary Training, Health Careers Opportunity Program and Centers for Excellence Program

The Secretary should work with the Office of Management and Budget (OMB) and Congress to seek increased funding for the Quentin N. Burdick Program for Rural Interdisciplinary Training, authorized by Title VII, Section 754 of the Public Health Service Act. Priority should be given to Quentin N. Burdick applicants whose programs include dentists or dental hygienists. The Secretary should also attempt to obtain more funding for the Health Careers Opportunity Program (HCOP) and Centers for Excellence (COE) Program, authorized by Title VII, Sections 739 and 736, respectively. The additional funds should be used to increase the number of dental schools receiving HCOP and COE grants. This would provide more support for dental schools that seek to recruit additional minority and disadvantaged individuals and to expose students to practice opportunities in underserved communities.

Recommendation 04-11: Ensure Adequate Funding for the National Health Service Corps

The Secretary should ensure adequate funding for the National Health Service Corps under Section 331 of the Public Health Service Act and should encourage it to pursue innovative strategies that will attract more dentists and dental hygienists to take part in the program.

Recommendation 04-12: Seek Additional Funding for the Recruitment and Loan Repayment of Indian Health Service Dentists and Hygienists

The Secretary should work with the Office of Management and Budget to seek additional funding for the recruitment and loan repayment of Indian Health Service dentists and hygienists and to ensure the Indian Health Service dental facilities and equipment are adequate to meet the demand for services.

Recommendation 04-13: Establish a Program that would Fund the Fluoridation of Small Community Water Supplies

The Secretary should work with the Office of Management and Budget and the Congress to explore the establishment of a new categorical grant program that would provide funding to States for the fluoridation of small community water supplies and provide ongoing technical assistance and maintenance for such systems.

Recommendation 04-14: Establish State Dental Offices in All 50 States and U.S. Territories

The Secretary should work with Congress and the Office of Management and Budget to establish a Federal-State partnership that is modeled after the State Offices of Rural Health Grant Program. This partnership would support the establishment of State Dental Offices with full-time directors in all 50 States and U.S. territories. Since the majority of oral health policy issues are under State jurisdiction, it is important to ensure that States have an adequate infrastructure to address pressing oral health issues and coordinate Statewide oral health initiatives.

Recommendation 04-15: Direct the National Institutes of Health and the Agency for Healthcare Research and Quality to Conduct Studies on Oral Health Disparities

The Secretary should direct the National Institute for Dental and Craniofacial Research and the Agency for Healthcare Research and Quality to conduct a series of studies on rural oral health disparities. These studies will provide additional information on the oral health status of rural residents and will provide critical information that will be used to guide evidence-based policymaking.

Recommendation 04-16: Develop a Demonstration Program to Explore Innovative Approaches to Providing Transportation to the Rural Elderly

The Secretary should develop a demonstration project through Section 301 of the Public Health Service Act that would explore innovative approaches to providing transportation to rural elderly and would examine current Federal and State regulations and opportunities to use existing systems operated through Area Agency on Aging programs, Head Start and State and local transportation systems such as school buses.

Recommendation 04-17: Support Research that Examines How Rural Seniors Access the Services Provided under the Older Americans Act

The Secretary should support research that examines how rural seniors access key services provided under the Older Americans Act to determine if there are any service gaps particular to rural communities.

Recommendation 04-18: Track Expenditures in the National Family Caregivers Support Program

The Secretary should work with the Agency on Aging to track expenditures in the National Family Caregivers Support Program to determine how much of the funding goes to rural communities.

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2003 Recommendations

Recommendation 03-1: Promote Demonstrations through CMS that Examines How Reimbursement can Promote Quality Improvement

The Secretary should work with CMS to promote demonstrations that examine how reimbursement might be used to promote quality improvement in the rural setting.

Recommendation 03-2: Increase Funding for State Survey and Certification Activities

The Secretary should increase funding for state survey and certification activities. The survey and certification agencies are consistently under funded and this has a disproportionate effect on rural providers given their heavier reliance on using the survey and certification program and less reliance on accreditation compared to their urban counterparts.

Recommendation 03-3: Amend the Seventh Scope of Work for the Quality Improvement Program

The Secretary should amend the Seventh Scope of Work for the Quality Improvement Program to make this program more relevant for rural communities. This would include creating a stand-alone task focusing on rural health. It would also include a new evaluation methodology for reviewing the work of the Quality Improvement Organizations that includes more localized measures of areas with populations that suffer health disparities. The sole reliance on measures of state-wide improvement acts as a disincentive for working with harder-to-reach populations.

Recommendation 03-4: Increase Funding for the Quality Improvement Program

The Secretary should work with the Office of Management and Budget to increase funding for the Quality Improvement Organizations to encourage Quality Improvement Organizations to reach out more meaningfully to rural communities to rural communities and to help providers prepare for public reporting in hospital, home health and individual ambulatory provider settings.

Recommendation 03-5: Solicit Input from Rural Health Care Providers in Identifying Measures for Public Reporting

The Secretary should solicit (via Federal Register notice) input from rural health care entities in identifying which measures shall be used for public reporting for all healthcare providers and include not only outcome measures but also process measures. This activity should promote appropriate benchmarking that compares organizations with similar characteristics such as geography, size, and volume. This is very important as outcome measures require statistical significance frequently not available in a typical rural facility due to lower volumes or that may not be appropriate for rural facilities.

Recommendation 03-6: Ensure that Research Translated into Practice Include a Focus on Rural Health Care

The Secretary should work with AHRQ and NIH to ensure that each Agency's efforts to translate research to practice include a focus on rural health care quality issues as well as translation of findings to rural practice, dissemination and adoption of recommendations. AHRQ and NIH should also identify and examine "models that work" in rural areas.

Recommendation 03-7: Fund the new Small Health Care Provider Quality Improvement Program

The Secretary should work with the Congress to fund the new Small Health Care Provider Quality Improvement Program authorized in Public Law 107-251.

Recommendation 03-8: Support Re-Authorization of the Medicare Rural Hospital Flexibility Grant Program

The Secretary should support re-authorization of the Medicare Rural Hospital Flexibility Grant program in a manner that strengthens the program's orientation to promoting quality in Critical Access Hospitals.

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2002 Recommendations

Recommendation 02-1: Require a Uniform Medicare Disproportionate Share Hospital Adjustment Policy

The Secretary should work with Congress to require the use of a uniform Medicare Disproportionate Share Hospital adjustment policy that treats all hospitals the same regardless of their urban or rural location.

Recommendation 02-2: Raise the Cap on Medicare Disproportionate Hospital Payments

The Secretary should work with Congress to raise the cap on Medicare Disproportionate Share Hospital payments for rural hospitals to an appropriate level that provides equity for rural hospitals.

Recommendation 02-3: Expand Options for Using Medicaid Disproportionate Share Hospital Payments for Eligible Rural Hospitals

The Secretary should work with States to expand options for using Medicaid Disproportionate Share Hospital Payments for eligible rural hospitals, including the ability to upgrade the financial stability of rural hospitals or to assist rural hospitals to develop physician or clinic networks.

Recommendation 02-4: Ensure Re-Authorization and Continued Funding of the Rural Hospital Flexibility Grant Program

The Secretary should work with Congress to ensure re-authorization and continued funding of the Medicare Rural Hospital Flexibility Grant Program, which is up for re-authorization in FY 2002.

Recommendation 02-5: Eliminate the Medicare Per-Visit Payment Cap

The Secretary should work with Congress to eliminate any financial challenges to FQHC's providing care to the uninsured by eliminating the Medicare per-visit payment cap.

Recommendation 02-6: Increase Access to Capital and Expand Eligible Uses of Grant Funds for Rural Providers

The Secretary should work with Congress to increase access to capital and to expand eligible uses of grant funds to include construction, renovation, and modernization of health center facilities.

Recommendation 02-7: Increase Federally Qualified Health Centers in Rural and Frontier Areas

The Secretary should encourage the development of criteria that will increase the number of FQHC sites in rural and frontier areas.

Recommendation 02-8: Increase Rural Health Clinics Payment Limit

The Secretary should work with Congress to increase the RHC payment limit under section 1833 (f) of the Act to more closely correspond with the increase in payments for primary care services resulting from the full transition to the physician fee schedule.

Recommendation 02-9: Amend Reimbursement Methodology for Rural Health Clinics

The Secretary should amend the reimbursement methodology for Rural Health Clinics (RHCs) payment so that RHCs that 1) are non-profit, 2) see all patients regardless of ability to pay, and 3) elect to use a sliding fee scale do not have to count uninsured patients in determining the aggregate number of patients seen for calculation of the per-visit payment rate.

Recommendation 02-10: Work with Congress to Conduct Strong Oversight of the Implementation of the Medicaid PPS

The Secretary should work with Congress to conduct strong, ongoing oversight of the implementation of the Medicaid PPS to ensure that States comply with requirements in the Federal PPS statute and that access to FQHC and RHC services are protected.

Recommendation 02-11: Work with Congress to Evaluate the Medicaid PPS to Ensure that FQHCs and RHCs are being Adequately Reimbursed

The Secretary should work with Congress to evaluate the Medicaid PPS to ensure that FQHCs and RHCs are being adequately reimbursed to protect access to care, including access to care for the uninsured. This includes examining whether the Medicare Economic Index (the current measure of inflation used in PPS) is sufficient to protect Medicaid reimbursement for these critical safety next providers.

Recommendation 02-12: Issue an Advisory Letter Disseminating the Legality and Specific Requirements of the Income-Related Sliding Fee Scales

The Secretary should issue an advisory letter that spells out the legality and specific requirements of income-related sliding fee scales and disseminate it widely.

Recommendation 02-13: Support and Enhance the 340B Discount Drug Program

The Secretary should continue to support and enhance the 340B Discount Drug Program and support Medicare reforms that include access to prescription drugs.

Recommendation 02-14: Propose an Increase in Funding for the National Health Service Corps

The Secretary should propose an increase in funding for the National Health Service Corps at levels sufficient to support the multi-year plan to expand health centers and to meet the pressing needs of other rural areas for health professionals.

Recommendation 02-15: Create a Focal Point within the Department to Coordinate the J-1 Visa Waivers

The Secretary should create a focal point within the Department to coordinate the J-1 Visa Waivers issued by all Federal agencies and the communities in which they are placed to ensure that the visa waivers are used to meet patient care needs.

Recommendation 02-16: Consider Allowing HHS to Issue J-1 Visa Waivers for Primary Care Physicians if the USDA Declines to Continue Issuing Those Waivers

The Secretary should consider allowing HHS to issue J-1 Visa Waivers for primary care physicians if the USDA declines to continue issuing those waivers. If USDA continues to offer J-1 Visa Waivers, the Secretary should work with the Congress to re-authorize and expand the scope of the Conrad State 20 program to more adequately meet the primary care needs of rural communities.

Recommendation 02-17: Increase the Amount of Medicare Incentive Payment to 20 Percent

The Secretary should work with the Congress to increase the amount of the Medicare Incentive Payment to 20 percent.

Recommendation 02-18: Allow Nurse Practitioners and Physician Assistants to Qualify for the Medicare Incentive Payments

The Secretary should work with the Congress to allow nurse practitioners and physician assistants to qualify for the Medicare Incentive Payments.

Recommendation 02-19: Eliminate Medicare Payments to Urban Specialists

The Secretary should work with Congress to eliminate Medicare Incentive Payments to urban specialists.

Recommendation 02-20: Change the Current Auditing Procedures Used the Medicare Contractors

The Secretary should change the current auditing procedures used by the Medicare Contractors to ensure that providers who claim the Medicare Incentive Payment will not have any greater likelihood of being audited than providers who do not claim the extra payment.

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2001 Recommendations

Recommendation 01-1: Evaluate the Need for a Low-Volume Adjustment in Medicare

The Secretary should evaluate the need for a low-volume adjustment within all of the Medicare prospective payment systems.

Recommendation 01-2: Research into the Cost of Providing Care to Medicare Beneficiaries in Rural Areas

The Secretary should promote research into determining the true cost of providing care to Medicare beneficiaries in rural areas that take into account factors related to access, geographic isolation and volume. The results of this research should be used in redesigning the Medicare program to ensure equity of benefits for rural beneficiaries.

Recommendation 01-3: Continue Collecting Data on Occupational Mix

The Secretary should continue collecting data on occupational mix and implement an adjustment to the wage index as soon as possible.

Recommendation 01-4: Collect Wage Data for the Skilled Nursing and Home Health Service Areas

The Secretary should collect wage data for both the skilled nursing and home health service areas and evaluate the impact of constructing an occupational mix adjustment within the wage index for both of these payment systems.

Recommendation 01-5: Refine the Methodology for Determining the Disproportionate Share Adjustment for Hospitals

The Secretary should continue to refine the methodology for the disproportionate share adjustment for hospitals to treat all hospitals equally.

Recommendation 01-6: Develop a Standard Benefit Package for Medicare Beneficiaries

The Secretary should develop a standard benefit package that includes access to a reasonable prescription drug benefit under Medicare fee for service.

Recommendation 01-7: Provide Demonstration Waivers to Rural Communities for Innovative Health Care Models

The Secretary should provide demonstration waivers to rural communities for innovative models that improve access to care and that focus on chronic care, case management, and preventive care.

Recommendation 01-8: Examine Impact of Prospective Payment Systems in Home Health and Skilled Nursing for Medicare Beneficiaries

The Secretary should examine the impact of the new prospective payment systems for home health, skilled nursing, and outpatient services to determine what impact these changes have had on access to care for rural Medicare beneficiaries.

Recommendation 01-9: Monitor the Closures of Skilled Nursing Facilities

The Secretary should monitor the closures of skilled nursing facilities and the impact of moving swing beds under skilled nursing facilities prospective payment to determine the impact on access to care for rural Medicare beneficiaries.

Recommendation 01-10: Ensure Core Services are Available to all Medicare beneficiaries

The Secretary should ensure that the core services (primary, preventive and chronic care management) and the full continuum of care are appropriately available for all Medicare beneficiaries.

Recommendation 01-11: Amend the Medicare Conditions of Participation

The Secretary should amend the Medicare Conditions of Participation. Also, the Secretary should provide resources through entities such as the Peer Review Organizations to develop quality improvement tools to fit the rural environment with appropriate flexibility and an emphasis on outcome standards.

Recommendation 01-12: Encourage Development of Appropriate Quality Measures for Rural Areas

The Secretary should encourage the development of appropriate measures that take into account a rural environment that features low volume of primary care and ambulatory services.

Recommendation 01-13: Encourage More Training of Health Professionals for Rural Communities

In recognizing the link between quality health care and the workforce, the Committee recommends that the Secretary encourage more training of health professionals for rural communities to ensure access to high-quality care for Medicare beneficiaries.

Recommendation 01-14: Support Research Related to Volume and Outcome for Primary and Ambulatory Care

The Secretary should support research that looks into issues related to volume and outcome in the rural context based on primary and ambulatory care.

Recommendation 01-15: Support Changes to Medicare Policy to Provide Exceptions for Rural Training Programs

The Secretary should support changes to Medicare policy to provide exceptions to the residency cap for rural training programs and provide direct and indirect GME funding for these programs.

Recommendation 01-16: Promote More Community-Based Trainings

The Secretary should support changes to Medicare policy that promote more community-based training of residents.

Recommendation 01-17: Require Training Programs that Receive Graduate Medical Education Funding to Have Rural Training Sites

The Secretary should support changes to Medicare policy so that residency programs receiving GME funding would be required to provide training in rural settings.

Recommendation 01-18: Support Rural Graduate Medical Education Demonstrations

The Secretary should support Rural GME demonstration projects that address workforce shortages in rural areas.

Recommendation 01-19: Promote Rural Training in Title VII and Title VIII Programs

The Secretary should expand the scope and focus Title VII and Title VIII training grants to promote more rural training.

Recommendation 01-20: Increase Funding for the National Health Service Corps to Promote More Clinicians Serving in Rural Areas

The Secretary should increase funding for the National Health Service Corps to promote more placements of Corps clinicians in underserved rural areas to serve Medicare and Medicaid beneficiaries.

Recommendation 01-21: Protect and Strengthen the Medicare Fee-For- Service Program

The Secretary should protect and strengthen the Medicare Fee-For-Service delivery option under any redesign or reform of the Medicare program. This should include an acknowledgment that Medicare + Choice in its present form is not a viable option for bringing managed care and equity of benefits to rural beneficiaries. Consequently, the Secretary should recognize that fee-for-service delivery will continue to be the dominant service delivery mechanism for rural Medicare beneficiaries.

Recommendation 01-22: Ensure that Rural Health Care Providers are Kept in Mind during any Redesign of the Medicare Program

The Secretary should ensure protections for key rural service providers (critical access hospitals, sole community hospitals, Medicare-dependent hospitals, rural referral centers, rural health clinics and federally qualified health centers), in any redesign of the Medicare program to ensure access to care for rural beneficiaries.

Recommendation 01-23: Explore Potential New Service Delivery Models for Rural Areas

The Secretary should explore the development of new service delivery models for rural beneficiaries that recognize the special circumstances of providing care in sparsely populated rural areas. Options such as coordinated care, primary care case-management and other forms of partial risk or capitation that emphasize local control and flexibility should be explored.

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2000 Recommendations

Recommendation 00-1: Improve Coordination of Federal Public Health Activities

The Secretary should seek an Executive Order for the creation of a Federal Interagency Public Health Coordination Committee comprised of senior representatives from the various public health agencies and federal departments. The committee would study current efforts by each of the Federal Agencies involved in public health activities overall while evaluating ways to integrate funding stream to benefit rural communities in the areas of leadership development, workforce development, viability of the safety net, impact of managed care, and telecommunications. The newly formed committee would produce an annual report based on their studies. This committee would include appointed representatives from the Department of Health and Human Services, the Department of Agriculture, the Environmental Protection Agency, the Department of Commerce, the Department of Veteran Affairs, the Department of Labor, the Department of Education, the Department of Housing and Urban Development, the Department of Transportation, the Department of Defense and any other relevant Federal agencies.

Recommendation 00-2: Create a Dedicated Funding Stream for Public Health Activities

The Secretary should support the development of a dedicated funding stream for public health infrastructure activities with assurances that funding is equitably distributed among rural and urban health departments at the local level.

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1999 Recommendations

Recommendation 99-1: Incorporate an occupational mix adjustment into the Wage Index

The Committee recommends that the Secretary incorporate an occupational mix adjustment into the calculation of the Medicare Hospital Wage Index. This will require the Department to begin gathering data on wage and hours by occupational category in the Medicare cost reports or by obtaining it from the Bureau of Labor Statistics.

Recommendation 99-2: Develop Separate Wage Indexes for Sub-Acute Care PPS

The Committee recommends that the Secretary develop separate wage indexes for the prospective payment systems for skilled nursing facilities and home health agencies within three years after these payment systems are in place.

Recommendation 99-3: Remove Teaching Physician Costs from the Wage Index

The Committee recommends that the Secretary remove teaching physician costs from the hospital wage index since these costs are recognized elsewhere in the Medicare system through Graduate Medical Education payments.

Recommendation 99-4: Collect and Evaluate Hospital-Specific Labor Data for the Wage Index

The Committee recommends that the Secretary begin collecting hospital specific wage index market data during the next three years and develop and implement a New Medicare wage index based on hospital-specific labor market areas by FY 2003. The new wage index calculation would base wage-related costs on the costs incurred by neighboring hospitals.

Recommendation 99-5: Low-volume adjustment for the Medicare Outpatient Prospective Payment System for Rural hospitals

The Committee recommends that the Secretary include a low-volume adjustment in the final rule for the Medicare outpatient prospective payment system to compensate rural providers who may be at a disadvantage under the new payment system if they serve low numbers of patients.

Recommendation 99-6: Low-volume adjustment for the Medicare Home Health Prospective Payment System for Rural Providers

The Committee recommends that the Secretary include a low-volume adjustment in the final rule for the Medicare home health prospective payment system to compensate rural providers who may be at a disadvantage under the new payment system if they serve low numbers of patients.

Recommendation 99-7: Low-volume adjustment for the Medicare Skilled Nursing Facility Prospective Payment System for Rural Providers

The Committee recommends that the Secretary include a low-volume adjustment in the Medicare skilled nursing facility payment system to compensate rural providers who may be at a disadvantage under the new payment system if they serve low numbers of patients.

Recommendation 99-8: Low-volume adjustment for the Medicare Ambulance Fee Schedule for Rural Providers

The Committee recommends that the Secretary include a low-volume adjustment in the final rule for the Medicare ambulance fee schedule to compensate rural providers who may be at a disadvantage under the new payment system if they serve low numbers of patients

Recommendation 99-9: Revision of the Medicare Disproportionate Share Payment Adjustment for Rural Hospitals

The Committee recommends that the Secretary revise the formula by which rural hospitals receive disproportionate share payments under the Medicare program to more adequately compensate those rural providers that shoulder a large burden of indigent care.

Recommendation 99-10: Creation of a Rural Hospital Capital Need Loan Program

The Committee recommends that the Secretary to support the creation of a loan program for physical capital needs in licensed acute care rural hospitals that encourages consolidation and coordination of services at the local level.

Recommendation 99-11: Critical Access Hospital Grant Incentives

The Committee recommends that the Secretary give a preference in the reviewing of grant proposals to projects that include a Critical Access Hospitals as a part of the applicant consortia or network under Federal health grants administered by the Department of Health and Human Services.

Recommendation 99-12: Encourage Development of Rural-Specific Quality Standards

The Committee recommends that the Secretary encourage national and state accrediting bodies to examine rural-specific quality issues and work with the Department to develop relevant standards appropriate to the size, setting, and services provided by rural hospitals, health systems, rural provider practices and health plans serving rural areas. The Secretary should also support recognition of these issues by Congressional members and staff.

Recommendation 99-13: Development of Two Sets of Definitions for Rural Areas

The Secretary recommends that the Secretary support the development of two sets of standards for the delineation of metropolitan and nonmetropolitan areas. This would include:

• A county-based set of standards as OMBs official standards, for statistical reporting purposes and as one option for federal funding programs.
• A Census tract-based system, to be available as an alternative option for federal funding programs and experimental use for reporting federal statistics.

Recommendation 99-14: Improved Coordination of Federal Public Health Activities

The Committee urges the Secretary to seek an Executive Order for the creation of a Federal Interagency Public Health Coordination Committee comprised of senior representatives from the various public health agencies and federal departments. The committee would produce an annual report (the first of which would be produced within 12 months of the establishment of the Committee). The Committee would study current efforts by each of the Federal Agencies involved in public health activities overall while evaluating ways to integrate funding streams to benefit rural communities in the areas of leadership development, workforce development, viability of the safety net, impact of managed care, and telecommunications.

Recommendation 99-15: Creation of a Dedicated Funding Stream for Public Health Activities

The Committee urges the Secretary to support the development of a dedicated funding stream for public health infrastructure activities with assurances that funding is equitably distributed among rural and urban health departments at the local level.

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1998 Recommendations

Recommendation 98-1: Allow Referring Practitioner to Bill For Telehealth Consultations

The Committee recommends that the Secretary ensure that the new regulations for telehealth reimbursement allow a referring practitioner, usually located in a rural area, to bill for a primary care visit on the same day as a video consultation if the primary care visit is the basis of the consultation or was for a medical problem unrelated to the consultation.

Recommendation 98-2: Reimburse for Telehealth Services in All HPSAs

The Committee recommends that the Secretary ensure that the new regulations for telehealth reimbursement interpret "rural health professional shortage" area as being all rural health professional shortage areas, including partial county, whole county and multiple county as well as governor-designated HPSAs. The original legislation did not specify which HPSAs were eligible.

Recommendation 98-3: Base Telehealth Payment on Consultant Setting

The Committee recommends that the Secretary ensure that the new regulations for telehealth reimbursement require that the fee schedule be based on the location of the consultant rather than the referring clinician. The original legislation did not specify whether the payment should be based on the patients location in the rural area or the specialists location, which is usually in an urban area. The urban payment tends to be higher.

Recommendation 98-4: Medicare Adopt a Broad Telehealth Consultation Definition

The Committee Recommends that the Secretary ensure that for the purpose of telemedicine payment, interactive consultation should be interpreted in as broad a manner as is possible. A video interaction between two practitioners where enhanced information is provided by the referring practitioner involving tele-imaging and appropriate medical history, physical findings, and diagnostic/management concerns for use in the consultation should count as an interactive consultation, even if the patient is not present.

Recommendation 98-5: Allow Same-Day Office and Telehealth Consult Billing

The Committee Recommends that the Secretary ensure that the referring provider should be permitted to bill for a primary care visit on the same day as a video consultation if the primary care visit is the basis of the consultation, or was for a medical problem unrelated to the consultation.

Recommendation 98-6: Allow Unbundling of Telehealth Consultation Fee by Participating Providers

The Committee Recommends that the Secretary ensure that the unbundling of the fee between the two providers should be left to the discretion of the two providers (institutions or practitioners) involved and should not be specified in regulation. In the event that it is determined that this is not permissible because of the provisions of other legislation, then the unbundling should be designed to ensure that there are incentives for both the referring and consulting physician to participate in telemedicine consultations.

Recommendation 98-7: Adopt a Broad Definition of Interactive Consultations

The Committee Recommends that the Secretary should support a technical amendment that defines an interactive consultation. For the purpose of telemedicine payment interactive consultation should be interpreted in as broad a manner as is possible to include video interactions between two practitioners in which enhanced information is provided by tele-imaging and appropriate medical history, physical findings and diagnostic/management concerns are provided by the referring practitioner for use in the consultation, even if the patient is not present.

Recommendation 98-8: Allow Nurse Presenters in Medicare Telehealth Consultations

The Committee Recommends that the Secretary support a clarification of the statute that would allow a nurse, under the supervision of a practitioner who is not physically present in the room, to present a patient for a teleconsultation.

Recommendation 98-9: Support Full Funding of the Rural Hospital Flexibility Program

The Committee recommends that the Secretary support a $25 million appropriation to implement the Rural Hospital Flexibility Program and ensure that it is administered by the Office of Rural Health Policy in the Health Resources and Services Administration.

Recommendation 98-10: Support a legislative change to 1997 GME Legislation

The Committee recommends that the Secretary support legislation to make technical changes on a series of GME provision from the Balanced Budget Act. Specifically, the legislation should:

• strike the phrase "in the hospital" from Section 4621 of the Balanced Budget Act of 1997. This section of the BBA establishes a cap on FTEs based on the number of residents who were being trained in the hospital on or shortly before December 31, 1996.
• allow an increase in a hospitals FTE count if residents are moved from another teaching hospital at the discretion of the hospital accredited to sponsor the residency.
• permit the expansion of primary care residencies when they are the only program sponsored by the institution.
• Change the cutoff date to September 1999 to allow recently accredited primary care programs to become established.

Recommendation 98-11: Include Residency Programs Producing Rural Physicians in the Definition of Serving Rural Areas

The Committee recommends to the Secretary that the Health Care Financing Administration consider not only where a residency program is located but where its graduating physicians practice in their definition of programs servicing rural or rural underserved.

Recommendation 98-12: Assure Access to Mental Health Care in Medicaid Managed Care

The Secretary should assure access to care for rural Medicaid eligible individuals served by managed behavioral health care systems. Toward that end, the Secretary should

• Actively monitor and evaluate the design and implementation of State Medicaid managed health plans
• Require that the Health Care Financing Administration, the Substance Abuse and Mental Health Services Administration and the Office of Rural Health Policy work together to address issues related to Medicaid managed behavioral care in rural areas.
• Increase the supply of training programs and technical assistance materials for States on the design, implementation and oversight of Medicaid managed behavioral health care in rural areas
• Recommend that States' savings realized through Medicaid behavioral health be reinvested in rural areas with a shortage of behavioral health care.

The Secretary should require States, as part of defining the requirement for the State Request for Proposals, to commission a study of the rural impact of changing Medicaid provision of behavioral care services to delivery by a managed care organization. This commission should:

• Define adequate rural access
• Establish a stratified rate structure that takes into account the increased expense of service provision in rural areas.
• Establish a patient-level database and a process for monitoring the rural impact of providing Medicaid behavioral health care through a managed care organization, and provide for cessation of rural managed care service provision during the implementation period in the event that minimum performance standards are not achieved.

The Secretary should disseminate best practice guidelines for managed behavioral care organizations which recommend that managed care organizations recognize, utilize, and reimburse properly trained primary care providers as essential components of the behavioral health systems, especially in rural areas. These guidelines should ensure that:

• Managed care organizations recognize and adopt means which improve and integrate behavioral health services such as networking and telehealth technologies.
• Managed care plans provide access for rural Medicaid eligible individuals and their rural providers to urban specialists
• Managed care plans provide access for rural Medicaid eligible individuals to appropriate psychopharmacologic agents and monitoring for therapeutic outcomes and side effects
• Managed care plans coordinate physical and behavioral components of health care

Clinical records and reports must exist to demonstrate the accomplishment of effective coordination of physical and behavioral components of health care of individuals

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1997 Recmmendations

Recommendation 97-1: Adjustment to the Medicare AAPCC Rate for Managed Care

The Committee urged the Secretary to support changes to the way Medicare pays for managed care services. Medicare pays a set amount for each beneficiary under the Average Adjusted Per Capita Cost (AAPCC) rate. Specifically, the Committee urged a new formula that would allow greater equity of payment between rural and urban areas.

Recommendation 97-2: Imposition of a Cap on Provider-Based RHCs

The Committee urged the Secretary to impose a cap or per-visit limit on provider-based rural health clinics.

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1996 Recommendations

Recommendation 96-1: Expand the EACH/RPCH Program Nationwide

The Committee recommends that the Secretary create a national limited service hospital program based on the EACH (Essential Access Community Hospital)/RPCH (Rural Primary Care Hospital) program.

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1995 Recommendations

None

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1994 Recommendations

Recommendation 94-01: Adjust for Occupational Mix in the Medicare Wage Index

The Committee recommends that the Secretary base the wage index, which is used to calculate Medicare hospital payments, on relative labor costs adjusted to a standard occupational mix. To accomplish this, the Secretary should establish a data base for making a labor market specific occupational mix adjustment.

Recommendation 94-02: Payments for Physician Services

The Committee supports the goal of providing incentives for physicians to provide primary care, as contained in the Health Security Act, and urges the Secretary to continue to support such provisions in the absence of national health reform.

Recommendation 94-03: Historical Costs

The Committee recommends that the Secretary consider alternatives to the use of historical costs as the basis for setting fee schedules, premium caps, or any other cost containment mechanisms introduced as part of health care reforms.

Recommendation 94-04: Medicaid Eligibility for Farm Families

The Committee recommends that the Secretary initiate a change in the federal regulations for AFDC (aid to Families with Dependent Children) regarding self-employment income for farmers. AFDC regulations at 45 -CFR 233.209(a)(6)(V)(B) require that states include the depreciation of business investments when calculating earned income from self- employment. The Committee recommends that depreciation of farm investments not be included in farmers' incomes when calculating their eligibility for AFDC because AFDC guidelines generally drive a family's eligibility for Medicaid.

Recommendation 94-05: Rural Representation

The Committee recommends that all governing and advisory boards that are established to implement any future health reform be specifically required to have rural representatives among their members. In particular, any alliance (or similar body) that includes a rural population should be required to have substantial rural representation on its governing board and professional advisory board. In addition, any requirements for these boards to consult with outside interest should include a requirement to consult with individuals and organizations representing rural interests.

Recommendation 94-06: Technical Assistance Programs

The Committee recommends that the Secretary develop technical assistance programs to strengthen rural health care delivery systems and prepare rural areas for health care reforms.

Recommendation 94-07: Antitrust

The Committee recommends that the Secretary, in conjunction with the Department of Justice and the Federal Trade Commission, use the federal Office of Rural Health Policy (or any other appropriate office) and the State Offices of Rural Health to educate rural providers and health professionals about antitrust aspects of developing alternative health delivery systems.

Recommendation 94-08: Telemedicine Pilot Projects

The Committee endorses the Secretary's current efforts to evaluate and test payment methodologies for telemedicine. The Committee recommends that additional pilot projects be established within the next fiscal year to test payment methodologies and collect data on costs, utilization, outcomes, provider and patient satisfaction, etc. The pilot projects should be non-proprietary, open architecture systems using a variety of telemedicine technologies and configurations. These projects should be evaluated on an ongoing basis with annual reports to the Secretary. After two years, each annual report should include information that will assist the Secretary in developing appropriate payment policies.

Recommendation 94-09: Increasing the Rural Sample of Leading National Health Surveys

The Secretary should increase the rural samples and take other steps to improve the rural analytic capability of two key national health surveys -- the National Medical Expenditure Survey and the National Health Interview Survey. This improved capability is critical to assessing differences in access to health care for citizens living in communities that vary by degree of rurality, for example, by population density and distance to an urban area. In addition, the Secretary should direct the National Center for Health Statistics to explore augmenting the rural sample of the Health and Nutrition Examination Survey.

Recommendation 94-10: Risk Adjustments

The Committee recommends that explicit attention be paid to rural concerns as risk adjustment methodologies are developed in conjunction with health insurance reforms. Such concerns include the lack of good cost data on rural minority populations and occupational illness and injury. The Committee urges the Secretary to consult rural experts, including the Committee, in developing data bases and methodologies for risk adjusters that include rural populations.

Recommendation 94-11: Fair Competition for Rural Grants and Contracts Applicants

The Committee recommends that the Secretary take steps to ensure that grant and contract program announcements issued by the Department do not ignore rural realities and disadvantage rural applicants. The Committee also recommends that the Secretary find additional methods for announcing program opportunities in rural areas, rather that relying exclusively on the Commerce Business Daily and Federal Register.

APRIL 1994 RECOMMENDATIONS ON PROPOSED HEALTH SECURITY ACT

Recommendation: Medicare under Health Care Reform

The Committee reiterates recommendation 93-15 from the Sixth Annual Report on Rural Health asking the Secretary to assimilate Medicare beneficiaries into the health alliances of the reformed health care system as quickly as possible.

Recommendation: Medicare Dependent Hospitals

The Committee recommends that the Secretary establish a short-term task force to study the need to continue the Medicare Dependent Hospital program under health care reform.

Recommendation: Migrant Workers

The Committee recommends that the Secretary consider development of separate health alliances for migrant workers in each of the migrant streams.

Recommendation 94-12: Alternative Rural Health Care Delivery Systems

The Committee recommends that the Secretary support legislation to authorize the Health Care Financing Administration (HCFA) to conduct demonstrations of alternative rural health care delivery systems that require waivers of the Medicare conditions of participation for hospitals.

Recommendation 94-13: Health Professions Education

The Committee reiterates the recommendations it made in its Sixth Annual Report on Rural Health addressing health professions education (93-5 to 93-14).

Recommendation 94-14: Tax Incentives for Practitioners in Rural HPSAs and MUAs

The Committee recommends that the Secretary support legislation to provide tax incentives to primary health care practitioners who locate their practices in rural Health Professions Shortage Areas (HPSAs) and Medically Underserved Areas (MUAs). Such incentives should be offered both to new and existing rural practitioners.

Recommendation 94-07: Mental Health and Substance Abuse Services

The Committee recommends that the Secretary support enhanced mental health and substance abuse services.

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1993 Recommendations

Recommendation 93-1: Personnel Qualifications for Physician-performed Microscopy

The Secretary should expand the personnel qualifications for physician- performed microscopy procedures to include other primary care practitioners, i.e., nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (Pas), and certified nurse-midwives (CNMs).

Recommendation 93-2: Requirements for General Supervisors of High Complexity Laboratories

The Secretary should extend the grandfathering clause for general supervisor of a high complexity laboratory to all individuals who were qualified, as of February 28, 1992, to serve as the general supervisor of a hospital laboratory under the clinical laboratory requirements published March 14, 1990.

Recommendation 93-3: Designation of Rural Primary Care Hospitals

The Secretary should support legislation authorizing the Secretary to designate Rural Primary Care Hospitals (RPCHs), as defined by law, in communities where hospitals have been closed for more than one year.

Recommendation 93-4: Rural Representation on the Clinical Laboratory Improvement Advisory Committee

The Secretary should appoint a rural representative to the Clinical Laboratory Improvement Advisory Committee (CLIAC).

Recommendation 93-5: National Health Professions Workforce Plan

The Secretary should develop a national health professions workforce plan that specifies goals for the types, specialties, and geographic distribution of health professionals necessary to meet the health care needs of the nation.

Recommendation 93-6: Outcomes-based Funding of Health Professions Education Programs

The Secretary should support legislation to restructure federal funding of education programs for health professionals so the funding decisions are based on the success with which the training programs contribute toward achieving the goals of the health professions workforce plan.

Recommendation 93-7: All Payers Contribute to Health Professions Education

The Secretary should support legislation requiring all health care payers to participate in funding health professions education.

Recommendation 93-8: Training in a Variety of Settings

The Secretary should support legislation to make health professional education funding available to health professional and residency programs in varied settings, not just those owned or operated by a hospital.

Recommendation 93-9: Rural Training Sites

The Secretary should support the development of rural practice sites as training sites for both undergraduate and graduate health professional training.

Recommendation 93-10: Interdisciplinary Training Programs

The Secretary should encourage the development of interdisciplinary training programs

Recommendation 93-11: Train Local Health Care Workers

The Secretary should develop initiatives to broaden access and innovation in health care delivery by supporting local programs that utilize indigenous community workers and paraprofessionals as essential members of community health care delivery teams.

Recommendation 93-12: Broaden use of Medicare Graduate Medical Education Dollars

The Secretary should support legislation to modify the Medicare payment provisions for graduate medical education to provide funding for undergraduate and graduate training of physicians and other health care professionals.

Recommendation 93-13: Medicare Payment for Non-hospital Based Training

The Secretary should support legislation to provide Medicare funding for training in varied settings, not just those owned or operated by a hospital.

Recommendation 93-14: Align Payment Incentives with Educational Incentives

The Secretary should support, both through policy development and legislation, a restructuring of the Medicare physician payment system so it contributes toward achieving the goals of the health professions workforce plan.

Recommendation 93-15: Assimilate Medicare Beneficiaries into the Health Alliances (repeated in April 1994)

The Secretary should support legislation to assimilate Medicare beneficiaries into the health alliances of the reformed health care system as quickly as possible.

Recommendation 93-16: Consider Rural Needs in Developing Mental Health and Substance Abuse Benefits under Health Care Reform

The Secretary should consider the special needs of rural areas in the further development of mental health and substance abuse benefits under health care reform, and the need to improve access to these services in rural areas. The Committee recommends several general principles to be considered in meeting the needs of rural areas.

Recommendation 93-17: National Plan for Mental Health Professionals in Rural Areas

The Secretary should direct the Bureau of Health Professions to develop and implement (in collaboration with the National Association of State Mental Health Program Directors, the Center for Mental Health Services, and the Office of Rural Health Policy) a national plan to respond to the severe shortage of mental health professionals in rural areas.

Recommendation 93-18: Substance Abuse and Mental Health Services Administration (SAMHSA) Reauthorization Act

The Secretary should support the Center for Mental Health Services, the Center for Substance Abuse Treatment, and the Center for Substance Abuse Prevention in developing the capabilities required to effectively carry out their respective missions as stated in P.L. 102-321 (the SAMHSA Reauthorization Act) in ways that are responsive to the needs and concerns of rural areas and populations. In responding to this recommendation, each Center should:

• establish a least one full-time position devoted to ensuring that rural interests are taken into account in national mental health and substance abuse public policy;
• create a coordinated and focused rural technical assistance capacity; and
• ensure that their statistical and analytic reports describe, in comparative fashion, the full range of variation by setting (metropolitan, suburban, rural, small town, frontier) and region in the delivery of mental health and substance abuse services.

Recommendation 93-19: Technical Assistance to Integrate Mental Health and Substance Abuse Services with other Rural Health Care Services

The Secretary should direct the Substance Abuse and Mental Health Services Administration to develop technical assistance programs to integrate mental health and substance abuse service with "generic" rural service delivery systems (i.e., primary health care, education, aging, developmental disabilities, criminal justice, etc.) and increase the capacity of these systems to meet the needs of their clients with mental health and substance abuse problems.

Recommendation 93-20: Equal Access to Federal Funding for Mental Health and Substance Abuse Services

The Secretary should support the development of new ways to ensure that rural areas and populations have equal access to federal funding and support in mental health and substance abuse. Specifically, the Secretary should:

• should increased mental health and substance abuse block grant funding with a mandate that at least 25% of these funds be expended in rural areas in service to rural populations, and
• create a task force of Public Health Service officials and rural service providers to study and recommend new ways that federal support can be make available to rural and frontier areas.

Recommendation 93-21: Rural Parent Education and Support Program

The Secretary should establish a demonstration grant program to rural communities to provide early parenting education and support to first-time parents. the demonstration program should include a three- pronged strategy that would involve the development of local family resource centers, community-based assessment and home visitation services, and the development of networks and referral agreements between related programs and services.

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1992 Recommendations

Recommendation 92-1: Rural Hospital Transition Grant Program

The Secretary should support legislation to continue the Rural Hospital Transition Grant Program.

Recommendation 92-2: Essential Access Community Hospital/Rural Primary Care Hospital (EACH/RPCH) Program

The Secretary should convene a meeting of the key participants in the EACH/RPCH program to resolve problems and to develop legislative and regulatory strategies that will facilitate implementation of the program.

Recommendation 92-3: Geographic Reclassification of Hospitals for Purposes of the Wage Index

a) The proposed guideline for hospitals seeking a higher wage index should require wage payments that are 100 percent instead of 108 percent of the average hourly wages of the area in which they are physically located.

b) The Secretary should seek a legislative or administrative change that would permit reclassification decisions to be made for periods of three years rather than one year.

Recommendation 92-4: Targeted Adjustments for Volume Increases Under the Medicare Physician Payment System

The Secretary should support a legislation change that would allow for different adjustments in fees paid to rural and urban providers if volume of services rendered by urban providers rises faster than for rural physicians.

Recommendation 92-5: Incentives for Rural Physicians

The Secretary should propose legislation that provides additional financial incentives for physicians to practice in rural areas. The incentives should be greatest for physicians practicing in rural Medically Underserved Areas (MUAs) and rural Health Professional Shortage Areas (HPSAs).

Recommendation 92-6: The Clinical Laboratory Improvement Amendments of 1988 (CLIA) and Rural Health Clinics (RHCs) (repeated in 1993)

The Secretary should reconcile the regulatory requirements for clinical laboratories and the regulatory requirements for RHCs to make it possible for RHCs to comply with the requirements of both programs as "certificate of waiver" laboratories.

Recommendation 92-7: Utilizing Health Care Reform Principles

When reviewing health care reform proposals, the Secretary should use the principles developed by the Committee as a guide for evaluating the appropriateness of the reform proposal for rural areas.

Recommendation 92-8: Basic Health Care Benefits for All Americans

The Secretary should support legislation that will establish a set of minimum, portable, uniform benefits for all Americans. The program should not exclude individuals from eligibility for health insurance and access to health care due to employment status or lack of permanent residence. The benefits should provide a continuum of services ranging from preventive care to rehabilitative and long-term care.

Recommendation 92-9: Demonstration Programs to Encourage Collaboration Among Providers

The Secretary should develop demonstration programs that allow and encourage collaboration of all major health care providers to make health care available in rural communities.

Recommendation 92-10: Assuring Adequate Access to Health Care

The Secretary should support health care reform legislation that will assure that rural residents have adequate access to health care. Specifically, support should be given for the following areas:

• programs to increase the numbers of primary care providers -- physicians and mid-level practitioners;
• programs and payment levels that encourage primary care providers and other health care professionals to locate in underserved areas;
• transportation, emergency, and technological systems so rural residents of all ages can receive, and providers can render, health care;
• targeted programs that address the special needs of farm families, rural minorities, migrants, and Native Americans.
• policies and regulations that assure flexibility for communities and/or states to respond to local health care needs.

Recommendation 92-11: Integration of Health and Education Services

The Secretary should support health care reform legislation that encourages the integration of health and education services for all segments of society.

Recommendation 92-12: Rapid Resolution of Payment Disputes

The Secretary should support health care reform legislation that provides for rapid resolution of payment disputes.

Recommendation 92-13: Establish a Coordinating Forum on Agricultural Health and Safety

The Secretary should direct the Office of Rural Health Policy to establish a coordinating forum on agricultural health and safety for the purpose of sharing information and coordinating agricultural health and safety activities across federal departments or agencies.

Recommendation 92-14: Increased Support for State Offices of Rural Health

The Secretary should seek an increased appropriation for the State Offices of Rural Health Program (SORHs) to enable each State Office to take a leadership role in, and provide a forum for, addressing rural occupational health and safety issues (including farming, logging, fishing, and mining) within their respective state and local health communities.

Recommendation 92-15: Development of Continuing Education Programs in Agricultural Health and Safety

The Secretary should seek an appropriation for the Bureau of Health Professions (BHPr) of the Health Resources and Services Administration to support the development of continuing education programs in agricultural health and safety, including prevention, diagnosis, and treatment.

Recommendation 92-16: Safety Training for Farm Children

The Secretary of Health and Human Services should ask the U.S. Department of Agriculture to request that the Cooperative Extension Service begin a child farm safety course for farm children and the parents of children who help on the farm. The course should include a manual of information, similar to the Hunter Safety Course now offered by the National Rifle Association. This manual could be all inclusive, from equipment to pesticides, to hypothermia, to first aid, and so forth.

Recommendation 92-17: Health Career Opportunities Initiative

The Secretary of Health and Human Services should work with the Secretary of Agriculture to develop cooperative programs and incentive funding to attract rural young people to health careers. This should be accomplished in cooperation with the Youth-at-Risk Initiative of the Extension Service's 4-H Development Program. Special attention should be paid to providing opportunities to young people from ethnic and cultural minorities. Whenever possible, this initiative should involve the State Offices of Rural Health, and should be developed with participation from AHECs, the Office of Minority Health, and local health departments.

Recommendation 92-18: Mandatory Rollover Protective Structures and Seat Belts

The Secretary should work with the Secretaries of the Department of Labor, Commerce, and Agriculture to seek legislation for the mandatory inclusion of Rollover Protective Structures (ROPS) and seat belts on all new tractors, and a five-year incentive program to retrofit ROPS and seat belts on tractors currently in use. The cost of the tractor retrofits could be shared by state and federal governments, equipment manufacturers, and tractor owners. Tractor-like devices used in logging should be included under the provisions of this recommendation.

Recommendation 92-19: North American Free Trade Agreement

In anticipation of the North American Free Trade Agreement (NAFTA), the Secretary of Health and Human Services should work with federal, state, local, and private agencies and businesses on both sides of the U.S./Mexico border to identify and create effective working models that address the health care challenges faced by populations living along the border. The models should address housing, sanitation, water quality, infectious disease, pesticide and other environmental hazards, and occupational health and safety. In addition, the models, should, as much as possible, reflect a community organization approach that empowers local residents.

Recommendation 92-20: U.S./Mexico Rural Border Area Projects

In cooperation with the Mexican Ministry of Health, Pan American Health Organization (PAHI), and/or private foundations, the Secretary of Health and Human Services is urged to support six to eight binational U.S./Mexico Rural Border Area projects to demonstrate improved, comprehensive, primary health care services. This would include sanitation and preventive care focusing on maternal, infant, and adolescent health.

Recommendation 92-21: Shortage of Mental Health Professionals in Rural Areas

The Secretary should urge the newly-created Center for Mental Health Services in the Substance Abuse and Mental Health Services Administration (SAMHSA) to address the severe shortages of mental health professionals in rural areas as one of its first priorities.

Recommendation 92-22: Models for Intergovernmental Collaboration

The Secretary should direct the Administration for Native Americans to develop and disseminate a technical assistance document that reviews current roles and responsibilities of federal, state, local and tribal governments for rural Native Americans' and Alaska Natives' health. It should provide examples of rural models for collaboration among these governmental entities.

Recommendation 92-23: Expansion of Initiatives to Address Native American Health Problems

The Secretary should direct the Indian Health Service to develop strategies for improving health services to Native Americans through the expansion of specialized women's clinics, school-based clinics, enhanced support of substance abuse and fetal alcohol syndrome prevention initiatives, and increased training and use of physician assistants and nurse practitioners.

Recommendation 92-24: Technical Assistance: Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHC)

The Secretary should provide technical assistance regarding FQHC and RHC programs by: 1) offering a technical assistance hotline so that questions about program elements, distinctions of the two programs, and requirements can be answered; and 2) offering regional workshops, marketed to a broad spectrum of practitioners and facilities, to assist attendees in understanding the similarities and differences in the programs.

Recommendation 92-25: Recruitment and Retention of Health Personnel

The Secretary should direct the Bureau of Primary Health Care to set aside dollars appropriated to the National Health Service Corps (NHSC) for more travel and on-site consultation with states to promote a greater understanding of the goals and the policies of the NHSC program.

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1991 Recommendations

Recommendation 91-1: DHHS Program Priority: Improving Health Care Access for Rural Citizens

At least one of the annual policy objectives or program priorities of the Secretary, the Assistant Secretary for Health, and the Administrator of the Health Care Financing Administration should address improving access to health care for America's rural citizens.

Recommendation 91-2: Impact on President's Budget on Health Care Access in Rural Areas

Concurrent with the annual submission of the President's budget, the Secretary should prepare an analysis of the budget's impact on programs that provide access to health care in rural areas.

Recommendation 91-3: Adjustments for Budget Neutrality in Transition Rules for Medicare Physician Payment System

Any adjustments for budget neutrality in the transition rules for phasing in the new fee schedule should incorporate only those adjustments which can be shared equally by all physicians, not just those whose fees are, by design, significantly increased under the new fee schedule.

Recommendation 91-4: Targeted Adjustments for Volume Increases in Medicare Physician Payment System

The Secretary should direct the Health Care Financing Administration (HCFA) to examine the expected volume response to the new system by specific specialty groups and for specific procedures. Based on this examination, HCFA should develop methods to penalize only those providers whose volume of services increases inappropriately, rather than all physicians.

Recommendation 91-5: Elimination of Geographic Payment Adjustments Under the Medicare Physician Payment Fee Schedule

The Secretary should seek legislative change which would eliminate all geographic payment adjustments under the new fee schedule for physicians.

Recommendation 91-6: Malpractice Adjustment

The Secretary should direct HCFA to refine its malpractice adjustment in the Medicare physician fee schedule formula to recognize the actual services provided by rural primary care physicians.

Recommendation 91-7: Medicare Capital Payment Floor

The Secretary should establish a minimum level of financial protection of all hospitals under the new Medicare prospective capital payment system. Specifically, a "payment floor" of 80 percent should be established so that under the new system, no hospital would receive less than 80 percent of its actual capital costs.

Recommendation 91-8: Old Capital

The Secretary should direct HCFA to include leasing costs in the definition of "old capital" under the new system.

Recommendation 91-9: Capital Payment Policy for Essential Access Community Hospitals and Rural Primary Care Hospitals

Essential Access Community Hospitals and Rural Primary Care Hospitals should receive special financial protection under the prospective payment system for capital.

Recommendation 91-10: Coverage of Certified Nurse-Midwife Gynecological and Family Planning Services Under Medicare (repeated in 1992)

The Secretary should direct the General Counsel of the Health Care Financing Administration (HCFA) to review the Administration's (HCFA's) original interpretation of OBRA-87 -- Section 4073 relating to the coverage of nurse-midwife services under Medicare.

If, upon review of the original interpretation, a decision is made to cover gynecological and family planning services provided by CNMs under Medicare, HCFA should issue revised manual instructions to the carriers in an expeditious manner and issue regulations pertaining to the statute no later than March 1, 1992.

If, upon review, the General Counsel concludes that the original interpretation of the statute is the best (in light of the legislative language), the Secretary should propose that Congress amend the statute to provide for coverage of CNM services outside of the maternity cycle.

Recommendation 91-11: FQHC Payments Based on Actual Cost Experience Without Arbitrary Urban and Rural Distinctions

Any cost-based payment system for FQHCs should reflect their actual cost experience, without imposition of arbitrary limits. The FQHC payment system should not incorporate arbitrary distinctions between urban and rural areas.

Recommendation 91-12: FQHC Reporting Requirements for Look- Alikes

The Secretary should require annual reports from FQHC look-alikes and develop a recertification process for them that occurs at least every three years.

Recommendation 91-13: Obstetrical Access and Medical Malpractice

The Secretary should direct the Agency for Health Care Policy and Research (AHCPR) to establish obstetrical access and liability as a research priority within its legal-medicine program in 1992. As a component of this priority, the Agency should evaluate state health care malpractice and liability initiatives that address obstetrical access.

Recommendation 91-14: Community and Migrant Health Centers - Federal Tort Claim Coverage and Risk Management

The Secretary should continue to work closely with the Department of Justice to support legislation that would provide relief to community and migrant health centers from excessive malpractice insurance costs. This relief could be provided by amending the Federal Tort Claim Act to extend coverage to community and migrant health centers (C/MHCs) and to health professionals who are employees or contractors of C/MHCs, or through some alternative mechanism.

The Secretary should allow dollars currently being utilized by health centers for malpractice premiums to remain in the health centers. The dollars should be directed to risk management and quality improvement activities, as well as activities to expand or enhance patient care. The Secretary, through the Bureau of Health Care Delivery and Assistance, should continue to support rigorous risk management and quality improvement activities in C/MHCs.

Recommendation 91-15: AHCPR User Liaison Program: Rural Focus on Medical Malpractice and Liability

The User Liaison Program of the Agency for Health Care Policy and Research (AHCPR) should include a rural focus in programs developed to educate state legislators and executive staff about medical malpractice and liability issues.

The Committee further recommends that AHCPR include the 1987 DHHS Report of the Task Force on Medical Liability and Malpractice in its program materials. Last, it recommends that AHCPR provide the technical assistance needed to help implement the model Health Care Provider Liability Reform Act or a comparable comprehensive reform model act.

Recommendation 91-16: Rural Representation in the AHCPR Guideline Development Process

The Agency for Health Care Policy and Research should assure that rural representation is included in all phases of the guideline development process, including rural representation among peer review consultants and among the facilities in which clinical guidelines are pilot-tested. It should further seek to include rural representation, including rural consumers, on the guideline advisory panels. The AHCPR should work with the Office of Rural Health Policy to identify rural consultants for the peer review process and rural facilities for the pilot-testing of the standards.

Recommendation 91-17: Medicare Payment Formula for Home Health Services

The Secretary should instruct HCFA to amend the Medicare reimbursement formula for home health services to cover additional costs of delivering health care in rural areas that result from such factors as increased travel distances.

Recommendation 91-18: Implement the "Social Factors" Medicare Payment Provision of the Peer Review Norms Amendments in OBRA '87

The Secretary should instruct HCFA to issue specific regulations or instructions to implement the "social factors" provision contained in OBRA '87. This provision directs Peer Review Organizations (PROs) to approve, under specific circumstances, inpatient hospitalization for treatment that would otherwise be on an outpatient basis. Specific circumstances that justify inpatient hospitalization include special problems associated with delivering care in remote rural areas, the availability of service alternatives to inpatient hospitalization, and other factors that could adversely affect the safety or effectiveness of treatment provided on an outpatient basis (Public Law 100-203, sec. 4094(a)).

Recommendation 91-19: Rural Initiative for Prevention, Health Promotion and Wellness with Older Persons

The Secretary should direct the Office of Disease Prevention and Health Promotion and the Administration on Aging to develop, in cooperation with the Office of Rural Health Policy, a health promotion initiative that focuses on rural communities. This effort should also involve the USDA Cooperative Extension Service, and any foundations that are investing in this issue.

Recommendation 91-20: Improve Transportation Services for Older and Disabled Persons Living in Rural Areas

A. The Administration on Aging (AoA/DHHS) should work with the Urban Mass Transportation Administration (UMTA/DOT) to: 

• Conduct a study on the current status and problems that rural transportation pose to obtaining health care.
• Identify and remove Federal barriers to transportation service coordination in rural areas.
• Develop and implement programs to improve the coordination of Federal, State and local transportation services to older persons and others with special needs in rural areas.
• Identify "best practices" in transportation services for older and disabled people living in rural areas, disseminate information on these models to rural communities, and provide technical assistance to state and local agencies to help them apply this information to their own transportation programs.

B. The Secretary should request that DOT fund demonstration projects from UMTA funds that will improve access to health services for the rural elderly.

Recommendation 91-21: Develop a Quality Assurance Strategy for In- Home Services and Extended Care Facilities

The Secretary should work with States to develop a quality assurance strategy for certified home health services and services provided at extended care facilities in rural areas.

Recommendation 91-22: Expand Research on In-Home and Community- Based Health Care Services for the Chronically Ill Rural Elderly

The National Institute on Aging should direct its Exploratory Centers on Aging and Health in Rural America to work with the ORHP-funded Rural Health Research Centers, as appropriate to:

• conduct a study on the availability of and barriers to in-home services for chronically ill rural elders, including the costs of providing access to such services in rural areas, and
• conduct a thorough review and synthesis of the literature on rural programs that enable rural elders with functional disabilities to prevent or delay institutionalization for long-term care by providing in- home and community-based services. The synthesis should assess the effectiveness, including quality of care, and the potential for replication of the various programs, and discuss the policy implications of the findings.

Based on these findings, NIA, in consultation with ORHP, should determine whether it is desirable and feasible to conduct a pilot project implementing some of the best approaches.

Recommendation 91-23: Improve Information Dissemination on the Rural Elderly

The Secretary should improve the availability of information regarding the rural elderly through support of activities such as the Rural Information Center/Health Services (RICHS) at the National Agricultural Library, the National Resource Center for Rural Elderly at the University of Missouri-Kansas City, and the Rural Outreach Program of the National Library of Medicine (NLM).

Recommendation 91-24: Increase and Target Funding for Titles VII and VIII Health Professions Programs (U.S. Public Health Service Act)

The Secretary should seek increased appropriations for Title VII and Title VIII health professions programs, targeting funds to programs which train health professionals for practice in rural and other underserved areas.

Recommendation 91-25: Rural Interdisciplinary Training Grant Program

The Secretary should support legislation to amend Title VII to include the Rural Interdisciplinary Program, and should seek an increased appropriation for this program

Recommendation 91-26: Rural Medical Education Demonstration Program

The Secretary should support legislation to amend Title VII of the U.S. PHS Act to include the Rural Medical Education Demonstration Program. The program's authorization should be amended to expand the program to ambulatory settings and authorize start-up grant funds.

Recommendation 91-27: Funding Factors for Health Professions Programs

The Secretary should establish the following funding factors (preference and priorities) for the Title VII and VIII health professions programs:

• A funding preference for programs that provide clinical experiences in rural and other underserved areas.
• A funding preference for medical schools that have a department of family medicine.
• A funding priority for programs that link rural clinicians and the faculty of teaching institutions.
• A funding priority for programs whose curricula address the health needs of rural and other underserved individuals and the health systems serving them.
• A funding priority for programs that weight admission criteria to favor rural, underserved and/or disadvantaged/minority applicants.

Recommendation 91-28: Modification of the ADMS Block Grant Apportionment Formula

The Secretary should direct the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) to revise the ADMS block grant drug apportionment formula used to allocate drug monies between states. The formula's preferential weighting for urban populations should be adjusted downward to more accurately reflect the actual differences in urban and rural drug abuse rates. The Secretary should then propose legislation that incorporates the revised funding formula.

Recommendation 91-29: Modification of Substance Abuse Set-Aside Requirements

The Secretary should propose legislation to eliminate the mandated set-aside for drug abuse services within the ADMS block grant's intra-state substance abuse funding component. This should be eliminated to allow the intrastate allocation of funds to more accurately reflect the actual rates of alcohol and drug abuse in rural areas.

Until legislation can be enacted to ensure a more equitable distribution of substance abuse monies within states, ADAMHA should expedite the granting of waivers to states for the intravenous drug abuse set- aside.

Recommendation 91-30: ADMS State Block Grant Plans

The Secretary should require that each state describe in its ADMS block grant plans how it will address the specific service delivery needs of its rural populations.

Recommendation 91-31: Integration of Alcohol, Drug Abuse and Mental Health Services with Other Primary Care Services in Rural Communities

The Department should identify ten model communities where the provision of alcohol, drug abuse and mental health services are currently integrated into the delivery of other primary care services. Their successful strategies should be described and promulgated to other rural communities across the nation. Any legislative, regulatory or administrative barriers that impede such integration should be identified and targeted for elimination.

The Office of Rural Health Policy should work closely with the "Primary Care - Substance Abuse Linkage Initiative" of the Office of Treatment Improvement, ADAMHA, to coordinate activities and strengthen its rural focus.

Recommendation 91-32: The Office of Rural Health Policy's Role in Mental Health and Substance Abuse Policy

The Secretary should seek legislation to expand the authority of the Office of Rural Health Policy to include policy issues on rural mental health and substance abuse and should seek an increased appropriation to support such activities.

Recommendation 91-33: Improve Data Collection on Alcohol, Drug Abuse and Mental Health Needs, Services and Personnel in Rural Areas

The Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) should develop research strategies to establish the epidemiology of substance abuse and mental health problems in rural areas, identify the full range of professionals providing mental health services to these populations, and measure the current level of service availability.

Recommendation 91-34: Defining the Scope of Rural Primary Mental Health Services and Educating Professionals to Provide These Services

The Secretary should direct the National Institute of Mental Health to conduct research to define the scope of primary mental health services needed in rural areas.

When this research has been completed, the Secretary should:

• seek funding to support educational programs that prepare individuals for rural primary mental health practice;
• develop mechanisms concurrently to finance the services provided by these individuals; and
• identify any additional barriers to the utilization of appropriately qualified mental health professionals and initiate Federal actions to eliminate them.

Recommendation 91-35: Educational Programs, including Continuing Education, for Providers of Rural Mental Health and Substance Abuse Services

The Secretary should implement targeted educational initiatives, including continuing education, to increase the number of health and human service professionals providing rural mental health, substance abuse prevention and treatment services.

• The Secretary should seek an increased appropriation for preventive and clinical training in mental health, and should direct NIMH to establish a rural priority in its clinical training grants (e.g., individual faculty scholar program).
• NIMH and HRSA should develop an innovative, joint clinical training grant program that utilizes the training resources of each agency.
• Federal programs which fund mental health training programs should encourage the use of Federally-funded clinics in underserved areas as clinical training sites through incentives such as funding priorities.
• A specific AHEC initiative should be funded to enhance the skills of rural primary care providers in mental illness and substance abuse diagnosis, treatment, referral and prevention.
• ADAMHA should review the educational initiatives it currently funds, including its public education programs, to determine their sensitivity to rural needs. Such initiatives include the DART program (Depression, Awareness, Recognition and Treatment). In conjunction with the Office of Rural Health Policy, ADAMHA should then develop mechanisms to better target its programs to rural needs.

Recommendation 91-36: National health Service Corps Mental Health Professionals

The Secretary should direct the National Health Service Corps (NHSC) to: 1) establish a second priority within its scholarship and loan repayment programs for individuals in the five core mental health professions, and 2) seek an increased appropriation to support this second priority.

Recommendation 91-37: Evaluation of the Health Personnel Shortage Areas (HPSAs) "Greatest Need Criteria" on Frontier Areas

The Committee requests that the Health Resources and Services Administration analyze the impact on frontier areas of the new criteria for allocating National Health Service Corps (NHSC) personnel to "HPSAs of greatest need." If the new criteria appear to be detrimental to the placement of personnel in frontier areas, the Bureau of Health Care Delivery and Assistance should work with the Office of Rural Health Policy to revise them for the 1993 placement cycle.

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1990 Recommendations

Recommendation 90-1: Medicare Payment for Mid-level Primary Care Services (Part e. repeated in 1992)

By October 1, 1991, the Secretary should draft legislation to establish direct payment of mid-level providers practicing in rural areas according to the following criteria:

1. Definition of Mid-level Providers: Mid-level providers are primary care physician assistants and advanced practice nurses (nurse practitioners and clinical nurse specialists) who meet state licensure requirements.
2. Services and Settings: Payment should be made for primary care services covered by Medicare physician payment policies. The existing Medicare definition of primary care services include: office and clinic visits, hospital visits, nursing home visits, emergency care, and home visits.
3. Geographic Areas: Payments for such services should be limited to mid-level providers practicing in rural Health Manpower Shortage Areas (HMSAs), rural Medically Underserved Areas (MUAs) designated by the U.S. Public Health Service, or non-metropolitan counties with a primary care physician-to-population ratio less than the national rural average for the same ratio. Primary care physicians are defined as physician providers in the fields of Family Practice, General Practice, General Internal Medicine, General Pediatrics and Obstetrics/Gynecology, excluding medical residents and fellows.
4. Collaboration with Physicians: Formal collaboration and referral arrangements between mid-level providers and primary care physicians should be an essential condition of participation in the Medicare program. Consultations provided by primary care physicians should be reimbursed appropriately under a relative value scale, except as already provided through other payment programs such as the Rural Health Clinics Act.
5. Payment Policy: The payment level for mid-level providers should be set at a level of 100% of primary care physician payment for the same services.
6. Assignment Policy: The assignment policy for mid-level providers should be the same as the assignment policy for primary care physicians.

Recommendation 90-2: Delay Implementation of the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88)

The Secretary should delay implementation of CLIA '88 until its impact on access to care in rural areas can be adequately assessed.

Recommendation 90-3: Modification of the Essential Access Community Hospital (EACH) Program

The Secretary should propose legislation to modify the EACH Program. The legislation would be amended to give States and rural hospitals more flexibility in designing rural health care networks. The recommended changes would: 1) Provide for a waiver of the 72 hour limit on inpatient stays within a Rural Primary Care Hospital (RPCH) for states that submit acceptable proposals to establish a set of services which may be appropriately provided within the RPCH or for other alternative approaches to defining a RPCH; (2) Provide for waivers that would allow states to propose alternative definitions for the EACH; (3) Clarify that hospitals designated as a RPCH are allowed to participate in the swing bed program; 4) Stipulate that states may propose to include hospitals in adjacent states in a rural health network.

Recommendation 90-4: Modification of the Rural Hospital Transition Grant Program

The Secretary should create a set-aside fund under the Rural Hospital Transition Grant program specifically earmarked for rural hospitals that propose a transition from a full service acute care facility to an institution which offers less intensive but essential services to its community. The fund would also support experimental efforts toward the development of the "primary care hospital" concept.

Recommendation 90-5: Provide a Rural Focus in the Department's Efforts to Improve the Health Status of Minority Populations

To ensure a rural focus in the Department's efforts to improve the health status of African Americans, Hispanics, Native Americans and Asian/Pacific Islanders, the Secretary should direct the Office of Minority Health, in cooperation with the Office of Rural Health Policy, to:

1) Sponsor and conduct a national conference on improving minority health in rural areas; and

2) By September 1, 1991, subject a report which outlines recommendations for departmental initiatives to reduce the health disparity of minorities living in rural areas.

Recommendation 90-6: Establish a Task Force on Improving Coordination of Departmental Service Programs and Training Programs

The Secretary should establish a task force to develop strategies that promote coordination of Bureau of Health Professions (BHPr) and Bureau of Health Care Delivery and Assistance (BHCDA) programs to better link training and service in Federal programs. More specifically, the task force should develop strategies that foster utilization of rural community and migrant health centers (C/MHCs) as sites for conducting career awareness and clinical training activities. As a component of this initiative, a demonstration program should be developed to provide funding to rural C/MHCs to engage in career awareness activities and clinical training.

Recommendation 90-7: Modify Departmental Health Career Awareness Programs to Promote Career Development Among Rural Minority Populations

The Secretary should direct the Health Resources and Services Administration to make the following changes in its programs to promote awareness of health career opportunities and promote career development among rural minority populations:

• Modify the regulations governing the Bureau of Health Professions' (HPr) Health Career Opportunity Program (HCOP) to allow for career awareness, counseling, and academic enrichment activities in grades 7-12 in rural schools. (Career awareness activities should be developed for both students and counselors in these rural school systems.) Additional funds should be appropriated for the HCOP program to allow it to fund this specific activity.
• Develop a funding priority in the Area Health Education Center (AHEC) and the Health Education Training Center (HETC) programs for proposals that address the career awareness needs of rural, minority youth. Also, develop a funding preference in these programs for minority health professions proposals that utilize rural training sites (e.g., C/MHCs).
• Develop evaluation criteria within BHPr programs that recognize the time-intensive nature of working with disadvantaged students who require enhancement/remedial activities such that programs are not penalized for low faculty/student ratios.
• Revise the reporting requirements of the Bureau of Health Care Delivery and Assistance and the productivity formula for C/MHCs to reflect the impact on productivity of teaching. The productivity formula should, at a minimum, ensure that C/MHCs are not penalized for engaging in training activities, and should ultimately be revised to provide incentives for C/MHCs to engage in training activities.

Recommendation 90-8: Incorporate Urban/Rural and Racial/Ethnic Identifiers in All Departmental Surveys of Health Professionals

The Secretary should direct that all Departmental surveys of health professionals be designed so as to permit analyses by urban/rural and racial/ethnic classifications. Departmental surveys should be designed to permit evaluation of personnel information on minority health professionals by urban and rural location of practice. Data collection systems should also be devised which permit the further categorization of rural data into"frontier" and "non- frontier" rural areas.

Recommendation 90-9: Sponsor an Invitational Workshop on Rural Minority Data Collection on Health Professionals

The Secretary should sponsor an invitational workshop for the purpose of developing a standardized format for the collection of rural/urban and racial/ethnic health professional data. The workshop should include representation from national health professional associations, health education associations, and training programs.

Recommendation 90-10: Improve Data Collection in Departmental Health Professions Training Programs

The Secretary should direct the Bureau of Health Professions (BHPr) and the National Institutes of Health (NIH) to require a health personnel training programs funded by them to routinely collect program monitoring data that use both urban/rural and racial/ethnic identifiers, consistent with the Privacy Act and confidentiality constraints. In addition, the programs should be required to track participants as to where they practice upon completion of their training. These data should be collated and analyzed by the various funding agencies, and reported to the Office of Rural Health Policy and Office of Minority Health.

Recommendation 90-11: Improve Federal Data Collection on HIV Disease in Rural Areas

The Department of Health and Human Services should collect accurate, comprehensive information about the extent, characteristics, and impact on HIV disease in rural areas. The Agency for Health Care Policy and Research, the Centers for Disease Control, the Alcohol, Drug Abuse, and Mental Health Administration, and other Federal agencies or programs, as appropriate, should fund studies to improve understanding of the epidemiology, demographics, impact, and trends of HIV disease in rural areas.

Recommendation 90-12: Require States to Have a Statewide Plan which Designates a Single State Agency as Responsible for Coordinating State Response to HIV/AIDS and which Addresses Rural HIV/AIDS Needs as a Condition of Receiving Federal AIDS Block Grants

Federal block grants to states for HIV disease prevention and treatment services should be contingent upon the existence of a statewide plan which effectively addresses rural HIV/AIDS needs and the designation of a single state agency responsible for coordinating the state's response to HIV disease.

Recommendation 90-13: Provide Federal Support for Technical Assistance to Community-Based Organizations which Address the Needs of HIV Infected Persons in Rural Areas

The Centers for Disease Control and the Health Resources and Services Administration should develop and support a coordinated program of technical assistance for community-based organizations doing HIV prevention and providing services to HIV-infected persons in rural areas.

The community-based organizations play a critical role in preventing the spread of HIV and providing services to HIV-infected persons. These programs need technical assistance with organizational development and programming. Currently technical assistance is provided by a number of agencies and programs. These are not well coordinated, and there is no assurance that all important areas of training are addressed. Training and technical assistance should address at least:

• Targeted prevention programs;
• Service programs;
• Organizational development;
• Program evaluations; and
• Fund Raising.

Recommendation 90-14: Provide Federal Support to Foster Local Leadership to Respond to the HIV/AIDS Challenge in Rural Areas

The appropriate Federal agencies, in particular the Centers for Disease Control and the Health Resources and Services Administration, should support programs to promote and foster local leadership to orchestrate the HIV response in rural areas.

Recommendation 90-15: Expand the AIDS Education and Training Center Activities to More Effectively Reach Rural Primary Care Providers

The AIDS Education and Training Centers should establish or expand telephone hot line services and other programs to assure that rural primary care providers have easy, rapid access to HIV/AIDS treatment information, drug trials and referrals. Further, the AIDS Education and Training Centers should expand networks linking rural health care providers with major medical centers, to ensure access and quality care to persons with HIV disease.

Recommendation 90-16: Establish State 800 Numbers to Provide Information on Medicaid Eligibility and Coverage of Services for HIV Infected Persons

State Medicaid Offices should establish 800 numbers to provide information on Medicaid eligibility for and coverage of HIV-disease to HIV-infected persons, providers, patient advocates, and the state's local social service offices.

Recommendation 90-17: Provide Federal Guidance to States on Implementation of Ryan White Act

The Secretary should provide guidance to states in their use of the Ryan White Act HIV/AIDS funds to assure attention to the needs of the increasing number of HIV-infected persons in rural areas.

Recommendation 90-18: Accept the Recommendations of the National Commission on AIDS

The Secretary should accept the recommendations of the third report of the National Commission on AIDS, especially their recommendations to develop comprehensive community-based primary health care systems and to expand AIDS education and outreach services to rural communities. (National Commission on Aids, Report No. 3, Recommendations One and Two.)

Recommendation 90-19: Develop a Compendium of State Initiatives Undertaken to Address Obstetrical Malpractice

The Secretary should direct the Health Resourcesand Services Administration to develop a compendium of state initiatives that have been undertaken or are currently underway to address obstetrical malpractice. In addition, the compendium should describe state initiatives to train and place practitioners of all levels (physicians and mid-level practitioners) in rural areas to more effectively meet these areas need for obstetrical practitioners. The compendium should include copies of legislation (proposed and enacted) and should be disseminated to the National Governors Association, National Conference State Legislatures, Council of State Governments, the National Association of Counties, state offices of rural health, and other appropriate entities.

Recommendation 90-20: Monitor State Initiatives which Address Obstetrical Malpractice

The Health Resources and Services Administration should work with the Agency for Health Care Policy and Research (AHCPR) to track or monitor ongoing state initiatives that address obstetrical malpractice issues and evaluate their effects.

Recommendation 90-21: Establish a Commission on Obstetrical Access

The Secretary should establish a special commission to examine the barriers to effective and efficient utilization of all obstetrical providers (both physicians and mid-level practitioners) who provide care in rural areas. The commission should be charged with proposing policy and strategies for implementation at Federal, state and local levels. Strategies should include the development of incentives to promote more effective utilization of all health professionals who provide obstetrical services. To facilitate the development and acceptance of policies and strategies, the commission should include representatives from the National Governors' Association, the National Conference of State Legislatures, the Council of State Governments, and the National Association of Counties.

Recommendation 90-22: Establish a Funding Priority in the Bureau of Health Professions Training Programs for Rural Primary Care Practice Programs that Include a Strong Obstetrical Practice Component

The Bureau of Health Professions should establish a funding priority for health professions education/training programs which prepare health professionals for rural primary care practice and which have a strong obstetrical practice component.

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1989 Recommendations

Recommendation 89-1: Create a Medicare Payment Floor for Rural Hospitals With Less than 50 Beds and for Sole Community Hospitals

The Secretary should propose legislation to the Congress that would establish a Medicare inpatient payment floor for rural hospitals with less than 50 acute care beds and for Sole Community Hospitals (SCHs). The payment floor would be based on an individual hospital's current cost experience. The legislation would be effective for hospital cost reporting periods beginning on or after October 1, 1989, and end at such time that special Medicare payment provisions for essential access facilities are implemented. For the purposes of this legislation, acute care beds include swing beds, but exclude licensed beds for long-term care and newborn bassinets.

Recommendation 89-2: Establish a single National Standardized Payment Amount by Fiscal Year 1993

The Secretary should propose legislation that would establish a single national standardized payment amount to replace the separate urban and rural Medicare standardized amounts. The single payment rate system should incorporate more sensitive adjustments for differences in case-mix, severity, area wage levels, and other non-labor price adjustors. The current urban-rural differential should be phased out over a 3-year period such that a single national standardized amount would be implemented for cost reporting periods beginning no later than October 1, 1992.

Recommendation 89-3: Develop and Test a Refined Area Wage Adjustment

By the beginning of FY 1991, the Secretary should implement a refined area wage adjustment to better reflect differences in hospital wages. Prior to implementing this adjustment, the Secretary should develop and test the appropriateness of an area wage adjustment that assumes a single national labor market for professional personnel.

Recommendation 89-4: Update the Area Wage Index Annually

By the beginning of FY 1992, the Secretary should have in place a mechanism of annually updating the area wage index used in the Medicare PPS. The data collected should reflect the true labor costs of hospitals for professional and non-professional occupational categories of employees.

Recommendation 89-5: Evaluate the Impact of Prospective Payment Systems on Rural Hospital Outpatient Care Under Medicare

Given the congressional mandate for the Secretary to develop a legislative proposal on prospective payment for hospital outpatient services, the Secretary should evaluate carefully the impact of such proposals on rural hospitals.

Recommendation 89-6: Continue and Increase Support for Research and Demonstrations on Innovative and Alternative Delivery Systems

The Secretary should continue the Department's support for the Medical Assistance Facility Demonstration Project in Montana. Additional research and demonstrations should be supported to encourage communities to test various transition strategies to ensure continued access to health services in their communities.

Recommendation 89-7: Define and Identify Essential Access Facilities

By April 1, 1992, the Secretary should submit to Congress legislative proposals for implementation, by October 1, 1992, of a coordinated strategy to protect the financial viability of essential access facilities (EAFs). The strategy should include uniform guidelines for identifying EAFs, a process for designating such facilities, and the design of appropriate Federal program protections. Incentives and specialized grant programs should be developed to encourage adoption of the EAF concept and enhance the quality and scope of services available in these facilities. The Office of Rural Health Policy should be charged with the responsibility for defining and developing the strategy because EAFs play a major role in ensuring access to health care in rural communities.

Recommendation 89-8: Improve Access to Capital for Rural Facilities

The Secretary should work with the Department of Housing and Urban Development (HUD) and the U.S. Department of Agriculture to improve access to capital for rural facilities through increased availability of Farmers Home Administration direct and guaranteed loans (non-farm), HUD 242 and 232 loan guarantees, and PHS Section 1610(a) and (b) grants for construction and modernization. Such funding would be limited to those facilities determined to be critical for access to health care in the community.

Recommendation 89-9: Support the Rural Hospital Transition Grant Program and Broaden Its Scope to Include Community Needs Assessment

The Secretary should support the rural Hospital Transition Grant Program through FY 1990. Beginning in FY 1991, legislation should be proposed to the Congress that would make non-hospital health organizations, community organizations, agencies, or political subdivisions eligible as grantees. The program's title should be changed to "Rural Health Services Transition Grant Program" and be broadened in scope to include a community needs assessment which encompasses comprehensive health care, health promotion, alcoholism, substance abuse, mental health, and emergency medical services.

Recommendation 89-10: Implement Federal Grant Programs to Promote the Integration and Coordination of Services in Rural Areas

By October 1, 1992, the Secretary should develop a series of programs that would facilitate integration and coordination of services in or among rural communities. The programs should include new demonstrations and increased emphasis in current programs on improving both horizontal and vertical linkages, integration, and cooperation between community and migrant health centers, local primary care providers, hospitals, medical group practices, and public health departments. These programs should be the result of a careful analysis by the Office of Rural Health Policy of existing demonstrations and should reflect a thorough review of existing Federal and state barriers, both legislative and regulatory, that impede integration.

Recommendation 89-11: Establish a "One-Stop Shopping" Demonstration Program

The Secretary should propose legislation to the Congress establishing a demonstration program (10 rural sites) that would consolidate all categorical funds and programs for health into a single "one- stop" office, particularly in very poor or small communities.

Recommendation 89-12: Medicare Physician Payment Policies

The Committee recommends that any policy positions adopted by the Department that relate to a restructured reimbursement system for physicians should adhere to the following principles:

1) Medicare payments to all physicians practicing in rural areas should be increased to eliminate existing urban-rural differentials.

2) Payment increases for rural primary care physicians should be accelerated. During the transition period to any new reimbursement system, the payment floor for primary care services should be increased from 50 percent to 80 percent of national average prevailing charges to be effective January 1, 1990. The increased payment schedule should be restricted to physician specialists in family practice, general practice, general internal medicine, obstetrics and gynecology, and general pediatrics who practice in designated rural (i.e., non-metropolitan statistical) areas of the Nations.

3) Provisions for updating any physician fee schedule should allow for differential updates according to geographic locations, category of service, or other pertinent variables explicitly related to addressing access problems of the underserved.

4) Attempts to define, by legislation, a geographic practice cost index should be deferred until 1991 to allow sufficient time for the Physician Payment Review Commission to complete proposed studies and subsequent evaluations related to alleged variations in the geographic costs of practice.

5) In the event a restructured payment system is not adopted by Congress, the Secretary should recommend an increase in the payment floor as noted above in Principle 2.

Recommendation 89-13: Stabilize Current Levels of Primary Care Providers in Rural Areas through Tax Credits and Incentive Pay

The Secretary should propose legislation to amend the Internal Revenue Code of 1986 to provide refundable income tax credits to primary care providers who work in federally-designated rural health manpower shortage areas (HMSAs). Primary care providers should be defined as doctors of medicine or osteopathy, physician assistants, nurse specialists who provide direct patient care and practice principally in one of the four following primary care specialties: general or family practice, general internal medicine, general pediatrics, and obstetrics and gynecology.

The Secretary also should support legislation to extend the Medicare incentive payment bonus for physicians practicing in Class 1 and Class 2 designated HMSAs to primary care physicians practicing in all designated rural HMSAs, and increase the bonus such that these physicians receive not less than a 10 percent payment bonus.

Recommendation 89-14: Revitalize the National Health Service Corps (NHSC) Scholarship Program

The Secretary should seek appropriations from Congress in FY 1990 and subsequent years to provide scholarships to entering medical and osteopathic, nurse practitioner, nurse-midwifery, clinical nurse specialist and physician assistant students. In addition, the Secretary should make or, where necessary, seek the authority to make, the following programmatic changes to revitalize the scholarship program:

Priority for scholarships should be limited initially to medical, osteopathic, nurse practitioner, physician assistant, nurse midwifery and clinical nurse specialist students who intend to specialize in family practice, general internal medicine, general pediatrics, or obstetrics/gynecology.

• Priority for scholarships should be given to qualified applicants from HMSAs, MUAs and rural areas, to qualified minority applicants, and to qualified applicants with exceptional financial need.
• Participation should be targeted to those educational institutions that graduate a significant proportion of professionals (as identified in the first bullet) who enter primary care practice in rural or other underserved areas.
• Adequate personnel and dollars should be made available to the NHSC program to enable it to provide support services for scholarship and loan recipients necessary for their continued commitment to the program while in training, and necessary for their retention in HMSAs once placed.

Recommendation 89-15: Support MHSC Loan Repayment Programs

The Secretary should support states in their efforts to establish effective loan repayment programs by providing adequate funding to states. The Secretary should also continue to seek to develop an effective Federal loan repayment program. As such, the Secretary should seek increased appropriations for the loan repayment program and support legislation that eliminates the tax liability of the Federal loan repayment programs. Among techniques the Secretary should consider to attract larger numbers of qualified individuals into the Federal loan repayment program are: (1) increasing publicity about the program; (2) increasing the loan amount the Government can repay; and (3) covering undergraduate loans.

Recommendation 89-16: Maintain and Target Funding for the Health Professions Programs Administered by the Department of Health and Human Services

The Secretary should recommend that funding for the health professions programs administered by the Department of Health and Human Services be maintained to preserve the capacity and continuity of education/training programs that ensure a supply of competent health care providers for rural areas and other underserved groups. Special priority should be given to programs that prepare individuals for primary care, rural practice, or practice with other underserved groups.

Recommendation 89-17: Establish a Task Force to Assess Policies of Health Professions Accreditation Bodies and State Approval Entities

The Secretary should establish a special short-term task force to develop specific recommendations addressing barriers in health professions accreditation and licensure standards that impede the development of rural clinical experiences, internships, preceptorships and residencies.

Recommendation 89-18: Fund the "Health Care for Rural Areas" Program

The Secretary should seek an appropriation of $5 million for the "Health Care for Rural Areas" program, authorized in 1988 (P.L. 100-607). The program would provide grants to develop innovative, interdisciplinary training programs that would educate health professionals for rural practice.

Recommendation 89-19: Expand the "Rural Medical Education Demonstration Projects" Program

The Secretary should propose legislation to expand the "Rural Medical Education Demonstration Projects" program to an additional 12 demonstrations, half of which utilize rural hospitals as a teaching site and half of which would utilize a rural ambulatory practice setting. The expanded program should incorporate flexible geographic criteria for awarding demonstrations that would result in a reasonable representation of provider sites across the Nation.

Recommendation 89-20: Support Increased Funds for Community and Migrant Health (C/MHC) Programs

The Secretary should propose an increase for the C/MHC programs in the Department's FY 1991 budget. At least 50 percent of the increase should be earmarked for projects in rural and frontier areas.

Recommendation 89-21: Maintain the Current Process for Designating Heath Manpower Shortage Areas and Medically Underserved Areas (HMSAs and MUAs)

The Secretary should ensure that the current process for designating HMSAs and MUAs is maintained until a full evaluation is conducted on the implications that any change would have on the myriad of programs that utilize the designations.

Recommendation 89-22: Improve the Administration of the Rural Health Clinics (RHC) Act Program

The Secretary should disseminate information to promote an increase in the number of RHCs. Technical assistance should be provided to assist potential providers in qualifying for RHC designation.

Recommendation 89-23: Convene a Federal Interagency Rural Health Work Group and a Presidential Rural Health Council

The Secretary should direct the Office of Rural Health Policy to convene and staff a Federal Rural Health Work Group composed of all Federal agencies that have programs/activities with a rural health-related mission (e.g., Departments of Agriculture, Transportation, and Veteran's Affairs). Further, the Secretary should recommend establishment of a Presidential Rural Health Council to mobilize the public and private sectors to better address rural health problems.

Recommendation 89-24: Expand Federal Activities to Improve the Availability of Emergency Medical Services

The Secretary should establish a focal point within the Department for the planning and coordination of emergency medical services (EMS) activities. The Secretary should propose legislation to improve the availability of EMS in rural areas through matching grants to states.

Recommendation 89-25: Ensure that Federal Block Grants Address Rural Health Problems

The Secretary should issue a policy directive to states that implementation of all block grants address the unique service needs of rural areas.

Recommendation 89-26: Ensure a Rural Focus in the "War on Drugs"

The Secretary should ensure that current departmental efforts to address education and treatment in the "war on drugs" include a focus on rural communities.

Recommendation 89-27: Establish a National Occupational/Environmental Health Program and a National Network of Rural Occupational/Environmental Health Services Centers

The Secretary should propose legislation to the Congress that would establish a national occupational/environmental health program to address major health hazards through an interdisciplinary educational program in conjunction with high schools, colleges, academic health centers and Cooperative Extension Services.

In addition, the Secretary should propose legislation to the Congress that would establish a national network of 10 rural occupational/environmental health services centers in conjunction with academic health centers or major medical centers. These would provide screening, diagnosis, treatment, research, and educational services using an interdisciplinary team approach.

Recommendation 89-28: Establish a National Adolescent Health Demonstration Program

The Secretary should propose legislation to the Congress that would establish a national demonstration program (five rural community sites), in cooperation with states and the private sector, to establish different types of adolescent health programs. Such demonstrations would include implementation of a comprehensive K through 12 health education curriculum in combination with on-site counseling, preventive and social/health services within a school district. These services would be provided by a health professional.

Recommendation 89-29: Increase the Quantity and Quality of Rural Research

The Secretary should support continuation of the HCFA "10 percent set- aside" of research and development funds for rural health research. The Office of Rural Health Policy should encourage the rural health research centers to sponsor a national conference.

Recommendation 89-30: Develop a Compendium of Model Rural-Focused Health Professions Education and Training Programs

The Secretary should direct the Office of Rural Health Policy to identify and catalog models of rural-focused health professions education and training programs, including those programs which address leadership, management and governance. A compendium of these models should be developed and disseminated.

Recommendation 89-31: Promote Uniform Data Collection on Rural Health Personnel

The Secretary should ensure that all Federal health personnel data collection efforts permit analysis by urban and rural classifications. Further, the Secretary should work with public and private organizations that are involved in rural health personnel research and data collection efforts to promote the uniform gathering and analysis of data using urban and rural categories.

Recommendation 89-32: Provide Adequate Funding for the National Library of Medicine's Rural Outreach Activities

The Secretary should seek adequate funding to enable the National Library of Medicine (NLM) to implement its outreach program. The Committee believes priority should initially be given to the following areas:

• Increasing the marketing of Grateful Med and other NLM services to rural and other underserved health care individuals and agencies, and provide opportunities for individuals to learn how to access the Grateful Med system.
• Expanding the capabilities of entities that enable rural professionals to access information in rural communities (e.g., regional medical libraries and health facility libraries). Existing networks such as Area Health Education Centers and community colleges and universities should be utilized whenever feasible.
• Augmenting the biomedical database to include pharmacy, social work, nursing and other allied health listings and increase listings relevant to rural health.

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