Tuesday, May 22, 2012

How Will the New Health Care Impact Rural?

06/29/2011

11:45 a.m., June 29

Broadband advocates connect over common concerns
 
The most widely discussed issue in broadband talk today is the impending AT&T/T-Mobile merger, and sentiments at the Assembly are decicively negative. There is concern over the creation of monopoly – e.g., decreased consumer choice – and over the possibility of wireless dominance over wired access.
 
Though the market is moving toward this end, participants in this morning’s breakout session insist that many of the opportunities that internet access opens to rural areas are contingent on wired service. Central to this debate is the issue of net neutrality.
 
The Rural Broadband Policy Group has published a letter denouncing the merger, which teh group intends to send to policy-makers in Washington.

Alex Bloedel

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Steph Larsen Shawn Poynter Steph Larsen from the Center for Rural Affairs led the "Rural Healthcare: Answers and Opportunities" breakout session on the second day of the National Rural Assembly in St. Paul, MN.

11:30 a.m., June 29

Obama Administration's Affordable Care Act in Rural   

“People are just freaked out” about the new national health care reform care legislation, said a woman from Virginia. People are talking about death panels and whether “government will make us buy broccoli.” 

But what’s in the bill for smaller communities? A sample:

• The act sets us Area Health Education Centers, which will help steer rural people into health care jobs. The idea is that it will be easier to train and keep rural residents in health care professions rather than try to convince city dwellers that they need to transfer to much smaller towns.

• The bill will fund the National Health Care Service Corps, another program aimed at encouraging health care workers to locate in underserved areas.

• The bill sets up a rural residency program. Most residencies (for doctors) are in cities, where doctors “learn how to do urban medicine,” explained Steph Larsen, who is with the Center for Rural Affairs. This new program will set up residencies for doctors who want to learn to do rural medicine.

(Yes, the medicine is the same, rural and urban. But rural docs needs to have a broader array of skills.)

• The law has a 10% incentive payment for doctors who do primary care in underserved areas.

• The bill has increased funding for community health centers.

One area that could have an impact on rural businesses is the creation of health insurance marketplaces. These marketplaces will make it easier for people and businesses to choose among health insurance providers.

This could undercut local insurance brokers, who are particularly active in rural communities. 

Bill Bishop

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11:00 a.m., June 29

Rural Philathropy ~ An Insider Approach

With all the talk about economic development – both domestic and international – it’s easy to get confused. What, after all, is the difference between rural development philanthropy (RDP) and traditional community philanthropy? It was only in the past couple decades that philanthropy became an organized industry in the first place.  

The first breakout session on rural philanthropy is meant to help us answer these questions. It is a “comprehensive approach” that does not depend on an “outside funding stream,” said John Molinaro, co-director of the Aspen Institute Community Strategies Group. 

Rural communities, which constitute one half of communities around the world and 20% nationally, certainly warrant development efforts. These communities are often rich in natural resources but poor economically, due to the outside control of resource production and refinement – often by large corporations that “strip mine” (literally and figuratively) these areas without consideration for the population’s wellbeing and sustainability. 

Rural philanthropic efforts have often been managed in the same way with one-size-fits-all solutions, said Molinaro. He champions the idea that the key to sustainable, inclusive, forward-thinking development is Rural Development Philanthropy. This approach facilitates a ground-up, community-led approach that has the promotion of wellbeing for all community members built into its definition. 

Check back this afternoon for updates on the second rural philanthropy session. 

Alex Bloedel

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olga cardoso 2 Shawn Poynter Olga Cardoso, Director of Youth Programs at the Llano Grande Center, Edcouch-Elsa, TX, spoke at the "Rural Truth to Power" session of the National Rural Assembly in St. Paul, MN.

9:45 a.m., June 29

“Let’s Make It Real”

Maybe it’s corny to say that young people “are the future,” but it seems true in rural America.
Demographer Ken Johnson began the Wednesday morning session with a report from the U.S. Census. Rural population grew in the last ten years, but at a far slower pace than in the cities.

But there were indications that where there was some economic opportunity, young people were moving back to rural counties. (In retirement counties, for example, both older people AND younger adults are moving in, for example.)

The consensus among the panelists responding to Johnson’s report was that young people must now be considered “assets,” not only for the rural economy but for local cultures. “Young people want to stay with us,” said Kim Phinney with YouthBuild USA. “They are our ultimate wealth creation.”

(Phinney was less excited about the Obama administration’s relatively new council on “community solutions,” a White House group created without a single member from rural America. Phinney noted that the new group concluded that its number one priority was “disconnected youth.” Phinney noted that there was a lot of disconnection going on.)

Chuck Fluharty, with the Rural Policy Research Institute, said there were two points rural Americans should agree on. The first is that “the future of rural America is young champions.” The second is that “culture matters.”

Fluharty said he had hopes for the new White House council on rural America. Four working groups have been formed in the White House, Fluharty said. Some are meeting today. Cabinet secretaries will go out into rural communities this summer.

The key, Fluharty said, would be for rural Americans to push. “The issue is, let’s make it real,” Fluharty said. “And this assembly has something to say about it.”

Bill Bishop

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Rural Assembly panelists Shawn Poynter Panelists on the "Future of Rural America and the Rural Assembly," (from right) Peter Morris, Kim Phinney, and Delia Perez, watch a presentation by Kenneth Johnson, senior demographer for the Carsey Institute, at the National Rural Assembly June 29.

9:30am, June 29

Rural Demography

"New Trends in Birth, Death, and Movement: America’s Future in Education, Youth Development, and Diversity"
 
Kenneth Johnson of the Carsey Institute talked a lot about demographics, and had plenty of fresh data to back up his claims.
 
Rural America grows in two ways, he said, citing the birth-to-death ratios and migration, both domestic and foreign immigration. This dual process leads, he said, to “diverse patterns of population change."

Perhaps most shocking, Johnson reported that there are 750 non-metropolitan counties – that’s 36% of all rural counties -- where more people die than are born. There are “four funerals for every baptism” in certain Minnesota counties, Johnson said, quoting a friend.
 
Johnson called the current influx of middle-aged and elderly adults into rural communities, a trend coupled with an outflow of adolescents and young adults, “a perfect storm.”
 
But the “biggest story coming out of Census 2010,” Johnson said, “not just for rural America but for all of America,” is the growing diversity of the nation’s population from children to seniors.
 
“America is changing from the bottom up, from the youngest to the oldest,” he said; 46% of the population under 18 years of age is minority.
 
Johnson added that poverty is “one more kind of diversity that rural America has.”
 
Once the stage was opened up to roundtable talk among the invited speakers, Kim Phinney of YouthBuild USA criticized President Obama’s rural policies, which take as their first priority so-called “disconnected youth.” Phinney sees the policies as themselves disconnected. 
 
But “what on earth are we going to do about [these problems]?” Brian Dabson asked.
 
The answer, said Delia Perez and the Llano Grande Center, is education. Phinney added that we need an “asset-based approach” regarding our young people, who are our “ultimate [form] wealth creation.”
 
“We will have completely missed the boat” with economic development policies, Phinney said, if we do not focus efforts on youths.
 
A different approach: “Culture and values are at the heart” of rural America’s opportunities, said Peter Morris of the National Congress of American Indians. The opportunity to take advantage of collaboration with Native nations, he says, is crucial to building an inclusive and prosperous nation.

 Alex Bloedel

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CArolyn Ford Shawn Poynter Carolyn Ford, the North Florida Educational Development Corporation, spoke to the National Rural Assembly on Tuesday, June 27, 2011.


8:50 a.m., June 29
Partnering for the Future
 
Brian Dabson of the Rural Policy Research Institute (RUPRI) prodded members of the National Rural Assembly to look forward and focus on the opportunities.
 
Introducing Day Two of the gathering in St. Paul, MN, he advocated a “new model” that is based on equity and sustainability. In this way, Dabson said, rural citizens can become “full partners” in their region’s development.
 
“The tide now needs to change,” he said. “The keys to our future are also the keys to the nation’s future.”

 Alex Bloedel

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8:45am, June 29
Good morning, Rural Assembly
 
The 300 participants in the 2011 National Rural Assembly are gathered again into the Minnesota Ballroom, where last night’s speeches were set, orating the outset Day Two.
 
Talks this morning include St. Paul Mayor Christopher Coleman, who continued yesterday’s themes of connectedness and cooperation. “If we keep on hitting ourselves against each other,” he said, “we’re not going to get very far.”
 
Coleman urged participants to “inform us on urban boards like Minneapolis and St. Paul,” saying, “I hope we [in cities and rural areas] start to understand each other.”

 Alex Bloedel

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Daily Yonder's Bill Bishop, Alex Bloedel and Shawn Poynter covered the three days of the National Rural Assembly in St. Paul, MN, a gathering of 300 rural advocates and national leaders June 28-30. Check the following links for all the posts from Tuesday, Wednesday morning, Wednesday afternoon, and from Thursday morning here and here.

Also, Center for Rural Strategies has compiled a library of up-to-date materials on rural transportation, youth, broadband, native nations, education, environmental justice, and more. Find those papers here.

Comments

Bad branding

I am appaled that with all the good conversations being held at this event, you chose to title this article "Obama Care"

The session on Health Reform didn't focus on people "freaking out" (quoting myself in the session). It focused on what the provisions are and how we can help rural people understand those provisions.

Learn from the Tuesday dinner speakers - focus on the positives so we can move forward.

Myth of Obamacare

I am also concerned by any mention of Obamacare. As with terms such as government control and death squads, this is prejudicial language meant to exert maximum control over the minds of Americans with minimal effort.

Obamacare is a term that is vague and has been promoted by those against any real health plan for most Americans. Obama's proposals did not have time for even reasonable discussion before cut off by insurance company executives and others who figured out that they would lose. Medicare and Medicaid were real changes that lasted a relatively brief period from 1965 to 1980 before being essentially crafted into more spending upon fewer Americans for less overall result - the true design of American health care for many decades.

Managed care lasted maybe 5 years and could have been branded Clinton Care in many ways but was not - worth reflection.

Obamacare did not even make it through the proposal process before substantial influences were applied by the usual suspects with the usual result. Those in firm control of the designs have firm control of the revenue streams and information streams such that change is quite difficult and requires a predominant majority of very dedicated Americans to change.

Over 70% of rural Americans should be tired of words without action by any party just like 60% of urban Americans.

Robert C. Bowman, M.D. www.basichealthaccess.org

SMART or Not SMART

From the perspective of rural health personnel shortages, much more specific efforts are required. This roughly follows the SMART acronym - Specific, Measurable, Achievable, Realistic, and Timely - something current health access efforts are not.

  • Specific - To insure that this spending works, the funds must be spent specifically on trainees that are obligated to serve long term in rural locations. The spending should also be tracked to rural locations for maximal rural economic impact.
  • Measurable - the result of any current program is uncertain
  • Achievable - substantial barriers remain with regard to rural workforce outcomes even if more is spent before training or during training
  • Realistic - This is about commitment. Trainees that understand that they are required to enter primary care and rural practice prior to admission are also most likely to prepare specifically for rural primary care every day of training throughout their careers. The same commitment is required for those who train them.
  • Timely - Poor overall coordination has been the rule with the exception of 1970 to 1980 in training, in practice support, and in outcomes. Timing must involve 30 yeas of graduates or an entire generation that makes up a workforce. The current failures began in 1980. Failures 1980 to 2010 will result in failures until 2040 - by design (or lack thereof).

Specific spending for rural health workforce that is specific to rural intent, rural training, rural economic benefit, and rural workforce result should be the top priority.

Area Health Education Center funding is too little to accomplish much, is not allowed to be specific to future workforce development, is not specific for rural health workforce production,and is sent to locations with top concentrations of workforce. 

National Health Service Corps spending upon scholarships did result in more primary care and more rural health care delivery although the cost was high for the scholarships not counting orientation and administration and maintenance. Loan repayment is certainly a lesser cost, but cannot be demonstrated to actually increase primary care or rural workforce, especially during a time of substantially increasing costs of medical education and widening gaps between health access career choices paid least and those paid the most and increasing the most in pay.

Graduates taking the loan repayment have chosen primary care long before they even get a chance to choose loan repayment and also have the same probability of higher distribution - with or without the loan repayment. Substantial cost is involved in loan repayment and administration when compared to marginal change in outcomes.

There is little benefit for rural locations when graduates who would have chosen marginal rural locations with 120 physicians per 100,000 are redirected to slighly more underserved rural locations with 80 to 100 physicians per 100,000. Both locations are still far below the national average of 280 physicians per 100,000 as marginal or underserved locations have one-third of the physician levels and one-half of the primary care that Americans need.

There is also the problem of federal programs that move health professionals outside of the state that invested in the graduate from birth to final graduation.

All of the federal programs suffer from the designation distortion. Hundreds of zip codes have designation as a shortage area despite average to top concentrations of health professional workforce. A third attempt at reform is not likely to help as opposition involves those who would rather keep receiving federal funding even when they have better situations than locations still far behind. Those that oppose change and those that oppose any funding represent a formidable obstacle.

CHCs funding should be at least 40% spent in rural locations to match the higher poverty most underserved locations of the United States  in rural areas but the actual result is less than half of this.

CHC and other federal spending has been influenced in ways not specific. In recent decades a strategy for academic and large systems has been to influence CHC locations to reduce their cost of indigent care. It has been a very good strategy for academic and large systems to increase revenues and reduce costs, but this strategy is not a help for rural locations.

Unanticipated consequences cause problems when those with top workforce concentrations are impacted. Tens of thousands of NP and PA grads were diverted from family practice and primary care to teaching hospitals to fill gaps left by resident work hours restrictions. Hospitalists have grown to over 30,000 as a workforce but at the cost of primary care workforce losses. Urgent and emergent workforce gains come at primary care loss and concentrate health spending away from locations in need of economic impact. 

Special programs are small and are easily negated. Small gains of a few hundred are negated by thousands or tens of thousands lost the opposite direction.

Rural residency programs are a good idea but they require a before and an after to actually help them work at all.

The before component is medical students that will choose family medicine and will choose rural locations. The after component is also a problem as there is no guarantee of rural outcomes in any intervention.

The US has been closing and downsizing rural residency training for years primarily due to fewer medical students willing to do family practice, family practice positions opening up in major urban and western locations, and fewer medical students interested in rural training. You cannot have residency programs without medical students that will select the program and without the support of medical schools. Those directing these efforts have first hand experience with both of these problems as well as closures of rural training programs.

What works is SMART - specific, measurable, achievable, realistic, and timely.

AHEC, rural medical education funding, rural residency funding, and special incentive programs are not needed when graduates are committed before beginning training.

Japan obligates 100 per year for long term rural practice obligations in a dedicated rural medical school. Japan has also requires medical schools in each of its 47 prefectures to contribute another annual graduates to rural workforce. All told this is about 1000 obligated at admission knowing that they will be serving at least 6 years in rural locations. The effort in Japan adjusted for population is the equivalent of 2400 annual graduates entering rural practice in the United States. One way to look at this is one physician for every underserved county in the United States each year. With a six year obligation, this is actually too much rural workforce and too much primary care workforce - a nice problem to have.

Solutions That Work

The solutions that are most likely to work are specific, measurable, and achievable. Current US solutions are speculative at best as they are not specific, not measurable, and not achievable. The not achievable is the most difficult to understand but should makes the most common sense to rural Americans. Under current US policy that supports primary care, rural, and underserved workforce least, the policy result is that MD, DO, NP, and PA graduates are driven away from what is most needed for rural America - primary care, family practice, rural, and underserved.

Minnesota has had a more specific focus for 40 years with Duluth and the Rural Physician Associates Program. HRSA has been more than notified about these successes but has not taken the opportunity to be specific by replicating this successful effort. HRSA could have specific primary care training for RN, MD, DO, NP, and PA graduates, but prefers generic focus even when the outcomes are not specific, measurable, achievable, realistic, or timely.

Reliable rural workforce is available from specific rural medical schools or specific family medicine medical schools with long term or permanent results. These have also not been chosen just as permanent PA or NP family practice has been avoided.

Also bidding wars are heating up for practice locations in 30,000 zip codes with 65% of the US population. These are all zip codes that have deficits of health care workforce. Those already behind in health spending and health workforce are required to spend even more each year in ante just to play for the limited primary care workforce that remains. And rural locations are not in the best position to play this game at all.

SMART works for rural workforce. We must be SMARTer.

Robert C. Bowman, M.D. www.basichealthaccess.org