Monthly Commentary from the Executive Director - August 1st, 1996
Approval Close For Single Payment Localities
HCFA has published a proposal to significantly reduce the historic bias in Medicare payments for physicians who work in most rural communities. Your letters are needed now to show support.
After years of sustained rural advocacy, the Health Care Financing Administration (HCFA) of the federal Department of Health and Human Services has published a proposal to significantly reduce the historic bias in Medicare payments against physicians who work in rural communities. HCFA has given those in favor and those opposed until September 3rd to comment.
Please write (and encourage others to also write) to strongly support HCFA's proposal to expand from 22 to 34 the number of states that have a single locality for payments made under the Medicare physician fee schedule. (These new states are: Alabama, Arizona, Connecticut, Idaho, Indiana, Kansas, Kentucky, Mississippi, Nevada, Virginia, West Virginia and Wisconsin.) Rural areas in the remaining states will also be significantly helped by the overall consolidation of payment localities from 210 to 89.
Written comments (1 original and 3 copies) must be received by September 3rd. Use the following as is or as the starting point for your letter; it can be brief and handwritten, but needs to be sent to the:
Health Care Financing Administration
Department of Health and Human Services
P.O. Box 26688
Baltimore, MD 21207-0488.
To Whom It May Concern:
We strongly support your proposal to expand from 22 to 34 the number of states that become a single locality for payments made under the Medicare physician fee schedule. Rural areas in the remaining states will be helped by the overall consolidation of payment localities from 210 to 89.
We agree with your position that "Option 1i with a 5-percent threshold would attain the goal of simplifying the payment areas and reducing payment differences among areas while maintaining accuracy in tracking input prices."
We agree that the proposed payment area changes should be fully effective in calendar year 1997.
We support single payment localities because:
- Data indicators used by HCFA to calculate the Geographic Adjustment Factors do not accurately reflect the cost of health care delivery in rural areas.
- Rural areas typically have higher percentages of Medicare, Medicaid, under and uninsured populations than urban areas.
- Rural areas have increasing difficulty recruiting physicians for a variety of reasons, and lower Medicare reimbursement is one of the contributing factors.
- The current geographically differentiated system of reimbursement, if stringently implemented, is likely to further restrict access to specialists for rural residents currently provided by specialists visiting from urban based clinics.
- Lower levels of reimbursement in rural areas create a downward spiral that affects overall health care access.
Even Moderate Physical Activity Is Effective
The first Surgeon General's report on physical activity was released on the eve of the Centennial Olympic Games. The full report is available from at the Department of Health and Human Services web site.
- People of all ages, both male and female, benefit from regular physical activity.
- Significant health benefits can be obtained by including a moderate amount of physical activity (e.g., 30 minutes of brisk walking or raking leaves, 15 minutes of running, or 45 minutes of playing volleyball) on most, if not all, days of the week. Through a modest increase in daily activity, most Americans can improve their health and quality of life.
- Additional health benefits can be gained through greater amounts of physical activity. People who can maintain a regular regimen of activity that is of longer duration or of more vigorous intensity are likely to derive greater benefit.
- Physical activity reduces the risk of premature mortality in general, and of coronary heart disease, hypertension, colon cancer, and diabetes mellitus in particular. Physical activity also improves mental health and is important for the health of muscles, bones, and joints.
- More than 60 percent of American adults are not regularly physically active. In fact, 25 percent of all adults are not active at all. (See RWHC map below re the national distribution of couch potatoes.)
- Half of American youths 12­p;21 years of age are not vigorously active on a regular basis. Moreover, physical activity declines dramatically during adolescence.
- Daily enrollment in physical education classes has declined among high school students from 42 percent in 1991 to 25 percent in 1995.
- Research on understanding and promoting physical activity is at an early stage, but some interventions to promote physical activity through schools, work sites, and health care settings have been evaluated and found to be successful.
Once Upon A Time, Tax Exempt Hospitals
Once upon a time, hospitals were tax exempt, businesses were taxable. But as hospitals have been forced to become more "business like," the distinction between their tax exempt and taxable activities has gotten increasingly blurry.
Last month the Wisconsin Health and Educational Facilities Authority (WHEFA) approved (4 to 1) a suburban Milwaukee hospital's request for a $15 million dollar tax-exempt bond to construct a 72,500 square foot health and fitness center. (I was the dissenting vote.)
Afterwards, Larry Nines, WHEFA Executive Director stated the rationale of the majority, that under Wisconsin Statutes "the Members were presented with a financially feasible project that was represented by legal counsel to be eligible for this type of financing. The statutes are very restrictive and specific in that if these tests are met, authorization must be given."
This request has created a firestorm of opposition that threatens to inflame the already smoldering opposition to tax exemptions by non-profit health care providers. In a rare example of bipartisanship, two Milwaukee area Congressman, Republican James Sensenbrenner and Democrat Jerry Kleczka have responded by introducing the Taxpayer Bond Fairness Act, a bill to prohibit tax-exempt financing for fitness spas run by nonprofit hospitals, and make those activities subject to the Unrelated Business Income Tax.
Whether approval is given to issue these bonds is a question now before the Attorney General, the next step in the normal process; as we haven't had controversy like this in the past, this application has now entered uncharted waters. The final decision may be that of the market place, it may be very uninterested in buying bonds surrounded by so much controversy.
What is clear is that the larger policy debate, in Washington and Wisconsin, will be about whether any new restrictions will be put on tax exemptions currently available to non-profit health care providers. The July 13th Milwaukee Business Journal quotes State Senator Joe Wineke as saying that WHEFA "should be abolished or modified so that its board takes larger policy issue into consideration."
As noted earlier, the health of couch potatoes (myself chief among them) would clearly benefit by greater familiarity with fitness centers. However, healthy food, fresh air and red wine in moderation are all good for your health. Somewhere between a rural health clinic and a wine shop, we need to draw the line on which projects should be eligible for tax exempt financing. Changing times have caught up with inadequate statutes. Over reaction is easy, good public policy will require effort from both sides in this interesting debate.
Californians Aim To Balance HMO Power
Yet another referendum from California. With over 800,000 signatures, The Patient Protection Act is on the ballet to ward off perceived managed care abuses. The initiative is sponsored by the California Nurses Association; the following summary is taken from their WWW site (http://www.igc.apc.org/cna/initit.html); haven't seen a site sponsored by the opposition.
What the Patient Protection Act does:
- Bars HMOs and insurers from refusing to authorize treatments, tests, or referrals to specialists, unless the denial is based on a physical exam by a qualified health care professional.
- Prohibits HMOs and insurers from paying physicians bonuses or other incentives to deny or delay care.
- Prohibits termination, discipline, or blacklisting of physicians, registered nurses, or other licensed caregivers for advocating for their patients.
- Guarantees full disclosure of medical information to patients.
- Requires safe and adequate staffing in all health care facilities.
- Establishes a fund to enforce the Patient Protection Act, to maintain community health services, including trauma centers and emergency rooms, and to assist those affected by cutbacks in Medicare and MediCal and the uninsured.
- Bars forced arbitration as a condition of coverage; guarantees the right to sue in court.
A WI Rural Health Agenda
The RWHC Board at its meeting on July 12th approved the following rural health issues for consideration by the Wisconsin Legislature as a new legislative cycle begins after the fall elections:
- Any Willing Provider protection for rural communities. Compel insurers to sign on any rural based provider who agrees to abide by the terms of their contracts (including utilization and quality criteria) and to accept their payment levels.
- Prohibit the Preferred Hospital Agreement for the HIRSP program from exacting a 10% discount in rural counties (in addition to that currently mandated by statute).
- Narrow, don't eliminate, the focus of tax-exempt financing for health care facilities. There is a clear need to reform the rules governing tax exempt financing, not eliminate it as proposed by some.
- Access to tax exempt financing through WHEFA for rural medical centers. Projects that are currently eligible for WHEFA financing if done by a separately licensed entity should be eligible if done by an entity licensed as a rural medical center.
- Require that the Emergency Medical Services Board's Physician Advisory Committee include at least three physicians whose primary practice is in rural, primary care settings.
- Clean up the existing Certificate of Public Advantage statute and write the rules necessary to allow the law to be used by rural providers needing state immunity from antitrust enforcement.
- Implement the Rural Health Development Council recommendation to modify the Physician Loan Assistance Program and make similar modifications to the Health Care Provider Loan Assistance Program. (Increases utility as a recruitment tool by shortening term and increasing front end load.)
- Support the Rural Health Development Council recommendation that both of Wisconsin's medical schools build on their current success by formally committing to a collaborative process to further improve the distribution of physicians in Wisconsin's underserved communities.
- Condition future State allocations to the Area Health Education Center System on the system being directly accountable to a governing board independent of either medical school and that the board's composition be at least 50% from community representatives not employed by either school.
- Implement the recommendation of the Workforce Forum convened by the Consortium for Primary Care in Wisconsin to "create the capacity to provide technical assistance in three to five communities yearly that have the most severe recruitment and retention problems.
- Start-up funding to create a freestanding Center Of Excellence For Cooperative Health Care. Such a center started with state funds would be likely to attract private funds for purposes of research, education and demonstration projects relevant to cooperative or collaborative health enterprises.
Congratulations & Thanks To An Institution
People have asked me what makes rural health in Wisconsin, well, so Wisconsin. I haven't had a good answer, but one has now come to mind--in some good measure it is the stick-to-it-ness of some of its individuals. For example, this year marks the twentieth anniversary of the Wisconsin Office of Rural Health (WORH) and its original Director, Fred Moskol.
Early on, Fred pushed the Cooperative to think more broadly and he deserves a share of whatever progress we are deemed to have made. In partial thanks, here is unrequested free publicity for Fred and the Office. As they have not tended to blow their own horn, you may be surprised about how much they do. (The following is from their web site but I can attest to its accuracy.)
"WORH works to improve access to health care services for Wisconsin's rural and underserved communities. Established in 1976, the WORH is part of the University of Wisconsin Center for Health Sciences. Developed out of a growing concern for the accessibility of quality health care in rural Wisconsin, its mission was to identify areas of need for health care services, help rural communities recruit needed health care providers, and develop sites in rural areas for the training of health professionals. Reflecting the center of rural health emphasis at the time, the WORH became part of the UW Department of Family Medicine & Practice in 1979. Throughout the 1980s, the WORH worked with many programs at the federal and state levels designed to bring services to underserved areas. The WORH moved to the UW Medical School Dean's Office in 1990, and has significantly expanded its mission and programs during the past few years."
"New Physicians for Wisconsin (NPW) is the non-profit physician placement and retention program of the Wisconsin Office of Rural Health. NPW serves as a statewide resource assisting communities and physicians in meeting their placement needs. Since its inception in 1979, NPW has helped place more than 230 physicians in nearly 100 Wisconsin communities."
"Primary Providers for Wisconsin is WORH's non-profit program devoted to the placement and retention of nurse practitioners, physician assistants, and certified nurse midwives in Wisconsin. Established in 1994, the program's goals include assisting in the recruitment and retention of NPs, PAs, and CNMs in rural and underserved areas; increasing the awareness of NP, PA, and CNM practice capabilities and benefits of care; and initiating statewide collaborative efforts to increase access to care in rural and underserved areas."
"The Health Professions Loan Assistance Programs provide educational loan repayment to primary health care professionals who agree to practice in medical shortage areas. Eligible physicians in primary care receive up to $50,000 in reimbursement over a five-year period and, since the program's inception in 1991, 71 placements have been secured. Nurse practitioners, certified nurse midwives, and physician assistants qualify for up to $25,000 in loan reimbursement over five years, and the first award period in April 1995 assisted 14 of these providers."
"Interdisciplinary Training in Rural Areas, funded by the U.S. Public Health Service, is for the purposes of recruiting, training and deploying nurse practitioner, physician assistant, social work and pharmacy students into rural medically underserved areas in Wisconsin. Faculty from the four health professions programs at UW-Madison work with community partners in three rural Wisconsin communities during the three years of the grant (1993-96) to develop community-based education/training and employment opportunities for students interested in rural primary care practice with an interdisciplinary focus."
The WORH also conducts a variety of activities designed to provide information, technical assistance, and coordination of efforts to rural health entities statewide under a grant from the Federal Office of Rural Health Policy. For information call (608) 263-6394.
Reasonable people adapt themselves to the world; unreasonable people persist in trying to adapt the world to themselves. Therefore, all progress depends upon unreasonable people. George Bernard Shaw
WI AHEC, Time To Close Walk-Talk Gap
Wisconsin's Area Health Education Center system has accomplished much in its initial years but has much more to do. If we are to continue to move forward we must recognize that we have outgrown our initial structure; essentially governance and management by and between two medical schools.
There is a growing consensus that we are at the point in our system's development where the governance structure needs to actually reflect the often espoused community partnership, and that we need a single Director to lead this increasingly complex network of programs. How to get there is the question; one that is likely to be answered over the next few months.
The Wisconsin Primary Care Association (WPCA, representing urban and rural community health centers) and the Cooperative strongly support this direction. Donna Friedsam, WPCA's executive director, has summarized what needs to be accomplished:
- "Establish an executive director, separate from each medical schools' AHEC program offices."
- "Establish a true governance body that reflects a balance between community and academic interests. The AHEC System executive director should "report to" this Board."
"...the 'board' should include both Medical School Deans (or their designees), each local AHEC Director, a representative from the Statewide Nursing Advisory Council (SNAC) and two community (not AHEC or academia­p;based) representatives who are elected by the Statewide Program Advisory Committee (SPAC). SPAC and SNAC should remain advisory to this board."
"The Deans of the two Medical Schools (or whoever acts as the immediate supervisor to the executive director within his or her institutional setting) would need to agree that they do not retain veto authority over decisions made by this governing board, and that the executive director will be expected to respond to the decisions of the Board."
"The Board governance model is entirely compatible with the need of the federal agency to have a Principal Investigator (PI) on the contract. The Board, through its written agreement with the executive director, could simply delineate the executive director's authority as PI. Federal agencies regularly enter contracts and cooperative agreements with private non­p;profit corporations (community health centers are only one example) that are governed by community­p;based boards. The executive director is named Project Director."
- "Strengthen/better define the program offices at both medical schools. Each program office director should hold a faculty appointment, and have staff who report to him/her."
- "Establish an AHEC directors council to address issues related to administration and operations. This council may be chaired by the AHEC System executive director."
RWHC Clinical Services Director, Bonnie Laffey
Bonnie has been with RWHC for twelve years. She is responsible for Physician Staffing and Clinical Services.
Bonnie lives in Waunakee with her husband (an attorney) and is the proud mother of three daughters ages 8, 6 and almost 1.
Free time is somewhat of a dream, but spending time with a large extended family and an occasional cross country run are key areas of interest.
The Official Answer To What Is Rural
The following is from a book compiled by Denise Denton with cartoon art by Eddie Denton. All proceeds go to the Colorado Rural Health Center, 225 East 16th Avenue, Suite 1050, Denver, CO 80220 (303-832-7493). Send them ten dollars and a few bucks for postage and handling; you will have something special.
Rural is where:
All you need is a name and a town to get your mail.
It is okay that you put your family dog's obituary in the weekly paper.
There's one stop shopping at the gas station.
You live in a rural area if:
You don't trust a person with a clean suit and a clean car (except at weddings and funerals).
When you miss church on Sunday - you get a "get well" card on Tuesday.
You can hunt in your front yard.
A town is rural if:
Few people can get away with lying about the year they were born...
You know all the news before it's published and just buy the hometown paper to see if the editor gets it right.
You have to drive further for a Big Mac than a bale of hay.
In a rural area:
The nurse, respiratory therapy, lab tech and EKG tech are all the same person.
You call a patient; get a wrong number, but it was someone you needed to talk to anyway.
An "integrated delivery system" has to include a veterinarian.
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