Monthly Review & Commentary On Health Issues From A Rural Perspective - October 1st, 1997

Rural Zones of Collaboration Energized
Contrary to the heated health care competition evident in Wisconsin, HMOs and insurers are out to show they can also collaborate when working in the state's south-central rural counties. With their broad support and participation, the Rural Wisconsin Health Cooperative (RWHC) based in Sauk City has received a Rural Health Network Development Grant to expand collaboration already underway among competing HMOs, insurers and rural providers.
Starting October 1st, RWHC, on behalf of the Wisconsin Rural Zones of Collaboration Initiative, expects to receive $600,000 over the next three years from the Federal Office of Rural Health Policy. A similar amount will come from program revenue and in-kind support. "The progress being made by the 'Zones' participants suggests that this approach has tremendous potential for improving both the quality and cost-effectiveness of health care in this region," says Chris Queram, CEO, The Employer Health Care Alliance Cooperative.
The Zones Initiative grew out of multiple groups--RWHC with 28 hospitals and member systems, the Community Physicians Network (CPN) with 400 physicians and the Zones Task Force--RWHC, CPN and seven HMOs or insurers, an employer health care purchasing cooperative, two state public health representatives and the state hospital association. "The CPN and RWHC have a unique relationship based on a long history with Unity Health Plans and even more now as we go together beyond that single relationship to better serve the health care needs of rural communities throughout south-central Wisconsin," according to Cathy Connelly, Executive Director, Community Physician's Network.
These monies will allow the Rural Zones Initiative to proceed immediately to begin to implement five collaborative rural strategies: (1) a centralized approach to verifying provider credentials, (2) collaboration on data collection, site visits and other administrative audits required of practitioners by regulatory/accrediting bodies, (3) a common clinical practice guideline review and adoption process, (4) clinical quality management projects in which multiple practitioners, hospitals, health plans and direct purchasers share a common interest and (5) a centralized health plan satisfaction survey.
Ann Haney, Vice President of Development and Dean Health Plan's representative to the Task Force sees it this way: "Dean has a predominantly rural service delivery area of seventeen Wisconsin counties. We want to make it as easy as possible for people to access our providers with hassle free coverage. We see the work of the Rural Zones of Collaboration Initiative as crucial to improving access to health care for rural people."
Nicholas Reiland, Unity Health Plans CEO, sums up the Initiative: "We appreciate being part of this effort from the beginning and appreciate seeing the breadth of support. These areas will greatly streamline cumbersome, costly processes and improve the quality of delivered care and the consistency with which care is evaluated." Additional insurer participants include: Gundersen Lutheran Health Plan, Physicians Plus, Security Health Plan and Wisconsin Physicians Service Insurance Corporation.

Institute of Medicine Looks at Collaboration
RWHC has been invited to talk about its experience as part of the Rural Zones of Collaboration Initiative at a meeting sponsored by the Institute of Medicine's Managed Care Panel at the National Academy of Sciences. (Thanks to Chris Queram at the Alliance for helping to make this link.) The focus of this working session of about 50 people is exploratory--"to understand the potential for collaboration among local competitors on quality of care issues." Issues to be discussed include:
· "The need to rethink the potential for quality improvement in the new world of competition; how this is evolving and the implications for measuring and improving quality."
· "The need to think about collaboration as effective use and leverage of resources, reduction of duplication and conflicting standards."
· "The nature of local markets and application for collaboration in, e.g., rural markets, overlapping networks vs. non overlapping networks, and so forth."
· "Possible areas of collaboration among plans to improve quality of care."
Urban Measures Right for Rural Care?
The following is from a proposal written by the University of Minnesota Rural Health Research Center and funded by the federal Office of Rural Health Policy:
"On one hand, purchasers of care--individuals, employers and governments--demand greater accountability from health care providers. Policy makers increasingly are requiring health care providers to participate in standardized quality measurement and reporting systems for the purpose of identifying deficient providers, improving quality of services and providing comparative information. On the other hand, the quality measurement methods developed to date are insufficient. The desire to measure quality conflicts directly with adequacy of the methods for doing so. Although quality measurement is a problem in all areas of health care, rural health care providers--especially low volume areas--present a special problem, one that is frequently overlooked by the designers of new quality measurement tools."
"The measurement of clinical outcomes in rural areas is a controversial subject. For example, the hypothesized relationship between volume and outcomes has been challenged by several researchers. The federal Health Care Financing Administration's experience with reporting hospital mortality rates by Diagnostic Related Groups demonstrated the problems inherent in using certain indicators in low-volume hospitals. While it is not entirely clear how clinical outcomes in rural areas can best be measured, it is, perhaps more clear that some methods should not be used to measure the quality of rural health services."
"Both the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee on Quality Assurance (NCQA) review the structure, process and outcomes of health care organizations and make explicit judgments about the quality of services delivered by or through them. If stakeholders are to make decisions based upon these indicators of "quality" and if accreditation is to be based on these same criteria, it is essential that all parties be aware of potential measurement issues that may affect the assessment of quality in rural areas."
"For this project, the accreditation standards and processes of JCAHO and NCQA will be considered as extended examples of the problems associated with measuring quality in rural areas. The report will suggest ways the identified problems may be addressed and specific suggestions for improving the JCAHO and NCQA accreditation systems. A working paper is expected by the end of 1998."
Rural Based Recommendations to Shalala
The federal National Advisory Committee on Rural Health had its fall meeting in Washington, D.C. in mid September; a summary of key recommendations sent to Department of Health & Human Services Secretary Donna Shalala in response to passage of the Balanced Budget Act are as follows:
· "The membership of the National Bipartisan Commission on the Future of Medicare should include rural representatives, and the rural perspective should be included in the Commission's efforts to collect information and develop proposals."
· "The Secretary should make every possible effort to obtain an appropriation and expedite implementation of Section 4201 to implement Critical Access Hospitals." (CAHs are limited service inpatient facilities that preserve important emergency, observation and short term treatment services to sparsely populated rural communities.)
· "The Secretary, in implementing the provision to limit payment for some hospital transfers to post acute care, must be sensitive to the potential adverse effects on rural hospitals when selecting the 10 DRGs and setting the time periods included in the definition of a transfer."
· "The Secretary should ensure that provider-sponsored organizations (PSOs) have adequate safeguards for unanticipated financial shortfalls. Adequate levels of financial reserves, reinsurance or guarantees must be documented."
· "The Secretary should seek legislation to provide that teaching hospitals reimburse the indirect medical education costs of rural teaching sites."
Other recommendations include:
· "The Secretary should assure access to care for rural Medicaid eligible persons assigned to managed behavioral health care systems."
· "The National Advisory Committee on Rural Health believes that there is a basic level of health care that is appropriate for every community. Access to care in frontier areas (6 or fewer persons per square mile) is of particular concern. The Secretary should perform a study of health care delivery configurations in frontier areas of the United States to identify and quantify the available models."

Hell Finally Freezes Over
RWHC and the National Rural Health Association have long spoken about Medicare Payment inequities, in particular the need to make technical improvements in the Medicare hospital wage index. Of long-standing concern has been the "double counting" of high wages in counties with a high concentration of specialty care.
Hospital interests benefiting from that error have until now been successful in blocking efforts to even talk about reforming the process used to calculate the wage index. As noted in the August 29th Federal Register, HCFA has agreed to convene a Work Group. We hope that NRHA will be part of this work group and that agreement can be reached to improve the model used in fairly adjusting Medicare payments for true variances in labor markets. HCFA's proposed intent is as follows:
"As stated in the proposed rule, we are concerned that the rapid and dramatic changes occurring in hospitals' operating environments, combined with the current time lag in the data used to construct the wage index, is leading to a situation where the wage index may be becoming less representative of hospitals' current labor costs. Hospitals' increasing reliance on contract labor for a broadening array of functions, hospital mergers and the development of integrated delivery systems, and the expansion of the prospective payment system to other sites of care are factors that indicate a need for a concerted effort to ensure that the data required for calculating the wage index are available and reliable."
"Furthermore, despite the improvements that resulted from the work of the special Medicare Technical Advisory Group (MTAG) several years ago, technical questions about the treatment of certain types of labor costs continue to arise."
"We will proceed with the development of the wage index work group. We will be in contact with interested parties to arrange a meeting to discuss issues related to its structure and focus. We believe that utilization of a work group will expedite many procedural improvements in the wage index process."
Town Hall Meeting on Women's Health
Congressman Scott Klug will host his 2nd annual Town Hall Meeting on Women's Health Issues, Saturday, November 1st at the Dane County Expo Center.
Building on the framework of last year's meeting, speakers will address a wide range of issues from domestic violence to exercise, menopause to breast cancer. The day will begin with a keynote address given by nationally recognized author and lecturer, Dr. Alan Leshner. Dr. Leshner is the director of the National Institute on Drug Abuse, located in Bethesda, Maryland. This will be followed by a choice of four sessions designed to give each woman the maximum amount of information about her health and healthcare needs in an educational and engaging format. The day will conclude with a luncheon and talk by Dr. Jane Albright-Dieterle, coach of the University of Wisconsin women's basketball team. Call Nicole Young at 608-257-9200 to register or for more information.
Small-Firm Employees Fuel Backlash?
The following is from "Small Employers And Their Health Benefits, 1988-1996," by Jon R. Gabel et al in Health Affairs, 9/97:
"Perhaps because of a later start, small firms appear to have made the switch to managed care more rapidly than large firms have. Many small firms have replaced a single conventional plan with a single managed care plan. Small firms have attempted to make this transition easier by emphasizing PPOs. PPOs constitute a much larger share of small-firm plan offerings than large-firm plan offerings, and employees in small firms have less access to conventional plans."
"The rapidity of this transition might help to explain some of the current backlash against managed care. During early stages of the transition for large firms, virtually all employees who enrolled in managed care did so voluntarily. Some employees switched because they preferred certain aspects of managed care, but even those who switched to save money expected to be better off than if they stayed in a conventional plan. In small firms, many employees are offered only a managed care plan, and they might feel that they have not received anything of value in return for perceived disadvantages."
Reversing Course From Vertical Integration
From "The Third Alternative" by David G. Knott, Ph.D. in the Healthcare Forum Journal, 9/97:
"There are already signs that some of the leading competitors in the healthcare industry are beginning to define what component of the value chain they intend to occupy as a service provider going forward and are initiating or experimenting with various forms of alliances to fill in the missing pieces."
"Perhaps the most dramatic example is Aetna/US Healthcare's recently announced 10-year strategic partnership with MedPartners. This alliance will allow Aetna/US Healthcare's members to access MedPartners affiliated physicians across the country. In announcing the deal, Aetna/US Healthcare stated that strategic alliances with selected providers will replace its former strategy of owning physician practices--thereby explicitly abandoning a piece of the healthcare value chain. Together, Aetna/US Healthcare and MedPartners will now leverage their complimentary expertise to define quality enhancement criteria and improve the health status of plan members."
"For health industry participants in situations in which alliances prove an important vehicle for value creation, essential new capabilities will need to be developed over the coming decade. These players will need to learn how to:
(1) identify core competencies,
(2) screen extended enterprise alliance partners,
(3) define/negotiate venture objectives and partner responsibilities,
(4) model financial arrangements
(5) monitor alliance performance and
(6) devise conflict resolution mechanisms.
Lessons learned from alliance activity in other industries suggest that experience--'How many alliances do you have under your belt?'--will be a driver of success."
"If results being achieved through alliances in other industries are any indication, players in the healthcare industry would do well to begin developing advantaged alliance design and execution capabilities now. It will often be through extended enterprise alliances, not just common ownership of payer and provider components, that the managed care leaders of the future will seek to achieve sustainable competitive differentiation and profitable growth."
Policy and Video Networks Merge Capacity
The Wisconsin Network for Health Policy Research is for the first time offering its fall seminar series via its new video-conferencing capacity. This new approach means a change in the location of the seminars at UW-Madison and the addition of 3 locations around the state. The four seminar locations are:.
Madison Room 3265 Medical Science Center
1300 University Ave.
Marshfield Room GJ-1 (Ground Floor)
Marshfield Clinic, 1000 North Oak
Milwaukee Suite 6000, Plankinton Building
161 W. Wisconsin
UW-M, Center for Continuing Education
LaCrosse Room 345, Morris Hall
1701 State Street
The two remaining seminars this Fall are:
Fundamentals of Medicaid Managed Care
Thursday, October 9th, 3:30 - 5:00 p.m.
Sara Rosenbaum, J.D.
Center for Health Policy Research
George Washington University
Public Health and Managed Care: The Future
Thursday, December 18th, 3:30 - 5:00 p.m.
Paul Nannis, Commissioner of Health,
City of Milwaukee
For more information call: 608-263-6294 or email

Innovative Program in Population Health
The University of Wisconsin-Madison has initiated a M.S./Ph.D. Program in Population Health, growing out of its Programs in Health Management. The following is from an open letter by Donn D'Alessio, Chair, Department of Preventive Medicine:
"The sweeping changes in biomedical science and health care of recent years are underlain by increasing attention to the health of populations rather than just the individual and an increased appreciation of the many factors, biological, environmental, socioeconomic and cultural, that bear on population health status. Our conviction is that we will achieve the greatest return on our investment in health only through a more fully integrated understanding of the factors most important in determining the population's health and consequently designing new ways to organize and manage the systems by which public health and medical services are delivered."
"The MS/PhD Program's in Population Health first aim is to provide students rigorous grounding in their disciplinary emphasis. However, disciplinary expertise alone is no longer sufficient given the complexities we face. A second critical program aim is to provide an integrated understanding of the major issues in public health and health care and a working knowledge and appreciation of the approaches and methods related disciplines bring to the study of the health of populations and the factors that enhance it. We feel that this combination represents the forefront of this new field and will put our students at the cutting edge of practice and research in our current health care environment."
More information is at their web site:


Wisconsin's Medigap Helpline: 1-800-242-1060.

This is a statewide toll-free number which has been set up by the state to answer questions the elderly have about health insurance.

Mental Health, Drug Abuse & Managed Care
The following is taken (as written) from Trends in Public Sector Managed Behavioral Healthcare prepared by The Lewin Group for the federal Substance Abuse and Mental Health Services Administration, 7/1/97:
"Today's model for the evolving health delivery system is based on the for-profit managed care entity, which has developed largely in the commercial insurance sector for an employed population. Mental health and substance abuse services in that model focus on individuals whose goal is to maintain or regain functionality in the workplace. The model is now being adapted to address the Medicaid/welfare population comprising largely mothers and their children. It was never designed with the typical public sector substance abuse or mental health patient/client in mind."
"Individuals with severe mental illnesses and individuals with chronic alcohol and other addictive disorders--the model clients for public behavioral health systems--frequently require a level and range of services far beyond what is typically provided under physical health managed care programs, such as HMOs. To successfully serve the public behavioral health population, state managed care models are 'carving out' behavioral health and incorporating what public sector agencies and other stake-holders have learned over the last two decades in providing services to this population."
"An emerging trend to watch is the reintegration of specialized carve-out plans into comprehensive health waivers. States initially included the AFDC population in their managed care plans, choosing to enroll more disabled populations eligible for Social Security Income (SSI) after they gained experience. As states begin to enroll more and more disability groups, they will be pressed to consolidate and coordinate population-based programs into a more unified system. It may be increasingly difficult to sustain separate managed care programs (i.e. carve -outs) for specific populations and services as managed care becomes more diverse. How to develop a coherent managed care policy without compromising the special needs of and services for people needing substance abuse or mental health services will be a challenge for public sector decision makers."
The Art of Organizing Ourselves
From "The Era of 'Big' Government: Why You'd Miss It If It Went" by E.J. Dionne in Kettering Review, 7/97:
"The overriding need in the United States and throughout the democratic world is for a new engagement with democratic reform, the political engine that made the industrial era as successful as it was. The technologies cannot construct a successful society, any more than industrialism left to itself would have made the world better. The industrial age needed to be rescued from those who thought that technology on its own could save the human race. Now the information age must also be saved from the 'cyberutopians.' Even the most extraordinary breakthroughs in technology and the most ingenious applications of the internet will not save us from social breakdown, crime, or injustice. Only politics, the art of how we organize ourselves, can even begin to take on such task."
"Politics and government cannot raise children, write love songs, create computer languages, invent the technology after the microchip, or discover a cure for cancer. But politics and government do shape the conditions under which such acts of creativity are made easier or harder, more likely or less likely."
(Small world postscript: while eavesdropping at the Madison airport, I realized that one of the speakers was E.J. Dionne so I got to thank him personally for the above definition of politics. T.S.):
Promoting Rural Health & Rural Jobs
The following invited report was written by Catherine Clark, Executive Director, Southwest Wisconsin AHEC:
A partnership between the Southwest Wisconsin Area Health Education Center (AHEC) and the County of Grant was recently formalized with a Community Based Economic Development (CBED) grant award from the Wisconsin Department of Commerce. Southwest Wisconsin AHEC will take a lead role in developing an economic analysis of the health care sector in Grant County. Grant County is typical of a rural district that struggles to compete with larger metropolitan areas in attracting and maintaining families and businesses. The county has lost approximately half their primary care providers during the past five years and has experienced two hospital closings.
The purpose of the Grant County Economic Impact Assessment is to begin a process that recognizes the role that health care plays in the local economy. The project has two primary objectives:
· Evaluate and quantify the importance of the health care sector on the economic well-being of Grant County.
· Develop a balanced plan of action that community leaders can use to retain health care dollars in Grant County and improve their local economy.
With technical assistance from the Center for Community Economic Development at the University of Wisconsin - Madison, the project will develop a set of specific tools and indicators that local communities and businesses in Grant County can use to reach more informed and rational decisions about how to maintain local health care delivery systems.
An equally important outcome of the project will be to foster an awareness among community leaders and citizens that health care is a major economic force in Grant County that needs to be nurtured like every other sector. A steering committee for this project is currently meeting and includes local leaders in business and health care.
For more information call Ms. Clark at 608-831-2168.
A Rural Practitioner's Guide to Agromedicine
Practitioners serving rural patients are often on the front lines of diagnosis and treatment for agriculture-related illnesses and injuries. Now there is a handy desktop reference for those who need to act quickly.
Stanley H. Schuman, M.D., Dr.P.H.
William M. Simpson, Jr., M.D.
Medical University of South Carolina
Charleston, South Carolina
Diagnosis and Management at a Glance
This 35-topic desk reference is constructed in an easy-to-use, two-page, open-face format for guidance in the treatment of rural exposures, including prevention, pathophysiology, presenting complaint, and differential diagnosis. Selected topics include agriculture-related disease and injury, pulmonary and respiratory hazards, acute agrochemical poisonings, dysrhythmias, insect bites and stings, rodent-borne diseases, tick-borne diseases, and bovine tuberculosis. 98pp.
Available from:
American Academy of Family Physicians:
National Rural Health Association:
Beating the Nicotine Addiction
From the Center for Disease Control Fact Sheet, 9/97:
"The fact that tobacco use is addicting underscores the need to do more to help people to stop smoking. An estimated 48 million adults currently smoke in the U.S. Nearly 70 percent (33.2 million) of adults want to quit smoking completely, but because of the addictive nature of nicotine many smokers find it difficult to stop.
The following are some facts about quitting."
· "Of current every-day adult smokers, 18.1 million (37.7 percent) quit smoking for at least one day. Approximately 1.2 million smokers in the U.S. (2.5 percent) quit permanently each year."
· "Nicotine replacement products are not "magic bullets;" they don't make smokers want to quit, but they can reduce the intensity of withdrawal symptoms. Nearly all smokers experience some symptom of nicotine withdrawal even with medication. Smokers should give themselves at least a month to overcome these symptoms. The intensity of withdrawal symptoms is greatest in the first week after quitting."
· "Smoking cessation has major and immediate health benefits for smokers of all ages. Former smokers have better health, fewer health complaints, and fewer illnesses than current smokers. After one year off cigarettes, the excess risk of heart disease caused by smoking is reduced by about half. After 10 years, the risk of lung cancer for former smokers drops to less than one-half that of a continuing smoker. In five to 15 years, the risk of stroke for former smokers returns to the level of those who never smoked."
For more information, visit CDC's web site at:

The web site for tobacco crop subsidies is not known.
An Educational Cooperative in Cyberspace
Northwoods HealthNet is an innovative response to the knowledge based information access concerns of rural northern Wisconsin's health professionals and students. Funding is from the Northern Wisconsin Area Health Education Center (NAHEC) and the National Library of Medicine. Activities within the NAHEC service area include on-site consultation, basic and advanced training in use of the internet, interlibrary loan support and an internet home page as a guide for searching the world wide web. The Northwoods HealthNet home page can be reached at:

As a reminder, free Medline searching via Internet Grateful Med is available at:

Birth of Wisconsin Rural Health Association
The Wisconsin Office of Rural Health (WORH) under the leadership of Fred Moskol has got the ball rolling to create a multi-disciplinary and grass-roots, community driven state rural health association. This association would hopefully become a state affiliate of the National Rural Health Association.
Minutes for this meeting can be found at the WORH www site:

The nominations committee is as follows:
· Harold Brown, Prairie du Chien Memorial Hospital;
· Kathy Farnsworth-Family Health Center, Marshfield;
· Patricia Jensen-St. Mary's/Duluth Clinic System;
· Jennifer Morgan-Southwest AHEC, Middleton;
· Kate Nelson, NP, F.P.H.S., Stevens Point.
Once an interim board is named, a mission statement and by-laws will be developed. Please contact any member of the nominating committee if you are interested in serving on the interim board; community members (in addition to providers and others employed in health care or education) are particularly sought.
Thanks to Rural WI Leaders
George Johnson, CEO, Reedsburg Area Medical Center, (and long time RWHC Board member) has been nominated as Chair-Elect of the Wisconsin Health & Hospital Association.
Bobbe Teigen, Administrator, Sauk Prairie Memorial Hospital, (and a relatively new RWHC Board member) is being honored as a Young Healthcare Executive of the year by the American College of Healthcare Executives for her hospital and community contributions.
Mark Bishop, M.D., Dodgeville and Jerel Berres, M.D., Richland Center are the first rural physicians appointed, respectively, to Wisconsin's EMS Board and Wisconsin's EMS Physician Advisory Committee.
Governor Tommy Thompson presented the 2nd annual Primary Health Care Educator Awards at the State Capitol on September 19th to John Beasley, M.D., Professor, School of Medicine, U.W.-Madison and to Sally Lundeen, Ph.D., R.N., F.A.A.N., Associate Dean, School of Nursing, U.W.-Milwaukee.
Cheryl Maurana, Statewide Director, of the Wisconsin AHEC System, acquired unexpected but much needed additional federal funding for the Eastern and Southwest AHECs ($100,000 each), for additional statewide program initiatives ($250,000) and for AHEC Partnership Council development activities ($150,000).
Almost Not the Wisconsin Badgers
From Wisconsin, The Way We Were by Mary Shafer:
Our state is named after the Wisconsin River that runs diagonally through it northeast to southwest. The current spelling and pronunciation of Wisconsin grew out of the French name "Ouisconsin" given the river by a French speaking Jesuit priest. In turn, that name derived from the Algonquin for "muskrat hole."

Click here to return to RWHC Home Page.