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

Nation Needs Honest Debate on Uninsured
From "Commentary" by Uwe Reinhardt in the Journal of the American Medical Association, 11/5/97:
"Throughout the past 3 decades, Americans have been locked in a tenacious ideological debate whose essence can be distilled into the following pointed question: As a matter of national policy, and to the extent that a nation's health system can make it possible, should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family?"
"At any moment, over 40 million Americans find themselves without health insurance coverage, among them some 10 million children younger than 18 years. All available evidence suggests that this number will grow. America's policymaking elite has remained unfazed by these statistics, reciting the soothing mantra that 'to be uninsured in these United States does not mean to be without care.' "
"There is, to be sure, some truth to the mantra. Critically ill, uninsured Americans of all ages usually receive adequate if untimely care under an informal, albeit unreliable, catastrophic health insurance program operated by hospitals and many physicians, largely on a voluntary basis. Under that informal program, hospitals and physicians effectively become insurance underwriters who provide succor to hard-stricken uninsured and who extract the premium for that insurance through higher charges to paying patients."
"The alarming prospect is that the more effective the techniques of 'managed care' will be in controlling the flow of revenue to physicians and hospitals, the more difficult it will be to play this insurance scheme otherwise known as the 'cost shift'. It can be expected that, within the next decade, the growing number of the nation's uninsured will find themselves in increasingly dire straits."
"Typically, the opponents of universal health insurance cloak their sentiments in actuarial technicalities or in the mellifluous language of the standard economic theory of markets, thereby avoiding a debate on ideology that truly might engage the public. It is time, after so many decades, that the rival factions in America's policymaking elite debate openly their distinct visions of a distribute ethic for health."
Preventing Mid-Night Fire Sales
Just over a year ago, Linda Miller, President of Volunteer Trustees Foundation for Research and Education spoke in Lake Geneva (Wisconsin) about the national trend of non-profit enterprises being taken over by for-profits under very questionable circumstances. Her bottom line: "if a deal looks too good to be true, it probably is." Attorney General Jim Doyle has proposed a bipartisan bill to the Wisconsin Legislature similar to that promoted by the Trustees Foundation and already adopted by many states.
From an article by Richard P. Jones, Milwaukee Journal Sentinel, 10/28/97:
"Doyle said moneymaking firms would have to notify his office of bids and pay for an independent review of the proposed transaction. Submitted documents would be public records. If the buyer and the non-profit hospital's board of directors fail to conduct the transaction openly, Doyle said his office could prevent the new hospital from getting a state license."
"Doyle said the goal was to prevent 'midnight fire sales' that have occurred elsewhere. 'We are not reviewing the wisdom of the deal nor whether a hospital should go from profit to non-profit,' Doyle said. 'Those decisions should be made by the community board, but with public scrutiny and hearings so that the public has full knowledge of what is going on.' "
"Bob Taylor, President of the Wisconsin Health and Hospital Association said 'if we didn't think there was a problem, we wouldn't be supporting this legislation. Communities and hospital boards in other states weren't prepared for what he called a 'Wall Street blitz.' "
Postscript: Many, if not most, hospitals believe this law should also apply to non-profits doing take-overs.
Developing Relevant Health Policy
The following is from a presentation (by Tim Size, RWHC Executive Director) at the first annual conference of the Wisconsin Network for Health Policy Research; the session was entitled "Ensuring the Usefulness of Health Services Research for Policy-Making: Perspectives from the Field:"
It is an honor to have been asked to speak during part of the time originally allocated to Alice Hersh, until her untimely death, Executive Director of the Association for Health Services Research. She made a real difference in organizing the research community to better inform the development of health policy; her ongoing contribution will be missed. I will also remember her as a particularly stylish person, the one person I knew who regularly wore my favorite perfume, Rive Gauche.
My wish list for health services research:
#1 Integrate Public/Private Distinctions
Yesterday David Kindig mentioned that he and I have been having an ongoing discussion regarding the development of public policy and whether there is a comparable body of processes that constitute the development of private policy. I am embarrassed to say I forgot to tell him that I just ran into what may be an answer.
I was in the lost luggage line at the Madison airport and overheard E.G. Dionne from the Washington Post being introduced right behind me. I couldn't pass up the opportunity this gave me to confirm the meaning of a quote of his that I had recently read--"politics is the art of how we organize ourselves." This is a nice conceptual bridge of the similar activities many of us have long experienced in both public and private arenas. I think he agreed with the expanded use of his quote but then I was between him and his lost luggage.
To take this idea one step further, if politics is the art of how we organize ourselves, then health policy is a product of that art. All health related organizations are simultaneously operating in both public and private arenas and effected by the policies, "rules" or traditions of public and private politics alike.
Given our huge public investment in the private health care sector and the increasing use of market forces to allocate those resources, we need health service researchers to think outside the box of traditional public policy. We need to better understand how the de facto policy development within the private sector affects the development of traditional public policy and vice versa, and how research can inform the whole interactive mess.
#2 Address Policies That Are Not Spoken.
Health policy exists whether or not we choose to recognize it, whether or not we have spoken it, whether or not it is the result of a deliberative process.
I hesitate to offer this audience the following example but I will--some public medical schools have seen themselves as responsible for how well their graduates practice medicine but have been indifferent to where they practice. Silence on this issue constitutes a very definite policy that at worst reinforces physician maldistribution, at best make no contribution to its remedy.
Another example: in the private sector, there is a widely unexamined belief that all you have to do to have competition in health care is to minimize government regulation. While recognizing the hostility that has greeted discussion in this area, the health services research community must more aggressively speak to the relative silence supporting the notion that "free" markets are inherently competitive.
#3 Accept the Challenge to Be Relevant
As David previously noted, health services research has a role as change agent that includes first documentation, then analysis and finally prescription. The bad news is that in this context, quite a lot is expected from health services researchers; the good news is that many are meeting the challenge with:
Courage - the courage to be data driven, particularly when we "so called users" may make that position uncomfortable.
Integrity - the integrity to be self aware of and try to keep your work clean of your own personal, professional and institutional biases; we all have them and researches are not exempt.
Vision - the vision to be working on the prescriptions for tomorrow's problems while we still have the time to do the research, agree on policy and make a difference.
Engagement - include providers and policy-makers in partnership; just as health is too important to be left solely to professional care givers, so is research too important to be left solely to professional researchers.
#4 Remember Health Care's Inherent Intimacy
I need to remind myself and each of you - we see what we look for. Our work is consumed with tactics and strategies driven by dollars, market share and the competitive value of quality score cards; health services research faces the same problem.
But we are much more than "covered lives" or focus group fodder; we are individuals, workers and on a good day, voters. My weekends like yours are sometimes not related to work. Last weekend I visited two friends in Chicago who were the new, proud grandparents of twins born prematurely, now at home doing well after a long hospitalization. At the same time, an old friend spent the weekend with his family, dying at St. Mary's here in Madison.
We need to remember that for health services research to have real meaning it must seek the larger, more holistic perspective that integrates the science of public and private sector policy development with the reality of our most intimate life events.
Nurse Practitioners Seek Balance With MDs
The following is from "The Future Wears White: Nurses Treading on Doctors' Turf," by Milt Freudenheim, in The New York Times, 11/2/97:
"Mary Bidgood-Wilson and her business partner of five years, Wendy Wilson, provide basic health care for 4,300 people in rural central New Hampshire, where doctors are scarce. Both women are nurse midwives. Ms. Bidgood-Wilson is also a family nurse practitioner. Insurers pay them the same rate as doctors."
"But nurses with the same skills find the going rough in big cities where many physicians are defending their turf and incomes against the inexorable inroads of managed health care. Most of the managed care companies pay the nurse practitioners only when they work for a doctor or medical group."
"The landscape for nurse practitioners, however, may be changing in the city. Recently several HMOs announced that they would pay a group of nurse practitioners in New York City $50 or $60 for each patient visit, the same as for primary care doctors."
"Although equal pay is a breakthrough, the nurses still must maintain a tie with a physician. The HMOs also hedged their bets by insisting that the nurses' practice be operated as a research project, to see how the health and satisfaction of patients, not to mention costs, compare with patients treated by physicians. Nurse practitioners argue that they are more cost effective than physicians because they are trained to deal with prevention and the whole person, which includes stresses on and off the job."
"Nurse practitioners, like those in New Hampshire, can deliver babies and treat ear infections and common ailments. Heart attacks, however, are referred to cardiologists, fractures to orthopedic surgeons and other serious illnesses to other specialists. These nurses, who often hold master's degrees, are state certified, and many of them, including Ms. Bidgood-Wilson and Ms. Wilson, operate independently in rural areas."
"Both government and private payers cite a glut of specialists and a scarcity of primary care doctors. With state and federal money dwindling for medical education, advanced practice nurses are in heavy demand inside hospitals that are reducing the number of residents who are training to become specialists."
Zones of Collaboration Goes to Washington
The Institute of Medicine's (IOM) National Roundtable on Healthcare Quality & Managed Care recently invited a number of us from the field to join them at a meeting. It was a heady experience, not the least as the National Academy of Sciences sits across the street from the Vietnam Wall Memorial. I had the opportunity to present an overview of the Wisconsin Rural Zones of Collaboration Initiative as well as interact with others doing similar work around the country. The four key observations I took away were:
#1 Significant collaboration among competing HMOs is happening around the country but is by no means common.
#2 Other industries have many examples of competing enterprise cooperating in specific areas.
#3 Anti-trust is an issue but not an absolute barrier.
#4 Most of us have a life long experience competing so we tend to do it even when we try to cooperate.
It appears that IOM will be proceeding to further understand and promote the role of collaboration in improving health care quality in competitive markets. Questions that they may address include criteria for collaboration, feasible areas for collaboration, elements for evaluation of successful collaboration, identification of the structures that are needed to promote collaboration and the role of government.
Internet Grateful Med may be the most useful information resource available to the rural health community on the world wide web. If that wasn't enough, it is also a free service, provided by the U.S. National Library of Medicine. Grateful Med allows you to identify journal articles by using a "key word" search as well as offering (at a fee) a mechanism to order the complete article, a particular useful service for many rural providers without local access to a main library.
MEDLINE is the primary data base provided by Grateful Med, allowing you to identify major clinical journals. Other on-line databases such as HealthSTAR, a source for administrative and policy journals are also available. This is powerful tool for the new internet user once you "break the ice." The following can be printed and then used to walk you through an on-line demonstration.
These steps assume you have access to the internet and have a web browser. It also assumes you know how to use your web browser to find a particular site on the internet; if necessary, consult your manual or a friend as the process, while straight forward, is specific to your software. The real time for this search was under five minutes.
Step #1
Using your own web browser, go to the Grateful Med web site:
It should look like the graphic at the top of this page. There are several options at this point that will allow you to get more information such as an on-line tutorial, but for now, just click on the button labeled "Proceed."
Step #2
The next screen will include the above picture. Type in the key words "Managed Care," "Rural" and "Medicare" as shown. (Do not type the quotation marks.) Then click on the button labeled "Perform Search." The resulting screen (as of 11/10/97) is shown below, the first of nine references that includes all of your three key words. You have just completed your first search. Follow the on-line instructions to print or save your results.
Step #3 - As this search is on a topic that contains significant administrative and health policy implications, the HealthSTAR database should also be searched. Click the button labeled "Return to Search Screen"; then click "Search Other Files" and you will see the screen below. Click on the button next to the word "HealthSTAR" and then click on the button labeled "Change Files."
Step #4 - The next screen will look like the earlier screen with the key words "Managed Care," "Rural" and "Medicare" still typed in but instead of MEDLINE, HealthSTAR will be shown as the data base to be searched. Again, click on the button labeled "Perform Search."
Step #5
The next screen will include the picture on the left, the first of now thirty-two references that includes all of your three key words. You have just completed your second search. Follow the on-line instructions to print or save your results.
Step #6
To help you determine whether or not you wish to obtain and read an article, many of the reference "cards" also provide you with an abstract. To see the abstract simply click on the actual title as shown above. You will then get a screen that looks like the picture on the right.
Tip: Aim for 50 references by making the key words more or less general. In this example, adding "Hospital" to "Rural" reduces the number of references found; deleting the word "Rural" increases the number of references returned.
NRHA Opposes Post-Acute Transfer Rule
The following language was developed by Marvin Cole, Chair of the National Rural Health Association's Hospital Constituency Group to express its opposition to applying the new Medicare "post-acute transfer rule" to rural hospitals; non-hospital non-technical folks may wish to skip this section but recognize this policy fight represents a major risk to retaining rural services.
"Due to the net effect on low-volume providers, the NRHA opposes the expansion of post-acute care transfers to 10 diagnostic-related groups (DRGs) as defined by the BBA. As a result of the expansion of post-acute care transfers, such providers may suffer disproportionately because of their narrower scope of service, resulting in significant reductions in reimbursement."
The rationale is as follows:
#1 "The DRG system is a system based upon averages. In the original research studies, based upon a large volume of patient discharges, hospitals were able to balance expenses for long stay patients with those of short patient stays. Both length of stay and cost per discharge were taken into consideration when determining reimbursement."
#2 "The effort to carve out 10 DRGs and initiate a transfer expansion process totally invalidates the DRG payment methodology, invalidating the applicability of the research upon which it was based. It arbitrarily imposes a process which will cause the Weighting process, which determines payment of DRG, to be destroyed. This results in improper payment for the remaining DRGs. The top 10 DRG discharges, for all categories of hospitals, represent a disproportionate percentage of discharges. The result of this policy will invalidate the Standardized Amount Calculations which determine payment for all DRGs."
#3 "HCFA each year determines the Weighting process based upon the previous years experience, and properly realigns payment based upon both length of stay and expenses. This process should be continued as it is a reasonably reliable method, and is based upon experience and reliable research."
#4 "Rural Hospitals could suffer disproportionately because of greater dependence on Medicare revenues."
#5 "This proposal will produce a disincentive to be efficient, as the policy punishes those who are efficient, and manage their patient discharges well."
#6 "Continual tinkering with the Hospital payment methodology, has historically made the payment methodology both cumbersome and complicated, requiring far more resources by hospitals to implement standard accounting processes, by the Fiscal Intermediaries to appropriately pay providers, and by the Federal Government to implement rules to govern the payment for services to providers. The result is a burdensome process which results in unnecessary expenditure of taxpayer funds."
NRHA Hosts On-Line Networking
National Rural Health Association (NRHA) members, for the first time can easily and quickly share ideas and questions nationwide without leaving their office or home. The newly expanded NRHA web site at <> has added the capacity of an interactive bulletin board. It is open to all members who wish to discuss any and all issues of common interest (not patently offensive to the rural web police).
The process is as simple as sending or reading email; the main difference is that the messages are all retained and viewable by anyone with access to the site. Typically one person posts a question or idea and asks other people to respond. For example I just posted an "inaugural" question to all NRHA members asking how the NRHA site can be made more useful. At any one time, multiple "threads" or discussions can be supported by the web site server.
Each member should have received an invitation with their annual request for membership renewal giving directions how to obtain a user name and password to enter the "Members Only" section of the NRHA web site. If you didn't notice that part of the mailing or haven't yet joined NRHA, please call the Kansas City office at 816-756-3140 to begin expanding your own personal state and national network.
On a related note, an excellent "must read" summary of the rural health implications of the recently adopted federal "Balanced Budget Act" is now available on line (this is not part of the restricted access area). Information is critical to rural survival and growth.
The Capital Area Rural Health Roundtable
The Roundtable is a Washington D.C. area "forum for the exchange of ideas and open discussion on important rural health topics. The Roundtable is committed to enlarging the circle of participation in rural health policy; encouraging collaboration through shared knowledge and mutual understanding; and promoting strength through diversity." Check their great web site:

ORYX Alert
Important Update: The RWHC Quality Indicators Program has been accepted by the Joint Commission for inclusion in the ORYX initiative for purposes of participating in the accreditation process as one of only two rural based performance measurement systems for the ORYX initiative. We believe the RWHC Quality Indicators Program will be of particular interest to rural hospitals and long term care organizations seeking quality performance measures from comparably situated facilities. Please contact Carla Gorski for additional information at (608) 643-2343, or e-mail
Medicare Rural Hospital Flexibility Program
The following was prepared by Rural Health Consultants (785-832-8778) under contract with the Federal Office of Rural Health Policy, describing the essential requirements to become certified as a Critical Access Hospital. An informational video tape has also been produced and distributed by the National Rural Health association to all state offices of rural health.
· The facility must be a rural nonprofit or public hospital which is currently participating in the Medicare program.
· A Critical Access Hospital (CAH) may contain up to 15 acute care beds. Hospitals that participated in the swing bed program prior to conversion may maintain up to 25 beds to furnish both acute and skilled nursing-level care, provided that no more than 15 of the beds are used for acute care at any one time.
· A CAH may provide inpatient acute care for up to 96 hours, unless transfer to a hospital is precluded due to inclement weather or other emergency conditions. A PRO or equivalent entity may also, on request, waive the 96-hour restriction on a case-by-case basis.
· A CAH must be more than a 35-mile drive, or 15 miles in mountainous terrain or areas with only secondary roads, from a hospital or another CAH. This requirement does not apply to CAHs that have been certified by the State in its rural health plan as being a necessary provider of health care services to residents of the area.
· A CAH must make available 24-hour emergency care but need not meet all the staffing and service requirements that apply to full service hospitals.
· CAHs, hospitals, and other health care providers are organized into rural health networks and maintain agreements for the transfer and referral of patients, the provision of transportation services, and the development and use of communications systems. Each CAH that is a member of a rural health network must have an agreement for credentialing and quality assurance with a hospital that is a member of the network, a PRO or equivalent entity, or another appropriate entity identified in the State rural health plan.
WI Rural Health Association Moves Forward
The Association had its second organizational meeting and is off to a strong start. Diverse providers, community people and others are committed to creating a statewide network and voice for rural health. For more information, call Fred Moskol, Wisconsin Office of Rural Health at 800-385-0005.
Top Notch Choice as Health Administrator
Wisconsin Department of Health & Family Services Secretary Joe Leean has made permanent the appointment of John Chapin as Administrator of the Division of Health. Chapin has served the Department for over a decade, alternating between the roles of interim administrator and key deputy.
Those of us who have seen more than a few administrators come and go are particularly grateful to have the position filled by someone with his depth of skills and experience. The administration of the complex interface of state government and the health sector is not an entry level position. While not in the job description, a well known, if not arcane, sense of humor has and will probably continue to prove of interest.
Laughter Requires Surgical Intervention
From "Seinfeld Humor Knocks Out Fan for Third Time"
by James Gorman, The New York Times, 10/30/97:
"According to a brief letter in Catheterization and Cardiovascular Diagnosis, a journal not widely known for its sense of humor, a 62-year old man fainted at least three times while watching "Seinfeld". The proximate cause was the behavior of George Costanza, as played by Jason Alexander. The man laughed so hard that he lost consciousness."
" 'During one event, he fell face first into his evening meal and was rescued by his wife,' wrote Dr. Stephen V. Cox and two colleagues from Lahey Hitchcock Medical Center in Burlington, Mass. Comedy, however, was not the real culprit. The man smoked, had high blood pressure and high cholesterol levels and had already had a coronary bypass. On examination, it turned out that blood flow to his brain was diminished by blockages in several arteries."
"The doctors inserted a catheter with an inflatable balloon to open up an artery and implanted a stent to keep it open. The patient was then able to watch the show--and laugh without passing out."
Guns, Germs & Steel
The following is from a book review in The New York Times by James Shreeve of Dr. Jared Diamond's Guns, Germs, And Steel, The Fates Of Human Societies:
"On the morning of Nov. 16, 1532, the Incan Emperor Atahualpa greeted the Spanish conquistador Francisco Pizarro in the Peruvian highland town of Cajamarca. Atahualpa was surrounded by some 80,000 Indian warriors; Pizarro came accompanied only by a ragged group of 168 horsemen and foot soldiers. Within a few decades the Incan, Aztec and Mayan civilizations had crumbled, and within a few centuries 95 percent of the native population of two entire continents had disappeared as well."
"In Guns, Germs, and Steel, an ambitious, highly important book, Jared Diamond asks: How did Pizarro come to be at Cajamarca capturing Atahualpa, instead of Atahualpa in Madrid capturing King Charles I? Why, indeed, did Europeans and Asians always triumph in their historical conquests of other populations? Why weren't Native Americans, Africans and aboriginal Australians instead the ones who enslaved or exterminated the Europeans?"
"Most deadly human pathogens, Dr. Diamond (a professor of physiology at the U.C.L.A. School of Medicine) says, actually originated in animal hosts. The domestication of animals emerged in the Fertile Crescent around 8000 B.C. and quickly spread. Europeans had thus been living close to animals for millenniums -- ample time to develop a genetic resistance to diseases harbored in livestock and pets. In contrast, most of the wild animals that might have been suitable for domestication in the New World had been hunted to extinction by the earliest arrivals over the Bering land bridge, 12,500 years before the Europeans arrived."
"Ironically, if those first Native Americans had been less adept hunters, their descendants might have been able to domesticate the indigenous American horse and camel, providing them with an invisible arsenal of microbes of their own when Columbus made his first fateful landing thousands of years later. The European conquest of the New World would have been far more difficult, and might never have taken place at all."

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