Rural Health Advisory Committee Meeting Minutes
RURAL HEALTH ADVISORY COMMITTEE
Tuesday, November 27, 2007 9:30 a.m.-2 p.m.
Snelling Office Park, Red River Room
St. Paul, Minnesota
Members Present: John Baerg (Butterfield), Thomas Boe (Moorhead), Debra Carpenter (Erhard), Darrell Carter (Granite Falls via telephone), Ray Christensen (Duluth via video conference), Rep. Steve Gottwalt (St. Cloud), Margaret Kalina (Alexandria), Diane Muckenhirn-Chair (Hutchinson), Nancy Stratman (Willmar).
Members Absent: Thomas Crowley (Wabasha), Thomas Nixon (Deerwood), Rep. Mary Ellen Otremba (Long Prairie), LaVonne Schlieman (Morris), Senator Jim Vickerman (Tracy), Sen. Betsy Wergin (Princeton).
MDH Staff Present: Doug Benson; Renée S. Fredericksen; Jim Golden; Scott Leitz, Assistant-Commissioner; Sanne Magnan, Commissioner of Health; Mary Ann Radigan; Tamie Rogers; Mark Schoenbaum; Angie Sechler; Kristen Tharaldson; Karen Welle
Audience: Buck Alpin, Minnesota Ambulance Association; Kristi Berg, Emergency Medical Services for Children; Dave Brenner, Minnesota Medical Association; Liz Carpenter, Minnesota Pharmacists Association; Deb Fischer Clemans, Avera Health; Shari Gentilini, College of Pharmacy; Ann Gibson, Minnesota Hospital Association; Audrey Imberg, College of Pharmacy; Jason Kerska, College of Pharmacy (Duluth); Tom Larson, PREPP Institute, College of Pharmacy; Tom Lehman, retained counsel Avera Health; Barbara Meusing, Rural Health Association; Bob Ries of the Minnesota Department of Human Services (DHS); Kari Thurlow, Minnesota Health and Housing Alliance
WELCOME AND INTRODUCTIONS
Minnesota Commissioner of Health Sanne Magnan, M.D., Ph.D,
Commissioner Magnan introduced herself with a brief bio of experience and credentials related to her position with MDH. She invited advice from the Rural Health Advisory Committee on MDH's priorities: Prevention, Infrastructure and Health Care Reform. She further explained that Minnesota needs to look at quality and costs with a focus on prevention, root causes behind health issues, and chronic conditions. She supported safe and reliable systems offering: sufficient options, access to affordable care, cost containment and quality. She further advised Minnesota must purchase care based on value versus quantity.
Commissioner Magnan appreciated the unique needs of rural health care listed in Office of Rural Health and Primary Care publications on health care reform (e.g., an aging population, workforce shortages in a changing economy, increased immigration, higher rates of illness linked to lifestyle choices, and the importance of primary care).
Finally, Commissioner Magnan recommended that RHAC build upon rural assets (i.e., dense social networks with higher levels of social capital and a high quality of life). She observed rural communities could potentially function as laboratories to solve urban problems in the future, since they are experiencing many “age wave” factors today and possess the assets listed above.
Commissioner Magnan closed her address by thanking RHAC members and staff for a fine report on Health Care Reform, their advice and time given to ensure a healthy Minnesota.
John Baerg (Consumer Member)
The move to the new hospital in St. James went well. Now, the clinic, hospital, emergency room, physical therapy and cardiac care services are under one roof. The Mayo System is currently managing the hospital.
There are proposals to begin construction of a new hospital in Mankato. The question is, can a population of 55,000 support two hospitals? Approval from the Minnesota Department of Health is pending.
Thomas Boe (Licensed Health Care Professional)
Community dental clinics in Colorado are funded by separate tax on ski resorts.
A community dental clinic is starting up in East Grand Forks. Among 30 dentists in the area, only one sees Medicare patients.
A new dental clinic in Grand Forks opened recently. A 33 percent increase in comprehensive care is due in large part to the Community Dental Clinic at Minnesota State Community and Technical College in Moorhead.
Deb Carpenter (Consumer Member)
Deb works with Minnesota Rural Concentrated Employment Program on a health professional career program where she is doing outreach in high schools and has enrolled 24 students. Twenty percent of students screened are appropriate for health care occupations given levels of interest and prior work histories. Health insurance is an incentive for participation in the work study program.
Ray Christensen (Higher Education Member)
Given previous comments, we still need to determine how can we ensure everyone has adequate health insurance.
As clarification, primary care is the center for medical home, not a gatekeeper, and provides appropriate care when necessary.
Academy of Family Physicians is working on a new primary care model being discussed among professional organizations. Hope that medical schools, essential for producing primary care providers, are also doing their part.
Steve Gottwalt (House of Representatives Member)
Medical care home model is resurfacing and focusing on primary care. Confusion exists about whether “medical home” is simply another term for “gatekeeper,” used during the managed care era. A shift in compensation incentives toward primary care and for long term care workers and facilities needs to occur in order to staff proposed medical home model.
Margaret Kalina (Registered Nurse Member)
There has been expansion of the registered nurse and licensed practical nurse programs, due to the anticipation that within the next five years, the number of nurses retiring will be huge.
Concern over the cost of implementing electronic health records (EHR) continues given that each hospital is using their own vendor. An estimated 25 percent of EHR is tied up in hardware and software.
Diane Muckenhirn (Mid-Level Practitioner Member)
A pharmacy student from Gaylord, Minnesota reported that as the age of her clients rises so do the number of medical conditions and pharmacy complications. In her experience, Medical Assistance is the primary source of reimbursement.
Nancy Stratman (Long Term Health Care Member)
The Willmar Workforce Center health care initiative is expanding opportunities to train nursing candidates. A multicultural approach to address language barriers with tutors has added 14 Certified Nursing Assistants so far.
In long term care, we are seeing more chronic health issues. Reimbursements are not covering full costs in nursing facilities. Workforce shortages force facilities to refuse admissions, which further strains budgets. Sixteen facilities will apply for moratorium waivers this session. Physical environments in facilities are outdated (e.g., one-third of nursing facilities have four residents sharing a single bathroom).
LEGISLATIVE ISSUES PANEL
- Liz Carpenter of the Minnesota Pharmacists Association. Refer to handout.
- Dave Renner of the Minnesota Medical Association
Preventing scheduled Medicare physician payment cuts are a priority. Forty percent of physicians, nationwide, will have to cut current and future patients if the Medicare payment cuts occur.
Health reform is being given top priority as well. Discussion is focused on the concept of medical home, but different from the old gatekeeper system. The underlying question is how do we coordinate and get appropriate care to patients? It comes down to payment reform for primary care, although implementation will be a challenge given there will be winners and losers and how will it work in a small rural community?
Electronic Health Record investment is also a concern given the lack of capital in rural communities.
Also a priority are the health disparities among patients in need of medical interpreters and the role of insurance to cover these types of ancillary services as they continue to be a cost burden for clinics.
- Mary Krinkie of the Minnesota Hospital Association (MHA)
- Opposing current Minnesota legislative efforts to mandate statewide standards regarding nurse staff ratio in hospitals
- Cost burden of language interpreters being absorbed by hospitals in the form of uncompensated services given that patients cannot be turned away
- While money is being spent for health information technology, there still is a need for governmental regulation/standards to ensure interoperability with other systems, preferably before huge investments are made
- Given the $156 million surplus exists in MinnesotaCare fund, there should be an increase in access and eligibility to the fund.
- Advocating that a 20 percent ($8 billion) reduction in health care spending come from future rather than current spending
- Better management of chronic disease and ensuring the model works in both urban and rural settings
- Rewarding innovation for chronic disease management
- Administrative cost savings to be gained from workers compensation:
- Currently the slowest payer
- unpredictable given it denies certain services
- movement to electronic claims processing
- Professional lab technician licensure
- Currently labs are licensed by the state, not lab professionals
- MHA is looking for rural hospital input about whether establishing licensure for lab professionals would increase or decrease supply.
- Growing concern about obtaining emergency room on-call coverage from physicians for rural hospitals. Proposed question is whether hospital emergency rooms can be modeled on fire stations.
- Community benefit reporting due next year to Minnesota Legislature, but certain items, such as subsidies to clinic and attached nursing homes, and Medicare underpayments are not being counted.
- Kari Thurlow of the Minnesota Health and Housing Alliance
Specific challenges in rural Minnesota are:
- Age wave, residents of rural communities are already older than average
- Availability of workforce to provide long term care (LTC), unable to recruit or retain qualified nurses trained in LTC, especially given that a nurse can earn $22,000 more working in a hospital setting
- Reduction in family caregivers (women 45-65 years old). There are substantially fewer caregivers per dependent in rural areas of Minnesota than in urban areas.
Specific challenges for LTC in rural Minnesota include:
- Access and choice in certain regions
- Financial viability of LTC facilities due to the “rate equalization” regulation
- Older infrastructure does not accommodate the newer technologies, growing demand for rooms, older nurses and occupational needs.
- There is likely to be regional variation, thus developing a vision within each region will be necessary
- Medical home model emphasis on integration and seamless system of care can include LTC.
- Priority is ensuring the reimbursement system keeps up with the cost of LTC and a competitive labor market. Currently, $25 is lost per resident per day.
- Piloting a medical home model in LTC
- Better training, recruitment and retention of LTC workforce.
- Barbara Muesing of the Minnesota Rural Health Association (MRHA)
The mission of MRHA is to give voice to rural Minnesota health. A handout described the policies and priorities that were developed from this group’s annual retreat. Priorities included:
- Rural opportunity assessments to foster economic development and jobs
- MRHA promotion of identified strengths and assets
- Increased support for LTC facilities and posturing similar to Critical Access Hospitals
- Prevention campaigns to address healthier lifestyles
- Buck McAlpin of the Minnesota Ambulance Association
Every year, one to two ambulance service operations close in rural Minnesota. Growing concern over whether an ambulance will be dispatched when calling 911.
- First responder reimbursement is a priority. Currently, ambulance service can bill for services, but no mandate exists that insurers must reimburse them.
- Support for pension program improvement for workforce recruitment and retention through the EMS Regulatory Board.
- Not supporting a repeal of the No Fault auto insurance because a large portion pays for the current statewide trauma system.
- Small employer health coverage for ambulance services can be a workforce recruitment tool.
- Mental health transport falling to rural ambulance services since law enforcement is no longer providing it.
- Minnesota workers compensation does not cover mental health issues for emergency workers in need of such services after exposure to disturbing emergency scenes, e.g., 35W bridge collapse.
REINTEGRATION OF MINNESOTA'S RETURNING VETERANS,
Beyond the Yellow Ribbon, Deputy State Chaplain Major John Morris, Minnesota Army National Guard
Health care costs of returning veterans can be reduced with civilian re-integration strategies employed within the first 90 days of the soldier’s discharge. Including training to address:
- Culture shock associated with social alienation that often comes with an unpopular war
- Depression often associated with intensive training for unusual events after the event has passed (like Olympic Medal winners)
- Self identity and issues surrounding the termination of military identification
- Coming to terms with what actions the soldier witnessed or took while in military service.
Recommended strategies for returning veterans to rural areas include:
- Support for re-integration training that is offered
- Job fairs
- Partnership with Public Health nurses
- Counselors on every MNSCU campus
- Synchronized service systems
- Post combat insurance lasting up to six months from discharge
- Military and Veterans Administration counseling
- Reimbursement for family services
- Continued reimbursement for LTC costs of veterans.
Proposed Military Apprenticeship Program, Buck McAlpin, Minnesota Ambulance Association
The Workforce Center and Navy Mutual Aid Association will partner on an apprenticeship program for ambulance personnel and paramedics. Returning veterans will be recruited to fill this workforce shortage. Funding for the Department of Labor EMS program has been sought from Otto Bremer Foundation and matching funds will be sought from Minnesota Legislature this session.
OFFICE OF RURAL HEALTH AND PRIMARY CARE REPORT
Mark Schoenbaum, Director, Office of Rural Health and Primary Care
Introduction of Renée Fredericksen as the new supervisor for the Planning and Analysis unit.
Restructuring of the ORHPC includes telehealth developments under Karen Welle; formation of the Planning and Analysis unit to include staff formerly working in separate units devoted to planning and workforce analysis.
Minnesota’s receipt of $5.4M in federal funds from the FCC for technological infrastructure development in rural Minnesota under an application coordinated by Karen Welle.
Clarification on RHAC membership application deadlines amounting to a soft deadline of Nov. 27, 2007 with applications being accepted for consideration thereafter, also.
Discussion surrounding the growing issues surrounding complications associated with behavioral health patients’ transportation to distant facilities. The EMS Regulation Board recently published a report on this subject at
Congressional update on physician fee cuts and investments in telehealth and infrastructure development.
Recognition of Kristen Tharaldson and Angie Sechler for their dedication and fine work to support RHAC’s mission.
OTHER BUSINESS AND NEXT MEETING
ACTION: Chair Muckenhirn recommended a nominating committee be formed to name a chair elect for 2008 and include but not be limited to Ray Christensen, Diane Muckenhirn and Nancy Stratman. Motion by Margaret Kalina. Second by Thomas Boe. Passed.
RHAC – Rural Health Care Delivery Model Workgroup will be chaired by Margaret Kalina. All interested members were invited to join the workgroup and promised further information around upcoming meetings. Members volunteering to date included: Jon Baerg, Deb Carpenter and Diane Muckenhirn.
Chair Diane Muckenhirn presented Nancy Stratman with a plaque on behalf of the RHAC members to honor her service as an RHAC Chair.
The next Rural Health Advisory Committee meeting is scheduled for Tuesday, January 22, 2008 at the Freeman Building, 625 Robert Street, St. Paul, Minnesota. Members are invited to attend by interactive video conference and are asked to give advanced notice of intentions to attend to Tamie Rogers at ORHPC.
MEETING WAS ADJOURNED AT 2 p.m.