Rural Health Advisory Committee Meeting Minutes
RURAL HEALTH ADVISORY COMMITTEE
Tuesday, March 25, 2008 9-11:30 a.m.
Orville Freeman Building (Video Conference Meeting)
St. Paul, Minnesota
Members Present: John Baerg (Butterfield), Thomas Boe (Moorhead), Debra Carpenter (Fergus Falls), Darrell Carter (Granite Falls), Ray Christensen (Duluth), Tom Crowley (Wabasha), Rep. Steve Gottwalt (St. Cloud), Margaret Kalina (Alexandria), Diane Muckenhirn, Chair (Glencoe), Tom Nixon (Brainerd), Rep. Mary Ellen Otremba (Long Prairie), Nancy Stratman (Willmar).
Members Absent: LaVonne Schlieman (Morris), Senator Jim Vickerman (Tracy), Senator Betsy Wergin (Princeton).
MDH Staff Present: Doug Benson, Renée S. Fredericksen (via Glencoe), Tamie Rogers, Mark Schoenbaum, Angie Sechler, Kristen Tharaldson.
WELCOME AND INTRODUCTIONS
Meeting Summary Review-Meeting Summary passed without corrections.
John Baerg (Consumer Member) – At the county level, commissioners are looking at proposed legislation and are disgusted with the health care access fund being raided to balance the budget. A county-based purchasing approach will be utilized to cover Medical Assistance health care costs and a new group in southeast Minnesota is working on this. The new hospital in St. James is performing well and John looks forward to the possibility of RHAC members making a site visit.
Thomas Boe (Licensed Health Care Professional) – Regarding health care cuts at the state level, the governor has proposed using the health care access fund to help cover the shortfall. That fund is created through a tax on health professionals. The purpose of the fund is to help create access to care so this is cause for concern. Dentists in northwest Minnesota are moving to North Dakota or South Dakota to avoid this tax. Last year, North Dakota had a record number of new dentists coming to their state and taxes may be a factor in this trend.
Deb Carpenter (Consumer Member) – Area community and technical colleges are having difficulty filling health careers programs as programs have become longer and more costly. Specifically, the medical technologist program has not been able fill its class.
Darrell Carter (Medical Doctor Representative) – Trauma system development continues and more hospitals are getting on board to improve trauma care, especially rural trauma care. With FLEX grants, there is the ability to have increased training for rural providers. The State Trauma Advisory Council has gone on record to add a modified skills lab for providers throughout the state to make it easier for Critical Access Hospitals to get the necessary training.
Ray Christensen (Higher Education Member) – The summer internship program for medical students is quite successful thanks to the involvement of rural hospitals. However, there are issues with finding housing for professional students. If rural towns are looking at the internship program as a recruitment tool, this is a serious issue. Last year, 46 percent of University of Minnesota-Duluth students (21/46) went into family medicine. Others went into pediatrics, internal medicine, OB/GYN and other needed specialties. Family medicine was designed to take care of rural America, so it is good to see increases in these much needed specialties.
Thomas Crowley (Hospital Representative) – It is still a struggle to bring MDs to rural communities, so thanks to Ray and others for their work in training family doctors. St. Elizabeth’s is doing some remodeling to improve their facilities. St. Elizabeth staff are working on implementing electronic health records, which is a time consuming process, but they are making progress. St. Elizabeth’s recently developed a pharmacy residency program in partnership with the University of Minnesota to initiate a medicine management program. Elderly patients on several medications will be able to use the program to make sure their dosage is appropriate and there are no conflicts with multiple medications. Mental health transports are still a problem in rural areas as well as continued difficulty finding beds for inpatient mental health needs.
Representative Steve Gottwalt (House of Representatives Member) – The governor has some concerns with the health reform proposals. There is not unanimous support for some things coming out of the taskforce. It is likely that things are slowing down and we won’t see a rush to the proposed level 1/2/3 payment approach. Need to take more time for buy in and understanding, particularly for rural providers. If everything works out and questions can be answered, there is potential for great things in Minnesota. A lot of this is about long-term solutions to get primary care providers in rural areas. This means paying more for primary care, establishing a clear career track in this area and other related issues. This discussion will continue beyond this year. Some budget cutting will need to take place this year, so legislators are looking at differences between committee and governor budget proposals. A strong message received by the governor is that legislators and citizens don’t want to balance the state budget on the backs of nursing homes.
Margaret Kalina (Registered Nurse Member) – The health care delivery workgroup's first meeting in February had 22 participants. The meeting was well organized and ORHPC staff are responsible for the good start. Staff are currently working on scheduling the next meeting, so stay tuned. The local hospital policy committee is concerned about the health care access fund being raided for general purposes rather than addressing health care needs. It has been a busy winter with influenza, pneumonia, and other seasonal health issues, so hospital staff are glad it is coming to an end.
Diane Muckenhirn (Mid-Level Practitioner) – A walk-in clinic is opening in an area grocery store and will be staffed by physician assistants and nurse practicioners. More minute clinics are opening in small towns, which expands access and patient choice. There is a new director of public health in McLeod/Sibley/Meeker. She has been involved in emergency preparedness planning.
Thomas Nixon (Volunteer Ambulance Service Member) – Local emergency medical services' (EMS) issues with mental health transports continue, including long distance transports and low availability of mental health beds statewide. The rural volunteer EMS retirement fund is up for being cut this year. Walker EMS is being purchased by another outfit, so rural Minnesota will get increased access to advanced life support. Another station was also added in the Bemidji area to meet transport needs.
Mary Ellen Otremba (House of Representatives Member) – The Governor’s taskforce was great because it included community members' perspectives. Legislators spent a lot of time on the budget last week and it addresses the needs of nursing homes, disabled individuals and children. Most of what the governor wants will pass, so representatives did a good job putting together a house bill to protect those who are most vulnerable.
Nancy Stratman (Long Term Health Care Member) – It is common to hear about concerns to maintain nursing homes, so Nancy is glad the message has reached the Legislature. One fear is that nursing homes will continue to face increasing financial pressures.
Testimony on overview of education efforts targeted at primary care providers presented to the Minnesota House of Representatives Health Care and Human Services Finance Division (2/27/08) by:
- Rep. Thomas Huntley – Chair, House Health Care and Human Services Finance Committee
- Dr. George Schoephoerster – Family Medicine Physician and President-Elect of Minnesota Medical Association
- Mark Schoenbaum – Director, Office of Rural Health and Primary Care
- Dr. Joe Bianco – Family Medicine Physician, Ely, MN
- Frank Cerra - Senior Vice President for Health Sciences, University of Minnesota
After ORHPC staff reviewed the RHAC work plan, it is clear that primary care is central to it. So this testimony focused on primary care will help to inform RHAC members of what is being presented to and discussed by the state legislature this year.
Question: Is anyone looking at RBRVS to equalize payments? This weighting system has created greater inequities.
Answer: A concept out of the governor’s transformation taskforce is being used in reform bills called “single price” in which every provider sets their own price for individual services or bundled services (“baskets” of services). That price would not be subject to negotiation. Every patient and payer would be charged the same price. The expectation is providers would set the price based on cost.
Question: A lot of questions were asked about “baskets” of services. How can we cover costs of an “outlier?”
Answer: We cannot use a cookie cutter approach from patient to patient, so there are concerns about how this will play out. Concerns include if providers ask for too much, this can lower the patient load, or if providers set the price too low, they can put themselves out of business. A lot of discussion is needed to make this a practical approach.
It is interesting to think about how pay for performance would be incorporated into this new payment structure. There would be additional payments for quality indicators and improving health toward reaching these indicators. Conditions used for benchmarks would be chronic conditions (asthma, diabetes, etc.) commonly treated by rural providers.
Considering Dr. Schoephoerster’s concept of “change,” it will be slow because it needs to take place at the curriculum level. Health care educators are also stuck where their education left off and need training on new models of health care delivery.
Question: Shortages exists of lab technicians, LPNs and others. Some programs that were one year are now two year. Combined with an increased cost of tuition, how does this create a barrier to training, especially for those wanting to make a career shift?
Answer: One of the curriculum changes is dental assistants can choose a one- or two-year program. The difference between these programs is that a two-year program allows students to move on to B.S. degree. The current response is greater for the two-year program. So the choices students make will depend on the benefits of each degree.
The six aspects of primary care highlighted in the presentations are similar to those taught in nursing school. Health professional students will need to come together and blend practices so MDs and nurses can both practice at the top of their license. There is a need to teach all clinic and hospital staff and reeducate providers on how to deliver the best health care.
Gaps not addressed in testimony: A problem that drives us to specialty care is patient demand. Another corollary issue is legal requirements to push for more referrals. This will need to be addressed or things can’t move forward. Time demands on MDs and other health care providers also need to be addressed as part of an overall solution. Personal responsibility for one’s own health also needs to be addressed. Discourse among those pursuing medical degrees is to get more rewards and benefits through specialization. Many intend to work in rural, but end up choosing urban specialty medicine for several reasons.
Question: Is AHEC working with Dr. Cerra and the new Center for Interprofessional Education and what are they doing to promote interprofessional thinking in health career training courses across the state?
Answer: The initial discussions had to do with training doctors, physician assistants, nurses, public health professionals, dentists and pharmacists together, especially for a set of required core courses. The main struggle was with the scheduling part of it, but a process is there and this important work is taking place.
There are some concerns with the medical home, including limits to primary care physician knowledge and the need to know when to refer and maintain access to specialists. The idea of the medical home should include spending enough time with the patient to facilitate appropriate referrals.
OTHER BUSINESS AND NEXT MEETING
RHAC members are invited to attend the Rural Health Care Delivery Workgroup meeting, which is now scheduled on Friday, May 30 from 10:30 a.m. until 2:30 p.m. at the Metropolitan Mosquito Control District Building in St. Paul. Directions are online. The next regularly scheduled RHAC meeting will be at the Rural Health Conference in Duluth on June 23-24, 2008. Details regarding this meeting are to be determined. Costs for RHAC members to attend the conference (hotel, registration and mileage) will be covered by ORHPC.
MEETING WAS ADJOURNED AT 11:38 a.m.