Rural Health Advisory Committee Meeting Minutes

Rural Health Advisory Committee Meeting Minutes

Tuesday, November 30, 2010 10 a.m.-2 p.m.
Minnesota Department of Health-Snelling Office Park-Red River Room, St. Paul, MN

Members Present: John Baerg, Tom Boe, Tom Crowley, Jeff Hardwig, Margaret Kalina, Diane Muckenhirn,Tom Nixon, Nancy Stratman

Members Absent: Deb Carpenter, Ray Christensen, Jode Freyholtz, Steve Gottwalt, Mary Ellen Otremba, Yvonne Prettner-Solon, Julie Rosen

Guest Panelists: Sue Abderholden (National Alliance on Mental Illness - NAMI MN), Eric Dick (Minnesota Medical Association), O.J. Doyle (Minnesota Ambulance Association), Jennifer McNertney (Aging Services), Marnie Moore (Minnesota Rural Health Association), Joe Schindler (Minnesota Hospital Association)

MDH Staff Present: Doug Benson, Paul Jansen, Jill Myers, Mark Schoenbaum, Kristen Tharaldson, Karen Welle


Aging Services of Minnesota
See this as a year to:

  • Educate new legislators
  • Stress the importance of investing in independence of the elderly
  • Defend the elderly waiver
  • Prepare for future age wave and messages around personal responsibility

Minnesota Ambulance Association (MAA)

  • MAA is the only one of its kind in the United States and represents many interests including fire, hospitals, private, nonprofit, tribal and county EMS agencies
  • EMS services in Minnesota do not compete for calls, so organizations are united around EMS issues
  • Penalized fee schedule for “good performance” compared to other states
  • January 1 face 2 percent reduction in urban ambulance funding, 3 percent rural reduction, and 22.6 percent super rural reduction
  • GAMC created $9 million loss for state EMS services
  • Recruitment and retention for EMS faces $15 million loss
  • 2007 audit showed ambulance in urban areas are reimbursed at 6 percent below actual cost, and for rural areas reimbursement was 17 percent below actual cost
  • Minnesota is one of four states with no fault insurance law
    • Mandated $20,000 medical benefit ensures EMS gets paid (100 percent of costs, paid within 30 days)
  • 90 percent of seat belt fines go to emergency services and is needed as safety net funding
  • 911 surcharge provides small percentage of funding for MRCC (Metro Region EMS System Communications Advisory Committee covering metro west & east)
    • System helped during bridge collapse
    • Addresses day to day control of EMS surge capacity
    • Covers outstate areas
    • Allows ambulance personnel to speak to MDs prior to arrival
  • 62 percent of EMS workers are volunteer, even higher percentage in rural areas
    • Loss of volunteer ambulance services
    • EMS training standards are changing
    • Unsure how to address lack of EMS volunteers; try to recruit by offering health insurance coverage
      • Last year had the opportunity to make EMS volunteers eligible for MNCare without meeting financial criteria (affective 4/1/11)
  • Statewide trauma system development; no consideration by 3rd party payers that trauma systems cost money to develop and maintain
  • Air ambulance safety and mandated minimum standards
    • Other states are competitive which creates pressures on pilots (five deaths within 18 months in the United States due to pilot error)
  • Workers Comp: are volunteer-based EMS agencies required to provide this?

Minnesota Medical Association (MMA)

  • Wish list: early adaption of Medicaid option
    • addresses up to 133 percent poverty
    • GAMC population and single adults without kids
  • Still working on legislative agenda for the year; HHS and K-12 is 80 percent of state budget, so expect the majority of cuts to come from these areas
  • Hopeful to get traction on reimbursement issues
  • Provider tax should not be used to balance state budget or other general costs, but to support programs to address the medically underserved
  • Rumbling of changes to Right to Breathe Act
  • MMA is part of a coalition to increase the tobacco tax (currently Minnesota has 22nd lowest tax for cigarettes in U.S.)
  • SHIP will be challenged to stay funded in 2011
  • National health care reform; much concern over Accountable Care Organization (ACO) models

Minnesota Hospital Association

  • Recognize potential for cuts and prefer “shared pain” versus undue burden on hospitals
  • 16 percent Medicaid payment cuts starting July 1st 2011
    • Current payments are based on 2002 rates
    • No inflation or COLA equates to a “hidden tax”
  • Hospitals use 15 percent of state HHS budget; took disproportionate cuts in recent years
  • GAMC patients are limited to services at four urban hospitals; creates a problem for rural families and single adults with no children
    • Program scheduled to go away in Feb. 2011
    • Support early MA adoption; opt in early will catch GAMC & some MNCare patients (80,000 people) and uninsured (20,000 people)
    • Brings in 50/50 federal share moving towards 100 percent federal down the road
    • Only way out is early Medicaid option by January 15
  • Reduction in administrative mandates: get rid of anything not addressing or improving quality or safety
  • Continue to oppose nursing staff ratios
  • Transparency in PMAP important
    • With movement to ACOs, should be paying for value

Minnesota Rural Health Association (MRHA)

  • Advocacy committee still working on legislative issues; completed member survey
  • Two important issues (may not be addressed in 2011 session)
    • Medical education costs
    • Adequate broadband in rural areas; state has blueprint for 2015
  • Continue to build relationships with rural partners
  • February 2 is annual MRHA day at the state capitol; will hold regional meetings in 2011

National Alliance on Mental Illness (NAMI MN)

  • NAMI works with 27 local affiliates in Minnesota
  • Difficult legislation session in 2010
    • Mental health programs faced an $15.6 million loss overall
  • 2011 legislation session will also be difficult; the mental health system is fragile
  • Biggest focus is on maintaining 2007 state investments
    • Largest infrastructure investment in decades
    • $30 million in school services by mental health providers
    • Respite care critical for families
    • Crisis services and development of regional crisis teams; shown to be effective in reducing ER visits and readmissions
  • In every county adults are covered for mental health services; 80 percent of counties have mental health services for children
  • Work on training culturally diverse mental health providers (tribal and immigrant)
  • Parents are now on the screening team for out-of-home placements
  • Crisis teams in schools face problem of no consent form in schools; need to make this easy by having parents do ahead of time
  • Worried about jail MH programs
    • mental health courts in metro are working
    • Duluth wants to establish a mental health court program
  • Juvenile detention rates are disproportionate for youth of color
    • 70 percent or more of these youth have a mental health diagnosis
    • Mental health training for school safety officers helps fewer kids get caught in the justice system
  • Proposed Department of Education curriculum includes mental health
    • Suicide prevention
    • Safe Schools For All (no bullying for any reason)
  • Extended employment program has a long wait list
  • Policy issue to address: easy internet access to commitment records
    • Mental health issues are health issues and should be confidential
    • Folks with bipolar or other MH commitments are being denied jobs
    • Try to change so this is not part of the public record
  • Personal Care Attendant (PCA) services change July 1,2011; 3,000 children and people of color will lose this supportive service
    • Why so many children use this program? Don’t know exactly, possible mental health issues pervasive. Need input to develop new programs.
    • PCAs could use additional safety training around mental health issues
  • Early Medicaid option would ultimately help more people recover from mental health issues
    • With support, people can work and not depend on MA
    • Hard to get disability status (three denials before coverage kicks in)
    • Time without medical coverage is difficult, especially if need is access to mental health medications and medication management visits
  • Community Mental Health Centers lost money on GAMC changes
  • Bridges Housing Program used to take 18 months to get section eight housing; now wait list is four years and the program is underfunded
    • Supportive housing efforts are needed
  • Health reform opens insurance from other states to compete in Minnesota
    • Need to ensure they follow Minnesota state rules for coverage of mental health services
  • 2010 legislative session required DHS to look at community behavioral hospitals
    • Currently not set up to interface with local mental health providers
    • State redesign changed programs to fill more beds
    • Task force found MH transports should not be done by police
  • Important to access CD treatment with integrated mental health treatment programs
    • Do not have enough programs to do integrated chemical dependency/mental health treatment


Tom Boe – New loan repayment program through the National Health Service Corp (NHSC). Includes $60,000 repayment over two years and includes dentists practicing in underserved areas. Periodontal disease has a huge impact on other health status indicators (heart disease, diabetes, premature birth, etc.) so need to educate health care providers.

Diane Muckenhirn – Minnesota leads the way on health care access issues, but could work towards allowing nurse practitioners to provide independent care. Florida report showed nurse practitioners would save $1 billion/yr in Medicaid costs and create 9,000+ health care jobs if allowed independent practice. Robert Wood Johnson (RWJ) Foundation & AARP are working on defining next generation nurse practitioner roles. They will do a webcast to describe work of advanced practice nurses. JAMA published an article that showed nurse practitioners provide equal care and have satisfaction rates similar to MDs. Would like to review ORHPC’s APRN workforce report when it’s ready.

John Baerg – State is developing a voluntary local public health agency certification program using the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) model. This should improve efficiencies and help the public better understand what public health is doing and why it should be funded. Area is working on veterans’ access to local health care services. Currently is a very difficult process to figure out insurance and where veterans can get the best care.

Margaret Kalina – Transforming Care at the Bedside (TCAB) is a RWJ pilot project for hospitals and focuses on engaging frontline staff and unit managers who spend the most time with patients and their families. Looking at interstate licensure issues for nurses as 26 other states have interstate licenses available. One advantage is data will be available if a nurse loses a license in one state and wants to continue practicing in other states.

Jeff Hardwig – SMDC Health System/Essentia Health is combining behavioral health with medical health services. Local struggle continues with OB issues. Currently employ a 70-year-old surgeon who takes leave in the winter. One family practice MD covers c-sections in his absence. System will look at diverting OB services temporarily or need to cover at any cost.

Nancy Stratman – Minnesota Department of Human Services (DHS) are conducting statewide surveys of nursing home residents and their families. Results will be reported publicly on the Nursing Home Report Card. Nancy is currently serving on the local aging services board. The nursing home is engaged in an initiative to improve life at nursing home and highlight the benefits of nursing homes. This initiative is looking for additional partners. Nancy is pleased that healthy aging issues remain on the RHAC work plan.

Tom Crowley – Transportation for mental health patients is still an issue as coordination difficulties arise. Looking forward to DHS report on this issue. Counties budgets are tight and they are sharing resources. To share resources effectively in health care, need shared access to medical records. Primary care doctors are not interested in providing OB services. Hospital has nurse midwife but doctors don’t want to back up. Need legislation to allow nurse midwifes more autonomy. Locally, have outstanding nurse midwife health outcomes. Many moms travel 50+ miles for prenatal check ups. Many moms are not willing to drive so prenatal issues are not prevented or monitored appropriately. Believes several rural areas are facing this issue. RHAC should dovetail OB issues with findings on general surgery. The average family practice resident currently has not done much OB. Need to broaden rural residency opportunities to build confidence in OB skill set.

Tom Nixon – EMS 800 MHz system mandate is in place and are working locally to incorporate it with fire services. It costs a lot of money and liability remains a concern. Recently there is a decrease in ambulance calls for the majority of rural EMS providers, meaning less overtime and less paramedic jobs and training opportunities.


(1) General Surgery project – a work group meeting was held in November to address general surgery issues related to Minnesota’s statewide trauma system. Another meeting will be held shortly to address general surgery training and residency issues. A final general surgery work group report will be completed in early 2011.
(2) HIT – Key Health Alliance/REACH (Minnesota’s regional extension assistance center for health information technology) is having boot camps to address electronic health record readiness; Minnesota’s FCC grant project addressing broadband for healthcare continues.
(3) FLEX - Dec. 15 flex program mini-grants are due
(4) ORHPC positions - Paul Jansen was hired to perform data analysis on RHAC projects and for statewide trauma system development. Leslie Nordgren was hired to conduct a statewide assessment of the dental hygienist workforce and develop an evaluation of the new dental health therapist profession.
(5) State Health Care Workforce Planning – Minnesota Department of Employment and Economic Development (DEED) was the lead applicant for a federal health care workforce planning grant. The application was successful and work is beginning in conjunction with DEED, MnSCU Health Force, Area Health Education Centers (AHEC) and the ORHPC.
(6) Election results & next MDH leadership team – ORHPC will learn more in the near future about the new health commissioner’s level of involvement with advisory committees like RHAC; RHAC work products do get seen and used and cited by the commissioner and legislature.
(7) RHAC work plan – after some discussion, RHAC members decided to move the rural obstetric (OB) services project up on the timeline for several reasons: to dovetail with the general surgery report findings, because it is an important issue that affects recruitment of rural physicians, and to share ideas for solutions/coverage of OB in rural shortage areas. RHAC will convene around rural OB issues and may consider development in the following areas:

  • Nurse midwife legislation
  • Lack of prenatal care (access and quality issue)
  • RHAC impact statement (address as rural issues of importance)
  • Critical Access Hospital (CAH) impact statement (potential survey)
  • Minnesota Hospital Association OB survey (malpractice and time consuming).


Jeff Hardwig was nominated and elected chair of RHAC for 2011. Thank you to outgoing chair Margaret Kalina.


Five RHAC position terms expire in 2011 including two consumer members, one registered nurse member, one volunteer ambulance service member and one licensed health care professional member. Several legislative positions are also open. RHAC members who wish to reapply should do so and can contact Kristen Tharaldson at for more information.


The meeting adjourned at 1:05 p.m. The next RHAC meeting will be February 22 from 9-11:30 a.m. and will be conducted via videoconference.

Updated Tuesday, January 20, 2015 at 09:38AM