Rural Health Advisory Committee

Meeting Minutes

Tuesday, January 29, 2013
9:00 a.m. - 11:00 a.m.

RHAC Members Present: John Baerg, Tom Boe, Tom Crowley, Nancy Stratman, Ray Christensen, Ellen Delatorre, Margaret Kalina, Jackie Osterhaus, Millicent Simenson, Tom Vanderwal

ORHPC Staff: Rachel Gunsalus, Tim Held, Paul Jansen, Mark Schoenbaum, Kristen Tharaldson

Guests: Virginia Barzan (Minnesota Academy of Family Physicians), Pam Biladeau (EMS Regulatory Board), Lucinda Jesson (Commissioner, Department of Human Services)

RHAC Member Updates

Tom Boe (Licensed Health Care Professional, Moorhead). The Family HealthCare Center in Moorhead hired a dental therapist in 2012. They are trying to hire another one in 2013.

Tom Crowley (Hospital Representative, Wabasha).  A local student was accepted to the University of Minnesota-Duluth for their first year of medical school. It is exciting to have a student with a passion for rural health care who has gained experience at St. Elizabeth’s Hospital. There is a high demand for long-term care in Wabasha. There are at least 25 people on the waiting list for the nursing home, mostly for short term stays. There is a bottleneck in that area and it is difficult to help those individuals. Another difficulty is finding staff for the hospital’s emergency room.

Margaret Kalina (Registered Nurse Representative, Alexandria). Nurses are relieved that the flu season has peaked. Nursing advocates will be monitoring legislative activities around staffing ratios in hospital settings this session.

Jackie Osterhaus (Mid-level Practitioner Representative, Paynesville). Paynesville is going through due diligence with CentraCare and is likely to join the health system. The clinic has started a community wellness program and will offer a Weight Watchers program that will operate out of the clinic. Community members can register and the clinic is trying to get local businesses involved.

Millicent Simenson (Consumer Member, Bemidji/Leech Lake). There is local work being done to address the rural obstetric work group recommendations and expand doula services.

Ray Christensen (Higher Education Member, Duluth). Currently working on summer internship in medicine program, and hospitals are being canvassed across the state to see if they can participate. The program runs from July to September. An average of 70-90 students participate, and there is a lot of interest again this year.

Virginia Barzan (on behalf of the Minnesota Academy of Family Physicians): MAFP was pleased to invite Dr. Paul Grundy, an expert on health care homes/patient centered medical homes across the country, to Minnesota. He attended grand rounds with medical students at the University of Minnesota, a breakfast for employers, and an evening event for MAFP members. Dr. Grundy is tremendously enthusiastic about medical home models and gave attendees a lot to think about. Ms. Barzan is willing to share his slides with committee members. As a side note, RHAC member Daron Gersch is now the mayor of Albany.

Pam Biladeau (on behalf of the Emergency Medical Services Regulatory Board). The EMSRB is in the process of strategic planning to provide more services. They are looking at ways to reduce duplication of efforts and are excited to work with the Rural Health Advisory Committee, EMS associations, EMS educators (who are currently updating education standards for first time in 17 years), and supporters of community paramedic programs. The unknowns right now are health care reform and how Accountable Care Organizations (ACOs) will affect ambulance services. A key area of concern is what the Affordable Care Act (ACA) may require of smaller ambulance services, especially regarding 911 response.

John Baerg (Consumer Member, Butterfield). Mr. Baerg is no longer a county commissioner. He is eager to stay involved in statewide health promotion efforts. He is also a volunteer driver for human services, taking people to dialysis appointments.

Nancy Stratman (Long-term Care Representative, Cokato). The flu has taken its toll on long-term care residents and staff. Staff are getting better at implementing measures to control it (e.g. limited visitation hours.)

Roadmap to a Healthier Minnesota: Recommendations from the Minnesota Health Care Reform Task Force (Lucinda Jesson, Commissioner of Human Services)

Ms. Jesson walked through the recommendations of the health reform task force and gave a preview of next steps. The task force was looking at implementation of the ACA over the next five years, followed by a move towards broader changes in health care. The legislature will be using the recommendations to guide efforts now and in the near future. The bipartisan task force convened in December 2011 with the goal of creating a “road map” for moving ahead with health reform efforts. The task force divided the work into four work groups:

    • Care integration and payment reform
    • Work force
    • Public health
    • Access

The broad task force conducted outreach to discover what citizens want out of health reform. Results include a desire for better health at personal and population health levels. They understood there would be trade-offs for investment in health and patients/consumers were willing to move ahead with these investments. Citizens also highlighted the need to access information to make better decisions and be in control of their own health.

There was good rural representation on the task force, including Rep. Gottwalt (RHAC member), Rep. Schumacher from Luverne, and Dr. Zink from Zumbrota (rural family medicine physician and chair of the Workforce Work Group). Rep. Schumacher brought a long-term care perspective while Dr. Zink brought a primary care perspective to the work group.

One area the task force focused on was care integration and payment reform. “Our state needs to provide incentives to keep people healthy, and for health systems to be more efficient,” said Jesson. In the private sector, this trend was just starting. Our state is trying to move this into public programs, including working towards contracts with provider groups to change the incentives to encourage population health outcomes and shared savings. The state recently entered into agreements with six large provider networks to serve 100,000 new public program patients on Medicaid.

A joint effort between the Department of Human Services (DHS) and Minnesota Department of Health (MDH) is looking at expansions to home health programs and will strive to do a better job meeting those needs. The state is looking for new ways to get more health care for the dollar and achieve savings in ways that do not just push consolidation. This work requires sensitivity to the needs of independent and small/isolated rural providers. One strategic recommendation calls upon MDH to provide technical assistance to providers in rural areas and private independent clinics. “There is concern about rapid consolidation. There needs to be more outreach and upfront dollars,” said Jesson.

Another area for improvement is to build data sharing capabilities. To do this, policy makers may need to change state laws and create infrastructure to enable data sharing. The state needs to protect patient privacy while enabling data sharing between providers to improve patient health.

Maintaining an adequate health provider workforce is a huge challenge for Minnesota. The legislature will likely expand Medicaid, and the state is going to have 145,000 more people on public programs. Private insurance will be offered through a health insurance exchange, meaning there will be more insurance holders, but not more providers. Workforce issues to address include telehealth, primary care workforce, long-term care workforce, underserved areas/health professional loan forgiveness, increasing the numbers of mid-level providers, and fully restoring DHS funding for the Medical Education and Research Costs program (MERC).

Recommendations from the task force addressed some high-risk groups, including expansion of school-based behavioral health services. There are recommendations to expand Medicaid up to 138 percent of poverty and provide better preventive benefits for that population. MinnesotaCare, the health coverage program for the working poor, should be maintained as a separate program because putting the working poor into the exchange would be a step backwards from their current coverage.

Roadmap to a Healthier Minnesota Q & A

Tom Crowley: There are 50 people on our waiting list for short-term care in the nursing home. It is difficult to have adequate staff to provide that care. Do any of the task force recommendations address this common predicament in rural areas?

  • Lucinda Jesson: This document helps us make our case to legislators to have more funding for nursing homes and primary care. It is a bipartisan piece of work, and we need to get the word out about the recommendations. The DHS budget this year proposed increased payments for physicians and dentists. We need to have providers where they are most needed and pay them effectively. We need to make short- and long-term investments in our healthcare workforce infrastructure.

Ray Christensen: For future rural physicians, MERC funding is very important and experiential work sites are needed in rural areas. University of Minnesota student capacity has increased 30 percent, but rural residency options are limited (including ten slots in Duluth, four in St. Cloud, and four in Mankato). There are 60 medical students at the Duluth campus and the University of Minnesota-Duluth (UMD) works hard to admit family physicians willing to work in rural areas, but UMD has limited ability to place students in rural locations. Minnesota needs to work towards placing family practice residencies in rural communities that need more primary care access. It costs $150,000 per year to hire a medical resident, but there are programs in other states to emulate. In Washington State, residents start in urban areas and then rotate to rural areas. Rural hospital systems may need to partner with the state to afford rural residency slots.

  • Lucinda Jesson: Let’s meet and talk about it later. We need to take the next steps to support rural family medicine residency programs.

Tom Vanderwal: Volunteer ambulance services without community paramedics may not be addressed in the task force recommendations. How do they fit and what is your view on the health reform as it relates to volunteer ambulance services?

  • Lucinda Jesson: New health professionals need to fill in the gaps in underserved areas. This Roadmap is one report with good recommendations, but it does not have all the answers. I understand the important role that EMS plays. Contact Commissioner Jesson with any specific ideas or models that may be helpful as we move ahead.

Mark Schoenbaum: Today we discussed multiple issues related to health reform including the documentation of health outcomes, performance improvement, and cost effectiveness. These issues are moving ahead and accelerating consolidation. Do RHAC members have feedback on specific taskforce recommendations? Are there things we should be doing as a committee to give back to Commissioner Jesson?

  • Tom Crowley: Ray Christensen’s point was very critical. We need to do more in rural areas to address primary care and long-term care workforce issues.
  • Virginia Barzan: Recommendations relate to health care home certification and payment processes. MAFP would like to see specifics as soon as possible. DHS is working on payment reform as it relates to health care reform. This includes paying for everyone to have a health care home through recommendation #2- expanding health care home programs. If this is based on retroactive payment, it could benefit both urban and rural programs.

RHAC Work Plan Updates

Work Plan Priority 1: Health care growth and consolidation/Health reform. This work plan priority has been addressed through presentations, discussions at RHAC meetings and a critical access hospital (CAH) survey on growth and consolidation issues. The survey provided no clear answers to rural-specific questions. The recently published ORHPC issue brief on system growth and consolidation established that there is a trend in rural health system growth and consolidation and a decline in the number of independently affiliated hospitals. Hospitals have different reasons to consider consolidation. What are next steps?

  • Margaret Kalina: The issue brief analysis is correct. Consolidation is happening all over, and with all the impending changes in health care, it is not surprising it is happening. Health care reform predictions are that you must be a part of a larger system. This is truer now to a higher degree than in the 1990s.
  • Jackie Osterhaus: As a mid-level provider, I never wanted to be a part of a larger system. What are the outcomes going to be? What does affiliation mean to providers? Are the health care outcomes going to be better? We do not have the resources to implement what health care reform requires.
  • Paul Jansen: There are two fields of research. First, how does system affiliation affect financial stability? The literature does not give consistent answers to that question. Second, how does system affiliation affect patient outcomes? The literature is very sparse in this area. RHAC may need to decide what the most important outcomes may be, and what could we potentially measure in our state?
  • Ray Christensen: Patients want someone who will sit and listen to them. Some things are contrary to what is going on now. Patients need to experience healing relationships with their providers. Health systems are consolidating because of reasons related to capital. Readmissions are going to come back at some point. To reduce readmissions, and succeed in a pay for performance environments, providers need to offer one-on-one care. This is a very expensive way of doing medicine.
  • Paul Jansen: Is patient satisfaction correlated with better health outcomes? Does a better patient experience equate to better health outcomes?
  • Ray Christensen: In general, the answer to that is, yes. If I could let the patient own the decision making process, it makes it better. Shamans and traditional healers do this as well.
  • Tom Boe: Patients fill out a survey when they leave the office. They are generally satisfied with the outcomes from their care, but there might be aspects of the experience they are not satisfied with (e.g. length of wait time for procedures.)

Mark Schoenbaum: We should keep this work plan priority team going. One clear difference between independent and affiliated is presence/absence of local control over health delivery decisions. I have not been able to objectively document the effect of that difference. If a system buys a local hospital and decisions are made elsewhere, all of us in rural health, many of us, feel that something was lost. What was lost? Hospital CEOs said it didn't have an effect on access.

  • Margaret Kalina: There is an economic loss that people fear, that the money will end up going to metro areas through referrals to specialty services. They fear that surgeries that happen in your rural communities will now go to larger health care hubs.
  • Tom Vanderwal: With different management and payment systems, the “trust factor” is not there anymore from the patient’s perspective.
  • Virginia Barzan: There are advantages to keeping control of the local health care system. It could range from supporting good food options in the community, expanding exercise opportunities, and addressing specific or unique local needs. These are the advantages of local control.

Work Plan Priority 2: Health Promotion SHIP. SHIP funding has been restored in the governor’s budget to $40 million per biennium. Once it is in the governor’s budget, it could be taken out. Minnesota has made a lot of headway with the SHIP program. It addresses healthy eating, increased exercise, reduced obesity and reduced smoking in young adults. A related proposal would increase the state tobacco tax by 94 cents per pack with the dual goals of improving health and addressing the general fund deficit. Roadmap Strategy #19 addresses the importance of SHIP in reducing state health care costs. SHIP funding had been reduced 70 percent. The Governor is restoring it back to 40 million to be able to carry out the SHIP program in workplaces, schools and businesses. When it was reduced, the types of places were reduced and ability to do interventions reduced. If tobacco tax goes through, it will also be a big step towards prevention of future health care costs.

Work Plan Priority 3: Long-Term Care & Aging. This is a huge topic that covers workforce shortages, dementia, and Alzheimer’s, among other issues. This work plan priority team will convene led by Nancy and include Tom, Margaret and Jackie. The first assignment for the team will be to define unique rural aspects of aging issues, including the growing incidence of dementia and Alzheimer’s.

Work Priority Plan 4: EMS Toolkit 2.0. The EMS toolkit is now online. It offers leadership resources to volunteer ambulance agencies in Minnesota. Web viewers are encouraged to provide input on its usefulness and future applications.

Work Plan Priority 5: Rural Obstetrics. The Rural Obstetric Report and Roadmap Report have similar recommendations to address the needs of women who are receiving late or no prenatal care. Smoking is something that needs to be addressed in mothers-to-be. Nurses and doulas in the Bemidji area were very active in the Rural Obstetrics Work Group and are now working locally to make changes to how care is provided to pregnant women and their families. They plan to implement broad home visiting/doula care services. This includes training 10-12 new doulas to offer doula services in women’s homes. They could also be trained as smoking cessation counselors, lactation consultants and possibly community health workers as well. This will help to maximize reimbursement and expand services provided by doulas.

Nurses in the Bemidji area are planning to expand community and family education around healthy births. These services can be offered to pregnant women, their partners, family members and anyone who lives or works with infants and children. Education is needed on nutrition, healthy behaviors, the harmful effects of smoking/drinking/drug use, breastfeeding, post-partum mental health issues and healthy infant/child development. The ultimate goal is to create a community culture of confidence and support around births.

RHAC member Millicent Simenson was consulted on state legislation to improve pay for doula services for women covered by Medicaid. Kristen Tharaldson is working with Dr. Avery at U of M School of Nursing to propose federal legislation to create a health professional shortage area (HPSA) designation for rural obstetrics. She is also working with Dr. Kozhimannil, a researcher at the U of M Rural Health Research Center, to determine areas for future research on rural obstetrics. Dr. Kozhimannil is currently working on two new studies using national discharge data and quality of care outcomes.

  • Millicent Simenson: She has met with tribal council members about moving ahead with new birth support services in the Bemidji area. They have been very supportive of her involvement in the Rural Obstetrics Work Group and support follow-through on the recommendations.

Work Plan Priority 6: Mental & Behavioral Health Emergencies.
More work to come in Spring/Summer 2013.

ORHPC Updates

With the last election, the minority/majority parties switched in the Minnesota legislature. RHAC staff are working with the Governor’s office to get legislators appointed to open RHAC slots.

ORHPC is starting a strategic planning process. RHAC members will receive a survey asking for input on activities of our office.

RHAC member Ray Christensen is now president-elect for the National Rural Health Association (NRHA). The annual NRHA Rural Health Policy conference will be held in early February.

Mark Schoenbaum met with the new dean of the U of M Dental School. His background and expertise are very impressive. He is eager to learn more about the dental therapist role and the Moorhead clinic (where RHAC member Tom Boe works) is already on his radar for networking.

Meeting Adjournment

The meeting was adjourned at 11:03 a.m. The next RHAC meeting will be on Tuesday, March 26, from 9-11:00 a.m., via videoconference originating in the Freeman Building, B108, in St. Paul.

Updated Wednesday, February 20, 2013 at 09:40AM