Rural Health Advisory Committee
Tuesday, March 18, 2014
Minnesota Department of Health, Orville Freeman Building, 625 Robert Street, B-106 Conference Room, St. Paul
9:30 a.m. - 11:30 a.m.
RHAC Members Present: Ray Christensen, Tom Crowley, Ellen Delatorre, Daron Gersch, Margaret Kalina, Joe Schomacker, Nancy Stratman, Tom Vanderwal
RHAC Members Absent: John Baerg, Thomas Boe, Clark Johnson, Tony Lourey, Jacqueline Osterhaus, Julie Rosen, Millicent Simenson
ORHPC Staff: Tim Held, Katherine Schleiss, Mark Schoenbaum, Kristen Tharaldson
Panelist Members: Virginia Barzan, Julie Sabo
Introductions and Member Updates
Tom Vanderwal – Greater Northwest EMS – I have been closely following this legislative session for the trauma funding bill, and have encouraged it to come along but it will not be moving forward this session. It’s received a lot of attention, especially offline, and lobbyists have been working with insurance corporations. Some positive things for next session, we could possibly get funding next session. There’s a bill sponsored by Sen. Chris Eaton, I’ve encouraged her to support the STEMI bill because data is important to rural EMS so they can be recognized for what they do. With the help of the Helmsley Foundation, we have several EKG units going out to the state, as well as awards to EMS services so that local ambulance services with small volumes will have another opportunity to receive funding. The second step is to receive transmission units for the lead EKG units in the field. The last thing is the state stroke committee with the American Heart Association. Within the state, the stroke system is gaining traction and has reached out and worked with the regional EMS program to do some additional training as well as a grant to secure funding within the next few months. These efforts to develop this collaborative approach are gaining some traction. We appreciate this effort from the state stroke committee.
Ray Christensen – The University of Minnesota has a new dean on the Twin Cities Medical School campus, Brooks Jackson. We’ve traded ideas on rural programs for the UMD campus. One concern of mine is funding for primary care residency programs, in particular addressing the bottleneck where there are more medical students than residency slots available. We have Match Day on Friday, hopefully all of our students will match into residency programs. At the regional campus, Gary Davis has resigned. We also have more students in the RPAP, 37 now, and the rural scholars program will have 84 students from the Twin Cities and Duluth and students studying for their boards.
Mark Schoenbaum – Where will these additional funds for residency programs be coming from?
Ray Christensen –CMS was part of that discussion of increasing training opportunities into rural communities, in particular one program where students start in major, urban hospitals and then finish their residency training in a small, rural community.
Tom Crowley – We have a successful population health program going into communities and schools called 5210. It’s been well-received by students and faculty in schools, and it encourages students to have five fruit and vegetable servings, watch less than two hours of screen time per day, and drink zero sugar drinks while exercising every day. There was a school assembly on the benefits of doing this and we also sent materials back to the families. The success of the program really depends on how enthusiastically the faculty promotes it. Switching gears to the Affordable Care Act, from the hospital standpoint there is a decline in service utilization and more people have much higher deductibles. January, February and March were once the busiest months, but now September, October and November are the busiest as people have built up their deductibles. There’s a bit of a shift, as consumers have more financial skin in the game and are much more price conscious. It’s an interesting time right now in health care.
Ellen Delatorre – I have spent the past several weeks putting together an event for MNSure and there’s still time to coordinate an enrollment event, if someone would be interested in one that specifically covers your county. We’ve had well over 1,000 enrollment events, and we are rapidly approaching our goal of 150,000 people newly ensured.
Mark Schoenbaum –Workforce issues have emerged as a top priority in the two-year work-plan that RHAC established last fall. We’ve tried to focus for your consideration as a committee on the specific aspects of rural workforce issues that would be practical to get our arms around as a group during a work-plan period. Commissioner Ed Ehlinger was present at our last RHAC meeting and got us thinking about primary care, and there was a good discussion between you about primary care, and an interest in looking at physician issues and APRN (advanced registered nurse practitioner) issues, as well as an interest in identifying the pre-selection factors that predispose someone for going into nursing and APRN nursing work and remaining in a rural setting. It was our observation that you as a group have chosen to look at APRN and nurse practitioners (NPs) and primary care NPs, and you have expressed a desire to look at the issues and challenges facing this group. So, that’s the topic we can dive deeper into as the next item on our agenda and the context for our discussions and presentations today.
Margaret Kalina – I’m interested in looking at the selection process for all practitioners going into rural settings, not necessarily NPs specifically.
Kristen Tharaldson – PowerPoint Presentation “The Nurse Practitioner Workforce in Minnesota”.
Katherine Schleiss – PowerPoint Presentation “Minnesota’s Nurse Practitioners”.
Ray Christensen – How do we look to the future with this presentation? According to this data, only 2 percent of NPs are involved in emergency care and urgent care, but we see that many Critical Access Hospitals (CAHs) are covering ERs with midlevel practitioners. There are educational programs that prepare providers to cover emergency rooms, but how are we doing with supply and demand? Is there adequate supply in the marketplace? Is there any discussion from your end?
Mark Schoenbaum – That’s something we can dive deeper into.
Ray Christensen – It can be more of a tug of war, and not so much an issue of supply and demand.
Mark Schoenbaum – It could be fruitful to focus on this issue and see what we find. On the same slide discussing rural hospitals I was wondering whether that slice of the pie shows NPs working in hospitals, and how many of those had emergency department coverage responsibility for some part of their time in addition to broader responsibilities. In the hospital setting, I’m not sure we can know the answer to that, so I’d like to look deeper into that as well.
Ray Christensen – That’s a good point, Mark. Having 2 percent of NPs involved in ER care is more of a store-front model, and I’d even say that it’s more than 2 percent, because we’re seeing NPs function as hospitalists in CAHs under primary care MDs. There’s such a large demand for hospitalists and ER physicians, and we’re trying to utilize everyone to their highest degree of training.
Tim Held – These are interesting questions, but there’s no data and only anecdotal accounts. All CAHs are part of the system and most level 4 facilities can have a physician extender network for the ER. I don’t recall hearing much of anything about NPs in that role, really it’s all PAs that are covering ERs, but that’s all anecdotal.
Mark Schoenbaum – We have a lot of anecdotes, which are more in the remote, smaller CAHs where mid-level providers are more likely to be NPs and PAs, and they do whatever needs to be done.
Tim Held – If they’re working in the ER in CAHs, they need to have trauma training.
Ray Christensen – There’s a big difference between physicians and nurse practitioners because it’s a question of nursing versus medicine. There’s a difference in how physicians address things and how we address patients. Physicians have four years of medical school and three years of residency, there’s a vast difference in rigor between medicine and PA/NP programs.
Mark Schoenbaum – The MERC program is complicated in getting money to clinical training sites. Last year the legislature made some changes to distribute more of the funds to smaller sites, many of which will be rural, to help those small sites that train nurse practitioners. Other changes to the formula will offset that. We do know that historically most of the money in MERC goes to clinical training of physicians and their large numbers at the big hospitals. Historically, they’ve gotten most of the money with some changes at the margin, but something we have heard methodically from the education programs is that it’s harder to find clinical training sites for APRNs and to finance these sites because of pressures for production on provider sites. We’re hearing growing anecdotes that these sites are telling education programs they cannot take their students unless the educational institute pays them something, which is a troubling trend. The same challenges exist in training medical students. In each of the NP programs, students are out looking and searching for opportunities, and we need preceptors and physicians and NPs and PAs who are willing to teach students as they come out. It’s getting harder and harder.
Kristen Tharaldson – In the course of conducting research for this presentation I had accidently contacted a nursing school in Bethel, Colorado who explained that they do not place their students in Minnesota because the sites expect payment.
Daron Gersch – There’s difficulty in getting students into internship programs. Some clinical sites charge the school for providing this service. I’m wondering if there’s any benefit to some type of funding, perhaps MERC funding, to fund these clinical training sites. This may slow down the productivity of the preceptor.
Ray Christensen – In the past, these funds have been provided to local physicians, and then the money goes to the clinic and the clinical administration and into the general fund. Instead, let us give the check directly to the preceptor, because otherwise the people who are doing the teaching never see the money.
Mark Schoenbaum – The legislature has heard that the MERC money disappears into the sites that receive it. Among some of the changes made last session was the requirement that MERC funds must be spent on clinical training, and recipients of these funds must report their training expenditures. So, over time there should be some more transparency and accountability for those funds.
Daron Gersch – That’s too much of a hassle, just hand them the money.
Mark Schoenbaum – No, we need to know where the money goes, we need to know where the money went. You can’t have it both ways. Hopefully, we’ve gotten closer to that by at least requiring managers to spent it on training.
Daron Gersch – How do you define training? What does that mean?
Mark Schoenbaum – It’s a broad definition, but the money is required to be spent on training, instead of new furniture in the waiting room.
Julie Sabo – I don’t have any reflections. The only thing in the recent presentation was the expectation of a 3 percent increase of the total number of NPs each year by 2020. There are more doctoral programs than master’s programs.
Mark Schoenbaum – Let’s all do a little reflection on the next steps, if any. Katie and Kristen have given us a pretty full background and a picture of the landscape and the issues, and some of the strategies that are being used and could be used more to grow the number of rural practitioners. This was a priority area on your work-plan, and a couple options strike me possible actions from the committee. We could end things right here, we could put the material from the presentations and some additional materials as an issue brief on NP facts and issues in rural Minnesota, in particular Kristen’s presentation. I’ve heard many action steps, strategies and interventions that could affect the situation, we could try and put them into some context and turn them into recommendations and try to grow some things from this range of strategies. We could communicate these recommendations as a committee to policy makers, such as the discussion we had a couple years ago about the difference between a long, in-depth workgroup versus doing shorter, more focused projects. I’m thinking we may have the ingredients to take what we’ve gotten and turn it into the kind of issue brief and policy document that often comes out of a six-month workgroup process. If this is appealing to the rest of you and you’re interested, we could give that a try.
Margaret Kalina – I endorse this. Some follow-up could include another step beyond that. It’s an opportune time to put some data clearly in front of legislators and make it work before accountable care organizations (ACOs) are mandated.
Mark Schoenbaum – Let’s get all the pieces out on the table now. I think we would want to put a draft before you for review and also for some priority setting of the stages of the timeline and for all the choices to intervene in that pipeline. I think you would want to weigh in on what you want, such as supporting clinical site issues. We would want to frame that up for you to make some choices.
Ray Christensen – Where is this legislation going, would that have an impact?
Mark Schoenbaum – Probably not this year with no changes to MERC expected. Changes to scope of practice were hot this year, and something may pass. If you want to weigh in on a position, that’s your decision. For the committee as a whole, it’s too late for this year, so we would be looking towards next year.
Ray Christensen – One bill from this year is centered on pain management and nurse anesthetists versus the direct supervision of anesthesiologists. This could have an impact on rural communities. I’m concerned about the direction of this legislation.
Julie Sabo – That bill speaks to registered nurse anesthetists, not nurse practitioners. It’s controversial. I don’t know where it will end up this session. Can CNAs provide pain management in this setting? We will know after seeing the final bill today.
Mark Schoenbaum – Some of you may want to weigh in on that.
Margaret Kalina – The bill may include PAs. RHAC should do monitoring on changes in legislation that affect a number of NPs and PAs practicing in rural settings. If this bill were passed, it would change their practice setting.
Mark Schoenbaum – We can collect ongoing information on practice settings, which could be a paper on its own, but cause and effect is hard to prove.
Margaret Kalina –How long will they continue in practice? If this change happens, what might change in your practice going forward?
Tim Held – We can broaden that monitoring for all health care workforce change laws, put it on the radar and monitor all of that.
Work Plan Access and Updates
Kristen Tharaldson – For an update on Rural Obstetrics Report, the main recommendation from the report was to focus on doulas in rural areas, especially with the passage of the doula bill. By July 2014, doulas will have insurance coverage through Medicaid and rural areas will know more about doulas. We have been tracking implementation in a workgroup between Minnesota Department of Health (MDH) and Minnesota Department of Human Services (DHS), discussing coding and billing for doula payments. Another bill in the house is to include the JJWay Community Oriented Perinatal Educator course as an accepted training program for doula Medicaid payment. While Doulas of North American (DONA) are currently the largest doula training program, there’s no focus on health equity or patients of color like the Jennie Joseph program.
MDH sent a request to the U.S. Preventive Services Task Force to add doulas, and this will be a game changer nationwide. If this passes, all doula coverage will be covered under ACA for Minnesota insurers and MinnesotaCare. The committee from the ACA is reviewing the application right now, and we will hear back within the year. Another doula related bill that was passed this year is the Children’s Defense Fund legislation, which focuses on shackling for pregnant women in the jail setting. Women in labor can be shackled, along with other restrictions on women being able to bond with the baby before the baby is taken into foster care. Iris Rising, a prison doula project in Shakopee women’s prison, is working with incarcerated women to improve birth and parenting outcomes. In 2000, the Senate instructed all employers to create breastfeeding accommodations and eliminate discrimination against breastfeeding. Increasing maternity leave from 6 to 12 weeks passed through two committees in the house, and another recommendation addressed in the OB report includes better support for mothers with postpartum depression.
Mark Schoenbaum – For an update on Dental Therapists Report, ORHPC has been tracking developing and emerging occupations, like dental therapists. I have a summary of the report today, which was a preliminary snapshot on workforce characteristics. There are 32 licensed DTs, compared to 3,000-4,000 dentists and over 5,000 dental hygienists. Based on this early review, the results of the development of this profession is promising and making a difference. One thing of note, a respectable number of DTs are working in rural areas. There’s a private practice in Montevideo doing well using dental therapists. Another is St. Joseph’s Health Services in Park Rapids, which is a CAH that has its own dental clinic that has hired DTs and this is also working well. The impact is a little clearer in Park Rapids than compared to the Metro area, because they have additional capacity for dental therapists and this allows the hospital to divert dental emergencies from the ER to the dental clinic adjacent. They report that unneeded or avoidable dental visits to the ER have decreased, as well as a decrease in what looks like drug-seeking visits, as those with toothaches can be sent to the dental clinic. Our research will continue.
With the legislative updates that we’ve talked about already, it looks like we’ve already hit the top issues. One thing of interest, you identified that there’s a barrier to recruiting and retaining rural health care workers because of low wages. There are now direct attempts to raise the minimum wage. How do you think that would impact rural Minnesota?
Joe Schomacker – The minimum wage will have a bigger blowback for long-term care facilities in rural Minnesota. There will be a strong impact, and lobbying groups have been trying to find extra funds to push towards those facilities for those who would be affected by the minimum wage and would otherwise close because they would not be able to keep adequate staffing levels. One piece of legislation being pushed is the 5 percent campaign, which is asking for 5 percent rate increase in home and community based health care waivers, in addition to a 1 percent increase in quality care standards. It passed the House on Friday. We’ll know more in another week.
Mark Schoenbaum – What about the proposal to change loan forgiveness for nurses in nursing homes?
Joe Schomacker – There’s a lot focused on the retention end of things. Some bullet points include removing the exclusion of RNs and allowing them to participate in retention programs, reducing the number of hours from 20 to 15 in order to get into the retention program, reducing scholarship expenses such as childcare, and requiring facilities to commit to these programs. The bill covers home and community-based scholarships, and allows for funds with that. Some don’t have federal matching, so we’re working on that as well, and a push for targeted need funding. The target is K-12 for nursing assistant training, while focusing on higher education for growing capacity for training loan forgiveness programs for nurses, rate incentives for wage increases. That’s what the proposal does.
Kristen Tharaldson – The next Rural Health Conference will be held June 23- 24. You can reserve lodging now.
Mark Schoenbaum – For updates from staff, we’re gearing up for the Rural Health Conference. We’ve also hired a new employee for the federal innovation grant, with some activities for developing emerging occupations. Robyn Anderson starts next week.
The next Rural Health Advisory Committee meeting will be on Tuesday, May 20, 2014 in the MDH Orville Freeman Building. Videoconferencing services will be available.