Remarks to the Annual Rural Health Policy Institute

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by HRSA Administrator Mary K. Wakefield, PhD, RN

January 30, 2012
Washington, D.C.

It’s really nice to be with you this morning among friends and colleagues. And at the onset, I want to acknowledge the NRHA and thank you for the great work you do for rural America.  

I also want to acknowledge some HRSA leaders and staff here today – in particular the Office of Rural Health Policy staff here today.  Under Tom Morris’ terrific leadership, I can say from the helm of HRSA – this group is the best of the best.  And I would like to recognize Sahi Rafiullah’s work as Deputy for ORHP. Sahi is a key part of making the Office run on track.

When I saw the title of this conference – Fighting for Rural Together – I immediately thought of ORHP.  I can’t imagine rural health having a better ally inside the federal government.  ORHP’s leadership and staff are pleasant as can be in here, but don’t let them fool you, they’re a force to contend with in my work world.  We’re very fortunate to have them at HRSA.

I’m going to ask all HRSA staff to stand.  Please seek them out, let them know what you think, what your concerns and suggestions are.

For those of you who are not familiar with ORHP:  It is home to the Department’s only rural-specific grant programs, and the Office also counsels the Secretary on the impact of Medicare and Medicaid regulations on rural providers and communities.  

Tom Morris serves as the HHS representative, not the HRSA representative, on the White House Rural Council, which Secretary Sebelius just spoke about, so we have a great expert at the table. Tom will be speaking about rural health care and new primary care models on Wednesday morning, and I certainly encourage you to attend that session.

Also relevant to our work is the Secretary. We are all very fortunate to have a strong ally in Secretary Sebelius.  As the former governor of Kansas, she knows the health care challenges rural America faces every day – higher rates of poverty, lower rates of health insurance coverage, greater numbers suffering from health problems and chronic diseases like obesity, diabetes and cancer.

And I can honestly say there’s hardly a meeting that I’m in with her and with others where she isn’t inquiring about rural health impact or rural needs.

Well, the Secretary shared with you some of the broad provisions of the Affordable Care Act.  Implementing this law is how we spend a lot of our time these days.  Clearly, the ACA has significant implications for rural health care delivery and the health of rural communities.  And so that’s where I’ll focus most – though not all – of my remarks, looking at the overlay of ACA provisions with HRSA’s portfolio of programs and focus on rural.  There’s a fair amount of misinformation out there, so I appreciate the opportunity to tell you exactly what we’re doing.

While it is a great deal of work – and associated responsibility – I am very proud that the Administration has put its trust in HRSA to lead the implementation of 50 provisions of the Affordable Care Act, and to co-lead 16 other provisions.  And I think you’ll see that with the terrific staff at HRSA, we’re delivering on those expectations.

Before I get into some of that activity, I think it merits mention that the President’s budget, for the past three years, has included the Improving Rural Health Care Initiative. And for three straight years, the President’s budget includes funding for this important effort.

This initiative continues funding of HRSA's core rural health programs and supports key activities such as the identification of best practices, workforce recruitment and retention, telehealth and HIT coordination, and cross-governmental collaboration.

In support of the Initiative, ORHP is building a programmatic “evidence base” for our rural grant programs to ensure that we’re learning from past investments and using lessons learned to inform current and future grantees.

In May 2012, a few months from now, we plan to make more than 60 new awards for the Rural Health Outreach Program, which will fund projects based on an evidence-based or promising practice model.

ORHP is also moving towards a more evidence-based approach by selecting key measures to demonstrate the impact of  Medicare Rural Hospital Flexibility (Flex) grant dollars on improving hospital outcomes across quality improvement, financial and operational improvement, and health systems development.

In another quality initiative, the Medicare Beneficiary Quality Improvement Project (MB-qip), participation across the country continues to expand. As of today, 890 hospitals are involved, and 11 states have all of their critical access hospitals participating.  

MBQIP is a voluntary Flex program activity that allows hospitals to look at their own data, measure their outcomes against other CAHs, and partner with other hospitals in the state around quality improvement initiatives to improve outcomes.

We see the MB-qip program aligning tightly with the larger HHS activities in the Partnership for Patients Initiative that springs from the ACA because both the MB-qip and the Partnership for Patients programs share the goals of reducing patient harm and improving quality.

Partnership for Patients is a public private national partnership to improve the quality, safety, and affordability of health care for all Americans. This ACA provision is critically important to helping to strengthen the work necessary to prevent harm to patients.  The data paint a disconcerting picture – that for example one in about 20 patients has an infection related to their hospital care, or that – on average – one in seven Medicare beneficiaries is harmed in the course of their care, costing the government and so the taxpayer an estimated $4.4 billion a year.

Efforts to make care safe are, of course, as important for rural as well as urban health care infrastructure to address. We reached out early to our colleagues at CMS to make sure that rural was at the table on these activities, and they’ve been very receptive in working with us.

And by the way, at HRSA, we are very lucky to have Paul Moore, a senior advisor in the ORHP who previously served as president of the NRHA and is a pharmacist.  Paul has been instrumental in leading this effort and ensuring that rural health concerns around safety are considered by CMS and more broadly by HHS. Paul is here so please check in with him for more information on this topic.

This past November, we celebrated National Rural Health Day by co-hosting a webinar about Partnership for Patients with the National Organization of State Offices of Rural Health.  The number of rural hospitals participating in the Partnership is steadily increasing – more than 440 have signed the pledge so far – and no hospital is too small to participate.  

In an effort to inform the Partnership efforts, ORHP pulled together a group of rural quality experts in August of last year to develop suggestions on quality improvement in low-volume rural settings.  I sent the suggestions over to the CMS leadership, and we’re continuing to work closely together to ensure that rural providers are a key part of the ongoing work of the Partnership.

Another key element of the Improving Rural Health Care Initiative focuses on workforce, long a challenge in rural communities. I think it’s worth noting that we’re at the halfway point of two pilot programs focusing on rural workforce issues.

In terms of the first pilot:

• We’re in the second year of our Rural Network Workforce Development grants, which invested nearly $4 million in 20 communities to develop networks to promote training and preceptorships in rural health care facilities. The grantees in this pilot are looking at everything, from physician training to nursing to oral health.
• We’re also funding a grant with the NRHA to work with the 23 Rural Training Track family medicine residency programs around the country.  This pilot is looking at ways to expand the number of RTTs nationally while also increasing interest in this model among family medicine residents.

Another primary focus area for the Rural Health Initiative is in the area of health information technology (HIT) and telehealth.

As the Secretary mentioned, I co-chair the HHS Rural HIT Task Force with the National Coordinator for Health Information Technology, Farzad Mostashari.  

Much of the work of the Task Force has been adopted by the White House Rural Council. Some of our focus has been to reach outside of HHS, for example, on increasing access to HIT capital for rural providers by collaborating with our colleagues at USDA.

And, through the Rural HIT Task Force, we’ve also partnered with the Federal Communications Commission to look at ways to increase access to broadband for rural communities.

Within HRSA, in September of last year, ORHP invested $12 million to support 40 awards through Rural HIT Network Development Grants.   This pilot supports networks in their efforts to adopt HIT and certified EHR to effectively achieve “meaningful use.”    

We’re also excited about the work we’re doing in telehealth.  In the coming months, we’ll partner with the Institute of Medicine, which will hold a planning meeting on the role of telehealth in our evolving health care environment.

The Institute of Medicine will name planning committee members in the coming weeks and will hold the planning meeting later this spring.  

It will then publish a report, and I think the findings will be an important resource not only for HRSA but also for anyone interested in seeing how emerging health information technology applications can improve health care delivery and outcomes.  

Given all that is happening with health care reform and other changes in the field, it seems like a prudent time to carefully consider where telehealth fits into the health care delivery mosaic.

In the meantime, we hope to have the funding opportunity for new Telehealth Network Grants available next month, in February. These projects are designed to demonstrate the use of telehealth networks to improve healthcare services for medically underserved populations, obviously including rural communities.

As I mentioned at the beginning of my remarks, virtually all we do at HRSA – through every program – increasingly is filtered through a lens that includes a focus on what each particular initiative or program can mean for rural America.

Now I’d like to say a few words about what’s going on across HRSA.

As you know, health centers are one of the key parts of the rural health care safety net.  HRSA’s health center network treated 19.5 million patients at more than 8,100 service delivery sites in 2010.  The ACA makes significant investments over five years to expand health center operations.

In Fiscal Year 2011, we awarded almost $900 million to more than 500 health centers serving rural areas.  This funding included targeted expansion and quality improvement investments.  

For example, through the Affordable Care Act, we awarded:

• over $12 million for 26 awards to support health center new access points in rural areas;
• $4.5 million to 57 organizations in rural areas that are interested in becoming health centers through our Health Center Planning Grant program; and
• Over $200 million to 52 health centers to support major construction and renovation projects in rural communities.

Also as part of the ACA, we awarded $38 million to more than 100 school-based health centers in rural areas through the School-based Health Center Capital Program in FY2011.  And just last December, the program provided almost $8 million to an additional 26 school-based health centers in rural areas.

There will be a new funding opportunity this spring and it’s important to note that applicants may be health centers or health departments, hospitals, school districts and others.  In fact, to date half of the awards have gone to health centers and half to other types of organizations.

These awards are important as they address significant and pressing capital needs to support the expansion of services at school-based health centers by providing funds for construction or renovations and support the purchase of equipment.

For a lot of our rural schools that are hit by a variety of challenging economic constraints, these investments are critical to strengthening the availability of health care taken to where children are in schools.

On the quality front, 80 percent of health centers in rural areas made the commitment last year to becoming patient-centered medical homes, and the ACA provided about $15 million to support these efforts.

In addition to the important role that CHCs are playing in the rural safety net, I also want to stress the very important role played by the more than 3,700 rural health clinics and the more than 2,000 small rural hospitals across the country.

Research from the University of Southern Maine shows that 86 percent of independent Rural Health Clinics provide free care or a sliding fee scale, and 97 percent are accepting new Medicaid and CHIP patients.  

Looking out for the interests of patients seen at Rural Health Clinics has always been a priority for HRSA and for ORHP.  

We currently run a quarterly technical assistance series for RHCs to provide ongoing training and information around issues such as coding and billing, regulations, and examining issues such as the impact of health information technology.  

On average, 250 RHCs take part in these ongoing educational series.  We’re also working with State Offices of Rural Health to provide technical assistance to RHCs. And each year, when we review Medicare regulations, we look for impact on RHCs, making sure their concerns and considerations are taken into account in the rulemaking process.

And in addition to rural health clinics, we know that rural hospitals and other private practice physicians, NPs, PAs, pharmacists and others play a key role in measuring the health of rural communities.

Their financial health and the health of the people they serve often are linked to whether the people seeking care have health insurance coverage.  Historically, this picture hasn’t been a positive one in rural areas.  For example, our smallest communities of 2,500 have disproportionally higher rates of uninsured than other areas and our rural areas that are more distant from urban areas have higher rates of uninsured. And young adults in rural areas – ages 18-34 – have the highest rates of uninsured across all age groups and that is particularly true in rural areas where about one third of those 18-34 lack insurance coverage. That’s why one of the early ACA provisions now in effect – the ability of young adults up to age 26 able to stay on or get on their parent’s health insurance plans – is especially relevant for rural populations and providers.

And, as of today, there are 2.5 million young adults across the nation who have obtained health care coverage as a result of that provision, the benefits of which are obvious to their health and the economic health of the providers where they seek care.

Another other key piece in the complex mosaic that makes up the rural health care network is the National Health Service Corps.

As Secretary Sebelius mentioned earlier, the NHSC now includes more than 10,000 primary care clinicians serving communities across the nation.  This is a historic milestone for the Corps.  Half of these 10,000 Corps clinicians serve in rural areas, and more than 80 percent of them continue to serve in high-need areas after they fulfill their service requirements.  

As you probably know, the Obama Administration included Critical Access Hospitals as eligible NHSC-approved sites.  This is a very important opportunity now available for Crucial Access Hospitals and was designed to help ensure that the unique needs of rural communities and the providers that serve them are met.

Already, the program has approved 45 CAHs as NHSC eligible sites since it began in October.  In addition, another 96 applications are in progress. Since the NHSC loan repayment program application cycle opened in December, we have received 20 applications from health care providers working in a Critical Access Hospital.

This program is also very important to Rural Health Clinics.  In 2011, over 400 National Health Service Corps clinicians practiced at Rural Health Clinics, with a great many of those positions filled by primary care Physician Assistants and Nurse Practitioners.  

Obviously, strengthening access to a rural health primary care workforce requires us to further bolster the primary care workforce even as we work to retain the clinicians we have today in rural areas.

This is the focus of our Bureau of Health Professions, which provides financial support to colleges and universities for training and curriculum development, scholarships and loan repayments for students in the health professions.

In FY 2011, appropriations for HRSA’s workforce training programs totaled about $675 million.  Several of our health professions training programs give students the chance to train and serve in rural or other underserved areas.  And by promoting specific training in rural health settings, we hope to increase the number of primary care professionals practicing in rural areas.  

Through the programs in this part of HRSA, we support residency training programs in primary care to benefit rural communities through the Primary Care Training and Enhancement Program, the Area Health Education Centers Program, and the Teaching Health Centers GME Program.  In fact, 15 of the 22 grantees under the Teaching Health Center program, a new program that is a product of the ACA, the Teaching Health Centers serve rural communities through residency training.  

In addition, all of our nursing programs under Title VIII of the Public Health Service Act have a statutory funding preference for projects that substantially benefit rural or underserved populations – and we know how important nurses also are in providing care to underserved areas.  

Nurse anesthetists, for example, account for two-thirds of anesthetists in rural hospitals, and, in some states, are the sole anesthesia providers in nearly all rural hospitals.  HRSA is pleased to support training for this group of health care providers that are so important to rural health care delivery.     

We have also made significant progress in examining shortage designations through the work of the HPSA/MUA Negotiated Rule Making Committee.  This committee worked really hard over the past year-and-a-half to develop specific recommendations on improving HPSA and MUA designation methodology, including NRHA’s Alan Morgan, who served on the Committee, as well as other rural experts.  Thanks to their diligence, HRSA has valuable input as it works to make health care more accessible to more Americans.

Other HRSA programs and ACA provisions implemented through the new ACA authorities of the ACA also impact on the health of vulnerable populations in rural America. Another one of those key areas are mothers and children in rural communities.

For example, we just completed a survey and found that 15 percent of children in the United States have special health care needs.  Of these, nearly one in five, or 2.5 million, live in rural areas.  These children are more likely to have health concerns, and yet their service options are often limited.  

Even without special health care needs, children growing up in rural areas are less likely to have been breastfed after birth, are more likely to have trouble in school, are more likely to be overweight or obese, and are more likely to be exposed to secondhand smoke at home.

Each of these areas alone is a call to action – taken together – they present a composite of factors that can contribute to compromised health.

Within HRSA, our Maternal and Child Health Bureau’s Title V State Block Grant Program serves nearly 14 million children up to the age of 19 in rural areas each year.  The Affordable Care Act added to the Bureau’s responsibilities by creating a new five-year, $1.5 billion Home Visiting Program, which HRSA administers in collaboration with the Administration for Children and Families, another HHS agency.

Under this program, nurses, social workers and others visit expectant mothers and their families in high-risk communities.  There, they provide counseling and intervention services designed to improve health outcomes for mothers, infants and families, school readiness for children, parenting skills, and economic self-sufficiency.  

I’m happy to report that more than 40 percent of families served by this program will be in rural communities.

The MCH Bureau also administers the Healthy Start Program, which recently celebrated its 20th anniversary.  It began 20 years ago as demonstration projects at 15 sites, testing the value of service delivery models for pregnant women and their infants in some of America’s most challenged communities.  

Today, HRSA provides grant support to 105 Healthy Start locations in 38 states, some of these Healthy Start programs serve rural communities.

Another major HRSA program that is not often highlighted – but that is a very important asset for the rural poor – is the Ryan White Program, run by our HIV/AIDS Bureau. The Ryan White Program provides health care services for about half a million Americans infected with HIV who don’t have sufficient health care insurance coverage or financial resources to cope with the disease.  

Components of Ryan White that are of particular importance to rural areas include Early Intervention Services Program funds, which are available to rural health clinics among others, and Capacity Development Grants, which are awarded specifically to underserved and rural communities to help strengthen infrastructure and expand HIV primary care services.

In addition, we just announced a funding opportunity worth $70 million to provide care for women, infants, children and youth.  Those applications are due March 16.

Another Ryan White program worth noting is the AIDS Educational and Training Centers.  These support a network of 11 regional centers – and more than 130 local associated sites – that conduct targeted, interprofessional education and training for health care providers treating people living with HIV/AIDS.

This is an important resource that organizations like NRHA, SORH, PCOs and others can point clinicians to – it’s an excellent resource for providers who may not have a high volume of patients with HIV/AIDS but still can provide high quality care.

I also want to mention HRSA’s discount drug program known as 340B, which provides significant savings to qualified health care providers.  Here, too, the Affordable Care Act has an important footprint encompassing rural health care by adding new covered entities as eligible to participate, including:

• Children’s Hospitals;
• Critical Access Hospitals;
• Free-Standing Cancer Hospitals;
• Rural Referral Centers; and
• Sole Community Hospitals.

As of January 1, just a few weeks ago, we already have 1,086 Critical Access Hospitals, 76 Rural Referral Centers and 236 Sole Community Hospitals enrolled in the program and we expect those numbers to continue to trend up.  

So, as you can see, while the heart of HRSA and HHS’s focus on rural health is ORHP and its efforts, the rural reach extends across HRSA and so, provides opportunities for your input in many other parts of the agency.  More effectively addressing rural health care challenges is a crucial focus for HRSA, and within HHS.

As you look to the investments HRSA is making in your state and that have a rural impact, I want you to consider how you might leverage your work with those assets.

I encourage you to go to our new HRSA.gov and visit HRSA in Your State.  It’s an interactive website – HRSA.gov – that provides up-to-the minute, localized information on HRSA funded programs.  You should also go to HRSA.gov to see the regional office that covers your state and contact them for information about HRSA’s investments.

In closing, I want to thank each of you for everything you do to promote the health of the people living in rural America.  I’m very proud to be your partner as HRSA Administrator and to bring additional focus on rural health to the government and to all Americans.  

And on behalf of everyone at HRSA, we look forward to continuing to work with NRHA and with each of you toward our common goals. We couldn’t ask for better, more committed partners.

Thank you.