Remarks to the National Rural Health Association Policy Institute

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By HRSA Administrator Mary K. Wakefield

February 4, 2014
Washington, D.C.

Good morning, and thank you for inviting me here today. It’s nice to be back at NRHA’s Policy Institute. It’s always energizing to be among colleagues who are so totally committed to the extremely important work of improving the lives of millions of rural Americans.

Long before I came here to speak to you as the Administrator of HRSA, I came to these meetings as an attendee. I always found that this meeting served as one of the more important events of the year for anyone interested in rural health policy.

Looking out at the large number of you here today, I see that it continues to be an important meeting. And that makes sense. With so much going on in health care, right now it’s important to have a venue for rural stakeholders to convene.

The fact that you’re here really matters, and your opinions matter. Nobody knows better than each of you what challenges you face and where opportunities lie for improving health care for rural communities.

I looked at the meeting agenda, and NRHA has put together a terrific lineup, not easy to do with so much going on. The Department of Health and Human Services is well-represented here, with speakers from our Office of Health Reform and Centers for Medicare and Medicaid Services.  And we tried to coordinate a little to avoid redundancy so, for example, Catherine Oakar will take more of the ACA content than I initially was going to do.

On Thursday there are sessions on federal capital programs and a panel of CMS policy staff. And you’ll also hear about some of the new findings coming out of the Rural Health Research Centers, all of which are supported through the Office of Rural Health Policy.  So over the next few days, you’re going to hear a lot about key programs and policy issues from different agencies and leaders.

Before I begin formal remarks, I want to ask HRSA staff to stand. If you haven’t met some of them, please take a minute to catch them, it’s so important for us to hear from you.

Well, the long-overdue changes that have been ushered in by the ACA are, of course, a major focus of our work at HRSA, but they are not the only focus.  At HRSA and at HHS, we are also working to transform many of our programs.

I’d like to talk to you about some of the work going on specifically related to rural health that you might not be aware of. I think it illustrates some of the steps we’re taking to enhance our focus on rural issues.

First off, at HRSA, we are just finishing up an effort to better understand how the broad range of HRSA programs serves rural communities.

By virtue of being home to the Office of Rural Health Policy, HRSA has had a great awareness of rural issues and how our programs can support rural communities. What we’re working on now is how to quantify that impact across HRSA programs. So I’ve asked each of the HRSA bureaus to develop plans to better capture the rural impact of their programs.

That way, we’ll know more about how our key programs serve rural communities and how many grantees we have in rural communities, and where we could leverage more resources. The early findings are promising and confirm what we suspected: Just about every program in HRSA − whether it’s training health professionals, or serving those with HIV, or providing home visiting services − touches rural communities.

We’re also looking externally, for example, at ways to work with national associations and licensing bodies to obtain better access to workforce data, of which rural workforce is a part. This is all part of making sure we can better understand national workforce trends and use that information not only to inform policymakers, but also to help target our investments across our training and scholarship and loan programs.

And we’re continuing our work this year with the White House Rural Council to ensure that health care is front and center on their agenda. That commitment runs deep, as Dawn O’Connell, the HHS Deputy Chief of Staff, is a key part of this cross-departmental initiative, along with Tom Morris from HRSA’s Office of Rural Health Policy.

Later today, you’ll also hear from Dr. Patrick Conway about the work CMS is doing to reduce the regulatory burden for rural providers. Patrick is also heading up CMS’ Innovation Center, and we’ve had a terrific working relationship with Patrick and CMS in the development of the Frontier Community Health Integration Demonstration – or F-CHIP Demonstration – that was just recently announced.

I’ll leave the details of this initiative to Patrick, but I do want to note that his team and ORHP staff worked hand in glove to support the development of this initiative, which will develop and test new models of integrated, coordinated health care in the most sparsely populated rural counties with the aim of improving health outcomes and reducing Medicare spending.

And related to health insurance coverage in rural areas, as we’ve worked across HHS to implement the Affordable Care Act, we’ve seen great awareness of the unique opportunities provided for rural communities through coverage expansion. Our colleagues in the HHS Office of Planning and Evaluation have done some special analyses of the rural uninsured, and you’ll hear more about what that means from Catherine Oakar, from the HHS Office of Health Reform.

We’ve worked in a close partnership with Cat and her colleagues in the Office of Health Reform on ACA implementation generally and – over the past few months in particular − on outreach and enrollment of the uninsured into new insurance coverage through the Marketplaces, with attention to rural populations.

Many of you have stepped up and helped us to help people in your communities get health care coverage, and I just want to say thanks.

So this is just a quick sweep across parts of HHS to call out some of the efforts under way that directly and indirectly impact rural communities.

With that very general overview in mind, I want to focus my remarks more specifically on what we’re doing within HRSA to support rural health care and how we’re working to position our programs and resources moving forward. Our focus is driven in part by research findings – including, for example, the recent findings by a HRSA epidemiologist, MCHB’s Dr. Gopal Singh, of significant disparities in life expectancy between rural and urban areas in the United States.  As I mentioned, other parts of HRSA also make important contributions to research, and Gopal’s work is an example of that.

According to the article just published in this month’s edition of the American Journal of Preventive Medicine, the disparity in life expectancy of urban over rural areas stood at 2.4 years in 2005-2009.

And that’s part of a trend line that for rural America has been moving in the wrong direction. In fact, the disparity has increased since 1990, the article notes, because life expectancy has grown more rapidly in urban than in rural areas. Furthermore, the study’s findings indicate that mortality from cardiovascular diseases, injuries, lung cancer, and COPD is much higher in rural than in urban areas.

These findings may not come as a surprise to you. But they do speak to the tremendous importance of the work you all do to help improve the health of rural Americans, and the importance of ensuring that the programs and resources we manage are targeted for maximum benefit.

While I mentioned earlier that just about every program at HRSA has a rural dimension to it, the research supported by HRSA’s Maternal and Child Health Bureau that I just mentioned exemplifies that.  I’d like to focus on a few of our key program areas that are an essential part of the larger rural health area safety net.

First, as you all know, we continue to focus on doing what we can to increase access to care through investments in community health centers. We now have more than 9,000 health center service sites across the country, and about 36 percent of these 9,000 sites are located in rural communities.

And many of the health centers located in urban areas serve rural patients. In our most recent competition late last year for new access points under the health center program, about $83.7 million were awarded to 129 organizations located in rural areas. They, along with about 4,000 rural health clinics and small rural and critical access hospitals, play a key role in providing access in rural communities.

Another key part of the access challenge is making sure we have the right mix of providers on the ground and that they are well prepared to provide high-quality care. To help address this need, HRSA is undertaking new efforts in community-based training of physician residents.

It’s not talked about very much when people discuss the ACA, but our teaching health center program, which was established and funded through the ACA, is focusing primary care residency training in ambulatory settings by helping to support a key cohort of physicians, and to a lesser extent dentists, with a real grounding in community-based care, and with a notable inclusion of rural training.

We know, for example, that of the now 22 THC residency programs expanded and supported through the ACA, eight provided clinical training at rural sites in academic year 2012-2013.  And the THC residents that trained at a rural site provided over 38,000 hours of patient care. And 20 percent of THC residents said they came from rural areas.  So these are important settings for physicians from rural backgrounds to train in, settings that they may be most interested in practicing in.

In many ways, the ACA’s teaching health center program builds on the long-standing success of the Rural Training Track model that was pioneered in rural communities.

We’re pleased to be working with the NRHA to promote and expand this RTT model, and I’m happy to report that five new programs opened last year and one new program will open in 2014, in my home state of North Dakota, in a town called Hettinger, where they deliver both high-quality health care and a lot of pheasants during hunting season.

On top of these new investments, there are an additional seven rural training track programs in various stages of development. And this is happening at a time of increased interest in this model by medical students. The National Resident Matching Program filled 80 percent of RTT residency positions offered in March 2013, the best percentage results in the history of the rural training track program.

You know as well as I do, however, that training clinicians is just one part of the equation. We also have to work with them and encourage and support them to go to underserved rural communities. And HRSA’s National Health Service Corps and the NURSE Corps programs have been key tools in that effort.

In another example of the ACA’s investment in workforce, as a result of the support provided through the ACA and the 2009 Recovery Act, the number of NHSC clinicians working in underserved areas has more than doubled since 2008 to nearly 8,900 clinicians. When you consider that historically, about 50 percent of NHSC placements have gone to rural areas – and that based on HRSA data, about 80 percent of NHSC clinicians continue to serve in underserved areas after their commitment terms expire – you can appreciate the important impact that this program is having on access to health care in communities across rural America.

In fact, 26 states have a majority of their NHSC providers serving at rural sites; and right now, as a result of its funding, the ACA is supporting 93 percent of NHSC clinicians serving at rural sites. It’s not often mentioned when the ACA is discussed, but these are critical workforce provisions that are directly tied to this law.

We are also beginning our third year of allowing critical access hospitals to function as service sites in the NHSC loan repayment program. Currently, more than 200 critical access hospitals have been approved as NHSC service sites, and more than 50 providers at these particular hospitals are supported by the NHSC.

As you know, advertising job openings for health care providers at rural health care service sites has always been a challenge. What you may not know is that the NHSC has been holding a series of virtual job fairs to link up clinicians and providers, including one held in November that attracted 36 NHSC-approved sites and focused specifically on sites located on the US-Mexico border.

The NHSC also has an online job website where more than 3,600 NHSC-approved rural sites have completed their profiles. Getting on that job website and keeping your information current is important. It’s a go-to website for folks looking at employment opportunities in rural and urban underserved areas. In fact, the site averages more than 21,000 visitors a month.

In addition to programs such as the NHSC and Teaching Health Centers, the HRSA Bureau of Health Professions focuses specifically on training providers to work in underserved areas across many of its programs.

With these programs, you’ll see grantees focused not only on training rural health professions students, but also on increasing clinical training in rural settings so that more students are prepared to address the needs of rural communities.

For example, I don’t have to tell you the challenges rural communities face in attracting and retaining mental health professionals. The focus on meeting these challenges can be clearly seen in HRSA’s Mental and Behavioral Health Education and Training grant program. Ten of 24 ongoing grants include a primary focus on testing innovative ways to train doctoral-level psychologists and clinical social workers so that they get exposed to rural training.

Of note, for example, Nebraska is focused on training child psychologists, and Kansas’ program is focusing on using telehealth technology to extend the reach of its psychology training program. Our hope is that these investments will not only thrive over the long term, but will also serve as replicable models that other training programs can use.

The focus on training health care providers across the spectrum of much-needed health care services also includes HRSA’s nursing programs, which play a key role in helping support the training of advanced practice nurses. And I know from my time in my home state of North Dakota that Nurse Practitioners and Nurse Anesthetists play a key role in staffing up rural hospitals.

The Scholarships for Disadvantaged Students program is another training program that helps meet the needs of rural students and rural communities by providing funding to health professions schools to support scholarships for financially needy students. The program has been redesigned to give priority to health professions schools that meet key workforce development goals, including placement of graduates in underserved areas such as rural communities.

We also support rural communities with public health education investments through Public Health Training Centers. All of the Training Centers focus on the needs of underserved populations, and many of them specifically focus on rural issues. Many of the courses the Public Health Training Centers offer are available online and free of charge and can be accessed by people in your communities.

And we’re working to catalyze the delivery of health care by provider teams through interprofessional training – people working across disciplines and across settings to ensure that health care services are seamless, coordinated and collaborative – no gaps, no inefficiencies, and no compromised quality – all of which occur far too frequently when care is fragmented.

I should point out that our approach here applies not only to students but also to faculty. Educators who are trying to redesign medical residencies to train residents in new models of care – such as Patient Centered Medical Homes – need new skills, too.  These knowledge gaps should inform faculty development programs to achieve the crucial mission of training the workforce for redesigned health care delivery that emphasizes interprofessional team work, quality-improvement science, harnessing IT and telehealth, coordinating care across settings, robust patient engagement, and so on.

In order to bring a very precise focus to just some of these – that is, the combination of interprofessional education and team-based care – HRSA awarded a grant to the University of Minnesota to serve as the site of a new National Center for Interprofessional Practice and Education.

This five-year, $4-million initiative is designed to support the transformation of the prevalent siloed healthcare delivery system into an integrated health system where the workforce engages coordinated, collaborative, team-based practice that becomes the new national norm.

That, by the way, sounds a lot easier than it is.

Shifting gears for a moment, we’re also seeing increased investments in early childhood services in rural areas. Early childhood development is an important priority for the President, and HRSA has a role in this as well.

In the area of maternal and child health, the Healthy Start Program today includes 23 rural grantees, nearly one quarter of the total number of funded Healthy Start Programs, while the Maternal, Infant, and Early Childhood Home Visiting Program, which was created and funded by the ACA, uses research-based approaches to strengthen the health status of infants and young children. The Home Visiting Program now operates in more than 180 rural counties across the country, and may well be in some of yours.

And later this year, HRSA’s Maternal and Child Health Bureau plans to release a new funding opportunity entitled, “Reaching Underserved Practicing MCH Professionals Through Education and Training.” The MCHB will be working closely with ORHP to make sure that rural stakeholders are aware of this opportunity when it is announced.

So, these are just a few examples of the many ways we are focusing our programs and resources to ensure that rural America a clear focus of virtually everything we do at HRSA. To find out more about what we’re doing in your communities, I encourage you to visit our website at HRSA.gov and click on the “Grants” tab at the top of the page.

There you’ll see all the funding competitions that are open at the present time as well as all the active HRSA grants. You can also go to “HRSA in Your State” – that’s hrsainyourstate, dot hrsa, dot gov – and see HRSA’s programs and funding streams in each of your states, and programs that you may be able to align with.

Well, as I mentioned earlier, I remember the high value of this NRHA meeting before I came back to Washington. And given everything that is going on in health care today, I think it’s even more true.

As you know, in rural areas, a higher proportion of non-elderly people are uninsured compared to their urban counterparts. That one fact alone makes health reform critically important to both the health of those individuals and the financial health of the providers that care for them.

For those of us who have worked in health care our entire professional lives, the Affordable Care Act is creating a pivotal shift toward the opportunity for unprecedented improvements in the health of rural Americans.

Later today, you’ll hear more about the benefits people around the country, including many in rural areas, are getting from the Affordable Care Act. As implementation of the ACA proceeds, we see positive changes, as many newly insured take advantage of their new coverage. That not only helps the people who have long been standing outside of health insurance coverage, but it also helps improve the payer mix for rural hospitals and clinics by reducing their uncompensated care burden.

At the same time, the landscape is continuing to change. We’re seeing some consolidation and integration across the country, and rural areas are not immune to these changes. Insurers both public and private – and, quite honestly, employers and consumers – are looking for improved value from our health care system. So we’re seeing an increased focus on tying reimbursements to quality of care and patient outcomes.

As we sit here at the beginning of 2014, these and other changes beg the question, ‘What does all of this mean for rural America?’ I suspect that there are ways we can work together to help ensure that rural communities have access to high-quality health care services. And I think it starts in part with some of the HRSA programs that I mentioned earlier.

I’d also like to point to a few of the other more specific rural activities we have under way at HRSA that can be incorporated into that strategy to help position rural health care providers to leverage these new directions.

First, I’ve encouraged the Office of Rural Health Policy to be as entrepreneurial as possible in its programs. And that message has been amplified by the President’s Budget through the Improving Rural Health Care Initiative.

This charge from the White House calls on the Office to think more creatively about how to best target its programs, focus on evidence-based practices, and work across federal programs on key challenges such as quality improvements – as well as making sure that rural communities can leverage the promise of health information technology.

ORHP has taken that challenge head on. In the area of quality improvement, we’re seeing a lot of progress. The ACA’s Partnership for Patients, for example, stands out as a national effort to improve patient safety and improved outcomes. We’ve worked hard to make sure that the nation’s 2,000-plus rural hospitals are a key part of that through the work of the Rural Affinity Group.

Initial emerging results from the Partnership for Patients are encouraging. For example, more than 1,000 birthing hospitals in the Partnership have already generated a 48 percent reduction in early elective deliveries. And we are seeing improvements that reduce nearly all hospital-acquired conditions targeted by the Partnership. These are incredibly important directions, impacting both the health of rural populations and the cost of health care.

We also appreciate the support and flexibility that many of you have shown in our efforts to bring an enhanced focus on quality and performance improvement in the Rural Hospital Flexibility and Small Hospital Improvement grant programs.

And your participation in the Medicare Beneficiary Quality Improvement Program has been exceptional. To date, 45 states are participating in the MBQIP, and 93 percent of all critical access hospitals are registered.

ORHP’s Small Health Care Provider Quality Improvement Program can also be a key tool to help providers bring a renewed focus on chronic disease management, which is a high priority given the prevalence of chronic diseases and the associated costs of care.

And I want to credit CMS for its new project with quality improvement organizations to assess and enhance transfer and communication protocols from critical access hospitals to upstream hospitals in eight states. I’m sure Patrick will cover this in more detail, but I mention it here because it speaks to the important partnership between HRSA and CMS.

In each of those eight states, we’re linking the QIOs with the State Offices of Rural Health to build on our existing partnerships. We’ll also use the lessons learned from this project to help inform a national effort to expand use of the transfer measure across critical access hospitals.

So, as we think about quality and value, it’s our hope that these programs and initiatives will support increased value across the rural health care delivery system through important partnerships and collaborations.

And related to collaboration across government partners, the ongoing work of the White House Rural Council that I mentioned earlier provides a perfect mechanism to strengthen and leverage cross-federal resources for rural health, especially on a range of health IT initiatives.

HRSA, of course, has a lot of experience in rural heath IT issues, thanks to our long-term investments in telehealth. And lately, we’ve leveraged the potential of telehealth to enhance training for health care professionals.

In fact, many of our 20 telehealth network grantees use their systems for distance learning and supporting larger training efforts. For example, we’re seeing creative approaches in using telehealth to meet professional supervision requirements in behavioral health, and to allow students to take part in required training at a distance from their original training site.

A big challenge in coming years will be to learn more about how to use telehealth technology to improve health outcomes, and we’re planning a new competition later this year to support evidence-based telehealth networks’ efforts to address that very question.

Through the White House Rural Council, ORHP – which is the Council’s lead HHS representative – works closely on IT issues with the HHS Office of the National Coordinator for HIT, USDA Rural Development, and the Department of Veteran Affairs.

For example, HHS and the USDA have worked with several pilot states to help rural hospitals leverage USDA loan programs to provide capital for electronic health records. And HHS and the VA have collaborated on ways to use telehealth and health information exchange to enhance care for rural veterans.

In the course of this health IT work, we’ve learned about the growing need to train the staff needed to maintain and leverage electronic health records, telehealth systems, mobile health applications, and home monitoring equipment. As a result, we’re now funding 15 Rural HIT Workforce Training Networks that will make their training curriculums available for other rural-serving community colleges to replicate.

ORHP has also worked with NRHA and Grantmakers in Health to create the Rural Philanthropy Partnership to link rural-focused philanthropies with key federal programs that serve rural communities to identify ways we can work together to better serve rural communities. We think there are new possibilities for rural communities if we can combine our public and philanthropic efforts on behalf of improving health care in rural communities.

As we think about how best to adapt to the ongoing changes in health care, it will be important to learn from some of the ongoing innovations that we’re seeing today. Pilot programs and demonstrations going on with support from across HHS can play a key role in informing future rural health policy.

For example, we’re seeing broader rural participation in Accountable Care Organizations and Shared Savings demonstrations under the CMS Innovation Center. Initially, there were some concerns that this model may not work well for rural communities, but we’re seeing significant participation.

Today, new research from RUPRI shows that Medicare Accountable Care Organizations operate in non-metropolitan counties in every U.S. Census Region. Nine ACOs operate exclusively in non-metropolitan counties, including at least one in every U.S. Census Region. And I also want to mention the National Rural ACO group, which will have nine rural providers taking part in the CMS demonstration in the coming year.

Now I mentioned earlier that we’re asking our program folks to be more creative in meeting the emerging challenges rural health providers are facing. So we’ve made a real effort to alter the Rural Health Outreach programs to do exactly that.

Nisha Patel and her colleagues at ORHP have been working in this area. And over the past few years, we’ve focused on bringing an evidence-based focus to the Outreach, Network, and Quality programs. As many of you know, these programs provide start-up funding for community health projects, and more than 80 percent of our two most recent cohorts have continued their projects beyond our initial federal funding.

These programs now require applicants to submit and track baseline data and develop programs based on proven practices. As part of this work, ORHP has launched the Community Health Gateway, located in the Rural Assistance Center, to spotlight key lessons learned from these grants and other successful rural health projects.

We’re also providing support to the Rural Health Value website project with the University of Iowa to help rural providers through this period of transition. This grant helps providers share new models and innovations and place them in context for rural health systems and providers to aid in their decision-making.

Also in the arena of innovation, Patrick and his colleagues at the Innovation Center are playing a key role in informing future policy through a range of demonstration programs. I think the F-CHIP program that I mentioned earlier can play a key role in providing a rural perspective in the larger policy discussion.

That’s why I hope that many of the eligible critical access hospitals in the five states will apply. I think that the demonstration provides some unique solutions for enhancing care coordination and outcomes in frontier communities, and that the lessons we learn can help us determine how to better pay for and organize health care delivery in rural communities.

But that will only happen if we have robust participation in the demonstration. We’ll be working with eligible hospitals in the coming weeks to help sort through the specifics of the demonstration as they put together their applications.

While this is definitely a period of transition in health in general, and rural health in particular, one constant focus will be ensuring that we keep rural policy issues front and center, both at HRSA and in HHS.

As many of you know, ORHP is charged with advising the Secretary on rural issues, and while it’s located in HRSA, its broader policy role is the reason it was created. We’ve always reviewed all the regulations that come through HHS with an eye to how they will affect rural communities, and we take steps to ensure that when we see issues and challenges emerge, we flag them to the Department so that key players are aware of them.

And that’s one important place where the work of the Rural Health Research Centers comes into play. The ORHP policy folks work closely with the research centers to focus on key rural issues as they are emerging to ensure that we’re producing timely and policy-relevant research.

Their research findings and analyses carry a lot of weight, and more than a few times we’ve taken those policy briefs and shared them with our colleagues at CMS, or the Secretary’s Office, or the White House Rural Council.

We’ll continue to do that in the coming years. ORHP and the Centers are tracking a number of important issues on hospital finance and workforce, and also on the impact of the ACA’s insurance expansion. Those findings are a key part of informing our larger policy process.

And of course, all of you are crucially important to this policy process. As we look forward to both opportunities and challenges in the coming years, it almost goes without saying, we need to continue to hear from you as leaders in rural health.

Thanks for the opportunity to come back and join you.