The Membership Organization of State Offices of Rural Health
The RHIhub recently hosted a #RuralHealthChat with NOSORH for National Rural Health Day on Access to Healthcare in Rural Communities to celebrate the #PowerofRural. Read the tweets in order and catch up on what you missed! Kristine Sande, RHIhub Director, also spoke with Rural Health Leadership Radio about National Rural Health Day, the RHIhub, rural health challenges and strengths, and more!
What’s New on RHIhub?
The RHIhub updated its topic guide on Rural Tribal Health with new Frequently Asked Questions related to social determinants of health, community health representatives, and more. It also includes updated information throughout.
Join the RHIhub’s upcoming webinar on Wednesday, December 12 at 2:00 pm ET: Insights on Rural Health Insurance Market Challenges from the National Advisory Committee on Rural Health and Human Services. Featured speakers include Paul Moore and Normandy Brangan from the Federal Office of Rural Health Policy, Mary K. Rolf from Home Care of Central New York, and Abigail Barker from Washington University in St. Louis, Missouri.
Two new articles were published in the Rural Monitor:
Below are three new Models and Innovations:
NOSORH committees are great focal points for engaging in many NOSORH initiatives. Descriptions of all committees and contact information can be found on the NOSORH website.
Board- The NOSORH Board of Directors met last month to make plans for the annual board planning meeting in January. The Board member roster for 2019 was approved, and the Board reviewed and approved recommendations from the governance and structure task force.
Development –The committee met in November and heard updates on efforts relating to sponsorship, a data project to build capacity of RHC and provided feedback on a concept regarding a new learning opportunity for policy work.
Finance– The Finance Committee met in November to learn more about non-profit best practices for investment of funds and to consider some draft policy changes.
Communications- The Communications Committee continued making plans for National Rural Health Day, including webinar topics and presenters.
Policy Program Monitoring Team- Efforts last month included a review of the “Analysis of KFF Dataset –Trends in Insurer Competition, Analysis of 2019 QHP Insurer Competition and Plan Choice, Analysis of 2019 QHP Premiums.”
Last month, State Rural Health Associations were invited to join the NOSORH Policy Committee. The committee heard about the election results, an FORHP regulatory update and a preview of the work of the Policy and Program Monitoring Team. For more information or to join the Policy committee, please contact Matt Strycker.
The following update was provided by Hall Render, NOSORH Policy Liaison:
Democrats Set to Control Key Health Committees in Next Session of Congress
The Democratic takeover of the House of Representatives following the recent midterm elections will significantly change the political landscape for healthcare issues when lawmakers return for the 116th Session of Congress next year. Overall, the election results will mean divided government and a return to the era when little is accomplished legislatively. Lawmakers are expected to go from one “fiscal cliff” to another as they struggle to pass funding bills that will keep the government open.
The main focus of House Democrats is expected to be oversight of the Trump administration’s implementation of health policies but could extend to the idea of “Medicare-for-all” or other programs that would move the country towards universal health care.
Shoring up the Affordable Care Act (“ACA”), drug pricing and surprise medical bills are also anticipated to be some of the major healthcare issues tackled during the new Congress. After Republicans’ unsuccessful efforts to repeal and replace the ACA, House Democrats will be looking to pass legislation bolstering the ACA’s insurance markets and cementing the law’s provisions on pre-existing conditions. They will also look to fixing the cost-sharing reimbursement issue, which saw some bipartisan support in the Senate last year and could be one of the few pieces of legislation that makes it to the president’s desk. By contrast, the Senate, which will remain under Republican control, is expected to focus more broadly on health care.
Both parties are in alignment as to the necessity of lowering drug pricing. House Democrats will try to reign in pharma by making drug pricing one of their top issues. Incoming House Energy and Commerce Health Subcommittee Chairman Anna Eshoo (D-CA) said she wants to hold hearings before developing her prescription drug policy priorities. Meanwhile, Energy and Commerce leadership staff have signaled that 340B drug pricing program reform will no longer be a high priority for the committee. In addition, House Democrats are expected to conduct oversight of issues such as Medicaid work requirements and the Justice Department’s decision to back anti-ACA lawsuits.
At the committee level, Rep. Richard Neal (D-MA) will become the chairman of the full House Ways and Means Committee, which is expected to add at least four new Democratic members. On the Ways and Means Health Subcommittee, Chairman Peter Roskam (R-IL) and Health Subcommittee member Erik Paulsen (R-MN) both lost their races for reelection. With the retirement of Reps. Sam Johnson (R-TX), Lynn Jenkins (R-KS) and Diane Black (R-TN), Republicans will see very large changes in their membership on this subcommittee. Since Republicans currently hold an 11-7 majority on the subcommittee, these losses and retirements should mean no Republican will be removed from the subcommittee and one will be added. As for who will take the gavel as the subcommittee’s next chairman, Rep. Lloyd Doggett (D-TX) is currently expected to get the nod over Rep. Mike Thompson (D-CA) because he has more overall seniority in Congress.
At the House Energy and Commerce Committee, Rep. Frank Pallone (D-NJ) will become the full committee chairman and Rep. Greg Walden (R-OR) will become the Ranking Minority Member. Pallone has a reputation for “doing deals” across the aisle, which could make additional opioid funding a possibility. The change in control of the House means Rep. Michael Burgess (R-TX) will become the Energy and Commerce Health Subcommittee’s Ranking Minority Member once Rep. Eshoo takes the gavel. In addition to drug pricing, Eshoo’s agenda is expected to include coverage of pre-existing conditions and investment in biomedical research and development.
On the Senate side, drug pricing and additional opioid legislation could make some progress, but little else is expected to happen on the healthcare front. Senate Republicans, such as Bill Cassidy (R-LA), will continue to push for 340B reform, but any 340B legislation that passes the Senate should die in the Democratically controlled House. At the committee level, the Health Education Labor and Pensions Committee will see no loss in its membership. Sen. Lamar Alexander (R-TN) will remain chairman and Sen. Patty Murray (D-WA) will remain the Ranking Member.
At the Senate Finance Committee, Sen. Chuck Grassley (R-IA) is expected to become the next chairman. Sen. Grassley says he wants to work “on improving the affordability, quality and accessibility of health care, including in rural America.” Sen. Ron Wyden (D-OR) will remain the committee’s Ranking Member. Losses by Sen. Claire McCaskill (D-MO) and Sen. Dean Heller (R-NV) open one seat on the Democratic side of the committee aisle and one on the Republican, which are expected to be filled before lawmakers return for the 116th Session of Congress in January.
Congress Unlikely to Make Progress on Health Care Bills Before Year-End
As government funding battles overtake Capitol Hill, it appears Congress will not use the lame duck to resolve outstanding healthcare issues. While the desire to steer clear of health are fights is something different from prior years, outgoing House Ways and Means Committee Chairman Kevin Brady (R-TX) said this week that healthcare legislation will not be a priority during what’s left of the lame duck session.
Furthermore, Democratic control of the House of Representatives that comes in January has caused many Democratic lawmakers to push their healthcare priorities into the New Year. However, some policy changes could still surface as additions to a year-end spending package that must be passed before December 7 in order to avoid a partial government shutdown.
Luckily for a majority of healthcare programs, funding for most agencies within the Department of Health and Human Services (HHS) was included in a giant spending package Congress passed in September. Those that remain to be funded include the FDA, which receives its funding through a separate bill and user fees. A House Republican tax bill was released on November 26, but it did not address any of the Affordable Care Act’s taxes, such as the medical device tax and the “Cadillac” tax on health plans.
CMS to Expand Medicaid Covered Mental Health Treatment
On November 14, CMS announced that states can soon begin applying for waivers to expand treatment capacity for serious mental health issues. HHS Secretary Alex Azar highlighted the effectiveness of waivers for substance abuse treatment citing Virginia as an example. Virginia received approval for a waiver in 2016 and subsequently saw a 39 percent decrease in opioid-related emergency room visits.
Waivers will allow states to lift the “IMD exclusion.” The IMD exclusion prohibits the use of federal Medicaid funds to pay for substance use disorder treatment for patients age 21-64 at inpatient mental health treatment facilities that have more than 16 beds. It also prohibits Medicaid beneficiaries who are receiving treatment at IMDs from receiving additional Medicaid-covered care elsewhere. Many experts state the IMD exclusion is a large hindrance to treatment for low income people.
Health-Related Bills Introduced This Month
Sen. Orrin Hatch (R-UT) introduced S.3693 to amend Title XVIII of the Social Security Act to provide for the treatment of certain cancer hospitals.
Sen. Todd Young (R-IN) introduced S.3685 to amend the Public Health Service Act to expand the authority of the Secretary of Health and Human Services to permit nurses to practice in healthcare facilities with critical shortages of nurses through programs for loan repayment and scholarships for nurses.
Sen. Jeff Merkley (D-OR) introduced S. 3680 to require the Secretary of Health and Human Services to establish references prices for prescription drugs for purposes of federal health programs.
Rep. Erik Paulsen (R-MN) introduced H.R. 7177 to amend Title III of the Public Health Service Act and Titles XI and XVIII of the Social Security Act to accelerate the adoption of value-based payment and delivery arrangements among health care stakeholders intended to coordinate care, improve patient outcomes, share accountability or lower costs.
Sen. Bill Cassidy (R-LA) introduced S. 3619 to amend Title XVIII of the Social Security Act to restructure the payment adjustment for non-emergency ESRD ambulance transports under the Medicare program.
Rep. Erik Paulsen (R-MN) introduced H.R. 7122 to amend Title III of the Public Health Service Act and Titles XI and XVIII of the Social Security Act to accelerate the adoption of value-based payment and delivery arrangements among healthcare stakeholders intended to coordinate care, improve patient outcomes, share accountability or lower costs.
Sen. Rand Paul (R-KY) introduced S. 3610, known as the Medicare Patient Empowerment Act of 2018, to amend Title XVIII of the Social Security Act to establish a Medicare payment option for patients and eligible professionals to freely contract, without penalty, for Medicare fee-for-service items and services while allowing Medicare beneficiaries to use their Medicare benefits.
During the 2018 American Public Health Association (APHA) Annual Meeting, NOSORH presented Addressing the Social Determinants of Health in Rural Communities: Identified challenges, opportunities and available resources. This work was done in partnership with the Association of State and Territorial Health Officials (ASTHO) with funding from HRSA. Participants learned about challenges to multi-sector rural Networks, were introduced to joint ASTHO/NOSORH resources, and discovered ways that their State Office of Rural Health (SORH) and State Health Official (SHO) could assist in their efforts.
“This was a great opportunity for the public health sector to learn about the value of a SORH and begin thinking about what connections need to be made,” said Chris Salyers, NOSORH Education and Services Director. “Very few people in the room were familiar with SORHs, so I feel like we hit the exact audience that needed to learn about them.”
Numerous other presenters at the conference also pointed to the importance of a SORH during their presentations, including County Health Rankings community coaches, NORC Walsh Center for Rural Health Analysis, and the Indiana Rural Health Association. Melinda Merrell of the South Carolina Office of Rural Health presented her dissertation research related to the impact of rural hospital closures. Congratulations, Melinda!
Have you (or someone you know) received a phone call from your grandchild saying they’ve been arrested and need your help? What about someone calling claiming to be from the IRS and there was a problem with your taxes? These are a just two examples of fraud discussed at the Department of Justice (DOJ) Rural and Tribal Elder Justice Summit, the first meeting of this type hosted by the DOJ Elder Justice Initiative.
Through a developing partnership with the DOJ, NOSORH was able to introduce National Rural Health Day (NRHD), the Power of Rural movement, the work of NOSORH and State Offices of Rural Health to the participants of this two-day event. The Summit was held in Des Moines, Iowa, on November 14-15 and featured speakers Matthew Whitaker, Acting Attorney General; Pamela Teaster, Virginia Tech Center for Gerontology Director and Professor; and Marit Anne Peterson, Minnesota Elder Justice Center Program Director. The topics covered were as varied as the speakers and were delivered by panels of experts. Topics included Federal Efforts to Support Rural and Tribal Communities, Challenges and Opportunities in Rural and Tribal Communities, and Harnessing the Power of Technology to Respond to Elder Abuse in Rural and Tribal Communities.
Tammy Norville, NOSORH Technical Assistance Director, shared information regarding NRHD and the Power of Rural movement, providing a great segue to information about SORHs after discovering that most participants were not familiar with State Offices. Following her remarks, Norville made several connections with participants, including Lance Robertson, Assistant Secretary for Aging and Administrator of the Administration for Community Living. Robertson introduced Norville to his team to begin discussions regarding the Aging in Rural Interest Group.
Overall, the first Rural and Tribal Elder Justice Summit was successful and moved the developing partnership between NOSORH and the DOJ Elder Justice Initiative Team forward.
Contact Tammy Norville (tammyn@nosorh.org) for additional information.
By Beth Blevins
Loan repayment programs in rural Nebraska are showing huge payoffs: family medicine providers who participate in them are significantly less likely to leave small towns and rural areas than those who don’t.
“We’re trying to maximize the impact and the opportunities for loan repayment in rural and urban underserved areas in the state,” said Thomas Rauner, Program Manager at the Nebraska Office of Rural Health (NORH). “So we are assessing how effective the programs are, and how are they working.”
Towards that end, NORH issued a report in July that examined the impact of incentive programs on retention of family practice providers—the most frequent specialty participating in loan repayment programs and serving in rural areas, Rauner said. The findings showed that these programs are especially effective in rural areas of the state—for example, participating small town and rural area providers are more likely to remain in their positions than non-obligated providers by 23% and 42%, respectively. They remain significantly longer by 2.3 years (small town) and 4.3 years (rural) than non-obligated providers.
A sample visual from the “Analyzing the Impact of Incentive Programs on Retention of Family Practice Providers in Rural Nebraska” report.
One thing that makes the report interesting, Rauner said, is that it offers visual representations of the data. “We’ve been working in the last few years to come up with more visualization components,” he said. “You can look at number, but a picture makes it easier to understand and share with a much broader group.” In the future, he said, they will share data by a place-based and legislative format.
Though the report was issued earlier this year, it has been in the making for nearly two decades with resources from the State Office of Rural Health and Primary Care Office grant programs, Rauner said. “The data on family medicine providers was analyzed by a graduate student intern in our office, using information from the University of Nebraska Medical Center (UNMC) Health Professions Tracking Service (HPTS), which they collaborated with our office to develop over 20 years ago,” he said.
HPTS tracks providers enrolled in all state and federal loan repayment programs during and after their obligation, Rauner said. “Using HPTS, we’re able to track all the healthcare providers in our state,” he said. “The system also allows them not only to track whether physicians who served their obligation out there stay longer in practice than those who did not have obligations, but also gives them the capacity to look at that data over time.”
HPTS data can also be used for economic analysis, Rauner said. “Some of the more interesting findings from the report was that analysis based on years worked shows there is a significant economic benefit associated with rural healthcare providers—a total of $3.6 billion,” he said. “This benefit far outweighs the financial investment in incentive programs.”
HPTS tracks physicians as well as dentists, physician assistants, nurses, graduate-level mental health providers, and allied health providers—those who qualify for loan repayment in the state. Its data also has been used by UNMC authors for reports on primary care nurse practitioners, on physician assistants, and on the status of healthcare workforce in the state.
In addition to HPTS, Rauner said, NORH uses the Practice Sights Retention Management System “to solicit feedback from the providers while serving their obligation, determining if they would like and need to continue receiving loan repayment assistance, and their anticipated and actual retention.”
The data from the two systems benefit both providers and communities, Rauner said. “There are many variables when it comes to assessing workforce needs,” he said. “Each community desires the right care, right time, right place, and the right cost. NORH is continuing to work with communities to develop such a system of care, while working to improve the process and utility of loan repayment programs.”
With the proven success of the loan repayment programs in Nebraska, NORH also has been working to get more healthcare students enrolled in them. “We’ve been trying to simplify it as much as possible,” Rauner said. “We recently combined and changed our loan repayment applications to be a single online application. This will allow NORH to track and process applications for loan repayment and determine the best fit for the provider and the site.”
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Does your SORH have a “Promising Practice”? We’re interested in the innovative, effective and valuable work that SORHs are doing. Contact Ashley Muninger to set up a short email or phone interview in which you can tell your story.
National Rural Health Day (NRHD) was celebrated on November 15, 2018, with a record number of nationwide events held by State Offices of Rural Health, rural communities, providers and stakeholders. Activities this year included Walk with a Doc walks, Twitter chats, and a call to action to use the #PowerofRural on social media to create a coast-to-coast conversation on rural health. The #PowerofRural generated over 7 million impressions and over 2,200 tweets on November 15, surpassing 2017’s impressions by over 3 million!
NRHD received broader national attention and reached new audiences with many new partners engaged this year. Teryl Eisinger, NOSORH Executive Director, was interviewed on Cerner’s The Value of National Rural Health Day podcast, and she wrote a blog post, The Power of Rural to Improve Health, that was featured on the HHS Office of Disease Prevention and Health Promotion’s Prevention Policy Matters blog. In addition, Karen Madden, Director of the Charles D. Cook Office of Rural Health, and Dr. David Sabgir, Founder & CEO of Walk with a Doc, joined Eisinger for a Rural Matters podcast on the topic of NRHD and the Power of Rural.
Now in its fourth year, the 2018 Community Stars e-book was published on NRHD with inspirational stories of individuals and organizations who truly embody the Power of Rural. Over 100 nominations were received with 29 different states represented. Thanks to all who took the time to submit a nomination to formally recognize the work of the many unsung heroes of rural health!
There were many opportunities to participate in NRHD, including three live NOSORH webinars on rural health hot topics: A Conversation on Rural EMS, Policy and the Power of Rural, and Rural Networks: Making a Difference in the Opioid Epidemic. The presentations and recordings can be found here on the NOSORH website. A Telehealth Twitter Chat was hosted by HRSA and an Access to Healthcare in Rural Communities Twitter Chat was co-hosted by NOSORH and RHIhub. In addition, NOSORH partnered with Walk with a Doc to encourage rural communities to host a special NRHD Walk with a Doc, resulting in 17 walks held across 12 different states!
As always, NRHD wouldn’t be successful without support from all 50 State Offices of Rural Health and partners across the nation! Along with countless events promoted by national partners, many State Offices participated in NRHD activities, including obtaining Governor’s proclamations, visiting rural providers and partners, holding contests, producing videos, distributing press releases, hosting rural health conferences, presenting special awards, and much more.
Be sure to mark your calendar for Thursday, November 21, and join the Power of Rural movement throughout 2019!
For more information on NRHD, contact Ashley Muninger, NOSORH Communications & Development Coordinator.
RHIhub is excited to be co-hosting a Twitter chat with NOSORH for National Rural Health Day on Access to Healthcare in Rural Communities on November 15, 2018 at 12 pm Eastern. Please join us on Twitter for this important discussion. Also, watch RHIhub’s social media feeds for our countdown to National Rural Health Day, featuring successful rural programs around the country.
What’s New on RHIhub?
The RHIhub updated its topic guide on Rural Health Clinics (RHCs), which provides an overview of RHCs and includes information on certification, considerations for becoming an RHC, staffing requirements, reimbursement, resources related to maintaining the primary care workforce, and more.
Two new articles have been published in the Rural Monitor:
RHIhub recently held two webinars. If you missed them, check out the recordings online:
New in Models and Innovations:
RHIhub is hiring!
Please help spread the word that the RHIhub is looking for a dedicated and passionate person who wants to help rural communities across the country. Interested candidates can apply online by November 9, 2018 to join a team of Web Writers contributing to the Rural Monitor and Models and Innovations.
NOSORH committees are great focal points for engaging in many NOSORH initiatives. Descriptions of all committees and contact information can be found on the NOSORH website.
Aging in Rural Group – The Aging in Rural Group held its October meeting at the NOSORH Annual Meeting in Cheyenne, Wyoming. The group was fortunate to have two experts on hand to provide perspective and introduce the group to innovative programs. Dr. Kathy Black, Principal Investigator, Age-Friendly Sarasota, and faculty at University of South Florida Sarasota-Manatee, presented a plenary session on Rural Health Alignment with Age – Friendly Communities before joining the group discussion. She shared a vast array of resources and tools available for use in aging work. Shelly Jackson, OVC Visiting Fellow, Elder Justice Initiative, US Department of Justice, spoke to the group at length regarding the Rural and Tribal Elder Justice Initiative and associated resources. The group will continue to follow the work of these two highly regarded experts and will provide any relevant information and/or resources in coming months. If you have interest in joining the Aging in Rural group, please email Tammy Norville at tammyn@nosorh.org.
Development Committee – The Development Committee’s discussion centered around sponsorship status and potential growth of sponsorship opportunities moving forward. If you have interest in joining the Development Committee, please forward contact information to Tammy Norville (tammyn@nosorh.org).
Flex Committee –Harvey Licht, Varela Consulting joined the Flex Committee to share information regarding the CMS Star Rating Program for Hospitals proposed rules. Harvey is working with the PPMT Committee to formulate NOSORH comments on these proposed rules and having him join the Flex call provided members an opportunity to ask questions and provide “boots on the ground” input for consideration. There was also continued discussion around the desire for access to quality, affordable, easily accessible education for Board Members as well as potential topics for the coming year. Generally, the Flex Committee does not meet in November nor December. However, the Flex Guidance is scheduled for release in December, so there will be a call on Thursday, December 27 at 3 PM ET to discuss the Guidance. If you have interest in joining the Flex Committee, please forward contact information to Tammy Norville (tammyn@nosorh.org).
Executive Committee– Last month, the Executive Committee reviewed recommendations from the Governance and Structure task force, prepared for the NOSORH membership meeting and planned the appointment and election of Regional Reps to the 2019 Board of Directors.
Communications- The Communications Committee continued making plans for National Rural Health Day, including webinar topics and presenters. The group discussed the option of printing hardcover copies of the Community Stars e-book for the first time.
Policy Program Monitoring Team- Last month, the PPMT worked to finalize comments on rural ACO. At the Annual Meeting, Harvey Licht shared information on tracking state coverage initiatives and led a discussion on the increasingly important role of states on ensuring access. Analysis of these initiatives and several links for tracking these initiatives were included in the presentation. The work of the PPMT in November will include reviewing appropriate measures and recommends for hospital star ratings, and tracking efforts on global payment systems.
The Policy Committee invites all State Rural Health Associations to join the monthly meeting of the NOSORH Policy Committee. Updates will be provided on federal regulatory issues, efforts to reauthorize the SORH program and other policy issues.
SORH Reauthorization Bill Update
While the House and Senate were out of session for most of October, the House version of the State Office of Rural Health Reauthorization bill (H.R. 5641) continued to gain momentum picking up three new cosponsors. In addition to gaining House Energy and Commerce member Morgan Griffith (VA), Reps. Steve Russell (OK) and Elise Stefanik (NY) also signed on a cosponsor. NOSORH met with the Energy and Commerce Committee this fall and believes it is likely the SORH reauthorization bill advances next time the committee addresses public health legislation. The Senate has already passed the reauthorization bill. If there is a House member of the Energy and Commerce Committee in your state, please contact their staff and urge them to cosponsor H.R. 5641.
President Signs Opioid Reform into Law
On October 3, 2018, the “Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act” or short hand—the SUPPORT for Patients and Communities Act (the “SUPPORT Act”)—was approved by the Senate and sent to the President. The President has now signed the SUPPORT Act into law. The SUPPORT Act is the compromise version of the opioid response bills approved by the House and Senate earlier this year.
The bill package includes a broad array of new programs and reforms specific to the opioid crisis and substance use disorders (SUDs) generally advocated by the healthcare industry. The final compromise opioid package contains over 70 opioid-related bills. For a comprehensive summary of the package’s provisions, see the section-by-section summary at: https://tinyurl.com/y9vlrsmy. Some of the key issues addressed in the SUPPORT Act are: