Earlier I spoke of nine things we can do in Alabama as consumers to strengthen rural health care. Having spent a couple of days in Austin at the National Rural Health Association conference, Dale Quinney and I brainstormed and came up with four things the state of Alabama can do to improve the health care delivery system in rural Alabama right now:

The pipeline for rural primary care providers needs to be strengthened rapidly and effectively. There are opportunities to strongly encourage (pressure) Academic Health Centers in Alabama to produce sufficient primary care providers of the right background who are committed to practice in rural Alabama. These providers should include not only physicians who will go into Family Medicine, RURAL pediatrics or RURAL Internal Medicine but should also include mid level providers to be a part of the health care team. Alabama programs are leaders in selective admissions, pipeline programs, and rural tracks in both UAB and USA, wiht examples found here and here. Considerable expansion coupled with measurable outcomes (entrance into primary care specific post-graduate training, entrance into practice in rural Alabama, continued practice at 5 and 10 years) should lead to more providers very quickly.

Enhancing primary care delivery quickly will result in an improvement in health outcomes. The Office of Rural Health/Office of Primary Care or another agency in the Alabama Department of Public Health needs to become a leader in facilitating practice transformation. Physicians in rural Alabama will need more than just computers in their offices to practice in the new age of accountability and quality improvement. The Office should have sufficient staff and resources to functionally coordinate efforts by a myriad of agencies including AQAF, BC/BS, Al-REC and other HIE entities. The goal should be that every primary care practice in rural Alabama has the opportunity to participate in practice improvement activities and deliver measurably enhanced primary care. The goal should be that every primary care practice should be able to qualify for NCQA Patient Centered Medical Home Level 3 status within 5 years

The rules for licensure and practice protocols need to be scrutinized.  There are numerous instances where professional organizations or trade organizations have been allowed to make rules that while making sense on the face, serve to reduce the efficiency of rural practice. This is more true as technology changes.  An example is the Board of Dental Examiners which only tests once a year and does not grant reciprocity such that should a dentist consider relocating to Alabama he or she would have only one opportunity to do so annually. Given the ease of giving a test at a testing center, this seems antiquated. Another is the Alabama Board of Pharmacy’s rules limiting or preventing  telepharmacy, which would be a boon to rural hospitals. A third example is one of Psychiatry. There are acute mental illness needs in every state. In Alabama, these are exacerbated by a chronic shortage of mental health professionals. Several times over the past 10 years we have had natural or man made disasters where voluntary mental  health professionals have desired to come and assist with the acute crisis only to be thwarted by the Board of Medical Examiners. There are many  such instances that need to be addressed. There needs to be attention paid to this rapidly as technological advances have already outpaced many of these rules.

Technology such as telehealth offers tremendous opportunity to transform care delivery but there needs to be a local infrastructure in place. There are many examples of telehealth  and other technologies reducing disparities, eliminating costly transportation, and improving care. For the most part, these technologies are coupled with robust primary care and community hospital resources. It is vital to leverage technology to improve care. It is clear, however,  and supported by data that without the “high touch” component best exemplified in primary care practices outcomes will remain below that of the country and the rest of rural America. There needs to be an office whose responsibility is to assure that technology is leveraged to its fullest but that the outcome is always improved health for the citizens of Alabama.