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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.


Dale Quinney, Executive Director of the Alabama Rural Health Association, sent me the following assorted random facts that point to just how dire the needs are (or just how great the opportunities are) in rural Alabama.

51 of Alabama’s 55 rural counties are currently classified as having a shortage of primary care physicians.  Only Coffee, Dallas, Marion, and Pike counties are not currently considered shortage areas.  (This classification measures the provision of MINIMAL rather than OPTIMAL care.) 


To eliminate all shortage designations, Alabama needs an additional 128 primary care physicians.  402 additional primary care physicians are needed to provide optimal care. 


All 55 rural counties are currently classified as having a shortage of dental care providers.    To eliminate all shortage designations, Alabama needs an additional 288 dentists.  348 additional dentists are needed to provide optimal care.  Alabama’s only dental school currently admits only 55 students each year. 


All 55 rural counties are currently classified as having a shortage of mental health care providers.    To eliminate all shortage designations, Alabama needs an additional 44 psychiatrists.  185 additional psychiatrists are needed to provide optimal care. 


More than one half of all actively practicing primary care physicians in Alabama are aged 50 years or more. 


It is estimated that the number of annual office visits to primary care physicians in Alabama will increase by more than 1,785,000 by the year 2025 – primarily due to the aging of Alabama’s population.  Over 904,000 of these additional office visits will involve rural physicians.  This increase does not consider such adverse factors as obesity with nearly one third of all adult Alabamians currently being obese, not simply overweight. 


Only 20 of Alabama’s 55 rural counties have hospitals that perform obstetrics.  In 1980, 46 of these counties had hospitals performing obstetrics. 


More than one in every five (22.1 percent) rural Alabamians are eligible for Medicaid services.  This is nearly one half ((44.5 percent) for rural Alabama’s children. 


The per capita personal income for rural Alabama residents is $29,170 which is over 21 percent lower than the per capita income of $37,109 for urban residents and over 27 percent below the figure of $40,166 for the nation.  Five rural Alabama counties (Wilcox, Bullock, Barbour, Sumter, and Bibb) are among the 250 poorest counties in the nation. 


The motor vehicle accident death rate in Alabama’s rural counties is 25.1 deaths per 100,000 population.  This rate is only 14.6 for the nation.  30 rural counties have motor vehicle accident death rates that are more than double the national rate with eight having rates that are more than triple the national rate.  While there are a number of reasons for this disparity, the great variation in  emergency medical service among the counties must be recognized as a contributing factor. 


Nearly one in every ten (8.5 percent in 2000) rural Alabama households have no vehicle for transportation.  This percentage is in double digits for 22 rural counties.

The Alabama Rural Health Association is putting together a task force to deliver to policy makers a list of health reform actions that have been taken or will be taken as a result of the passage of the reform package. As a state, we tend to be a little wary of federal initiatives. We as an organization want to inform the gubernatorial candidates what policies are in place so that they can get beyond the political rhetoric. The National Rural Health Association has put together a list of initiatives that are already in the Patient Protection and Affordability Act which will help rural Alabama that we need to be prepared to react to as the opportunities arise. Perhaps one (or all) of the gubernatorial candidates will announce a rural health task force to allow his (all of the candidates are men) adminstration to take advantage of opportunities in a rapid fashion. The law has already been passed so I hope we won’t let politics get in the way of improving the health of our citizens:

Rural Health Care Workforce Improvements (as identified by the National Rural Health Association)

Rural Physician Training GrantsThese grants will help medical colleges to develop special rural training programs and recruit from students from rural communities.  This “grow-your-own” approach is one of the best and most cost-effective ways to ensure a robust rural workforce into the future. Alabama has some very good but underfunded programs

Expanding Area Health Education Centers (AHEC)  – Area Health Education Centers (AHECs) are critical to long-term health workforce strategies in rural America.  AHECs are directly responsive to State and local needs and serve to improve the supply, distribution, diversity and quality of the healthcare workforce, ultimately increasing access to health care in medically underserved areas.  The bill makes a strong investment in the continued success of this program. ALABAMA DOES NOT HAVE AN AHEC

Graduate Medical Education (GME) Improvements – Rural America faces a severe physician shortage, and this bill seeks to partially address this problem by improving GME.  First, it establishes a program for training of medical residents in community based settings by awarding grants or contracts.  This funding would help develop new primary care residency programs in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).  It would do so by creating a demonstration project program for RHCs, FQHCs and other “approved teaching health centers” in non-provider settings for which centers would be eligible for payments for their own direct GME primary resident costs in a manner similar to the payments hospitals would receive for providing similar services.  Additionally, the bill would establish a grant/contract program to train primary care residents in community-based settings.  These programs would recruit and train new residents and faculty, and would either create new programs or operate out of existing primary care residency facilities.  Preferences for this funding would go to programs serving underserved communities. ALABAMA does not have mechanisms in place to take advantage of this at this time.

Redistribution of residency slots – The bill redistributes unused residency slots under the Medicare GME program, enhancing the national capacity for health care provider training.  Not only does this provision protect rural programs from losing their slots, which may be difficult to fill, it also prioritizes the redistribution of slots to rural programs and rural training tracks and ensures additional placements to residents in primary care and general surgery. The funding mechanism was recently announced. Alabama does not have a mechanism to pay for the excess teaching costs associated with these new slots.

National Health Service Corps – The NHSC is critical to addressing the provider shortage crisis in rural America.  This bill includes a significant investment in the NHSC and allows health professionals to fulfill their commitment by teaching, further investing in the future of the health care workforce. The state office that formerly worked with the National Health Service Corps has had significant decreases in staffing.

Undergraduate medical education – Workforce improvements must be made at all stages of the process and a grant program to improve primary care training will enhance the primary care workforce nationally. The Alabama Family Practice Rural Health Board has some resources available to help position us to take advantage of this but they are not adequate.

National Health Care Workforce Commission – The Commission would provide recommendations to enhance the status of the health care workforce across the country.  It would be comprised of health workforce experts and require a balance between rural, urban, suburban, and frontier perspectives.  Additionally, the geographic distribution of the health care workforce would be a priority area for study. The Alabama Rural Health Association has some resources should policymakers have interest.

Important Medicare and Medicaid Improvements

10 Percent Bonus to Primary Care Physicians  – Building on the 10 percent bonus fee schedule payment already offered to physicians meeting certain guidelines, such as those practicing in health professional shortage areas (HPSAs), the bill includes a five-year 10 percent bonus on certain fee schedule evaluation and management (E & M) codes related to office, home, nursing facility, domiciliary, rest home, or custodial care visits. This bonus is available to primary care, general internal medicine, general pediatric and geriatric physicians, nurse practitioners, clinical nurse specialists, or physician assistants for whom primary care Medicare services accounted for at least 60 percent of their charges the abovementioned E & M visits. Alabama Medicaid and Blue Cross should follow suit.

10 Percent Bonus to General Surgeons Performing Major Surgeries in HPSAs – Any general surgeon performing major surgeries in health professional shortage areas (HPSAs) are eligible for an extra 10 percent bonus payment between 2011 and 2016.  Alabama Medicaid and Blue Cross should follow suit.

Medicare Physician Fee Schedule Improvements – Adjustment of the Geographic Practice Cost Indices (GPCI) Formula – For years 2010 and 2011, the “practice expense” component of the GPCI formula will reflect “1/2 of the difference between the relative costs of employee wages and rents in each of the different fee schedule areas and the national average of such employee wages and rents.”    Additionally, the bill includes a hold-harmless provision in the event of an area being adversely affected by this provision.  The legislation also directs the HHS Secretary to analyze a method of establishing geographic adjustments that “fairly and reliably establishes distinctions in the costs of operating a medical practice in the different fee schedule areas.” For the years following (2012 and beyond), the HHS Secretary is required to update the PE GPCI to reflect accurate geographic adjustments based on office rents and other factors.  Alabama Medicaid and Blue Cross should follow suit.

Medicare Rural Home Health Add-On

Because home health is more expensive to provide in rural communities due to distance and the availability of providers, Congress implemented, as part of the MMA of 2003, a 5 percent bonus payment bonus payment to providers supplying home health services in rural areas.  This bonus payment was first implemented in 2004, but because Congress did not extend the program it expired on December 31, 2006.  The health reform bill reinstated this program for the period between April1, 2010 and December 31, 2016.  Instead of the previous bonus amount, however, the bill provides a 3 percent bonus payment.

One-Year 5 Percent Bonus to Mental Health Physicians  – For 2010, physicians offering psychotherapy services will receive a 5 percent bonus payment. Alabama is in a mental health delivery crisis. Te system is broken and needs significant attention. This will help but will not be enough.

Providing Adequate Pharmacy Reimbursement   – The bill includes reimbursement for retail community pharmacies of no less than 175 percent of the weighted average of the most recently calculated average manufacturers price (AMP).  There are many area of Alabama that are not served by pharmacy services

Technical Correction for Critical Access Hospital Method II Billing Reimbursement (Section 3128) – This provision would correct a technical error in current statute relating to CAHs who elect to use the Method II, or Optional Payment Method.  This was in response to the recent CMS Inpatient Prospective Payment System (IPPS) final rule in which CMS interpreted current law to disallow CAHs who bill under Method II from receiving the typical CAH 101 percent reimbursement. Because of reimbursement policies of  Alabama Medicaid and Blue Cross, Alabama has been unable to take advantage of the Critical Access Hospital rules to improve care.

Additional Payments to Hospitals in Counties with the Lowest Medicare Spending – For 2 years, hospitals in the lowest quartile of counties in terms of Medicare spending on benefits will receive additional payments to offset their disproportionately low rates.  These payments will equal $400 million in ($200 million in FY2010 and $200 million in FY 2011) to address geographic disparities for PPS hospitals in the lowest spending quartile of the country.  Alabama needs to be prepared to take advantage of this.

Extension of Important Programs Ensuring Access to Physicians and Other Services Otherwise Set to Expire

–          Extension of Payment for Technical Component of Certain Physician Therapy Caps Physical therapy services are unavailable in many counties of Alabama

Extension of Ambulance Add-Ons Ambulance services are in financial difficulty in many counties of Alabama

–          Extension of physician fee schedule mental health add-on Mental Health  services are unavailable in many counties of Alabama

Extension of Important Rural Medicare Protections  – The Medicare Modernization Act (MMA) of 2003 included a number of provisions important to protecting the fragile rural health care safety net.  These protections are set to expire, and the NRHA is glad this bill includes provisions extending these programs.  They are:

–          Extension of Outpatient Hold Harmless Provision

–          Extension of Medicare Reasonable Costs Payments for Clinical Diagnostic Laboratory Tests Furnished to Hospital Patients in Certain Rural Areas

–          5 year extension and improvement of the Rural Community Hospital Demonstration Program

–          Extension of the Medicare-Dependent Hospital (MDH) Program

–          Temporary Improvements to the Medicare Inpatient Hospital Payment Adjustment for Low-Volume Hospitals

–          Improvements to the Demonstration Project on Community Health Integration Models in Certain Rural Counties

–          Extension of and Revisions to Medicare Rural Hospital Flexibility Program

–          Extension of Section 508 Hospital reclassifications

We need to be in a position to take advantage of these in Alabama

Additional Improvements

Strengthening Indian Health Services – The bill ensures Indians below 300 percent of the federal poverty level will not face any cost-sharing when enrolled in the state exchange.  The bill also eliminates the sunset for reimbursement for all Medicare Part B services furnished by certain Indian hospitals and clinics. We need to be in a position to take advantage of these in Alabama

Small Business Tax Credit   – This would create tax credit for small businesses who offer health insurance for their employees.  The credit would be equal to 50 percent (35 percent for tax exempt employer) of an eligible employer’s requirement set forth by the bill through the exchange or a suitable alternative. We need to be in a position to take advantage of these in Alabama

Increases in Funding for Community Health Centers – Community Health Centers are a cornerstone for patient-directed care for populations with limited access to primary health care services.  This critical additional new funding will allow health centers to increase care to millions of underserved patients. We need to be in a position to take advantage of these in Alabama

Expansion of the 340B drug program – The 340B Drug Pricing Program provides low cost drugs to certain facilities.  This bill would expand the program to include Critical Access Hospitals, Sole Community Hospitals and Rural Referral Centers, allowing these facilities to better serve their patients. We need to be in a position to take advantage of these in Alabama

Community Transformation Grants – These grants provide for the implementation, evaluation, and dissemination of evidence-based community preventive health activities. According to the manager’s amendment, at least 20% of these grant funds must go to rural or frontier communities. We need to be in a position to take advantage of these in Alabama