JOINT MEETING: RURAL HEALTH ADVISORY COMMITTEE &
RURAL HOSPITAL FLEX PROGRAM ADVISORY COMMITTEE
May 19, 2015, 10:00 a.m. – 2:00 p.m.
Metropolitan Mosquito Control District, 2099 University Avenue W. in St. Paul
RHAC Members Present: Daron Gersch (chair), Ray Christensen (by phone), Tom Crowley,
Margaret Kalina, Tom Vanderwal, Michael Zakula.
Flex Members Present: Brian Carlson (chair), Stacy Barstad, Rick Breuer, Sheila Gregoire,
Barb Heier, Ryan Hill, David Nelson, Bob Norlen, Joe Schindler, Randy Ulseth, Karla Weng.
ORHPC Staff: Craig Baarson, Judy Bergh, Darcy Dungan-Seaver, Teri Fritsma, Cindy LaMere,
Maria Rogness, Mark Schoenbaum, Karen Welle, Will Wilson.
Guests: Virginia Barzan (Minnesota Academy of Family Physicians), Samantha Mills (Sen. Al
Franken’s office), Gary Sabart (TSP Architects), Julie Sabo (Minnesota Board of Nursing).
I.
Welcome and introductions
RHAC chair Daron Gersch opened the meeting and asked everyone to introduce themselves. He
also announced Gov. Dayton’s re-appointment of four RHAC members: John Baerg (consumer
member); Ellen de la Torre (consumer member), Margaret Kalina (nurse member); and Tom
Vanderwal (ambulance service representative).
II.
RHAC and Flex program overviews
ORHPC staffer Judy Bergh gave an overview of RHAC and the Flex committee. Overall, RHAC
advises the commissioner of health and other state agencies on rural health issues, while Flex
advises specifically on the Minnesota activities of the federal Rural Hospital Flexibility Program.
RHAC’s priority areas for 2013-2015 are workforce challenges, health reform, access
challenges, health promotion, aging services and volunteerism and other community resources.
Mark Schoenbaum noted that the two bodies are complementary, with RHAC serving as the
policy arm and Flex the program arm. He also described examples of RHAC work and its
impact, including a recent call from an individual in Greater Minnesota who had found a 2009
RHAC report on health care delivery models helpful five years later.
III.
Rural Health Roundtables
Samantha Mills, field representative for Sen. Al Franken, presented on the “Rural Health Tour”
the senator and his staff have undertaken over the past year across the state. Sen. Franken, now
co-chair of the Rural Health Caucus in the U.S. Senate, is holding roundtables with rural health
leaders throughout Minnesota to hear both challenges and good things happening in rural health,
from “on the ground.”
Ms. Mills gave an overview of the stakeholders who’ve been participating in the 24 roundtables
held thus far, and where and how the events been held. She then discussed the challenges and
strategies that have emerged from the roundtables, which have clustered in the following
categories (outlined in more detail in her PowerPoint presentation):
• Workforce
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Access
Community/social determinants
Funding
Policies and requirements
Communication
She also discussed the overall conclusions reached: Communities across rural Minnesota are
working together to promote health and improve overall well-being, and through strong
collaboration and innovation have overcome major barriers to accessing and providing care, but
still face challenges that need to be addressed.
These are only preliminary findings. A fuller report will be available by the end of June. Sen.
Franken hopes to present more of that detail in his keynote address at the Minnesota Rural
Health Conference in Duluth (June 29-30), and would like this to be an ongoing discussion on
rural health.
Questions/comments from members:
• Were there any EMS providers at the roundtables? Ms. Mills said one roundtable was
EMS-specific, attended by 13 EMS providers from throughout the state. Other
roundtables had at least one EMS provider each, too.
•
Was there much discussion about Community Paramedics or Community EMTs, such as
funding issues or how to reduce unnecessary EMS trips? Ms. Mills said community
paramedics came up at nearly every roundtable, and especially the issue of
reimbursement and how to shift from being seen as a “supplier” to a “provider.” Another
issue was how to build out the local supply of EMS providers, beginning in high school.
•
Dr. Gersch noted the need to find a way to transport people after being treated in the
emergency room – whether it’s back to the nursing home, to a mental health facility or
elsewhere. It’s a glaring hole, and we also need to figure it out how to pay for it. Mr.
Vanderwal noted that telehealth can help to limit transports and address 72-hour holds
and other challenges.
•
Dr. Zakula asked how the panels of participants were selected, given the importance of
having a variety of perspectives. Ms. Mills said they worked with Sen. Franken’s field
representatives, who know many of the local people in their areas. They tried to get
frontline staff and community health workers too. They would have liked more patients
and caregivers.
•
Mr. Schoenbaum asked Ms. Mills to give a brief overview of the Rural Health Caucus.
She explained that its co-chairs are Sen. Franken and Sen. Roberts, and that its members
are mostly from states with large rural populations. In each session, the caucus introduces
a package of bills. Other members of the caucus have been very interested in how
Minnesota has done its roundtables and how those have gone.
•
Mr. Schoenbaum explained that the Flex program is a creature of the federal government,
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and he’d like to see it get back on track with inviting congressional staff to attend its
meetings. Ms. Mills said she’d like to share information back and forth, that it’s
important to hear these committees’ expertise. She also noted that the Rural Hospital and
Provider Equity (R-HoPE) Act, sponsored by Sen. Franken and his caucus co-chair,
addresses a lot of these issues.
•
Mr. Schindler, of the Minnesota Hospital Association, described several aspects of
pending federal legislation that would include removal of the 96-hour rule and addressing
other CMS barriers. He asked if Sen. Franken has been active in or heard much about the
issue of hospital closures, with many more recently reported in other parts of the U.S.
Ms. Mills said that stresses around reimbursement and other financial issues definitely
came through. Mr. Schindler noted that the MHA has been working with ORHPC and
others on creative payment reform recommendations so Congress can be better assured
around cost-based systems, and to allow reimbursement for care coordination and other
services called for in health reform. Rather than looking at across-the-board cuts in
payments, they’d like to see targeted payment reforms. Ms. Mills said she’d like to be
part of those conversations.
•
Mr. Breuer encouraged the senator to reach out to additional communities, in further
iterations of the roundtable, to keep extending the scope of who has been heard.
•
Dr. Gersch noted that Minnesota physicians have been trying to tamp down prior
authorizations. Their efforts stalled in the state legislature, but it’s a problem nationally.
Ms. Mills said this is an issue they are looking into, but would like to hear more.
•
Dr. Gersch discussed how important it is to seek rural providers from those who come
from rural, as the Duluth program does. This should be demanded of all higher education
institutions, as it would lead to a much higher rate of people going to rural areas. The
Duluth program is an excellent model. Ms. Mills said the state is very lucky to have the
medical school in Duluth, and Sen. Franken strongly supports “grow your own” K-12
approaches too. He’s looking at how to better support and expand rural training sites and
experience, and she encouraged suggestions.
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Ms. Dungan-Seaver asked about the track record of the Rural Health Caucus, and if it’s
likely that the bills it introduces will pass. Ms. Mills observed that there seems to be fresh
interest and momentum around rural health issues, so she’s hopeful.
•
Dr. Gersch thanked Sen. Franken for helping “kill the SGR beast.” Ms. Mills said the
senator has been very interested in payment reform, especially as it affects rural
communities. The voice of rural providers is very important in this.
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A Flex committee member asked if insurance/reform/access came up in the roundtables.
In his community, they are starting to see small businesses trying to offer insurance
through the market/exchange, but they tend to look at the high-deductible plans to keep
costs down. This makes is hard for both patients and providers, particularly when the
patient comes in for a preventive service but it turns into a diagnostic one, which means
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huge costs that a patient might not be able to afford.
Ms. Mills said they have heard a lot about this issue, especially from rural hospitals but
also from the consumer side. Part of it has to do with health literacy, and making sure
consumers really understand what they’re buying, etc. Community Health Workers
(CHWs) have helped with this, but they are hearing the larger issue is how to ensure
access. And they did have some payers at the roundtables, to hear their perspective as
well.
Dr. Gersch confirmed that he has seen this in his practice too, with colonoscopies a good
example. He’ll code something as a screening, but the insurance companies will change it
to diagnostic if a problem is found. A Flex member said this is a huge issue, and is
causing a lot of pushback. It could blow up health reform as we know it.
Ms. Mills encouraged participants to invite the senator’s office to events and other opportunities.
IV.
Rural Nurse Practitioners
Mr. Schoenbaum introduced the Rural Nurse Practitioner portion of the meeting by explaining
how the topic emerged from the RHAC work plan, which has workforce issues as its top priority.
The committee was especially interested in understanding more about the nurse practitioner (NP)
workforce in rural settings, including the roles NPs are serving and how those might be changing
given evolving health delivery models and health reform.
Julie Sabo, advanced practice nursing specialist at the Minnesota Board of Nursing, discussed
the following data and trends (outlined in more detail in her PowerPoint presentation):
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Background on the 2008 Consensus Model for APRN (Advanced Practice Registered
Nurse) Regulation, which is the foundation for Minnesota’s new APRN law. She
described the model’s essential elements and where/how it has been implemented around
the country. Minnesota is one of 11 states that have fully implemented the model; other
states have adopted it to varying degrees, with the list of implementer states growing each
year.
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An overview of Minnesota’s new APRN licensing requirements, including the following:
 Overall licensure requirements and grandfather provision of the new law.
 The four APRN roles: certified clinical nurse specialist, certified registered nurse
anesthetist, certified nurse midwife and certified nurse practitioner.
 The six populations that define an APRN’s scope of practice (with those
populations defined by the professional and certifying organization).
 Post-graduate practice requirements for clinical nurse specialists (CNS) and
certified nurse practitioners (CNPs).
 The certified registered nurse anesthetist (CRNA) practice of pain management.
 Credentials to be used by licensed APRNs.
 The APRN Advisory Council.
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ARPN statistics, being collected by the Board for the first time:
 As of May 15, the Board had issued 6,360 APRN licenses.
 Regional breakdown of APRN license applications (see PowerPoint presentation).
Northwest Minnesota has the lowest number of APRNs relative to other regions,
and has no certified nurse midwives.
 Education by APRN type.
 Regional distribution of APRNs by home and business addresses.
 Location of the state’s 18 CNRA Pain Management licensees (mostly in rural
areas).
 Licenses by type of APRN, with nurse practitioners representing 61 percent of the
licenses issued.
 Distribution of populations within each type of APRN license. The following
graph shows the distribution for nurse practitioners:
Women and Genderrelated
7%
Minnesota CNPs by Population Focus (n=3,867)
Psychiatric/Mental
Health
4%
Adult-Gerontology
27%
Pediatric
11%
Neonatal
5%
Family and Individual
46%
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APRN issues and trends include the following:
 The formation of the new APRN Advisory Council.
 Questions of credentialing and privileging of APRNs.
 Tele-health – including APRNs living out of state but applying for licensure in
Minnesota because they can provide services via telehealth technology.
 The rise in the number of Family NPs also becoming certified as Mental Health
NPs.
 The establishment of nurse-run clinics, which are expected to grow.
 Between 2010 and 2010, HRSA projects a 30 percent increase in nurse
practitioners.
Questions/comments from members:
 A Flex member asked if NPs will be able to do peer-to-peer review? Ms. Sabo said that
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some APRNs review other APRNs, but it’s not required by law.
Ms. Bergh noted that Critical Access Hospitals have specific requirements for APRNs,
including that all inpatient records be reviewed by a physician (because state law does not
specify otherwise). This does not apply to outpatient records (includes ER visits).
Ms. Dungan-Seaver then presented the results of the rural nurse practitioner survey, which
RHAC staff conducted in Fall 2014 (before the new APRN law was effective). As background
she first presented on the overall regional distribution of NPs in Minnesota. In all cases except
for the southern region (which includes Rochester) and the northeast (which includes Duluth),
the percentage of nurse practitioners in each region is lower than the percentage of the overall
population living there. In addition, 17 percent of the Minnesota population lives in small or
isolated rural areas, compared to 11 percent of NPs living in those areas. This is comparable to
the distribution of physicians and physician assistants.
She then discussed results from the survey itself (outlined in more detail in the PowerPoint
presentation):
 The survey was sent to 402 rural facilities, with a 60 percent response rate from Critical
Access Hospitals (CAHs), 40 percent rate from federally certified Rural Health Clinics,
and 21 percent response rate from other rural clinics. Responders were mostly from the
administration side of the facility: hospital administrators, clinic managers, directors of
nursing, human resources, etc. The response rate from clinics in large rural areas (also
sometimes referred to as “micropolitan” areas) was significantly lower than in small and
isolated rural areas, which should be kept in mind when looking at results based on
rurality.
 Number of NPs on staff: 80 percent of CAHs and 84% of clinics employ at least one NP.
 Composition of primary care provider (PCP) workforce: Responding clinics have a
slightly larger proportion of NPs, responding hospitals slightly more physician assistants.
Among clinics, NPs are more likely to make up more than 30 percent of PCP staff in
clinics in isolated rural areas; in small and large rural areas, they were more likely to
make up 30 percent or less of PCPs.
 Departments in which NPs are working: Clinics more likely to use NPs in a wider range
of practice areas, and in family medicine, geriatrics and OB/GYN. Hospitals are more
likely to use NPs in ER and intensive care. Notably, clinics are much more likely than
CAHs to use NPs in mental health (25 percent of clinics vs. 4 percent of CAHs). Clinics
in large rural areas may be more likely to use NPs in more specialized areas (such as
oncology or nephrology), and clinics in small and isolated rural areas may be more likely
to use them in emergency care.
 Number of rural facilities certified as a Health Care Home (33 percent of clinics and 18
percent of CAHs), or in the process of certification (36 percent of clinics and 23 percent
of CAHs).
 Number of rural hospitals in which NPs have admitting privileges (about half).
 Whether the facility has challenges in recruiting NPs (33 percent of clinics and 30 percent
of hospitals said yes); the type of challenges these are; and the incentives they use to
recruit.
 Whether the facility has challenges in retaining NPs (21 percent of clinics and 24 percent
of hospitals said yes); the type of challenges these are; and the incentives they use to
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retain NPs.
Recommendations/suggestions respondents had for recruitment and retention, including
those related to public policy, practice organization, education and training.
Whether CAHs be interested in a distance education/hybrid model NP residency program
(about half said yes), and suggestions for such a program.
Questions/comments from attendees:
 Mr. Schoenbaum asked for ideas regarding next steps. At a minimum, staff will draft a
brief/report summarizing the results of the survey, perhaps pulling out the responses from
clinics in large rural areas given how few of those were available. He also suggested a
small group perhaps taking another, deeper look at the results as preparation for the
report. Mr. Crowley and Ms. Kalina offered to help.
 Dr. Gersch suggested RHAC re-run the survey in 2-3 years, when impacts or changes
from the new APRN law will be more evident. This would be useful especially since the
one of the main arguments for expanding the NP scope of practice was that doing so
would lead to more NPs working in rural areas. Mr. Crowley noted that some of the
survey was a bit confusing to fill out, so we may want to tweak and test it before the next
run.
 Mr. Carlson found the results confirming of his own observations as a hospital CEO. It
will be interesting to see subsequent results and changes, particularly in areas like mental
health.
V.
Legislative update
Mr. Schoenbaum noted that although the regular legislative session technically ended yesterday
(May 18), some things are still up in the air; it’s unclear what the governor will decide to do
regarding the unsigned bills. There may very well be a special session.
He noted the following items that passed:
 Telehealth – Legislation was enacted requiring coverage of telehealth services by health
plans and mandating that telehealth and in-person services be reimbursed the same.
 Workforce – various, including $2.5 million in new loan forgiveness funds (effectively
tripling the amount in that program and adding new professions, including mental health,
public health nurses, and dental therapists); new primary care residency slots; and
scholarships for home and community-based services.
 Expanded support for nursing homes.
 Expanded MERC funding.
 New program for immigrant physicians.
 Major mental health investment, including mobile crisis teams and protected mental
health transport.
 Hospital violence prevention and training.
 CAHs – Updated Medicaid reimbursement for Critical Access Hospitals
 State Health Improvement Program (SHIP) was continued.
Mr. Schindler noted that the Minnesota Hospital Association has concerns about the viability of
the Health Care Access Fund.
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Mr. Vanderwal described measures that affect EMS, including the further development of
community EMTs, noting that the Flex and RHAC committees could be helpful in moving this
emerging profession along. Other legislation of note was increase in CALS funding, opiate
prescribing improvements, and EMS pandemic preparedness. EMS workforce issues continue to
loom large. Mr. Norlan noted that this is EMS Week and encouraged members to recognize their
local EMS providers.
Dr. Zakula reported that a coalition of organizations who provide dental care across
Minnesota worked for an increase in public program reimbursement, but this didn’t pass and was
therefore a disappointment for dental providers.
Meeting Adjourned at 2:05p.m.
The next RHAC meeting will be September 22, 2015 from 10 a.m. to 2 p.m. The next Flex
meeting will be held October 6 from 10 a.m. to 2 pm at FirstLight Health System in Mora.
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