The Conversation

By Lauren Hughes, State Policy Director, Farley Health Policy Center; Associate Professor of Family Medicine, University of Colorado Anschutz Medical Campus and Sameer Vohra, Pediatrician and Founding Chair, Department of Population Science and Policy, Southern Illinois University

Rural hospitals have struggled with financial troubles for years. Over the past decade, more than 130 have closed, forcing residents to drive farther or delay needed care. Now, the COVID-19 pandemic has many of them wondering whether rural health care systems will survive.

Twenty percent of the U.S. population lives in rural America, a region that fuels the country with food and energy. These Americans believe their health care needs have been overlooked or misunderstood by Washington for years.

This crisis is now in the hands of the Biden administration. To revive rural health care, the administration will have to expand its push for diversity to also include rural voices so the needs and priorities of rural Americans aren’t neglected in policy agendas for the next four years.

The solutions rural America needs aren’t just about expanding broadband or insurance coverage, both of which are critical to extend telehealth and health care access. Rural health care will have to transform to survive and then thrive.

One of the first crucial steps is to ensure that trusted rural health care professionals who intimately understand rural America’s challenges are in positions that empower them to shape federal policies that respect rural culture and context. The announcement of the original 13 experts nominated for the Biden transition team’s COVID-19 Advisory Board raised concerns because they largely reflected the coasts and cities at a time when the pandemic raged in rural areas.

As experts in rural health policy and population health, we work with rural health professionals on solving these challenges. Here are five creative ways the Biden administration can help.

Rethink how rural health care providers are paid

In 2019, Pennsylvania launched an innovative program to help the state’s struggling rural hospitals by changing how they are paid.

Normally, a hospital bills its patients per service. That can encourage hospitals to focus on elective procedures and new technology that can draw more paying patients, rather than promoting wellness and preventing disease. In small, rural hospitals, the volume of services – and ultimately, payment – can also fluctuate widely throughout the year.

Pennsylvania, working with the Center for Medicare and Medicaid Innovation, came up with a new design. The Pennsylvania Rural Health Model pays participating hospitals an annual fixed budget that covers inpatient and outpatient services provided at hospitals.

With a predictable budget, enrolled hospitals can focus on the care their communities need, such as treating addiction, increasing cancer screenings and improving the management of patients’ chronic diseases like diabetes to reduce the need for more expensive acute care. The goal is to reduce costs while improving care.

To accelerate rural health care transformation nationwide, the Biden administration could create a dedicated division within the Center for Medicare and Medicaid Innovation focused on rural health. Its mission would be to design and test solutions that address unique problems rural providers face like sparse populations and poorer health status. The administration may have some help coming. Pennsylvania’s former health secretary, Dr. Rachel Levine, is now Biden’s nominee for U.S. assistant secretary of health.

Expand mental health services

Mental illness rates are similar in rural and urban America, but significant differences exist in access to needed mental health services.

Expanding mental health and addiction services for Medicare and Medicaid recipients and integrating those services with primary care could improve access and reduce stigma. And that could avoid wasteful spending on preventable hospitalizations and medical transfers to larger facilities.

One way to do that is to change Medicare’s lopsided billing rules for mental health care.

Clinics that are designated as either Federally Qualified Health Centers or Rural Health Clinics already receive enhanced payments to provide primary care to Medicare and Medicaid patients. However, the Federally Qualified Health Centers, which are more prevalent in urban areas, can bill for a wider array of mental health and substance use treatment services than the Rural Health Clinics can.

Rural clinics could better address higher rates of behavioral illness and substance misuse if they could fully bill for these services. Changing how telemedicine visits are billed by making them equal to in-person visits would also help rural patients access needed services. To avoid unnecessary costs, these payment changes could be tied to quality measures, such as follow-up appointments after emergency department visits. Nearly a quarter of emergency department visits in the U.S. could be more appropriately managed in outpatient clinics, saving billions of dollars each year.

Build transformational leadership

Rural communities know how to train and recruit physicians through rural medicine rotations and loan repayment programs, but what about hospital administrators?

These are the people who ensure cash-strapped rural hospitals have the supplies and staff they need and can react quickly in a crisis and innovate. Yet, similar pipeline programs for investing in rural health care administration leaders are glaringly absent. Rural America needs leaders with the courage to transform health systems, people who can wisely steward resources and think outside the box while improving community health.

Two potential tactics: Rural professionals interested in administrative careers could enroll in innovative master’s programs, supported by their employers or through scholarships. The National Health Service Corps, which provides doctors with incentives to work in underserved areas, could also adjust its eligibility criteria to repay student loans for health care administration leaders in rural health professional shortage areas.

Bring back pregnancy care – in a better way

Fewer than half of rural counties nationwide have hospitals that deliver babies. That, along with difficulty accessing prenatal care, has led to increased childbirth complications like emergency hysterectomies and transferring critically ill newborns.

The new administration could offset costs necessary for Critical Access Hospitals – small, 25-bed hospitals that exist only in rural areas – to deliver babies through special maternity care payments tied to quality outcomes such as increasing breastfeeding rates. These payments would prevent the temptation for small hospitals to grow expensive surgical service lines to cover financial losses commonly associated with offering maternity care. Such payments would also allow rural hospitals to hire dedicated obstetrics nurses.

Additional grants through the Patient Centered Outcomes Research Institute could help address rural maternal health disparities and encourage academic medical centers to partner with rural hospitals, clinics and public health departments.

Invest in health-promoting rural infrastructure

Rural communities across the U.S. have witnessed their roads, dams and other infrastructure deteriorate in ways that have endangered health, jobs and their economic competitiveness.

Both the Obama and Trump administrations strengthened rural infrastructure by prioritizing transportation and telecommunication. However, these investments were often viewed as solutions rather than tools for innovation. Rural towns would benefit from infrastructure investments that also encourage healthy behaviors.

Sitka, Alaska, winner of the Robert Wood Johnson Foundation Culture of Health Prize, is an example. The town of about 8,600 people has created bike paths, beautified the downtown and built an accessible playground.

The U.S. Department of Agriculture could expand its existing rural infrastructure program by allocating more grant funds for health-promoting activities.

Rural America is rich in resourcefulness and diverse in its demographics, politics and economics. A transformative approach to revitalizing rural health care would respect its unique assets and culture. With the right commitment to innovation and accountability for achieving equitable outcomes.

Pennsylvania Governor Tom Wolf announced his intention to nominate Alison Beam to serve as Secretary of the Department of Health and named Dr. Wendy Braund Interim Acting Physician General.

“Alison Beam is a talented public servant who brings years of experience in health care policy and implementation to this position,” said Gov. Wolf. “Alison knows that a strong, widely available, and successful vaccination strategy is the path out of the pains of this pandemic. Her foremost and immediate focus will be on the strategic distribution of the COVID-19 vaccine, making sure Pennsylvania receives as many doses as possible from the federal government, and that the Pennsylvania Department of Health coordinates with hospitals, health centers, county and local governments, and pharmacy partners to make this vaccine as widely available as possible to Pennsylvanians everywhere.”

Beam currently serves as Deputy Chief of Staff to Governor Tom Wolf, coordinating initiatives and resources across Pennsylvania’s departments of Health, Human Services, Drug & Alcohol Programs, Aging and Insurance, as well as the Office of Advocacy and Reform. She has helped coordinate the administration’s COVID-19 pandemic response; the rollout of Pennie, Pennsylvania’s health insurance marketplace; the Reach Out PA campaign; and the Wolf Administration’s health care reform plan. Prior to transitioning to the Governor’s Office, Beam served as Chief of Staff to the Pennsylvania Insurance Commissioner. She previously served as Director of Public Policy and Associate Counsel for Independence Health Group in Philadelphia, Pennsylvania.

Beam graduated from Drexel University School of Law and holds a Bachelor of Science in Health Policy and Administration from the Pennsylvania State University.

Beam will replace outgoing Secretary of Health Dr. Rachel Levine, who has been nominated to serve as Assistant Secretary of Health in the federal Department of Health and Human Services. Beam will assume the role of Acting Secretary effective January 23, 2021.

The governor has also named Dr. Wendy Braund as Interim Acting Physician General, replacing Dr. Rachel Levine in that role.

“Wendy brings years of public health expertise and a commitment to improving public health practice in Pennsylvania to the role of Interim Acting Physician General,” said Gov. Wolf. “Wendy has been an integral part of our COVID-19 pandemic response efforts, and that experience will be an asset in this role.”

Braund, MD, MPH, MSEd, FACPM, currently serves as the COVID-19 Response Director for the Pennsylvania Department of Health. Previously, she was the Director of the Center for Public Health Practice, Associate Dean for Practice, and a Professor of Health Policy and Management at the University of Pittsburgh Graduate School of Public Health. Prior to her time in academia, she served as the Wyoming State Health Officer and Public Health Division Administrator for the Wyoming Department of Health. Before working at the state level, Dr. Braund was employed by the U.S. Department of Health and Human Services, first in the Office of the Assistant Secretary, Office of Disease Prevention and Health Promotion and then at the Health Resources and Services Administration, Bureau of Health Professions.

Dr. Braund has a BA from Duke University, MSEd from the University of Pennsylvania Graduate School of Education, MPH from the Johns Hopkins Bloomberg School of Public Health, and MD from the Penn State College of Medicine. She is a 2007 graduate of the Johns Hopkins Bloomberg School of Public Health Preventive Medicine Residency Program and is board certified in Public Health and General Preventive Medicine. She is a Fellow of the American College of Preventive Medicine.

Dr. Braund will assume the role of Interim Acting Physician General effective January 23, 2021.

Karl Blischke, Executive Director of the Pennsylvania Council on the Arts (PCA), announced the agency’s implementation of a funding strategy that addresses long-standing, historical inequities faced by Black, Indigenous, and People of Color (BIPOC) and rural communities in accessing support for critical community services and development efforts. This strategy applies to the PCA’s general operating support funding stream, known as Arts Organizations and Arts Programs (AOAP), which last year supported more than 300 arts organizations statewide and will result in increases for 73 percent of organizations in this funding category.

This strategy represents a departure from a historic formula that gave higher grants to organizations based on the size of their budgets. Through conversations with other arts funders and organizations throughout the creative sector, the PCA came to understand that this approach to grant making provided the highest grants to organizations with the most funding capacity while not adequately investing in smaller organizations, including those in BIPOC and rural communities, where the opportunity and need for community development is great.

“This is an important step in the PCA’s commitment to supporting the critical health of our communities through the arts, and to ensuring that our investments accurately reflect the demographics and geography of the entire commonwealth,” said PCA Chair Jeffrey Parks.

The PCA’s new strategy utilizes two funding tiers within AOAP—rural and BIPOC organizations, and non-rural/non-BIPOC organizations. For Fiscal Year 2020-2021, BIPOC and rural grantees will each receive a total of $26,000, and non-BIPOC/non-rural grantees will each receive a total of $13,000. While BIPOC and rural organizations will see increases in their grant amounts through this strategy, so too will 171 AOAP grantees in the latter funding tier, whose historical, annual funding levels were below $13,000.

In its adoption of this approach, the PCA Council also adopted formal definitions for rural and BIPOC-led organizations.

For rural organizations, the PCA is utilizing the Center for Rural Pennsylvania’s county-based definition, which includes 48 of the commonwealth’s 67 counties.

For BIPOC organizations, the PCA is utilizing 6 criteria, including: specific community served/impact on the community; mission/vision/founder; majority of artists/art presented, produced or exhibited; location in an area dominated by a specific culture, race, ethnicity; staff composition; and board composition; as well as an organization’s self-identification as BIPOC-led/centered.

This funding strategy is the result of more than ten years of research and conversation involving national arts service organizations, BIPOC and rural organizations, and the PCA’s analysis of its historical funding practices. Additionally, this funding approach aligns with the PCA’s strategic goal to promote equitable access for all Pennsylvanians to participate fully in a creative life and in the diverse forms of arts and culture in the commonwealth.

The Pennsylvania Council on the Arts is a state agency under the Office of the Governor. Governed by a council of 15 citizen members appointed by the governor, and four legislative members, the mission of the PCA is to strengthen the cultural, educational, and economic vitality of Pennsylvania’s communities through the arts. By leveraging the immense potential of Pennsylvania’s arts and cultural sector, the PCA supports jobs, builds community, motivates learning, promotes the commonwealth nationally and internationally, and sparks innovation.

Climate resiliency included for the first time in grant criteria

Pennsylvania Department of Conservation and Natural Resources Secretary Cindy Adams Dunn announced that grant applications are now being accepted for recreation and conservation projects in communities across Pennsylvania.

“This COVID-19 pandemic has demonstrated the critical importance of parks, forests and trails to our mental and physical health as demonstrated by the significant increase in their use, even now during the cold months,” Dunn said. “Our DCNR grants can assist communities with local park acquisition and improvements, trails and river access that are so critically in demand.”

Dunn noted that for the first time this year, climate resiliency will be included in the criteria used to review grant applications. Grantees are asked to explain how their project implements sustainable and climate resilient adaptations and/or mitigations. A document is provided to help grantees understand the green and sustainable practices that may be suitable for projects.

Every grant dollar generally leverages an additional $3 in local, county and private investments, giving every state dollar more power for the public good.

Grantees include local governments and recreation and conservation organizations.

The 2020 grant application round closes at 4:00 PM on Wednesday, April 14.

Funded through DCNR’s Community Conservation Partnerships Program, grants benefit planning, acquisition, and development of:

• Public parks
• Recreation areas
• Motorized and non-motorized trails
• River conservation and access
• Streamside forest buffers
• Open space conservation
• Regional and statewide partnerships to better develop and manage resources

There are numerous tutorial videos to help potential applicants learn about grant requirements and how to navigate the application interface on DCNR’s YouTube channel. Grant applications are only accepted through DCNR’s Grants Customer Service Portal.

Funding for Community Conservation Partnerships Program grants comes from several state and federal sources, including:

• Keystone Recreation, Park and Conservation Fund
• Environmental Stewardship Fund
• Pennsylvania Heritage Area Program
• Snowmobile and ATV Restricted Revenue Accounts
• Land and Water Conservation Fund
• Recreational Trails Program

DCNR’s grant programs have helped protect more than 180,000 acres across Pennsylvania for outdoor recreation, wildlife habitat, and water quality. One in three local parks in the commonwealth have received DCNR grant funding.

For more information, visit DCNR’s Community Conservation Partnership Grant Program website.

United States Department of Agriculture (USDA) Deputy Under Secretary for Rural Development Bette Brand yesterday announced that USDA is seeking grant applications for projects to improve housing, community facilities, and community and economic development in rural areas.

Subject to the availability of funds, grants will be established through USDA’s Rural Community Development Initiative (RCDI) program. Eligible recipients include public bodies, nonprofit organizations, and qualified private (for-profit) organizations.

Grants will be awarded to organizations that will use the USDA funding to provide support to entities to develop their capacity to undertake projects that will benefit rural communities. Applicants must provide matching funds in an amount at least equal to the federal grant.

For additional information, see the January 11, 2021, Federal Register. In Pennsylvania, contact Loan Specialist Rebecca Hurst by telephone (717) 237-2267 or email at Rebecca.Hurst2@usda.gov.

USDA encourages applications that will support recommendations made in the Report to the President of the United States from the Task Force on Agriculture and Rural Prosperity (PDF, 5.4 MB) to help improve life in rural America. Applicants are encouraged to consider projects that provide measurable results in helping rural communities build robust and sustainable economies through strategic investments. Key strategies include:

• Achieving e-Connectivity for Rural America
• Developing the Rural Economy
• Harnessing Technological Innovation
• Supporting a Rural Workforce
• Improving Quality of Life

If you’d like to subscribe to USDA Rural Development updates, visit our GovDelivery subscriber page.