Let me begin by saying it is an honor to be here today. Thank you to the Buffalo Prenatal-Perinatal Network for inviting me and for highlighting the often overlooked rural areas. Our lack of exposure is, in and of itself, a barrier to health care.

I'm from rural America. I'm from rural New York. I'm from the Northwest tip of Appalachia. I'm from the rural Southern Tier. I'm from Allegany County the second poorest county in New York State. How rural is it? The nearest Starbucks is 100 miles away. Recently the NY Times had an article about Starbucks opening in the Forbidden City in China. But no Starbucks in Allegany County. There are 51,000 residents living in my county, which is 26 square miles smaller than Rhode Island. There are 51,000 people working in a five-block radius of this hotel.

There are advantages to rural life. Although if you were to ask my 16-year-old he couldn't name one. I think he's fortunate to grow up in rural area. The rural lifestyle - is friendly, informal, usually safe, you generally know the background of people you're dealing with, meeting and mixing all the time with people from all different economic backgrounds, (towns are too small to have economically segregated neighborhoods), little traffic, rarely standing in line, community pulling together to help individuals and local institutions. Many opportunities to serve in local government, on local boards, vital volunteer activities which are key parts of community life.

There are of course, limitations to rural life. Disadvantages include distant from many amenities, from specialized services, limited ethnic diversity, difficulty in escaping from local tradition.

Rural health care system shares many of the same characteristics - advantages and limitations. Good News and Bad News. This morning, I would like to address factors affecting the special challenges to make the rural health care delivery system viable in the new millennium. I have been fortunate to have had nearly 30 years in the health and human service field. This experience gave me insights into the rural health care systems and struggles of individuals in obtaining quality medical care in rural areas.

I am currently President of RURAL HEALTH RESOURCES, a private consulting firm specializing in the design of new solutions to today's rural health care delivery challenges. I have worked for the New York State Department of Health in their "Practice Sights" project, which specialized in advancing rural health care capacity. Since the early nineties I have been intimately involved with the development of the Rural Health Network model. I was a Clinical Instructor at the University at Buffalo School of Medicine and Biomedical Sciences, where I was the Director of the Community Oriented Primary Care project at the Rural Residency Program. I've served on every major health and human service board in the area including the hospital Board of Directors. I worked in county government for twenty years, 17 years at the Office for the Aging, twelve of which as the Director.

A recent study by the Health Policy Center of the Urban Institute, called "Rural/Urban Differences in HEALTH CARE Are Not Uniform Across States," states the following. ". . . rural areas, may in fact, have greater health care needs and face access barriers that are no less substantial. . ." than urban poor. Rural health care problems like, older, poorer populations, lower level of education, fewer hospitals, fewer doctors, low incomes, inadequate insurance coverage, undetected health problems and lower rates of service utilization, all point to the need for a health care safety net in rural communities. Nationally there has been, is now and will continue to be, an increasing pressure to make quality health care more accessible and modern technology more useable. There has been more and more pressure, constraints and urgency to contain costs and avoid duplication.
The hidden purpose of health care reform, Nationally, as well as in rural areas, is that all the individual organizations involved in any kind of health care delivery must systematically redesign their own infrastructure, to assure the highest quality of care; avoid duplication of effort and trim cost. I'm sure you are aware which of those concerns gets the most attention. I could reduce this talk to two minutes by reciting the litany of rural health care issues.

Lack of access
Lack of health care professionals - all levels
Lack of providers taking certain insurance or Medicaid
Lack of an understanding of cultural and linguistic barriers
Lack of knowledge of how & when to access providers
Lack of coordinated responses within the health care system
Lack of communication between different levels of care
Lack of different types of providers/specialists
Lack of attention to social supports.
Lack of Emergency Medical Services Volunteers
Lack of "ologies"

There are so many rural health care issues it's very hard to know which ones to address. Some factors affecting quality care in Rural Hospitals are as follows. The Balanced Budget Act of 1997 has caused many small and rural hospitals to struggle to provide the basic services Medicare beneficiaries have been promised. Rural hospitals depend more on Medicare reimbursement than their urban counterparts and are far more vulnerable to any payment reforms and reductions.

Rural America has a disproportionately higher percentage of Medicare beneficiaries. Both Presidential candidates have spoken to targeted reforms in the Medicare system, but really nothing will get done if this Congress is deadlocked. We need reforms that will strengthen our nation's rural hospitals and ensure access to quality health care for the millions of Medicare and Medicaid beneficiaries in rural areas. The collective impact of rural reforms is minimal in comparison to the overall Medicare programs budget.

This same BBA of 1997 allows Medicaid to pay Federally Qualified health Centers and Rural Health Clinics less than it actually costs to care for the Medicaid patient.
Let me explain that by frontier, I mean those areas and states where travel to the nearest health care provider is hours rather than minutes. Frontier areas differ from rural areas in that they are characterized by more extreme remoteness, isolation, and population densities of less than seven people per square mile. ~ Idaho, Montana, Nebraska, Nevada, North Dakota, South Dakota, Utah, and Wyoming.
Rural and frontier residents comprise approximately one fifth of the U.S. population. However, they do not have the same level of access to basic health care services that is available to other Americans. Poverty, inadequate transportation, large geographic distances, and an aging population base complicate health care delivery in rural and frontier communities. It is these characteristics, coupled with a fragile or nonexistent health care infrastructure, that make the delivery of rural and frontier health care services a formidable challenge for states.
The changing demographics of rural and frontier populations exert pressure on the limited range of health care services and providers that exist in these communities. Younger people have been leaving many rural and frontier communities for urban centers, which makes filling professional and voluntary health care positions from within the community more difficult. Moreover, the number of elderly in these areas has increased, and this population is living longer. In the last decade alone the increase number of elderly ages eighty-five and older was very dramatic, more than 20 percent. These elderly residents also are very interested in alternative health care service options that enable them to age at home.
Rural and frontier residents of all ages also are more likely to be uninsured, 19.8 percent compared with 16.3 percent for those in urban areas. This is because private health insurance coverage is less available through rural workers' employers. In addition, farm families are less likely than other working families to have employers who contribute to health insurance premiums. Further, poverty is more widespread in rural and frontier areas, so many residents have difficulty purchasing their own health insurance. Rural health care providers spend a lot of time serving elderly and poorly educated populations.

Rural hospitals, especially Medicare dependent hospitals, are exceedingly vulnerable. Some studies suggest that by the end of this decade, half of the rural hospitals in rural America will close.
Rural and frontier communities are constantly struggling with how to build and support their limited health system capacity and infrastructure. They face difficulties in recruiting and retaining providers, establishing telemedicine systems, and maintaining adequate emergency medical services. In recent years, primary rural challenges have expanded to include developing more long-term care options and determining whether and how to incorporate managed care into rural health care delivery. States are responding to these challenges by: improving provider recruitment and retention strategies; developing telemedicine capacity; increasing the availability of emergency medical services; exploring long-term care options; and promoting community-based managed care programs that respond to rural health needs. Yes people are doing all these things, but with mixed results.

Rural Health Network Development ~ a Building Block to Rural Health Care Delivery. Rural health networks also are being used widely to shore up rural communities' competitiveness and participation in health care delivery systems design. They are composed of providers, such as hospitals, private providers, primary care clinics, local health departments, emergency medical service agencies, and specialty services providers, that choose to work together for a variety of reasons. Some networks share administrative and technical medical equipment and/or share quality monitoring systems. Rural health networks have combined their resources to recruit and retain health professionals; maximize reimbursement in all clinics and facilities through improved management practices; build integrated systems that involve physicians, hospitals, mental health clinics, public health departments, and EMS agencies; and some have retained health care dollars by offering some type of managed care plan. We have experienced a critical and profound challenge in health care reform in America. The debate, I'm sure will go on for years. Clearly one thing is for certain, things will never be the same again. It is said; " The most effective way to cope with change is to help create it." Rural areas have the opportunity to orchestrate their own growth and enrichment by using the rural health network model.

The Balanced Budget Act of 1997 created the Medicare Rural Hospital Flexibility Program. States can use this program to improve access to health care services for rural and frontier residents. The critical access hospital component of the Medicare Rural Hospital Flexibility Program offers states the opportunity to help convert full-service rural hospitals that have low hospital-bed occupancy rates to limited service hospitals that provide a reduced complement of inpatient services needed by a community. The Federal Consolidated Health Center program encompasses four initiatives: Community Health Centers, Migrant Health Centers, Health Care for the Homeless and Health Care for Residents of Public Housing. The program is scheduled to be reauthorized in 2001. Can you name the "special interest Lobbyists" for that Federal public law? The National Health Service Corps was not reauthorized in 2000, and reauthorization remains a top priority for all rural providers. What strategies can rural communities use to move the National Health Service Corps reauthorization forward in 2001? Most people don't know what the National Health Service Corps is. Rural and frontier residents live in remote areas with limited access to comprehensive health care services, so it is critical that they have an adequate emergency medical service (EMS) system to provide immediate, crisis-oriented medical assistance. EMS systems also provide rapid transportation and triage patients to appropriate medical facilities. Many rural and frontier areas have difficulty maintaining their emergency medical services system. The most common problem is an insufficient number of EMS personnel to serve local residents. States recognize that sufficient financing, adequate staffing, and appropriate training is needed to maintain community emergency medical services systems. As demographics, financing, and health professional training and licensure requirements continue to change in rural and frontier areas, meeting the demand for emergency medical services is more difficult. One of our projects was to establish a process to assist local volunteer ambulance organizations in submitting claims to the Health Care Financing Administration and private insurers to recoup EMS covered expenses.

Telemedicine is an emerging technology, so states are still debating and exploring ways to address the barriers to telemedicine development. To date, states have made the most progress in overcoming insurance reimbursement barriers. Medicare and Medicaid reimburse for telemedicine services in most states. In addition, several states, such as California, Louisiana, and Texas, have passed laws that require private insurance companies to cover telemedicine encounters. As states' telemedicine systems mature, they will continue to develop and test solutions to provider licensure, malpractice liability, patient confidentiality, and insurance reimbursement problems. Telemedicine enables patients and providers to interact with health care professionals located miles apart. It increases patients' access to specialists through video-imaging and real- time collaboration using computer and telecommunications technology. Telemedicine also brings continuing medical education and training to isolated providers. Quality health care is a quality of life issue. Technology offers awesome hope. But there are barriers such as the following.