The Rural Monitor, Volume 10, No. 1, Summer 2003
In this issue:
- Cover Story
Support Systems Crucial to Rural Welfare Reform by Thomas D. Rowley
- TANF Reauthorization
by Thomas D. Rowley
- Across the Country
Tutors on Nevada School Buses Offer Homework Help; Partnering to Address Health Care Workforce; Innovative Use of GME Dollars Helps Utah Meet Health Care Workforce Needs; Rural Cancer Outreach.
- Research Roundup
Best Practices in Revolving Loan Funds for Rural Affordable Housing; Rural Healthy People 2010: A Companion Document to Healthy People 2010, Volumes 1 and 2; Design of Enhanced Primary Care Case Management Programs Operating in Rural Communities: Lessons Learned from Three States; The Impact of Interim and Prospective Payment Systems on Home Health Providers and Medicare Beneficiaries in Rural Pennsylvania; Meeting the Challenge of Social Service Delivery in Rural Areas.
This issue is also available in PDF.
Support Systems Crucial to Rural Welfare
Reform
By Thomas D. Rowley
By
most accounts, the welfare reform act passed in 1996 has been a big
success. Coupled with a booming economy, the 1996 act has helped
get millions of people off the welfare rolls and into jobs, and on
to better lives for themselves and their children. It's a success
that has played out in both urban and rural areas.
According to Ron Haskins, a senior fellow at the Brookings Institution
and former Senior Advisor to President George W. Bush for Welfare
Policy, "the results ain't bad" for welfare reform in rural America-welfare
rolls have declined, poverty has decreased, and employment has increased.
But, he adds, the results "could have been better."
One of the key lifelines that emerged from the 1996 Welfare Reform
Act was a new program, Temporary Assistance to Needy Families (TANF),
which replaced the Aid to Families with Dependent Children (AFDC)
program. That assistance, which was funded to the states through
a block grant, provided support for many of the transition services
that helped reduce rolls and move recipients into the workforce.
The future of the TANF program is now being debated by Congress as
it re-authorizes the program (see story below) and the results of
this debate will have significant implications for continuing welfare
reform in rural communities.
Experts and advocates alike point out that welfare reform faces
obstacles in rural areas that often are more difficult to overcome
than obstacles in urban areas.
First and foremost of these obstacles is a lack of suitable jobs.
What, after all, is welfare-to-work without work? Yet, rural America,
where nearly 20 percent of welfare recipient families live, has higher
unemployment, more seasonal employment, and lower wages than urban
America. On top of that, seasonal, part-time, and low-wage jobs (the
kind so prevalent in rural America) are much less likely to offer
benefits like health insurance, retirement, paid vacation and sick
leave that families need in order to make ends meet. In short, many
rural areas simply may not have enough jobs to lift former welfare
recipients out of poverty.
Job opportunities, however, are only half the battle. Even when
jobs are available, former welfare recipients typically need help
getting and keeping those jobs. They need everything from job search
assistance, training and public transit, to health care and child
care. Unfortunately, it can be quite difficult and costly to assemble
and maintain these so-called work support systems in rural areas.
Much of the basic infrastructure of those services-public transportation
systems, licensed day care providers, and the like-is lacking, low
population density and long distances raise the per-unit costs of
service, and small, resource-strapped local governments are the norm.
The current round of state budget shortfalls, along with the national
economic downturn, exacerbates the problem as states are forced to
cut back on various services, according to Bruce Weber, who heads
the Rural Policy Research Institute's (RUPRI) Welfare Reform Panel.
"One thing happening in a lot of states is that services to low-income
working families are being cut and a lot of social services are not
getting funded at levels what they were prior to the downturn," Weber
said. "Low-income people are getting hit by a political inability
to deal with the changed economic situations."
Moving from welfare to work, and staying there, is difficult. Research
by the Urban Institute's Pamela Loprest shows that of all U.S. families
that left welfare between 1997 and 1999, about 22 percent returned
by 1999. The increased obstacles facing rural families mean they
have an even tougher row to hoe. According to work by Weber and others
on the RUPRI Welfare Reform Panel, welfare recipients in many rural
areas fare as badly, or worse, than anybody-even inner-city recipients-in
getting off the dole and onto career ladders.
Into the Workforce, With a Fair Bit
of Help
Diana Walters wants to earn a living for herself and her three small
children. She just needs some help doing it.
The 21-year-old, single mom lives in Ronco, Pennsylvania-a place
she describes as "just a little patch" in the mountainous southwest
corner of the state. With no high school diploma, no driver's license,
and three kids under the age of three, moving from welfare to work
has been no easy feat. In fact, she was not sure she could, but the
welfare office, she says, strongly encouraged her to look for jobs
and apply.
"They told me I had only so many days left on TANF and that there
was no reason why I couldn't go out and get a job," says Walters.
Now she's glad they did.
On TANF, Walters received $87 cash assistance for each child every
two weeks, a total of $522 a month. "It wasn't enough," she says.
She now works at Wal-Mart. It is the first job she has ever had.
With it, she gets not only a salary, but also earns income tax credits
and other key supports.
"Working is a lot better," she says. In the next sentence, she laughingly
admits that "It's a little bit of a pain in the butt. Some of the
customers are nasty."
To land her job, Walters needed help. To keep it, she needs still
more.
First, is childcare. Her boyfriend used to take care of the kids,
but now he has a part-time job. Others in her circle of family and
friends cannot be paid to baby-sit for fear of losing their social
security checks. (Many, says Walters, are disabled.) She hopes she
will soon have care lined up, and even help paying for it, through
the Fayette County Community Action Agency-a non-profit provider
of a wide range of services for low-income people and families.
After childcare, comes transportation. Walters has two vehicles
but no driver's license, and the only public transit in the area
is a limited, fixed-route bus service. Nationwide, research shows,
nearly 40 percent of rural residents live in areas with no public
transportation. Thus, for Walters, and for many others around the
country, getting to work, getting her kids to day care, indeed, getting
just about anywhere means hitching a ride with family or friends.
Then, comes health care. The state welfare office helps pay for
it. In that respect, Walters is fortunate. According to some experts,
sickness, of mother or children, presents the biggest problem to
former recipients in keeping a job.
To advance her career and improve her family's life, Walters plans
on enrolling in a certified nursing assistant training program, yet
another support system service, this one offered by the area's private
industry council. The training will take four hours two to three
nights a week for 16 weeks, all on top of working and caring for
her children. She admits it will not be easy and that she will need
help.
Providing That Help
Diana Walters' story is not unique. Tammy Knouse, Director of Customer
Service at Fayette County Community Action Agency (FCCAA), knows
countless other families in similar situations. According to Knouse,
Fayette County is mountainous, very rural and in "the top 10 in all
the things you don't want to be high on"-poverty, infant mortality,
drug abuse, alcoholism, illiteracy, and so on. Eighteen percent of
its residents live below the poverty level and 66 percent of its
families with children under the age of five live in poverty. Its
child poverty rate of 30 percent is the highest in Pennsylvania.
As a result, FCCAA served 38,000 people last year, not including
medical and dental clients, in a county of 148,000 people-one quarter
of the population. Knouse sees the problems passed from generation
to generation.
"The grandparents didn't graduate, the parents didn't graduate,
the kids don't graduate. It's the same with smoking and other behaviors.
The kids don't see any other options. Those that do move and we're
left with the kids that have the most trouble," she says. "We have
adults that can't read their mail or a newspaper to look for jobs."
The root of the county's troubles (a county that includes tiny Ronco
and the "big city" of Uniontown, population some 40,000) is economic.
The steel industry closed in the 1940's and nothing much has replaced
it.
The mountainous terrain and isolation of the county also works against
it. Knouse reiterated the transportation problems in the county that
provide another hurdle for folks like Diana Walters.
According to Knouse, there is no mass transit system and many of
the low-income people she deals with have no car. "Transportation
is horrible," says Knouse.
Against these odds, FCCAA seeks to help the area's disadvantaged.
Much of the work is done in partnership with state and local agencies
and other non-profits. Knouse says the groups work well together
because they are forced to. "Nobody has enough money [to do it on
their own]," she says.
Because the needs are so many, the programs and services FCCAA provides
range from education to housing, from employment to transportation.
Simply getting a job, as Diana Walters' story illustrates, is not
a magic bullet. Sometimes a job can work against a person by paying
too much for them to get assistance, but too little to meet their
needs.
"You can hit a point that makes your life more difficult, where
you make enough to not get enough assistance, but not enough to get
by," says Knouse. "We need to be able to supplement for folks who
work but don't make enough. We need to make it worth their while."
The research bears this out, showing that families who use transitional
support services are less likely to return to welfare than those
who do not.
Of course, such a long list of programs and services can be overwhelming
to a person seeking help. Knouse admits that it can be "hard to negotiate
the systems of assistance." The difficulty is compounded by the hesitancy
of those in need, their lack of education, and the time and travel
involved in accessing the systems. As a result, participation in
work support systems by low-income working families is low.
In recognition of those difficulties and their impact on participation
rates, a program in North Carolina is taking an inventive approach.
Connecting to Help in North Carolina
For
8,600 families in rural northeastern North Carolina's Work Central
program, access to support systems is getting much easier thanks
to the telephone.
Jackie Savage, president of Connectinc., the non-profit that runs
the program with help from a long list of private industry partners,
says the idea came from the fact that families in rural areas had
to travel long distances and then wait in long lines to get services.
Some simply could not do it; others became discouraged and quit going.
Providing services over the phone just made sense.
It works like this. One part-time and eight full-time staff members
work at a state-of-the-art telecommunications center in Rocky Mount.
Over the phone, they connect former TANF recipients-customers, they
call them-from 11 rural counties with a full range of services that
include helping them find and apply for a job, obtain health care
and day care, clean up bad credit and buy a car or even a house.
Then, in a conference call, staff members help customers get through
the queue and cut through the red tape to set up appointments, sign
up for classes, open an account, or whatever they need to do. At
the same time, they model appropriate behavior for customers in the
process-teaching them the language of business and showing them how
to successfully negotiate what for many can be an intimidating system.
As Savage says, "We champion them through the system-over the phone."
The software-a case management database and a geographic information
system that shows every business, every job, and every skill set
needed in the area-gives staff the ability to instantly pull together
everything a customer needs. They can even zap a resume to an employer
while they talk.
The service is free to customers and is entirely voluntary.
"They don't have to work with us if they don't want to," says Savage. "We
can't take a check away. We can't take a child away. We have to be
results-oriented or the families won't stay with us."
As for results, Work Central has helped customers earn $38 million
in wages in its nearly three years of operation. This is all the
more remarkable given the demographics of the region. Eastern North
Carolina has consistently had the highest poverty rates in the state
and many of the counties in the service area face severe challenges
in attracting and maintaining economic development. Last year, only
40 customers went back on TANF-all because of health reasons.
"We consider ourselves economic development, one family at a time," Savage
says.
TANF Reauthorization
By Thomas D. Rowley
The 1996 welfare reform act-the Personal Responsibility, Work Opportunity
and Reconciliation Act-eliminated the Aid to Families with Dependent
Children program and replaced it with Temporary Assistance to Needy
Families (TANF) block grants given to states that can be used for
cash assistance as well as providing work support systems. Along
with the grants came restrictions on eligibility, work requirements,
and time limits on assistance.
TANF is now up for reauthorization. And reauthorization, of course,
offers Congress a chance to make changes. Some see this as an opportunity
to improve TANF. Others fear Congress will only make things worse.
According to Bruce Weber, professor at Oregon State and chair of
the Rural Policy Research Institute's Welfare Reform Panel, improvement
will come only if Congress recognizes rural America's unique needs.
"There are structural barriers to getting and keeping good jobs
in rural areas," says Weber. "TANF reauthorization is a golden opportunity
to knock down some of those barriers. But that can only happen if
policymakers recognize that rural areas are different, with different
resources and different opportunities."
Weber says reauthorization needs to do four things to really help
rural welfare recipients.
First, it must fix a distribution formula that sends less money
to disproportionately rural states. Second, it must give rural recipients-with
fewer job opportunities and support systems-enough time to find a
job before cutting off their benefits. (The current law allows a
lifetime maximum of five years on assistance.) Third, reauthorization
needs to address the nagging lack of licensed child care in rural
areas. Finally, says Weber, it ought to extend benefits during recessions,
since jobs, particularly in rural areas, are harder to come by when
the economy is stumbling.
In February, the House of Representatives passed a reauthorization
bill. The Senate version is yet to come. At this point in the process,
Weber's recipe appears in doubt.
In testifying before a Senate commitee in March, Brookings Institution
fellow Margy Waller said that the House bill reverses much of the
flexibility given to states in 1996-a flexibility that many believe
led to the success of welfare reform. Waller said that the administration
is proposing to increase the number of participants and the number
of hours participants must work while narrowing the activities that
count towards work activity hours. For instance, education and training
would not count towards minimum work hours.
Given state budget crises, Waller said that these changes might
cause states to redirect funding away from child care, transportation,
literacy training, pregnancy prevention, and a whole host of support
services. "Pushing all of the administration's proposed work requirement
levers at the same time," said
Waller, "would be a recipe for failure-for the states, for low-income workers,
and for families on welfare."
One of the key support systems affected by the House bill is child
care.
Citing Congressional Budget Office estimates, Jennifer Mezey, Senior
Staff Attorney at the Center for Law and Social Policy, a Washington,
DC, advocacy group for low-income families, says that the bill's
new work requirements will increase the need for child care by $3.8
to 4.8 billion over the next five years. Inflation, she says, could
tack on another $4.5 to 5 billion.
To pay for that $8 to 10 billion increase, the House raises mandatory
funding for child care by $1 billion over the five years, and authorizes
a $3 to 5 billion increase in discretionary funding over the period.
Even if the authorized money gets appropriated, there could still
be a shortfall of some $4 billion.
The House bill also calls on states to increase the "matching funds" they
contribute by some $785 million over five years in order to get the
$1 billion in federal funds. Faced with crippling budget shortfalls,
states may be unable to come up with the money. Indeed, according
to a new study by the U.S. General Accounting Office, 23 states have
already reduced child care subsidies for poor families by restricting
eligibility, closing the program to new families, or increasing the
required co-payment.
On top of all that, welfare caseloads have been increasing in many
states in the last few months-the result of the faltering economy.
That means still more people who will need, and be eligible for,
subsidized child care.
GET CONNECTED
For more information on the people and sources described in the
previous article, you can check the following web sites:
Across the Country
Nevada
Tutors on School Buses Offer
Homework Help
Elementary students in rural Douglas County, Nevada, are taking
advantage of their long bus ride home in the afternoon to bone up
on their studies and get their homework done. Even better, they have
a teacher along to help. The Traveling Tutors program, funded by
federal Community Service Block Grant money, puts teachers on buses
to help at-risk and disadvantaged students from four elementary schools.
The students typically come from low-income families and may have
no one at home to help them learn.
According to Karen Goode, Supervisor of Social Services for the
county, the idea for the program came from teachers who saw both
a need and an opportunity. Kids were not learning as well as they
should have been and many had an hour bus ride every day. What better
way to spend the time than with a tutor? While the teachers are paid
for their efforts, Goode notes that they buy the kids treats and
things out of their own pockets, to encourage and reward them.
The program is in its third year of operation and is showing impressive
results. For the mere sum of $8,500 last year, Goode says that 157
students received help on the bus or at school after hours, and their
grades and the rate at which they turn in homework have both improved.
"I haven't seen a better program," says Goode. "I have great faith
in it."
For more information, contact Goode at kgoode@co.douglas.nv.us.
Wisconsin
Partnering to Address Health
Care Workforce
A partnership between the Lacrosse Medical Health Science Consortium
and the Western Wisconsin Workforce Development Board is helping
to kill two birds with one stone-lowering unemployment in the region
while alleviating its health care worker shortage.
The Consortium is a group of educational institutions and health
care facilities that formed 10 years ago to improve health care education
and research in the region-23 rural counties in Wisconsin, Minnesota,
and Iowa, which Debra Suchla, director of the Consortium, calls "the
forgotten corners of those states." The Workforce Development Board
is one of the mechanisms set up under the federal Workforce Investment
Act to help develop and find jobs for the region's workforce. Both
the consortium and the board had a similar goal, Suchla says, to
help folks in the region who needed jobs prepare for and enter the
health care field-a field short on workers.
As Suchla says, it was a "no-brainer to merge efforts."
A joint committee formed in March to:
- recruit, educate, employ, and retain an adequate
health care workforce;
- build a partnership between health care service
and continuing education;
- pursue grants;
- study trends and data on workforce development;
and
- address labor force shortages.
According to Suchla, neither group, by itself, could accomplish all
that needs to be done, but "when you pull the two together, we
really can be pretty powerful in a rural, isolated area."
For more information, contact Suchla at Suchla.debr@uwlax.edu or
(608) 785-5148.
Utah
Innovative Use of GME Dollars Helps
Meet Health Care Workforce Needs
The Utah Medical Education Council (UMEC) is breaking new ground
in health care workforce training through its use of Medicare and
Medicaid graduate medical education (GME) dollars, which are the
principal source of support for specialty training of physicians.
According to Gar Elison, Director of UMEC, a waiver obtained from
the federal Centers for Medicare and Medicaid (CMS) allows UMEC to
change the flow of GME dollars in a way that helps the state influence
residency programs and thereby better meet its workforce needs. In
the past, GME payments had been made directly to hospitals where
residents are trained. Under the waiver, direct GME dollars are carved
out and flow to UMEC, which then uses them as a "carrot" by passing
them on to residency programs that meet the state's workforce goals.
Elison says that the Council does not commit funds to a program until
that program has a plan showing how it will meet the workforce objectives.
The program then has to live up to its plan or have its funding reduced,
giving the effort a "stick" as well.
Historically, residency programs billed hospitals for the salary
and benefits of the residents based on their time in the hospital.
Under the waiver, programs bill hospitals a lesser amount because
the direct GME dollars now flow to the program directors. Program
directors-who hire the residents-are held accountable for achieving
the state workforce objectives. Directors are also responsible for
meeting accreditation requirements and filling the positions in the
program. In short, the waiver rationalizes the process and places
responsibility with those who have the authority to link training
with workforce needs.
Asked if the hospitals object, Elison says that "in many ways, they
actually favor it-once they understand it."
Current goals pursued by the program are to increase the rate at
which Utah-trained health care graduates stay in the state; expand
the size of certain residency programs to meet the needs for various
specialties; and develop training experiences that meet the state's
workforce needs,in particular, to increase the amount of training
in rural areas so graduates will know how to practice there.
"Just because it's rural," says Elison, "we don't want any decrease
in skills." In fact, he says, it's the other way around. Rural practitioners
need to know how to do almost everything.
The Council was created by state law in 1997 as a quasi-governmental
entity to help collect health care workforce information from various
entities without violating anti-trust regulations. The Council, by
statute, was also directed to obtain the CMS waiver for a demonstration
project for GME distribution.
Elison knows of no other state that has linked receipt of both Medicare
and Medicaid GME to workforce planning, but says that several are
looking into it.
For more information, contact Elison at gtelison@utah.gov or
(801) 526-4552.
Virginia
Rural Cancer Outreach
Cancer is the second leading cause of death for rural Americans,
partly because of lack of access to care. Oncology-like many medical
specialties-can be difficult to access in rural areas. Patients must
often travel, sometimes great distances, to see a cancer specialist.
That was the case for residents in several rural Virginia counties
until 1993 when the Virginia Commonwealth University/Medical College
of Virginia Massey Cancer Center in Richmond created its Rural Cancer
Outreach Program (RCOP). Now, five rural outreach sites serve patients
in eight counties.
Through the program, patients are diagnosed and treated by a team
of cancer specialists from Massey (currently three nurse practitioners
and five hematologist/oncologists) working with their own primary
care doctors and nurses. Surgical, chemotherapy, radiation, and hospice
treatments are all offered at the participating rural hospitals,
including Community Memorial Healthcenter in South Hill, Rappahannock
General Hospital in Kilmarnock, Southside Community Hospital in Farmville,
and Greensville Memorial Hospital in Emporia. A special oncology
nursing clinic provides chemotherapy services at Buchanon General
Hospital in Grundy.
The hospitals provide space, nurses and support services-lab, radiology,
pathology, and pharmacy. Doctors and nurse practitioners manage patient
care from Massey and provide consultative services to patients and
their local doctors during twice-a-month visits and through 24/7
availability on emergencies. The program also offers a free shuttle
service to Massey for patients that need to travel for special treatment.
"The patients love it," says Haidee Waters, one of the nurse practitioners
at Massey. "The people caring for them in these clinics-the nurses-know
these people and are very supportive." Being in the community, says
Waters, also allows family members to stay with patients during treatment
to offer support. In addition, patients can get treatment during
their lunch hour or after work-avoiding taking time off from jobs.
The program also benefits the rural hospitals by generating new
revenue for them, and, according to a 1999 study, generates enough
revenue for Massey to cover its costs.
For more information, see http://www.vcu.edu/mcc/mcc/RCOP.htm or
contact Dr. Mary Helen Hackney, MD, RCOP Director at 804 628-1933.
Call for Input
Something newsworthy going on in your part of rural
America? Send a one-paragraph summary to the editor at info@raconline.org (Attn:
Tom Rowley).
|
Research Roundup
Best Practices in Revolving Loan
Funds for Rural Affordable Housing
A. Rose and C. Holden. Housing Assistance Council,
April, 2003.
This case study analysis of four rural revolving loan funds looks
for best practices that are the most salient in different rural contexts.
The funds examined include the Kentucky Mountain Housing Development
Corporation, the Federation of Appalachian Housing Enterprises, the
Vermont Community Loan Fund, and the Northwest Farmworker Housing
Loan Fund.
It finds that different community lending structures are appropriate
to different rural contexts. It then outlines best practices that
are common to the four case studies. For example, in founding a loan
fund, a clearly focused mission, good technical assistance, and solid
initial capitalization are key. In structuring loan fund policies
and procedures, successful funds start with simple, user-friendly
procedures, and then diversify their lending products and practices
as their funds encounter competition from other community lending
groups. In the area of risk management, all types of funds must ensure
that the collateral for each loan will cover the costs of a possible
default, and delinquencies should be monitored as closely and as
soon as possible. Familiarity with borrowers through in-house technical
assistance (for development groups) and homebuyer education and counseling
(for individuals) also helps to prevent delinquencies. Finally, the
longevity of a fund can be promoted through investment in information
technology and staff capacity, so that the fund is able to handle
increasingly complex financing deals and reporting requirements as
it grows.
The benefits and drawbacks of obtaining certification and funds
from the Community Development Financial Institutions (CDFI) Fund
are also analyzed, with the conclusion that CDFI status has been
very important to the continued growth of three of the loan funds
studied. However, CDFI award recipients also caution that any organization
thinking of pursuing CDFI certification should examine its own capacity
very carefully to determine if it will be able to handle the application
and reporting requirements.
Available at http://www.ruralhome.org/pubs/credit/revolvingloanfunds.pdf.
Rural Healthy People 2010: A
Companion Document to Healthy People 2010. Volumes 1 and 2.
L. Gamm, L. Hutchison, B. Dabney, and A. Dorsey, eds. Southwest
Rural Health Research Center, Texas A&M University System Health
Science Center, 2003.
Volume One of this two-volume report provides 1) overviews of the
top rural health concerns and objectives associated with the focus
areas outlined in Healthy People 2010; 2) references
to key literature about these concerns; and 3) descriptions of models
for practice that rural communities can draw upon to achieve key Healthy
People 2010 objectives. Volume Two is an appendix that presents
more detailed literature reviews and associated references for the
top rural health concerns.
Healthy People 2010 identified 467 objectives within 28
focus areas intended to stimulate and support action to improve the
nation's health. These objectives were intended to guide actions
by national, state, and local governments and by numerous health
provider and community-based organizations across the country. This
report extends that analysis by identifying a number of those focus
areas and objectives of importance to rural communities and by providing
illustrations of approaches taken by rural areas to address their
needs.
Available at http://srph.tamhsc.edu/centers/rhp2010 or
(979)458-0653.
Design of Enhanced Primary Care
Case Management Programs Operating in Rural Communities: Lessons
Learned from Three States
S. Poley, P. Silberman, and R. Slifken. North Carolina Rural
Health Research and Policy Analysis Center, University of North
Carolina, March, 2003.
This findings brief focuses on the use of enhanced primary care
case management to provide benefits to Medicaid beneficiaries in
rural areas. It highlights lessons learned from Florida, North Carolina,
and Oklahoma. Among the findings, are that:
- Recipients in more isolated communities seem to
benefit greatly from the additional clinicians and individualized
care associated with case and disease management programs.
- Face-to-face care management is more difficult to
implement and maintain in rural areas because of the geographic
dispersion of enrollees and the limited number of recipients in
a given service area.
- Disease management programs that rely on telephone
case management are problematic, as some Medicaid recipients do
not have consistent access to telephones.
- Rural care managers may have more responsibilities
due to the lack of other available community resources to provide
patient education or address psychosocial problems.
- Partially capitated systems can ensure the viability
of rural primary care providers by guaranteeing a stream of revenue
with minimal financial risk.
Available at http://www.shepscenter.unc.edu/research_programs/rural_program/fb_77.pdf.
The Impact of Interim and Prospective
Payment Systems on Home Health Providers and Medicare Beneficiaries
in Rural Pennsylvania
C. Jeng Lin, M. Meit, M. Schwartz, L. Davis, J. Leon, J.
Davitt, and J. Marainen. University of Pittsburgh Center for Rural
Health Practice, May, 2003.
This report examines the effects of interim payment systems (IPS)
and prospective payment systems (PPS) on home health agencies in
rural areas. As the nation shifts health care away from traditional
and more expensive modes of delivery, home health care rises in importance.
The report finds that:
- Medicare home health agencies are operating under
more financially challenging circumstances now than before the
implementation of IPS and PPS.
- The number of consumers of Medicare home health
services has decreased since the implementation of IPS and PPS.
In addition, Medicare home health visits dropped 42 percent after
the implementation of the new payment systems.
- The majority of agencies experienced an improvement
in financial conditions under PPS as compared to IPS. Agencies,
on average, were able to realize gains. However, the average gain
per episode will drop significantly after accounting for payment
cuts in October 2002 and the elimination of the 10 percent rural
add-on effective April 1, 2003. Projections demonstrate that agencies
will begin losing money for episodes receiving a low-utilization
payment adjustment after this additional payment reduction. Furthermore,
the financial position of agencies may worsen given the additional
administrative burden placed on agencies.
- Medicare margins will decrease dramatically after
taking into account payment reductions effective October 1, 2002,
and removal of the 10 percent rural add-on.
- Home health agencies are delivering a different
mix of home health services, increasing the use of physical therapy
services and decreasing the use of skilled nursing and home health
aide services.
- Agencies and beneficiaries have faced increased
service utilization restrictions for Medicare home health services
since IPS and PPS were implemented. The result has been an increase
in patient use of private-pay nursing and aide services, as well
as an increase in the need for patient self-care and help from
informal caregivers.
Based on these findings, the report recommends extending the 10
percent rural add-on, providing technical assistance to small rural
agencies, and educating health care providers on the role of home
health.
Available at: http://www.upb.pitt.edu/crhp/home_health.pdf or
by calling (814) 362-8656.
Meeting the Challenge of Social
Service Delivery in Rural Areas
P. Friedman, Welfare Information Network, Issue Notes, vol.
7, no. 2, March, 2003
This report provides an overview of the challenges social service
agencies face in delivering services to rural residents. It draws
upon previous research and several innovative programs from around
the country. It also poses and addresses several key questions:
- Why should states consider development social service
policies that target rural areas and what should those policies
do?
- What role can state agencies play in service rural
families transitioning from welfare to work?
- How can service providers do a better job?
- What resources can states use to support the effort?
Available at http://www.financeproject.org/publications/meetingthechallengeIN.htm.
Note: If you experience any problems downloading these files,
please contact the researcher(s).
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